Injuries to Children and Adolescents by Law Enforcement: An Analysis of California Emergency Department Visits and Hospitalizations, 2005-2017

Police violence is a critical issue associated with adverse health throughout the lifecourse.¹ Exposure to police violence in youth may be uniquely harmful, as adverse experiences during sensitive developmental stages have health implications that compound into adulthood.^2,3 Long-standing work by activists and organizers to address police violence has led to calls for documentation of health outcomes among youth that are associated with policing practices.^1-3

To date, the few health studies on police violence among youth have elucidated mechanisms of exposure to policing practices, including direct contact (eg, stop and frisk), anticipatory contact (eg, surveillance), vicarious contact (eg, witnessing police violence), and in utero exposure.^2,3 They have also found associations between policing practices and adverse health outcomes, including anxiety and posttraumatic stress disorders, injury, and death, demonstrating the health harms associated with policing even when it is operating as designed.^3,4 Further, police violence against youth is patterned by experiences of structural marginalization, with racially minoritized youth disproportionately targeted and harmed by policing practices.^2-4 However, this literature groups together youth of all ages or reports findings for boys alone, potentially obscuring important patterns. We examined demographic and temporal distributions of hospital-treated injuries perpetrated by law enforcement among youth at the intersection of age, sex, and race and ethnicity.

We used statewide emergency department and hospitalization data from California between January 2005 and December 2017. The California Health and Human Services Agency and University of California, Berkeley Committees for the Protection of Human Subjects approved this study. Informed consent was not required because in California, confidential deidentified patient-level hospital data sets are available for research purposes through the Information Practices Act. Injuries caused by law enforcement among patients aged 0 to 19 years were identified using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and ICD-10-CM codes for legal intervention injury (eMethods in the Supplement). We calculated legal intervention injury rates per 100 000 person-years overall and by age, sex, and race and ethnicity (identified in the patient record), and at their intersections. We estimated rate ratios and rate differences with 95% CIs to examine inequities by demographic characteristics. Data set cleaning and creation were performed using SAS version 9.4 (SAS Institute) and analyses were conducted in R version 3.6.1 (the R Foundation). We conducted a sensitivity analysis to assess whether results were robust to changes in injury codes across the ICD transition (eMethods in the Supplement).

There were 15 967 youth treated for legal intervention injury in California hospitals from January 2005 to December 2017 (Table). The overall rate of injury was 11.9 per 100 000 person-years. Black youth experienced higher injury rates than youth of other races and ethnicities. Black boys aged 15 to 19 years had the highest rate (200.9 per 100 000 person-years), experiencing 143.2 additional injuries per 100 000 person-years (95% CI, 134.8-151.6) compared with White boys of the same age (rate ratio, 3.5; 95% CI, 3.3-3.7). Compared with White girls aged 15 to 19 years, Black girls of the same age experienced 4.3 times the injury rate (95% CI, 3.7-4.9). Relative inequities between Black and White youth were even greater among those aged 10 to 14 years. Black boys had 5.3 times (95% CI, 4.3-6.5) the injury rate of White boys, and Black girls experienced 6.7 times (95% CI, 4.8-9.5) the injury rate of White girls. The rate among Black girls was higher than all other groups except Black boys.

Legal intervention injury rates increased and then declined between 2005 and 2017, with Black boys experiencing a much sharper increase and later decline (Figure). The trajectory for Black girls was closer to that for White boys and Latinx or Hispanic boys than that of girls of any other race or ethnicity, and their rate of injury was higher than that of White and Latinx or Hispanic boys by 2017.

While youth are generally less likely than adults to be injured by policing practices, our findings note the protections of childhood are not afforded to all children.⁵ Black youth in California experience a substantially greater burden of injuries perpetrated by law enforcement than youth of other races and ethnicities. This is consistent with evidence that police violence is a pathway through which structural racism operates in young people’s lives, primarily impacting racially minoritized youth and contributing to health inequities.^2-4 Our intersectional analyses document the unique impact on Black girls, reflecting literature on how Black girls are more likely than White girls to be adultified—that is, perceived as older than they are, less innocent, and in need of less protection—with serious repercussions for more aggressive legal system targeting.⁶

This study has limitations. Research has found that death certificate data underreport when Black individuals in the US are killed by law enforcement.⁴ If similar patterns are present in hospital administrative data, the racial inequities documented in this study may be underestimated. Although sensitivity analyses confirmed result robustness across the ICD transition (eMethods in the Supplement), it is possible that ICD coding changes influenced post-transition rates. While California has a large, diverse population, future work should document legal intervention injury among youth in other contexts.

Joining in the precedent set by organizing movements, leading health organizations have recently issued guidance on systems-level interventions to address police violence and its implications for youth.^1,3 Concurrently, a new pediatric framework recommends well-child questions about police interactions.³ Clinicians can serve an important role in documenting these incidents, providing compassionate care and connection to services, and advocating for structural intervention.

Accepted for Publication: May 26, 2021.

Published Online: September 7, 2021. doi:10.1001/jamapediatrics.2021.2939

Corresponding Author: Kriszta Farkas, PhD, MPH, Division of Epidemiology, School of Public Health, University of California, Berkeley, 2121 Berkeley West Way, Room 5302, Berkeley, CA 94720 (kfarkas@berkeley.edu).

Author Contributions: Drs Farkas and Ahern had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Farkas, Duarte.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Farkas.

Obtained funding: Duarte, Ahern.

Supervision: Ahern.

Conflict of Interest Disclosures: Dr Farkas reports grants from the National Institutes of Health and the University of California Firearm Violence Research Center during the conduct of the study. Dr Duarte reports grants from the Robert Wood Johnson Foundation Health Policy Research Scholars program during the conduct of the study. Dr Ahern reports grants from the National Institutes of Health during the conduct of the study and outside the submitted work.

Funding/Support: This work was supported by grant DP2HD080350 from the National Institute of Child Health and Human Development Office of the Director and funding from the University of California Firearm Violence Research Center. Dr Duarte is also supported by a Health Policy Research Scholars program grant from the Robert Wood Johnson Foundation.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The analyses, interpretations, and conclusions presented are attributable to the authors and not to the California Department of Public Health.