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INTRODUCTION

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Violence is among the leading causes of death and disability for American children and adolescents. The epidemic of murder took the lives of approximately 2000 young people annually between 1980 and 2002. During this period, approximately 1 out of every 4 youth homicides was committed by juveniles. Overall, homicide was the third leading cause of death for youth aged 13 to 21 and the leading cause of death for African American young men in this age category. Altogether, violence claimed the lives of 6849 Americans under 22 years old in 2014 (7.5 per 100,000); homicide and suicide were among the top three causes of death in the pediatric population. Despite a recent national decline in the homicide rate, the United States continues to have one of the highest homicide rates in the world.

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While homicide is the most extreme form of community violence, many more young people are injured: In 2009, over 7000 children were hospitalized for firearms injuries alone; black children were hospitalized far more often than white children, and boys were hospitalized more often than girls. When surveyed in 2013, over one-third of high school students reported having been in a physical fight in the past 12 months (40% of males and 25% of females); in fact, the rate of injuries due to fighting has remained steady for decades. One in 6 youths reported carrying weapons in the past month, and 1 in 14 reported having avoided school due to fear of violence.

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The quality of the family and community environment during childhood and adolescence has profound and lasting effects, which persist into adulthood. Recent studies have demonstrated that exposure to violence is among the earliest and most pervasive adverse experiences. Childhood adversities have been linked to future physical, mental, and developmental health and to all major causes of morbidity and mortality in adulthood. While recent data are not available, in the 1990s, 1 out of every 10 children attending a Boston, Massachusetts, city hospital pediatric primary care clinic witnessed a shooting or stabbing in their homes or communities before the age of 6. This high prevalence of exposure to violence underscores the importance of violence as a public health problem.

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Pediatricians play a crucial role in preventing, identifying, and intervening in such situations. Contrary to the perception that violence consists of random acts in society, violence is most likely to be perpetrated by individuals known to the victim. Hospital readmission for subsequent assaults and homicide are high. Moreover, violence is associated with known risk and resilience factors that may be routinely assessed during the course of medical care.

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Well-established risk factors for violence-related injury include access to firearms, history of fighting or injury, violent discipline, alcohol and drug use, exposure to familial violence, media violence, and gang involvement. As this list of risk factors makes evident, distinct forms of violence rarely occur in isolation. In addition to ...

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