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Identifying mental health outcomes and evidence-based psychological interventions for supporting pediatric gunshot wound patients: A systematic review and proposed conceptual model

BMC Pediatrics volume 24, Article number: 397 (2024) Cite this article

Abstract

Background

Accidental and assault gunshot wounds (GSWs) are the second leading cause of injury in the United States for youth ages 1- to 17-years-old, resulting in significant negative effects on pediatric patients’ mental health functioning. Despite the critical implications of GSWs, there has yet to be a systematic review synthesizing trends in mental health outcomes for pediatric patients; a gap the present review fills. Additionally, this review identifies evidence-based psychological interventions shown to be effective in the treatment of subclinical symptoms of psychological disorders in the general population.

Methods

A comprehensive search was conducted using five databases: American Psychological Association (APA) PsycInfo, APA PsycArticles, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Education Resource Information Center (ERIC), and Medical Literature Analysis and Retrieval Systems Online (MEDLINE). Twenty-two articles met inclusion criteria.

Results

Findings suggest pediatric GSW patients are at a significantly elevated risk for mental health disorders when compared to other- (e.g., motor vehicle collision) and non-injured youth. Disorders include post-traumatic stress, disruptive behavior, anxiety, depression, and substance use. Hospital-based violence intervention programs, cultivating supportive relationships with adults in one’s community, and trauma-focused outpatient services were identified as effective interventions for treating subclinical psychological symptoms.

Conclusions

Depicted in the proposed conceptual model, the present study delineates a direct association between pediatric GSWs and subsequent onset of mental health disorders. This relation is buffered by evidence-based psychological interventions targeting subclinical symptoms. Results suggest brief psychological interventions can help treat mental health challenges, minimizing risk for significant long-term concerns. Cultural adaptations to enhance the utility and accessibility of interventions for all patients are recommended.

Peer Review reports

In 2019, accidental and assault gunshot wounds (GSWs) became the leading cause of death and the second highest cause of injury in youth ages 1- to 17-years-old in the United States [1]. Approximately 8,400 youth are impacted by GSWs annually: 2,200 die and 6,200 are left to cope with life-altering physical and mental health challenges [1, 2]. Accidental and assault GSWs comprise 83% of all pediatric firearm injuries and disproportionately effect Black youth. Comparatively, self-injurious and suicide-related GSWs make up only 14% of pediatric GSW injuries and are more common in White youth [3]. Unlike self-injurious and suicidal GSWs, accidental and assault injuries do not necessarily imply prior mental health challenges for pediatric patients [4, 5]. However, accidental and assault GSWs pose significant risk for the development of subclinical symptoms of psychological disorders that, when left untreated, often develop into anxiety, depressive, disruptive behavior, substance use, and post-traumatic stress disorders [4, 5]. Thus, treating subclinical symptoms of psychological disorders following a GSW is imperative to improve the mental health outcomes for this population. Despite the significant psychological impact that accidental and assault GSWs have, there has yet to be a rigorous examination of the literature regarding relations between GSWs and mental health outcomes while identifying evidence-based treatments for treating subclinical symptoms of psychological disorders.

In 1996, the Dickey Amendment was ratified by Congress in response to gun control debates. The amendment largely prohibited the allocation of federal funds towards gun control research [6]. In 2018, Congress modified the amendment by allotting $25 million towards research on GSW outcomes. Since the amendment, the majority of GSW research has investigated outcomes in adults. However, research has begun to examine mental health outcomes for pediatric patients [6,7,8,9]. Compared to adults, pediatric GSW patients differ in their clinical presentation and long-term psychological adjustment following injury and mental health outcomes are typically obtained through medical records [10, 11]. Given data on psychological adjustment for pediatric patients largely began in 2018 [6], a comprehensive synthesis of mental health outcomes following accidental and assault GSWs is warranted.

With growing evidence for the negative mental health implications of GSWs for youth’s psychological functioning, interventionists have begun to identify how best to support patients by treating subclinical symptoms of psychological disorders following injury. Preliminary findings suggest the majority of pediatric patients (63%) do not receive any mental health services within the first six months following injury, including during their hospital admission [1, 2, 11]. Of the 37% who receive services, most are only offered during hospital admission where providers are focused on symptom evaluation. Thus, the primary goal of hospital-based psychological evaluations at present is stabilization and minimization of risk, meaning that treatment of subclinical symptoms is seldom offered [12]. Of the implemented interventions aimed at treating subclinical symptoms, providers typically focus on hospital-based violence intervention programs. Such interventions teach adaptive coping skills, including emotion regulation, and fostering healthy social supports in one’s community [13,14,15]. Through these programs, patients learn coping skills that can help counteract the emotional lability that often results from GSWs, while bolstering supportive social relationships which can protect against the development of mental health disorders later on [14]. Although studies have begun to highlight potentially useful interventions for youth who have suffered GSW injuries, a systematic review has yet to compile all known data and identify avenues for future research to aid in improving intervention efforts.

Present study

To better understand the relation between GSWs and mental health outcomes for pediatric patients, the present study identified relevant articles published since 2018 following the modification to the Dickey Amendment. It was hypothesized that pediatric GSW patients would have significantly higher rates of mental health disorders when compared to non- and other-injured youth. A secondary goal was to synthesize data on evidence-based psychological interventions targeting subclinical symptoms of mental health disorders in this population. Interventions such as hospital-based violence intervention programs were hypothesized to moderate the relation between GSW injury and mental health outcomes, effectively treating subclinical psychological symptoms and relating to fewer long-term mental health disorder diagnoses when compared to untreated patients. To provide a visual aid regarding hypothesized relations, the present study proposed a conceptual model (Fig. 1).

Fig. 1
figure 1

Conceptual Model: Hypothesized Relations between GSW, Mental Health Disorders, and Evidence-Based Psychological Interventions. Note. Unidirectional lines are supported by empirical evidence in the present review. Solid line represents a positive association, dashed line represents a buffering effect, bidirectional/dotted line is a suggested future direction based on data in the present review

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Method

Search strategy

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 2020 guidelines [16]. The search began with a comprehensive review of the following medical and psychological databases: American Psychological Association (APA) PsycInfo, APA PsycArticles, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Education Resource Information Center (ERIC), and Medical Literature Analysis and Retrieval Systems Online (MEDLINE). Relevant Boolean search terms were used to capture the following topics: pediatrics, guns/weapons, youth outcomes, and psychological interventions (Table 1). Following identification, all articles were extracted and deduplicated using validated procedures [17]. Article extraction and reviews were carried out using Rayyan software.

Table 1 Boolean search terms
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Inclusion criteria and study coding

Identified articles were imported and screened by two independent reviewers. First, titles and abstracts for each article were reviewed using predetermined criteria: (1) peer-reviewed publication, commentaries, or theses/dissertations, (2) electronically published, (3) published in English, (4) published in or after 2018, (5) mean sample age from newborn to 20-years-old in line with the World Health Organization’s definition of a “youth,” (6) community sample, (7) no noted developmental disabilities prior to injury, (8) GSW victim, (9) accidental or assault as mechanism of injury, and (10) inclusion of mental health outcome and/or psychological intervention outcome following GSW injury. Given the increase in accidental and assault GSWs for youth [1], coupled with the correlation between premorbid mental health disorder and suicide attempts [18], articles exclusively reporting on self-injurious or suicide-related GSWs were excluded. The title and abstract for each paper were independently coded for inclusion/exclusion as 0 = did not meet inclusion criteria or 1 = did meet inclusion criteria. Following rankings, coders met to discuss discrepancies and resolve differences (Intraclass Correlation Coefficient; ICC = 0.95). Protocols regarding inclusion/exclusion criteria can be obtained via reasonable written request to the lead author (BLINDED FOR REVIEW).

Full-text analyses, data extraction, and risk bias assessment

Following title and abstract screenings, full-text reviews were conducted. Each review was again carried out by two independent coders and disagreements were resolved through discussion. Similar to the title and abstract review process, each article was coded as 0 = did not meet inclusion criteria or 1 = did meet inclusion criteria. A final sample of 22 articles was obtained (Fig. 2 for PRISMA flow chart) [17]. Once the full sample was identified, a risk bias assessment, Risk of Bias Assessment tool for Non-randomized Studies (RoBANS), was conducted for each empirical article (n = 15). Risk bias assessments were not conducted for commentaries in accordance with RoBANS guidelines [19]. Each empirical article was rated on six domains of potential risk as either low, high, or unclear. Low risk was found across all categories for all empirical articles and thus every identified article was retained for data extraction. For full details regarding RoBANS criteria, see Kim et al. (see Table 2 for RoBANS assessment by article) [19]. Data were then extracted following predetermined criteria (Table 3).

Fig. 2
figure 2

PRISMA 2020 flow diagram for new systematic reviews which included searches of databases, registers and other sources

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Table 2 Individual study risk bias assessment based on RoBANS criteria for empirical articles
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Table 3 Gunshot wound mental health outcomes and evidence-based psychological interventions
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After data extraction and synthesis, a risk bias assessment for the present systematic review was conducted by two independent coders (Risk of Bias Assessment in Systematic reviews; RoBIS) [20]. Different from RoBANS, the RoBIS is used to analyze risk within a systematic review across a variety of domains: predetermined inclusion criteria, identification of relevant articles, data extraction, and synthesis of findings. Scores ranging from low to high risk were provided by independent coders, then an overall score was calculated. Risk of bias in the present review was deemed to be low across all domains (ICC = 0.97). All data analyzed during this study are included in the citations provided in the current manuscript.

Inclusive language

Language in this systematic review is in accordance with the APA’s guidelines to prompt inclusivity and mitigate bias [21]. As such, some language from original articles has been modified in accordance with current APA standards (e.g., White instead of Caucasian). The shift in reported language was conducted to promote equity and inclusion in research and publication.

Results

Study descriptive and demographic differences

Prior to assessing rates of mental health disorders and evidence-based psychological interventions, sample demographic variables were assessed. Most empirical articles contained adolescent samples (age range = 13–20 years) [4, 5, 7, 10, 22,23,24,25,26,27,28]. Results suggest pediatric GSW patients were more likely to be Black, male, in mid-adolescence (i.e., ages 15–17 years old), living in an urban area, when compared to any other race, gender, age, and living environment [10, 29, 30]. Finally, Black youth were less likely to receive a psychological evaluation when compared to White youth as they were more likely to be admitted to an adult trauma center where psychological evaluations were less common when compared to pediatric hospitals [10].

Mental health outcomes

Results suggested pediatric GSW patients were at higher risk for developing a mental health disorder, specifically post-traumatic stress, disruptive behavior, anxiety, depressive, and substance use disorders, when compared to non- and other-injured (e.g., motor vehicle collision; sporting accident) youth [4, 5, 7, 11, 22, 25, 28, 30, 31]. Studies varied regarding prevalence rates of diagnosed mental health disorders following GSWs; ranging from 1.5 to 46.3% of study samples [4, 22, 28]. One study reported that, despite the prominence of mental health concerns following a pediatric GSW, less than half of patients were triaged for symptoms of mental health disorders during hospital admission [23]. Further, two articles reported that, of the pediatric patients screened for psychological concerns, patients were typically only assessed for post-traumatic stress symptoms [7, 31].

Evidence-based psychological interventions

The most frequently cited evidence-based psychological intervention for pediatric GSW patients following injury was hospital-based violence intervention programs (HBVIPs) [13,14,15, 22, 32]. Programs including Health Alliance for Violence Intervention [33], require an average of six sessions and focus on teaching adaptive coping skills (e.g., anger regulation, deep breathing, progressive muscle relaxation) and building supportive social relationships. HBVIPs identify the patient upon hospital admission, a period where patients are more likely to engage in psychological services due to ease of access compared to after discharge. Patients are connected with a mental health professional or trained “mentor” (i.e., adult from the community) who follow the patient during their hospital stay to assist in teaching curriculum-based coping skills. Studies suggested enrollment in HBVIPs minimized rates of GSW reinjury for pediatric patients from 11 to 4% when compared to youth who did not enroll. Such programs were also reported to significantly reduce subclinical symptoms of mental health disorders [14, 15, 22].

In addition to teaching coping skills, HBVIPs emphasize post-traumatic growth, defined as opportunities to create new meaning from a traumatic event [34]. Strategies utilized to promote post-traumatic growth include guided exposures in which the patient reimagines the traumatic event, putting words to what they were experiencing at the time of the event (e.g., describing what they saw, smelled, tasted, felt), expressing cognitions that occurred at the time and following the traumatic events, and reframing unhelpful cognitions that may center around concepts such as self-blame and guilt [22, 34]. Patients who engaged in HBVIPs reported increased subsequent use of adaptive coping and emotion regulation skills, as well as higher psychological well-being than youth who opted out of the program [13]. HBVIPs have been noted to be particularly useful for patients from marginalized backgrounds as access to mental health services are more easily obtained during hospital admission when compared to outpatient services following discharge [32]. Finally, HBVIPs allow for the integration of culturally-sensitive approaches, namely, discussion and implementation regarding how coping strategies and engagement with social supports may vary based on the social and cultural norms within the patient’s community [32].

A second identified psychological intervention was fostering and maintaining relationships with supportive adults in the patient’s community [24]. Similar to the community mentors utilized within HBVIPs, with the help of a mental health professional, this intervention, Positive Adult Connection, tasks pediatric patients with identifying “positive” adults in their life; someone with whom they feel close to, can discuss personal experiences with, and can seek for safety when they feel threatened or endangered. Supportive relationships can provide the patient with validation, emotional support, and problem-solving strategies after they are discharged from the hospital. Culbya and colleagues [24] reported of the pediatric GSW patients interviewed in their study, 86% reported they had at least one “positive adult connection.” Researchers posit such interpersonal relationships target subclinical symptoms, reducing the risk of developing subsequent mental health disorders. However, with only one study examining such effects, more evidence is needed to determine whether supportive adult relationships directly reduce mental health disorders post GSW injury.

The third proposed evidence-based psychological intervention was outpatient trauma-informed care, namely Trauma-Focused Cognitive Behavioral Therapy, Trauma Toolbox for Primary Care, and Children Who Witness Violence Program [27, 35,36,37]. Trauma-informed care is defined as “a treatment framework that acknowledges the effects of all types of trauma on [youth] and emphasizes physical and emotional safety during rebuilding to a sense of control and wellness.” [35, p. 2] Compared to non-injured youth, pediatric GSW patients are more likely to engage in outpatient trauma-informed care, likely due to post-traumatic symptoms that may result from an accidental or assault GSW [27, 35]. Treatments range in length from as short as a single session during a primary care visit to as long as 25 sessions with an outpatient therapist. Core to all trauma-informed interventions is a focus on validation of the patient’s emotional experiences and teaching adaptive coping skills [27, 35,36,37]. However, therapies varied in the degree of engagement and exposure the patient has with memories of their GSW. Evidence suggests exposure to traumatic events provides patients the opportunity to utilize newly learned adaptive coping skills when faced with intense emotional experiences while remembering the traumatic event. However, engagement in such therapies can be emotionally taxing on the patient, requiring youth to have the healthy social supports in place outside of therapy to help process the emotional turmoil that may follow intense therapeutic sessions [38, 39]. For a full list of synthesized results, see Table 3.

Cultural adaptations for interventions

In light of the significant socioeconomic disparities regarding risk of pediatric GSW injury and access to subsequent mental health interventions [10, 26,27,28], Kuo and colleagues [32] recommended “culturally-competent violence intervention programs,” suggesting such modifications could drastically improve the mental health trajectories of pediatric patients from diverse backgrounds. Modifications could include an emphasis on understanding the importance of individual and community factors that contribute to the root cause of violence such as examining aspects of self-identity and cultural values around masculinity, strength, and the acceptability of support-seeking through involvement in mental health services. By acknowledging individual lived experiences and community stigmas, interventions are likely to increase patient engagement and decrease subclinical symptoms and long-term risk for mental health disorders.

Discussion

Accidental and assault GSWs are the leading cause of death and the second-highest cause of injury for youth ages 1- to 17-years-old in the U.S [1]. For youth who survive an accidental or assault GSW, studies report up to half go on to develop a significant mental health disorder post-injury [1, 4, 5]. In light of the deleterious psychological implications of GSWs, the present study had two aims: (1) to synthesize known research published since 2018 regarding mental health outcomes for pediatric GSW patients and (2) identify evidence-based psychological interventions shown to treat subclinical symptoms of mental health disorders following a pediatric GSW injury. Hypotheses were supported and are depicted in the proposed conceptual model (Fig. 1).

Mental health outcomes

Differing from self-injurious or suicide-related GSWs, accidental and assault GSWs do not necessarily imply the presence of a mental health disorder prior to the acquisition of injury [4, 5]. However, in support of Hypothesis 1, pediatric patients who have suffered an accidental or assault GSW are at significantly higher risk for developing subsequent mental health disorders when compared to non- and other-injured youth [4, 5, 7, 11, 22, 28, 30, 31, 40]. Elevations in rates of mental health disorders may be explained by the inherent traumatic nature of the injury. Such an event qualifies as a Criterion A stressor in the Diagnostic and Statistical Manual of Mental Disorders (DSM), opening the door for a potential post-traumatic stress disorder diagnosis [21]. Additionally, other disorders including disruptive behavior and substance use are often diagnosed following an accidental or assault GSW [7, 31, 40]. These disorders may be brought on by maladaptive, avoidant coping in the aftermath of the traumatic event, particularly for youth who face difficulties with adaptive self-regulation. Avoidance can be expressed in a myriad of ways including use of substances to escape intense emotions or outward aggression/delinquency (i.e., disruptive behavior disorder) used to ignore heightened emotionality following trauma triggers (i.e., reminders of injury). If left untreated, avoidance can result in clinically significant mental health challenges [40]. Further, in the face of stress and avoidance, youth may develop exaggerated fear responses or feelings of hopelessness when adjusting to drastic changes to daily functioning (e.g., paralysis), giving way to anxiety and depressive disorders [5, 11]. Anxiety and depression are often comorbid, particularly during adolescence, a developmental stage that makes up the majority of GSW patients [4, 26, 41]. With increased risk for a myriad of mental health disorders, it is imperative that pediatric GSW patients be assessed for a wide range of psychological symptoms, even if symptoms have not yet crossed the threshold for clinical significance.

Evidence-based psychological intervention outcomes

The second hypothesis that evidence-based psychological interventions would help in the treatment of subclinical symptoms of mental health disorders was supported. The most commonly cited type of intervention was HBVIPs including Health Alliance for Violence Intervention and was shown to be effective for numerous reasons [13, 14, 22, 32]. First, HBVIPs target accidental and assault GSW patients directly upon hospital admission, allowing for immediate access to services. HBVIPs typically only require a minimum of six sessions which can be completed during a hospital stay [22, 34]. Such immediate and efficient access to evidence-based interventions is crucial given that 63% of GSW patients do not receive psychological services within the first six months following injury [2]. Further, the majority of GSW patients are Black, adolescent males of whom data show are less likely to have access to mental health services following hospital discharge [10]. HBVIPs focus on building coping skills, creating and utilizing healthy relationships in one’s community, and engaging in post-traumatic growth [13,14,15, 22, 32]. By giving pediatric patients adaptive coping tools, HBVIPs empower patients to effectively cope with the intense emotionality that may follow injury. Incorporating HBVIPs as a standard of care for all pediatric GSW patients could be the first step in creating more equitable access to necessary mental health services following a GSW injury.

In addition to HBVIPs, Culbya and colleagues [24] detailed the value of identifying and building supportive adult relationships to minimizing mental health disorders following injury for pediatric GSW patients using the Positive Adult Connection intervention. Supportive relationships provide youth a person with whom they can process their emotions and problem-solve daily life challenges that result from significant injury. Supportive adult relationships can also help youth thrive after a GSW by serving as a checkpoint regarding their mental health and assist in identifying services if needed. Notably, despite research suggesting supportive adult relationships are advantageous for adaptive psychological functioning and minimizing mental health challenges during hospital stay [13,14,15, 22, 32], and valuable after hospital discharge [24], further research is needed to quantitatively test whether these relationships provide a statistically significant reduction in risk of mental health disorders when compared to youth without such supports.

Two studies noted trauma-informed care in an outpatient setting can be effective in buffering against symptoms of mental health disorders following a GSW [27, 35]. Treatments including Trauma-Focused Cognitive Behavioral Therapy, Trauma Toolbox for Primary Care, and Children Who Witness Violence Program assist patients in processing their injury and providing emotional support by reducing the potency of trauma triggers. Despite the potential of these psychological interventions for patients, significant barriers to access exist, particularly for youth from marginalized backgrounds. Barriers include, but are not limited to, cost, transportation challenges, limitations in trained providers, and lack of culturally-appropriate adaptations to interventions [42]. Additionally, it is important to note that not all pediatric GSW patients will develop significant mental health challenges after a GSW, nor will all patients with trauma symptoms be willing to engage in outpatient trauma-informed care. Considering individual differences and listening to patient preferences regarding engagement in psychological services following injury is crucial in supporting optimal long-term psychological functioning.

Limitations

The present systematic review should be considered within the context of its limitations. First, included studies varied widely regarding study design and measures of mental health outcome data, barring meta-analyses. Given prior limited federal funding for GSW outcome research until 2018, studies included in the present review only span 2018 to present, truncating available data on pediatric GSW outcomes. Finally, no study quantitatively compared the effectiveness of psychological interventions for treating subclinical symptoms against one another. Future research may seek to empirically evaluate which interventions are most effective in treating subclinical symptoms in the wake of accidental or assault GSWs.

Conclusions

In sum, youth who suffer an accidental or assault GSWs are at significantly higher risk for developing mental health disorders following injury when compared to any other form of pediatric injury. Despite this risk, many patients do not receive comprehensive evaluations of their symptoms or access to psychological services. Therefore, it is recommended that hospital-based mental health providers evaluate a broader range of symptoms to best identify patients’ mental health challenges and provide appropriate recommendations. Pertaining to evidence-based psychological interventions for treating subclinical symptoms, HBVIPs appear to be the most immediate and equitable interventions. Whether incorporating formalized programming into hospital settings, or adopting pieces of curricula within existing hospital structures, providers working with pediatric GSW patients may seek to employ aspects of these interventions to optimize psychological well-being of their patients. Finally, given the majority of pediatric GSW patients come from marginalized backgrounds [10, 29, 30], implementation of equitable, affordable mental health care following an accidental or assault GSW injury is paramount in reducing significant mental health disorders for all patients.

Data availability

All data analyzed in this study are included in the citations provided. Authors did not obtain additional data beyond that included in citations.

Abbreviations

APA:

American Psychological Association

CINAHL:

The Cumulative Index to Nursing and Allied Health Literature

DSM:

Diagnostic and Statistical Manual of Mental Disorders

ERIC:

Education Resource Information Center

GSW:

Gunshot Wounds

HBVIP:

Hospital-Based Violence Intervention Programs

ICC:

Intraclass Correlation Coefficient

MEDLINE:

Medical Literature Analysis and Retrieval Systems Online

PRISMA:

Preferred Reporting Items for Systematic reviews and Meta-Analyses

RoBANS:

Risk of Bias Assessment tool for Non-randomized Studies

ROBIS:

Risk of Bias Assessment in Systematic reviews

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Acknowledgements

The authors thank all of the researchers and participants who partook in the initial articles that were included in the present systematic review.

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Authors and Affiliations

  1. Department of Psychology, University of Georgia, Athens, GA, USA

    Molly E. Hale & Kahyah Pinkman

  2. Department of Neuropsychology and Rehabilitation Services, Children’s Healthcare of Atlanta, Atlanta, GA, USA

    Alexis M. Quinoy & Kindell R. Schoffner

  3. Department of Rehabilitation Medicine, Emory School of Medicine, Atlanta, GA, USA

    Alexis M. Quinoy & Kindell R. Schoffner

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  1. Molly E. Hale
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Molly E. Hale and Kahyah Pinkman contributed to conceptualization, writing, analysis, and editing. Alexis M. Quinoy and Kindell R. Schoffner contributed to conceptualization and editing.

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Hale, M.E., Pinkman, K., Quinoy, A.M. et al. Identifying mental health outcomes and evidence-based psychological interventions for supporting pediatric gunshot wound patients: A systematic review and proposed conceptual model. BMC Pediatr 24, 397 (2024). https://doi.org/10.1186/s12887-024-04878-w

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Keywords

BMC Pediatrics

ISSN: 1471-2431

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