How treating gun violence as public-health issue could help children

Among high-income countries, the US accounts for 91 percent of firearms deaths for children up to age 14, according to a new Pediatrics report. Several research projects are taking stock of the effects of firearms on children – and also the factors that may boost their resiliency.

When he visits his grandmother in West Philadelphia, 16-year-old Horace Ryans III sometimes hears gunshots. It’s scary. But the gunshot that affects him the most happened before he was born. It killed his uncle, sitting defenseless in a car in the neighborhood.

“A picture [of him] hangs on my grandmother’s wall, and every time I walk into her house I see him,” Horace says. “If I one day get put into a terrible situation where I am a victim of gun violence, that could be me on my grandmother’s wall.”

Horace, a sophomore at Science Leadership Academy, participated in the walkouts on March 14, conducting interviews on gun violence and registering students to vote. As a member of the Philadelphia Youth Commission, he’s helping with a March 22 youth-voices forum on the topic, and he plans to attend Saturday’s March for Our Lives in Washington.

Whether they’re shouting from capitol rotundas or speaking volumes through 17 minutes of mass silence, young people like Horace are determined to make the country hear facets of the gun control debate. From their perspective, narrow proposals to boost school security, while necessary, don’t satisfy.

More and more, adults who research violence and work to prevent it are listening – and bringing youth voices to the center as they try to better understand the role firearms play in young people’s lives.

“Children … are really begging for adults to help them feel safe,” says Joel Fein, an emergency room physician and co-director of the Violence Prevention Initiative at Children’s Hospital of Philadelphia (CHOP). “What they know innately is when a child doesn’t feel safe, they cannot develop … in terms of the social, emotional, and intellectual growth that they need to become healthy adults.”

An estimated 19 children a day die from or are treated for gunshot wounds in the United States. Among all high-income countries, the US accounts for 91 percent of firearms deaths for children up to age 14, a new Pediatrics article reports.

Yet being shot – intentionally or accidentally – isn't the only form of harm young people face, experts say. What about the child who sees her mother threatened with a gun by a boyfriend? Or the teen robbed at gunpoint on the way to school?

Despite two decades in which it’s been difficult to get federal funding for gun research, a number of projects are taking stock of the effects of firearms on children – and also the factors that may boost their resiliency. They are part of a growing movement to treat gun violence as a public-health problem.

Listening to young people about guns

Kimberly Mitchell and her colleagues at the University of New Hampshire’s Crimes against Children Research Center have been listening extensively to young people talk about the role of guns in their lives.

In an Appalachian community in Tennessee, in Boston, and in Philadelphia, they've asked older children (and parents, on behalf of young ones) about hearing and seeing gunshots and being threatened with firearms. They've asked how upset or scared each incident made them feel and whether it made them hide or change their route to school.

These are among many questions being tested as they develop Youth-FiRST, a pioneering assessment tool that will cover firearm exposure, access, and safety practices.

“I’m a big believer in self-report data, because so much of [what we’re asking about] does not even reach the attention of officials,” says Dr. Mitchell, a psychology research professor.

Mitchell estimated in a 2015 study that 1 in 33 children nationally have been directly or indirectly victimized by a highly lethal weapon such as a knife or gun at least once during their lifetime.

Her current work is funded by the National Institutes of Health. Mitchell hopes to have data analyzed within a few months and to eventually develop a national assessment.

Gun safety practices are another element her survey covers.

Twenty-six years ago, the American Academy of Pediatrics noted that households without firearms were safest for children, but that risk could be reduced if guns were stored locked and unloaded.

Yet progress on this front has been slow. Among households with children at risk for self harm, 43 percent have guns, an article this month in Pediatrics reports. Of those households, 35 percent store the guns locked and unloaded, slightly more than the 32 percent of homes where the children have no history of risk factors.

When people receive safe-storage counseling from doctors, they tend to improve their practices, Fein says. He and colleagues from the University of Pennsylvania are researching better ways to get pediatricians to do more of that counseling.

Determining levels of risk

Emergency-department doctors have known for some time that youths seeking treatment for a violence-related injury are at greater risk for future gun violence – either as a victim or a perpetrator. But Jason Goldstick and colleagues at the University of Michigan have developed a scoring system to better sort out levels of risk even among those who come in for nonviolent injuries.

They analyzed data from a two-year study of 14- to 24-year-olds who had been treated by an emergency department in Flint, Mich.

The survey items that proved most practical and predictive, according to the researchers, were the frequency with which the person had been threatened with a gun, the frequency of hearing gunshots, how many of their friends carried weapons, and how many fights they’d had in the past six months.

Those items became a 10-point “SaFETy” score, published last year by the Annals of Internal Medicine. Among youths who scored 9 or 10 on the scale, 100 percent were involved in firearm violence within two years of their emergency department visit. For scores of 6 to 8, 81 percent; for scores of 0, only 18 percent.

The study only involved youths who reported substance use (mostly marijuana), but if further research externally validates it as a screening tool, the SaFETy score could be useful in urban emergency departments – “critical access points [for] … difficult-to-reach populations that you might not find in school,” Dr. Goldstick says.

Moving away from 'treat and street'

In Philadelphia, homicide is the leading cause of death for teens and young adults, and 1 in 8 high-schoolers carries a weapon to school in a given month, CHOP reports.

The hospital’s Violence Intervention Program (VIP) seeks to assist victims and their families break cycles of interpersonal violence. They provide counseling and help them navigate complex medical, municipal, and social support agencies. It’s part of CHOP’s larger Violence Prevention Initiative, which addresses everything from domestic violence to school bullying.

CHOP’s work is recognized as a model and is one of 32 members of a national network of such programs. These hospitals are shifting away from the traditional “treat and street” approach that many took when “it was thought there was nothing we could do” about cycles of violence, Fein says.

After young people in VIP spend three to six months learning about trauma and working on recovery goals, some become peer educators.

“They are so resilient and take what has happened to them and turn it around to make sure it doesn’t happen to someone else,” Fein says. That’s also what’s been so encouraging to him about the recent wave of youth activism in the wake of the Parkland, Fla., shooting. “We draw strength from the people that we are supposed to be taking care of.”