Traumatic Injuries and Radiographic Study Utilization Among Children With Drowning Presenting to U.S. Pediatric Hospitals

OBJECTIVE

The role of traumatic injuries in fatal and nonfatal drownings is poorly described. We sought to characterize the incidence of traumatic injuries and diagnostic imaging performed among children who received pediatric hospital care for drowning.

METHODS

We conducted a retrospective study of children (≤18 years) with drowning encounters at 45 pediatric hospitals, October 2015 through December 2020. We described the presence of clinically important traumatic injuries to the following body regions: brain, spinal cord, thoracic and intra-abdominal organs, axial skeleton, pelvis, and long bones, and major vessels. We described patient characteristics and radiographic testing. We compared patients with and without traumatic injuries using the Fisher's exact and Wilcoxon signed rank tests.

RESULTS

We identified 10,397 children with a drowning encounter. Most (83.4%) were treated in the emergency department and 52.8% were admitted. There were 238 (2.3%) encounters with clinically important traumatic injuries. Intracranial injury was the most common (1.0%) with other traumatic injuries occurring in ≤0.5%. Less than 2% of children had a moderate or severe injury severity score and approximately half of these children had a clinically important traumatic injury. Among children with traumatic injuries, a higher proportion were 10 to 14 or 15 to 18 years old and from ZIP codes with lower median household income. Computerized tomography imaging was performed in the following proportions: brain (11.4%), cervical spine (3.7%), abdomen/pelvis (1.2%), chest (0.5%) and face/orbits (0.2%).

CONCLUSIONS

Clinically important traumatic injuries in children with drowning are rare. Further studies are needed to guide the optimal utilization of radiographic studies in this population.

Exploring Firearm Access, Carriage, and Possession among Justice-Involved Youth

Firearm carriage and possession predicts youth firearm violence victimization and perpetration. This study describes self-reported factors associated with firearm access, carriage, and possession among justice-involved youth. We conducted an exploratory, mixed-methods study. Participants were recruited from May 2022 to February 2023 from the Juvenile Justice Collaborative, a diversion program for justice-involved youth. We used online anonymous surveys to investigate exposures related to firearm access, carriage, and possession. We performed semi-structured interviews using the phenomenology framework. We used descriptive statistics to examine firearm exposures by participant demographics. We performed qualitative analyses using an iterative approach with constant comparison to identify key themes. We completed 28 surveys and 5 interviews. Most survey participants identified as male (57%) and Black (61%) with a median age of 18 years. Interview participants described the socialization and cultural normalization of firearms, most prominently among peers. Survey participants reported whether they had ever carried (25%) or possessed (21%) a firearm. Survey and interview participants endorsed protection in the context of increasing violence exposure over time as the primary motivation for firearm possession. Interview participants describe accessing firearms primarily through social networks while survey participants also reported access from strangers (25%) and licensed sellers/gun dealers (18%). In conclusion, justice-involved youth believe firearm carriage and possession may be needed for protection due to increasing violence exposure. Further investigation is necessary to determine interventions that may decrease firearm access, carriage, and possession among justice-involved youth.

Improving Documentation of Firearm Access During Pediatric Emergency Visits for Suicidal Ideation

BACKGROUND AND OBJECTIVES

Approximately half of youth suicides involve firearms. The promotion of safe firearm storage in the home through lethal means counseling reduces suicide risk. We aimed to increase the documentation of firearm access and storage among children presenting to the emergency department (ED) with suicidal ideation or self-injury to 80% within 13 months.

METHODS

We conducted a multidisciplinary quality improvement initiative to improve the documentation of firearm access and storage among children <18 years old seen in the ED for suicidal ideation or self-injury. The baseline period was February 2020 to September 2021, and interventions occurred through October 2022. Interventions included adding a templated phrase about firearm access to psychiatric social work consult notes and the subsequent modification of the note to include all firearm storage elements (ie, locked, unloaded, separate from ammunition). Statistical process control and run charts were generated monthly to monitor the documentation of firearm access and storage, which was measured through a review of keyword snippets extracted from note text.

RESULTS

We identified 2158 ED encounters for suicidal ideation or self-injury during the baseline and intervention periods. Documentation of firearm access increased from 37.8% to 81.6%, resulting in a centerline shift. Among families who endorsed firearm access, the documentation of firearm storage practices increased from 50.0% to 78.0%, resulting in a centerline shift.

CONCLUSIONS

The modification of note templates facilitated increased documentation of firearm access and storage practices for children with suicidal ideation in the ED. Future studies should assess whether improved documentation is associated with improved storage practices and reductions in firearm suicides after ED encounters.

Childhood Exposure to Firearm Violence in Chicago and Its Impact on Mental Health

OBJECTIVE

To describe how often Chicago children are exposed to firearm violence, the types of exposure, and the parent-reported impact of these exposures on child mental health symptoms.

METHODS

Data were collected in May-July 2022 using the Voices of Child Health in Chicago Parent Panel Survey, administered to parents with children aged 2-17 years from all 77 Chicago neighborhoods. Firearm violence exposure was characterized as indirect (hearing gunshots or knowing someone who was shot) or direct (witnessing a shooting, being threatened with a firearm, being shot at but not injured, or being shot and injured). Parents indicated if children in their household had any of the following mental health symptoms associated with firearm violence exposure: fear, anxiety, sadness, isolation, difficulty concentrating, difficulty in school, or aggression. Chi-squared tests and multivariable logistic regression models were used for statistical analysis.

RESULTS

Responses were received from 989 Chicago parents. More than one third (37%) of children were exposed to firearm violence with an indirect exposure prevalence of 32% and a direct exposure prevalence of 10%. Mental health symptoms associated with firearm violence exposure were reported for 20% of children. Mental health symptoms were reported for 7% of children without firearm violence exposure compared to 31% with indirect exposure (aOR 6.2, 95% CI: 3.7, 10.6) and 68% with direct exposure (aOR 36.1, 95% CI: 16.6, 78.6) CONCLUSIONS: Chicago children with indirect and direct exposure to firearm violence had more parent-reported mental health symptoms than unexposed children. Trauma informed care approaches to mitigate the negative mental health effects of both direct and indirect firearm violence exposure are critical.

Mental Health and Violence in Children and Adolescents

This article examines the complex interplay between mental health and violence among children. Although children with mental illness are more likely to be victims of violence than perpetrators, this article describes the few mental health conditions associated with increased violent behavior among children. Next, the authors examine the spectrum of mental health sequelae among children following exposure to various forms of violence. Lastly, the authors discuss the underutilization of mental health services in this population and highlight screening and intervention tools available to pediatric clinicians caring for children exposed to violence.

Gun carrying among freshmen and sophomores in Chicago, New York City and Los Angeles public schools: the Youth Risk Behavior Survey, 2007-2013

BACKGROUND

This study evaluated trends and risk factors over time for self-reported gun carrying among freshman and sophomore public school students in Chicago, New York City and Los Angeles, chosen as high profile cities with different levels of firearm violence.

METHODS

The study used four biennial waves (2007-2013) of the Youth Risk Behavior Survey (YRBS), an anonymous, voluntary survey of public high school students. Analyses were restricted to freshman and sophomores given significant high school dropout rates among older students. School population weighted results are presented based on the YRBS complex survey design, including comparisons of reported gun carrying across survey waves and cities. A violence index was created from eight survey items that capture students' perceived threat level. Chi square tests and multivariable Poisson regression analyses were used to test the significance of differences across cities and over time in the likelihood of gun carrying controlling for sociodemographic characteristics, mental health risk factors and behavioral risk factors.

RESULTS

The study included a total weighted population estimate of 1,137,449 students across the three cities and four survey waves. Mean self-reported gun carrying across all survey waves was 8.89% in Chicago, 4.09% in New York City, and 6.03% in Los Angeles (p < 0.001). There were no significant changes in gun carrying prevalence within each individual city over the survey waves. Multivariable Poisson regression estimates showed increased likelihood for gun carrying among males (IRR 1.41, CI 1.27-1.58), among non-Hispanic Blacks (IRR 1.26, CI 1.07-1.48), and among those who reported a higher violence index. Each additional violence index count increase was associated with a 1.74 times (CI 1.70-1.78) increased likelihood for gun carrying.

CONCLUSIONS

There was a much higher self-reported rate of gun carrying and a higher burden of violence exposure in Chicago as compared to New York City and Los Angeles. Students' exposure to violence extended to other stressors illuminated by the YRBS including fighting, perceptions of safety, and other high-risk behaviors. Through the violence index we created, we are better able to categorize the most high-risk individuals and describe the magnitude of their increased likelihood to carry a gun.