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Pediatric Violence-Related Injuries in Boston
Results of a City-Wide Emergency Department Surveillance Program
Robert D. Sege, MD, PhD;
Sigmund Kharasch, MD;
Cathy Perron, MD;
Stacey Supran, MA;
Patricia O'Malley, MD;
Wenjun Li, PhD;
David Stone, PhD
Arch Pediatr Adolesc Med. 2002;156:73-76.
ABSTRACT
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Context Violence-related injuries among children are common, but age-based incidence
data are not easily available.
Objectives To describe injuries due to violence in a population-based case series
of children and to estimate injury incidence.
Design Prospective surveillance of children residing in Boston, Mass, who received
pediatric emergency department treatment for violence-related injury during
a 4-year period beginning April 15, 1995.
Setting Pediatric emergency departments in Boston.
Patients Children aged 3 through 18 years who came to a hospital emergency department
between April 1995 and April 1999. Violence-related injuries were defined
as those resulting from a situation of conflict involving 2 or more persons
with intent to harm, as assessed by health care personnel caring for the patients.
Self-inflicted injuries and injuries caused by child abuse (including any
injury resulting from a conflict with a parent or guardian) were excluded.
Homicides of Boston children aged 3 through 18 years who were killed during
the study period were included based on police data.
Main Outcome Measure Population-based violence-related injury rates.
Results There were 2035 injury-related visits caused by violence, which reflects
a rate of 52.7 (95% confidence interval, 50.5-54.9) per 10 000 person-years.
Most injuries were relatively minor; 6.4% of visits resulted in admission.
The youth violence-related injury rate in Boston declined at an average rate
of 12% annually during the period studied.
Conclusion Pediatric emergency department monitoring of violence-related injury
in Boston suggests that childhood injuries due to violence declined during
the late 1990s.
INTRODUCTION
YOUTH VIOLENCE is a major cause of death and disability for young people
in the United States, extending well beyond the purview of the health care
system.1-2 However, our understanding
of youth violence is based largely on deaths, criminal justice statistics,
and public surveys.3-6
Analyses of the incidence of violence-related injuries seen at a single site7 or during a brief period8
provide a snapshot of violence-related injury and cannot yield stable incidence
estimates. Recently, a city-wide surveillance in Washington, DC, demonstrated
a decline in violence-related morbidity and mortality in the late 1990s.9
We sought to establish a city-wide surveillance to measure the incidence
of violence-related injury to children. Public and private agencies have initiated
a variety of violence prevention efforts that include changes in the police
department, philanthropic support of community organizing efforts, the introduction
of violence prevention curricula into schools, and media campaigns designed
to affect public attitudes toward violence. Ongoing surveillance of violence-related
injury may be useful in supporting the evaluation of these efforts.
SUBJECTS AND METHODS
SUBJECTS
This report includes only pediatric patients who were residents of Boston,
Mass. Data were collected on all children who came for treatment of violence-related
injury to the emergency departments (EDs) of Boston Medical Center, Children's
Hospital of Boston, Massachusetts General Hospital (Boston), and New England
Medical Center (Boston). The first 2 hospitals, which together accounted for
more than 85% of all pediatric ED visits in Boston, began the surveillance
program on April 15, 1995. The third hospital joined November 1, 1996, and
the fourth joined February 1, 1997. The period studied was from April 15,
1995 to April 14, 1999. Two other nonhospital sites offer 24-hour urgent care
services and may have diverted some local patients from the EDs; however,
these sites were not included in this surveillance. The Massachusetts Department
of Public Health estimated that 95% of all pediatric ED visits were accounted
for by these 4 hospitals (Victoria Ozanoff, PhD, oral communication, April
1997).
METHODS
The detailed methods and rationale of this surveillance program have
been previously published6 and are summarized
below.
Definitions and Inclusion and Exclusion Criteria
Violence-related injuries were defined as those resulting from a situation
of conflict involving 2 or more persons with intent to harm, as assessed by
health care personnel caring for patients in the EDs.7, 10-11
Only injuries that seemed to be caused by interpersonal violence, excluding
child abuse, were included in this study. Exclusion criteria included: (1)
unclear intent; (2) injuries resulting from child abuse (identified by International Classification of Diseases, Ninth Revision, Clinical
Modification code E96712); (3) the "other
person involved" in the incident leading to injury was identified as a parent;
or (4) injuries resulting from attempted suicide.
Completeness of Data
Patients were identified prospectively (at the time of visit) or retrospectively
(by daily ED record review).6 All hospitals,
as a matter of policy, accept patients older than 18 years. The 2 hospitals
that contributed the greatest number of patients to the study routinely accept
patients up to the age of 21 years. Three of the hospitals have adult and
pediatric facilities in adjoining areas and all but the most severely injured
patients younger than the cut-off age receive care in the pediatric ED. Older
adolescents with severe, life-threatening injuries at these institutions may
have been cared for in specially equipped adult trauma rooms and may not have
been included in this study. In addition, children and adolescents who died
at the scene were not included in the surveillance.
Data Collection
We collected data concerning patient age, sex, and residence, injury
circumstance, victim-offender relationship, drug use by the patient, medical
description of injury and procedures, and weapon use. Information concerning
the body part(s) injured was systematically collected beginning in 1997. Reports
of homicides of persons younger than 19 years were provided by the Boston
Police Department.
Rate Calculations
To determine the annual incidence of violence-related injury, we analyzed
data on injuries to Boston residents. Population-based injury occurrence rates
were calculated for Boston residents only, using the results of the 1990 and
2000 US Census as the denominator.13-14
Age-specific population changes throughout the decade were approximated using
a linear model, ie, assuming equal annual increases and decreases throughout
the decade. We held the exposure (number of person-years) constant within
each calendar year.
Numerator data were computed using all visits made by Boston residents.
For the period in which only 2 hospitals participated, the actual incidence
of violence-related injury was inflated by a factor of 1.16 to account for
the proportion of visits seen at the other 2 centers. For the period in which
3 hospitals participated, the measured incidence of injury was inflated by
a factor of 1.099 to account for the fourth hospital. These ratios were determined
empirically, based on data from the period in which all 4 hospitals participated.
The number of events that occurred during a specified period was assumed to
follow a Poisson distribution.
Poisson regression models were used to assess the trend of incidence
rate change during the 4-year period. The confidence intervals (CIs) of incidence
rate ratios were constructed using a robust procedure. Regression analyses
were based on 128 age, sex, and year groups (ie, 16 age, 2 sex, and 4 year
groups). Data analysis was performed using Stata 7.0 (Stata Corporation, College
Station, Tex).
This study was approved by the human studies committees or institutional
review boards at each hospital.
RESULTS
A total of 2035 ED visits were made by Boston residents aged 3 to 18
years for the treatment of violence-related injuries during the study period.
The annual incidence of violence-related injury requiring ED care was 52.7
per 10 000 person-years (95% CI, 50.5-54.9). The ratio of deaths to admissions
to ED visits—the injury pyramid9, 15—was
1:4:59.
AGE AND SEX DISTRIBUTION
The median age of the injured children was 14 years. Age distributions
for male and female patients were similar, with an increasing frequency of
injury as patients grew older (Figure 1
and Table 1). The apparent decline
in incidence rate at age 18 is partially accounted for by the influx of college
students to Boston. There were many fewer 17-year-old (5887) than 18-year-old
residents (9625) in 1990. The number of violence-related injury visits by
17- and 18-year-olds was 294 and 222, respectively.
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Average incidence rate of pediatric injuries, 1995-1999, per 10 000
person-years.
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Table 1. Violence-Related Injury Incidence Rates by Age Group and Sex*
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INJURY CIRCUMSTANCE
One or more circumstances of injury were recorded for 79.8% of all patient
visits. Commonly reported circumstances of injury included: an argument (38.9%),
assault (20.0%), "horsing around" (5.8%), and crimes other than assault (3.6%).
The relationships between the patient and the other individual(s) involved
in the incident leading to injury were: friends or schoolmates (38.2%), sibling
or other family member (10%), strangers (9.0%), and boyfriend or girlfriend
(3.4%).
The relationship of the patient to the other person(s) involved was
unknown (or the patient was unwilling to say or the relationship was not documented)
in 28.5% of all cases. The fraction of unreported relationships did not seem
to be random: unknown or undocumented relationships were more commonly reported
in adolescent than in younger patients (33.4% of those 13 years or older vs
17.8% of those 12 years and younger P<.001). Compared
with girls, boys were less likely to have any relationship recorded (33.6%
missing for male patients vs 20.0% for females; P<.001).
Boys were also more likely to report a stranger (10.0% vs 7.3%; P = .02) and less likely to report a friend or schoolmate (36.3% vs
41.6%; P<.01) or sibling or other family member
(7.4% vs 14.4%; P<.01).
INJURY DESCRIPTIONS
Most injuries were relatively minor, involved the head, neck, and upper
extremities, and were the results of unarmed fights (Table 2). Most patients were treated and released, 130 (6.4%) were
admitted, and 2 died in the ED (.01%).
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Table 2. Description of Injury*
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Overall, weapon use (stab/cut, firearm, or blunt object) was reported
in 25.5% of all injuries. No children younger than 10 years were treated for
intentional injuries caused by firearms. Among 15- to 18-year-olds, the injury
incidence rate for firearm use was 3.3 injuries per 10 000 person-years.
Within this age group, males experienced an 11-fold higher incidence of injury
caused by firearms compared with females (rate, 6.1 for males vs 0.5 for females).
INJURY RATES OVER TIME
The incidence of violence-related injuries in Boston was lower in each
successive year of the 4-year study period (Table 3). Poisson regression models were used to assess the trend
of incidence rate change during the 4-year period. After adjustment for the
effects of sex and age, the incidence rate ratio over years was estimated
as 0.88 (robust 95% CI, 0.80-0.96; P = .005), or
a 12% rate of decline annually.
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Table 3. Incidence Rates by Year*
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FATALITIES
Two deaths were reported to the ED surveillance system. During the study
period, the Boston police reported 34 homicides (excluding 5 cases of lethal
child abuse) with victims younger than 19 years. Nineteen victims were aged
18 years, 9 were 17, 3 were 16, and the remaining 3 deaths occurred in children
younger than 16 years.
COMMENT
An ongoing surveillance of violence-related injuries to children aged
3 to 18 years treated in EDs in Boston has been established. During the 4-year
period beginning April 15, 1995, the overall injury incidence rate was 52.7
injuries per 10 000 person-years. Older children and boys experienced
higher injury rates than younger children and girls. Most injuries observed
resulted from arguments between people who knew each other and were minor.
During the 4-year period of the study, the rate of violence-related injury
affecting youth declined by approximately 12% annually.
These results are subject to the inherent limitations of a health care–based
surveillance system. Only those injured children who received medical care
from a pediatric ED for violence-related injuries, who disclosed the circumstances
surrounding the injuries, and who were properly coded would have been included
in this report. Each step in the process from injury to entry in the database
could have led to undercounting. In addition, the study specifically excluded
injuries caused by child abuse, ie, any injuries inflicted by a parent, thus
resulting in an underestimate of the overall effects of violence on children.
Injury rates reported here for older adolescents, in particular, are
likely to be lower than the actual rates experienced. Some older adolescents
with severe injuries were treated at adult EDs and thus were not included
in this report. In addition, our finding that histories of the relationship
between the patient and the other person(s) involved were more likely to be
incomplete for adolescents suggests that older pediatric patients may be reluctant
to divulge detailed information, which may contribute to undercounting of
violence-related injuries due to a failure to accurately ascertain intent.
The decline in hospital treatment for violence-related injury parallels
the decline in violent crime, youth homicides in particular.1
The association of dropping crime rates and falling rates in pediatric violence-related
injury suggests that the decrease in violence in Boston was widespread, including
types of violence that are not usually included in criminal justice statistics.
Cheng et al9 recently reported their
experience with injury surveillance of children aged 10 to 19 years in Washington,
DC, from June 15, 1996, to June 15, 1998. They reported significantly higher
rates of violence-related injury in Washington compared with our data from
Boston: 70 events per 10 000 person-years for youths aged 10 to 14 years
in Washington compared with the 57.7 events reported here; for those aged
15 to 19 years, they reported 523 events per 10 000 person-years compared
with our reported rate of 189. They also found that violence-related adolescent
morbidity and mortality declined in Washington, similar to the trend reported
here.
Previous studies have shown that a history of previous injury seems
to increase a young person's likelihood of both fighting and weapon carrying,
and may lead to serious mental health consequences.16-20
While most injuries treated were relatively minor and unlikely to lead to
long-lasting physical disability, these minor injuries to younger children
may offer a method to identify children at risk of more serious injury as
they grow older.
| What This Study Adds
Violence-related injury is an important cause of morbidity and mortality
in American children. Previous incidence estimates have relied on criminal
justice information, surveys, and estimates derived from the experiences of
single hospitals. These data suggest that youth violence is decreasing. This
article reports the initial results of an emergency department–based
surveillance program for the city of Boston. City-wide surveillance of pediatric
violence-related injury reveals that the decline in criminal violence and
homicide extends to the much more common minor injuries typically seen in
pediatric emergency departments. Further study is requisite to determine if
interventions focused on children with minor injuries will result in decreases
in the risk of later, more serious injury.
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AUTHOR INFORMATION
Accepted for publication September 13, 2001.
This study was funded by a Generalist Physician Faculty Scholar award
from the Robert Wood Johnson Foundation, Patterson, NJ, and by a grant from
the Deborah Monroe Noonan Foundation, Boston, grant R49/CCR115279-03 from
the Harvard Center for Youth Violence Prevention, Boston, and by the Public
Health Commission of Boston.
We would like to thank Steven Catalano of the Boston Police Department
Office of Strategic Planning for kindly providing us with police data, Christina
King for her meticulous efforts to ensure data integrity, and the staff of
the Boston Public Health Commission, in particular, Dan Dooley and Lise Fried.
We would like to acknowledge the enthusiastic participation of the physicians,
nurses, clerks, and social workers at all 4 teaching hospitals. We would also
like to acknowledge Tom Lang, PhD, and John Griffith, PhD, for critical discussions
in the preparation of this manuscript.
Corresponding author and reprints: Robert D. Sege, MD, PhD, New England
Medical Center, Box 351, Boston, MA 02111 (e-mail: rsege{at}lifespan.org).
From the Pediatric and Adolescent Health Research Center, the Floating
Hospital for Children's National Medical Center (Drs Sege and Stone); Department
of Pediatrics, Boston Medical Center (Dr Kharasch); Department of Emergency
Medicine, the Children's Hospital (Dr Perron); Division of Clinical Care Research,
New England Medical Center (Ms Supran and Dr Li); and the Departments of Pediatrics
and Emergency Medicine, Massachusetts General Hospital (Dr O'Malley), Boston.
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