October 2018, VOLUME142 /ISSUE 4

Firearm Violence: Silent Victims

  1. Lydia Furman, MD
  1. Department of Pediatrics, University Hospitals Rainbow Babies and Children’s Hospital and School of Medicine, Case Western Reserve University, Cleveland, Ohio

Gun violence has become a topic we cannot escape. School shootings, mass shootings, and 1-on-1 firearm violence are widely reported. Commentaries on the public health crisis of firearm violence headline medical journals. However, beyond the sheer volume of senseless deaths, the agonizing ripple effects of exposure to gun violence on young witnesses and survivors remain largely underrecognized. The door to this topic was opened in the lay press with a recent Washington Post article, “Scarred by School Shootings”; the authors counted students who were exposed to school shootings (in addition to those who died) and focused on victim impact: “Many are never the same.”1

The deep and invisible wounds inflicted by fear, personal loss, and desensitization if violence is repetitive may be hidden from physicians’ eyes and underreported by parents until behavior erupts or sadness strips meaning from everyday life.2,3 Although not every child or adolescent who witnesses or experiences gun violence will develop emotional, behavioral, or academic problems, the increased risk is documented in numerous old and new studies.25 Factors that promote resilience include a connection to a caring adult, ready access to mental health and substance abuse services, and friendships with peers who solve problems nonviolently. However, for youth in high-risk communities, the availability of protective factors is typically reduced, and violence exposures tend to be repeated and ongoing, increasing the risk for adverse personal outcomes.5 As pediatricians, we can act to (1) identify and listen to affected youth, (2) refer each identified individual to optimal psychological care, and (3) partner with first responder and community programs that are doing the same work.

It is easy to see flesh wounds from bullets, but it is harder to “see” gaping psychological wounds. Millions of Americans watching America’s Got Talent heard Flau’jae, the 14-year-old rapper from Georgia, perform “Put Your Guns Down!” (her moving rap elegy to her rapper father, who died of gun violence before her birth). Not all teenagers will be able to eloquently express their pain like Flau’jae did on a national stage, but we can make the choice to ask and to listen at each encounter. Pediatricians practicing in urban areas encounter survivors and witnesses of gun violence routinely, but the circumstances are rarely directly revealed to us. Many children and teenagers bear their pain in silence, and any intractable emotional, behavioral, or learning problem may be the only window through which we can identify an affected survivor or witness. A 15-year-old girl with depression, for example, is failing school and up all night on social media; ultimately, we learn her brother was murdered in her presence several years earlier, and she obsessively and endlessly wonders what she could have done differently. A 9-year-old boy has an abrupt deterioration in his grades and becomes physically aggressive at home; his mother did not realize that witnessing a shooting on the playground could affect him so directly. These are just 2 examples of visits in which a “gut feeling” that there was more to understand led us to a history of exposure to gun violence.

Careful screening for violence exposure and referral to trauma-informed care is a path forward. There is not a single validated short screener for violence exposure, so integrating screening into the interval history with a focused question is 1 strategy: “Has anything violence-related, bad, or frightening happened in your (child’s) school or neighborhood or to your child since you were here last?” Screening for violence exposure creates vulnerability in both the provider and the family, and each painful story revealed “takes a little piece of your heart.” But for the child or teenager with exposure or symptoms of exposure to violence, psychological care may be lifesaving. Trauma-informed care is a treatment framework that acknowledges the effects of all types of trauma on the individual and emphasizes physical and emotional safety during rebuilding to a sense of control and wellness. Pediatricians can find supporting resources and a starting point in the Trauma Toolbox for Primary Care.6 Additionally, both the American Psychological Association and the American Counseling Association offer text and scripting for parents and professionals who must address the immediate psychological needs of child witnesses or victims of violence. Pediatricians can use this information and share it with families also.

Beyond our offices, those most likely to be able to initiate early identification of violence exposure in youth are first responders and police officers who are called to the scene of violence in the home or neighborhood. This reality opened the door to a program in our locale, Children Who Witness Violence, which operates arm in arm with a traumatic loss response team and is now replicated in several communities across the United States. When they encounter a child or teenager who has witnessed or survived violence, police officers are trained to promptly contact the mental health professional who is on call and available at all times; these mental health specialists provide crisis intervention, psychiatric and support services, and case management for children and families (local information as an example is available at Other cities have similar programs with Web site resources for parents and professionals (eg, Boston Medical Center’s Child Witness to Violence Project).

Ultimately, primary prevention (ie, gun control and reduced access to guns) is the most effective strategy in preventing violence and its sequelae. In its policy statement, the American Academy of Pediatrics clearly “affirms that the most effective measure to prevent suicide, homicide, and unintentional firearm-related injuries to children and adolescents is the absence of guns from homes and communities.”7

Until that day when firearm violence is contained, we can use every health encounter to (1) screen for gun violence exposure, (2) refer, preferably, to trauma-informed counseling, and also (3) partner with Children Who Witness Violence programs, with point-of-care collaboration between police and mental health professionals, or advocate to establish them in our communities. Our collective ability to give each child and teenager the best chance for a positive and hopeful future hinges on our willingness to identify the “silent victims” of firearm violence, that is, the child (and parent) survivors and witnesses who desperately need prompt psychological care.


    • Accepted July 25, 2018.
  • Address correspondence to Lydia Furman, MD, Division of General Academic Pediatrics, Department of Pediatrics, University Hospitals Rainbow Babies and Children’s Hospital, Room 784, Mailstop 6019, 11100 Euclid Ave, Cleveland, OH 44016. E-mail: lydia.furman{at}
  • FINANCIAL DISCLOSURE: The author has indicated she has no financial relationships relevant to this article to disclose.

  • FUNDING: No external funding.

  • POTENTIAL CONFLICT OF INTEREST: The author has indicated she has no potential conflicts of interest to disclose.