Trends in Adolescent Firearm-Related Injury: A Time Series Analysis

Abstract

Background:

Firearm-related injury (FRI) became the leading cause of death among children/adolescents in 2019.

Purpose:

This study sought to determine changes over time in the population of adolescents affected by FRI in Atlanta, Georgia, such that high risk cohorts could be identified.

Research Design:

City-wide retrospective cohort review.

Study Sample:

Adolescent victims (age 11–21 years of age) of FRI, defined by ICD9/10 codes, in Atlanta, Georgia.

Data Analysis:

Descriptive, multivariate and time series analysis.

Results:

There were 1,453 adolescent FRI victims in this time period, predominantly Black (86%) and male (86.6%). Unintentional injury was higher among ages 11–14 years (43.1%) compared to 15–17 years (10.2%) and 18–21 years (9.3%) (P < .01). FRI affecting females increased at a rate of 8.1 injuries/year (P < .01), and unintentional injuries increased at by 7.6/year (P < .01). Mortality declined from 16% in 2016 to 7.7% in 2021.

Conclusion:

Our data provides evidence for firearm policy reform. Interventions should target prevention of intentional injury among AQ4 females and seek to reverse the trend in unintentional injuries.

Brief Report

Firearm-related death and injury among children and adolescents has been on the rise in the United States in recent years. Between 2010 and 2020, firearm-related homicide increased 14%, and firearm-related suicide increased 39% among those aged 15–24 years.¹ While some geographic areas experienced reduced rates of homicide or suicide in the general population during this time period, counties with increasing rates of homicide clustered in the Southern and Southeastern United States.² Comprehensive evaluation of firearm injury epidemiology in a Southeastern city could thus meaningfully guide interventions there. To meet this challenge, all Atlanta-area trauma centers that care for adolescents joined together to create a single database of adolescent injuries. This study uses this database to characterize recent trends in adolescent firearm-related injury and death in our city, paying particular attention to injuries among females and unintentional injuries.

Approval for this study was granted by the Emory University Institutional Review Board. Four trauma programs contributed to the study. Data was obtained from January 2016 to June 2021. Adolescent patients were defined as those age 11 to 21 years, consistent with the American Academy of Pediatrics. All patients who experienced firearm-related injury, defined by International Classification of Diseases (ICD) 9 and 10 codes, were included. Patient demographics and injury characteristics were obtained.

Descriptive statistics were calculated for demographics (age, gender, race and Hispanic/Latino ethnicity), mechanism of injury (self-inflicted, interpersonal intentional, or unintentional), injury severity score (ISS), and mortality by year. Race, mechanism of injury, mortality, and injury severity score were compared by sex with Chi-square testing. Age was stratified into 11–14, 15–17, and 18–21 year groups, and mechanism of injury was compared by these categories. Univariable linear regression was performed to assess changes in sex and gender of injured adolescents over time. Multivariable logistic regression was performed to assess contributions of all other variables to mortality.

There were 1,453 adolescent victims of FRI seen at Atlanta’s trauma centers between 1/2016 and 6/2021. Males comprised 86.6% (n = 1259), and the same proportion were Black. The overall mortality rate was 12.9%, declining from 16% in 2016 to 7.7% in the first half of 2021. Males had a mortality rate of 12.3% compared to 8.9% in females (P = .08). Nearly three-quarters of the injuries were intentional interpersonal injuries (n = 1081, 74.4%). The overall proportion of unintentional injury was 12.9% (n = 187). The mean ISS for all adolescent victims of firearm-related injury was 12.9 with no significant differences between males and females or across the years. Neither race nor mechanism were significantly different between males and females.

On age subgroup analysis, the mechanism of injury varied significantly by age, with highest rates of intentional injury in older adolescents (78% for 18–21 years, vs 46% for 11–14 years, P < .01). Conversely, the rate of unintentional injury was 43.1% in the 11–14 year age group compared to 10.2% in the 15–17 year group and 9.3% among the 18–21 year group. Rates of self-inflicted injury were also higher for the younger age group at 6.6% compared to 2.6% and 3.2% in the other age groups, respectively.

The proportion of all FRIs affecting females was 8% in 2016, 13% in 2017, 13% in 2018, 16% in 2019, 14% in 2020, and 14% in 2021. The change in number of females injured and proportion of injuries that affected females were 8.1 injuries/year (P < .01) and 1.3%/year (P = .03) (Figure 1). The rate of increase in unintentional injuries was 7.6/year (P < .01) (Figure 2).

Figure 1.

City-wide patterns of firearm-related injury incidence in adolescent females in Atlanta, GA from 2016 to 2021. *Monthly counts are displayed. Univariable linear regression coefficients with P values are shown.

Figure 2.

City-wide adolescent firearm-related injury in adolescents in Atlanta, GA from 2016 to 2021 stratified by intentionality. *Univariable linear regression coefficients shown for unintentional injury with P values.

The overall mortality rate for the cohort was 11.9% (n = 173) with rates of over 16% seen in 2016–2017 followed by steady decline to 9.3% in 2020 and 7.7% for the first half of 2021. On multivariable logistic regression for mortality, this pattern persisted; the odds ratio (OR) associated with injury in 2021 vs 2016 was .38 (95% confidence interval [CI] .18-.78, P = .01). Increased age was associated with increased mortality (OR 1.16 per additional year, 95% CI 1.08–1.25, P < .01). Additionally, increasing ISS and the presence of self-inflicted injury had an increased risk for mortality (OR 1.10 per point, 95% CI 0.37–3.47, P < .01, and OR 3.42, 95% CI 1.53–7.58 vs interpersonal injury, P < .01, respectively). Conversely, unintentional injury was associated with reduced mortality compared to intentional interpersonal injury (OR .24, 95% CI 0.06-.70, P = .02).

Firearm-related injury among adolescents is a public health epidemic in the United States, and this study demonstrates that Atlanta, GA is no exception. These results not only show an alarming increase in the overall incidence of adolescent FRI, but also reveal specific, vulnerable populations that are being disproportionally affected in our community. Our findings support local implementation of preventative interventions for unintentional injuries to youth, as well as development of strategies to target adolescent females, specifically.

Unintentional injuries to young children are unspeakably tragic, but strategies have been developed to address the upward trend we observed.¹ Our results depict that unintentional injuries were disproportionately burdensome to younger adolescents. In addition to legislative forms of primary prevention, studies have shown secondary prevention strategies, such as anticipatory guidance with parents, safe-storage counseling, and provisions of firearm safes or lockboxes, to be effective in reducing FRI in youth and young adults.¹ We recommend continuing to support and advocate for such initiatives within Atlanta.

From 2016 to 2020, the proportion of female victims of FRI increased by over 50% and was on track to surpass this number in 2021. While most national data find adolescent males at a higher risk for FRI, our data depicts the rate for female victims with a steeper upward trend than their male counterparts.³ One possible contributor to this is that Atlanta has seen a significant rise in rates of domestic violence since the COVID-19 pandemic.⁴ The significant risks that females face warrant further investigation and targeted prevention efforts.

Interestingly, while the overall incidence of FRI increased in adolescents, the mortality rate steadily declined between 2016 to the first half of 2021. Further study is necessary to determine the underlying causes of this improvement.

The authors would like to acknowledge the limitations of this study. First, the use of ICD codes to retrospectively define intentionality may be affected by bias or inaccuracy. Second, it is possible that a more comprehensive database could be constructed by combining data from all area hospitals with police records. Third, each institution had slightly different internal reporting practices which limited the number of covariates that could be examined. Lastly, it was conducted in a single city, potentially limiting the generalizability of the results to other regions.

Overall, in the context of a pivotal time for firearm policy reform in America, our data can help guide policy makers. These results suggest that efforts within the city of Atlanta should (1) be targeted towards understanding the etiology for the rising incidence of female victims of FRI and targeting injury prevention efforts accordingly, and (2) be focused on safe firearm storage and curbing the incidence of unintentional discharge among adolescents, with a specific focus on the younger end of this demographic.