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March 1, 2000

Youth Violence Prevention: The Physician's Role

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JAMA. 2000;283(9):1202-1203. doi:10.1001/jama.283.9.1202-JMS0301-5-1

Violence and violent injury have become major health issues for children and teenagers in the United States, which has the highest rate of youth homicides and suicides among the 26 wealthiest nations.1,2 Whether as victims, witnesses, or perpetrators of violence, the consequences for children and youth who experience violence are serious.3 The recent shootings in Columbine and other high schools have once again clearly demonstrated that the causes and effects of violence cross all geographic and socioeconomic boundaries. Efforts to decrease morbidity and mortality from violence have focused on 2 main areas: control of firearms and social intervention.

The Role of Guns

The most lethal form of violence is gun violence. Since the mid-1980s, 10 to 15 Americans under the age of 19 have died every day from gunshot wounds.4 Firearm injuries represent the third leading cause of death among Americans aged 10 to 14 and the second leading cause of death among those aged 15 to 24.4 For every firearm death, there are an estimated 4 nonfatal firearm injuries, many resulting in severe disabilities.5

Many factors (eg, poverty, family dysfunction, and substance abuse) affect the frequency of youth violence,6 but guns increase the lethality of violent incidents. The dramatic increase in the US homicide rate from 1985 to 1993 was due to a steady increase in firearm homicides, especially handgun homicides.7 From 1987 to 1993, the firearm homicide rate doubled for those aged 15 to 24, while the nonfirearm homicide rate decreased.8,9 Firearm suicides also steadily increased during this period among 15- to 24-year-olds.8 Firearms are used in roughly 70% of all homicides and in 60% of all suicides. Among youth aged 15 to 19, the proportions are even higher (80% and 68%, respectively).7,10

Many other countries have rates of violence similar to those of the United States, but most have lower rates of fatal violence because firearms are less used.11 International comparisons reveal that gun death rates increase along with gun ownership. Data from 14 countries, as well as Australia, Canada, and the United States, show that gun ownership is significantly associated both with the rate and proportion of homicides and suicides committed with a gun.12 Further, residents of countries with low rates of gun ownership did not more frequently use a means other than a gun to commit homicide and suicide.12

The higher firearm homicide rates in the United States are largely due to handguns.13 Over time, gun death rates in the United States have paralleled handgun production.14 Available information indicates that guns in the home increase the risk of homicide almost threefold and the risk of suicide almost fivefold.15,16 These risks are statistically significant and most of the risk is related to handguns. Thus, handguns pose a particular danger, though they are not the most common or the most powerful guns.17

What Can Physicians Do to Prevent Gun Violence?

Physicians have been crucial to success in reducing the toll of other scourges, such as polio, cigarette smoking, and motor vehicle injuries. Those who seek to reduce gun death and injury have many opportunities. Effective firearm injury prevention cannot be designed, implemented, or evaluated without good data. The United States has complete state and national counts of firearm deaths but only estimates for nonfatal firearm injuries and very little information about the role of the gun in each injury (type of weapon, whom it belongs to, how it got to the scene) or the circumstances of the injury.

Physicians and hospitals can help remedy this situation by compiling regular reports on the number and type of gun injuries they treat and including as much detail as possible on clinical course and cost.18 Individual hospitals can collaborate with one another and with health departments, coroners, police, crime labs, and others to establish an area-wide firearm injury data system. Several such efforts are under development.19

Beyond seeking to control the most lethal weapons used in violence, clinicians have focused interventions on the root causes of violent behavior, and some professional groups have identified ways they can contribute to violence prevention.20 These interventions encompass many activities already within the purview of health professionals, including screening, patient education, treatment, and advocacy. Physicians particularly well situated to participate in violence prevention are those providing primary care, emergency care, and mental health services.

Violence Prevention in the Clinic

Violence at the clinical level should be treated as a recurrent chronic disease with definable risk factors. Hospital readmission rates for patients suffering subsequent assault-related injuries have been noted as high as 44%.2123 Rates of patients suffering prior assault-related injury and then becoming homicide victims have been reported as high as 20%.2123 Violent injury and death occur far more commonly as a result of arguments between family members and acquaintances than from criminal activity involving strangers.24 Recurring violent injury may therefore be due to the persistence of violence risk factors associated with the patient's social context.

Given the high recidivism rates of violent injury, the currently accepted methods for treating such injuries should be reconsidered. When patients present with suicide attempts, evaluation for future risk and follow-up treatment are considered standard practice. However, individuals treated for violent injuries generally receive no further evaluation, although recently some emergency rooms have implemented assessment protocols and counseling services for such patients. Data showing that the risk of recurrent injury and violent death is high suggest the need to always evaluate these patients for future risk. Information required to assess this risk includes intent of revenge, the circumstances of the injury, weapon ownership and carrying behavior, and the underlying mental health condition.

Specific risk factors predisposing children to increased involvement with violence may be readily recognized in clinical practice. A major risk factor that can be detected through screening is family violence. Children who experience or witness violence early in their lives are at particularly high risk of involvement in subsequent violence.25 These data suggest that implementing family violence screening in all health care settings should be seriously considered. Currently, family violence screening occurs in emergency departments, obstetrical practices, and pediatric offices. Effective screening requires personnel properly trained in screening methods, enhanced knowledge of community resources available to respond when violence is identified, and clinicians educated to understand and be comfortable with issues of hidden violence.

Another avenue for intervention includes improved patient education. Parents would benefit from a better understanding of the factors that may put their children at risk for developing violent behavior, including extensive exposure to television violence, and repeated corporal punishment.25 Clinicians can assist parents in identifying healthy alternatives to violent punishment by promoting the use of "time outs" instead of spanking. Discussing strategies to limit television viewing and monitoring what is watched will also help reduce the degree of exposure to violent role modeling. Foremost is the need to encourage nurturing interactions between parents and children. Acknowledging and praising sociable behaviors is a healthy way of reinforcing their habituation.


Major medical groups—including the American Medical Association and many specialty societies—now urge their members to assess patients' risk for violence and counsel patients on safety practices related to guns, just as they do on practices related to substance use and sex.26,27 As public health approaches to reducing gun injuries have grown, gun injury rates have fallen.28 From 1993 to 1997, the firearm homicide rate for 15- to 24-year-olds fell, 29% from 19.9 to 14.1 per 100,000 persons;8 reasons for the falling rates are not yet clear.

A recent survey of physicians indicated that 84% of internists and 72% of surgeons believe that physicians should be involved in firearm injury prevention, yet fewer than 20% said they actually are so involved.29 Physicians and health care professionals should be aware of the importance of their roles as clinicians and advocates and use their considerable credibility to promote practices and policies based on accurate data that will contribute to violence prevention.

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