Pediatric resident Tamar Rubinstein recalls being frustrated by not being able to get a young patient with a serious condition into the Harriet Lane Clinic at Johns Hopkins for treatment. The reason, she learned, was that both the girl and her family found themselves living in the middle of gang violence.
“We worry about diet and exercise and patients getting all the meds they need, but they go home and their biggest fear is getting shot,” Rubinstein said. “The parents aren’t as concerned about the things we’re so concerned about.”
The experience spurred Rubinstein to look into the epidemiology of youth violence in urban environments like East Baltimore and to explore ways in which pediatricians can help. Among her findings culled from the Centers for Disease Control and Prevention (CDC) and other sources, which she recently shared at Children’s Center Grand Rounds –
- In this country, 60 percent of children are either victims of violence or have witnessed a violent event.
- The majority of victims of gang violence are African American and Hispanic males 12 to 19 years of age.
- Homicide is the 2nd leading cause of death in Americans 13 to 21 year of age, and the leading cause of death in African American males ages 13 to 21.
- In 2008, 23 percent of homicide victims were younger than 20 years old.
- Homicides in Baltimore declined from 353 in 1993 to 223 in 2010, but East Baltimore saw an increase in homicides over the past two years.
What are the effects on children and adolescents? Rubinstein noted an increased risk of –
- Psychological distress, including anxiety and depression
- Substance use and abuse
- Intent to use violence, and
- Participation in gang activity.
In a survey of 700 adolescents exposed to community violence, Rubinstein said, 22 percent either belonged to or expressed interest in joining a gang. The strongest associations with the frequency that these youth used violence or carried weapons were multiple substance use and lifetime exposure to violence and victimization (Journal of Pediatrics 2000:137;707-713).
Noting that 44 percent of trauma incidents seen in urban emergency departments are repeat episodes (Journal of Surgical Research 2011:165;25-29), Rubinstein reported that in-hospital violence prevention initiatives like the University of Maryland Medical Center’s VIP, or Violence Intervention Program, have had an impact. Through a team of parole/probation officers, psychiatrists, social workers, trauma surgeons and tutors, VIP resulted in an 83 percent decrease among participants in repeat hospitalizations for violent injuries, a 75 percent reduction in criminal activity, and an 82 percent increase in employment (Journal of Trauma 2006:61(3);534-537).
While violence prevention and related support and education can start in the hospital setting, Rubinstein noted, programs like VIP are secondary prevention measures. “Ideally, you want to catch them before they show up in the emergency room,” Rubinstein said. “There has to be more work in primary prevention, in pediatricians’ offices.”
So, what can pediatricians do about youth violence? What should they screen for?
Family conflicts, school failure, substance abuse, and victimization, Rubinstein stressed, are all risks for youth violence. When such red flags pop up in the Harriet Lane Clinic, staff bring in behavioral specialists, social workers, staff tutors and, in some cases, legal counsel.
“These are some of the things that we try to do, and whether they are effective or not is hard to say,” Rubinstein said. “Regardless of how effective we are we have to at least acknowledge the problem and try to find ways to ensure younger kids don’t fall into the same cycle.”
For more information, visit the Center for the Prevention of Youth Violence at the Johns Hopkins Bloomberg School of Public Health, and the CDC’s website on violence prevention.