Non-Accidental Trauma

It was the end of my last year of pediatric residency. My last block was spent with the Protective Services Team (PST), a consulting service that provides assessment and care guidelines for children who are victims of neglect or abuse. Aside from consultations within the main hospital, the PST holds clinic times throughout the week, where they meet with families who have needs beyond the initial consultation.

It was in this clinic that I met a girl, who I will call Star. She was a third grader who arrived with her mother and younger sibling to discuss a disclosure made to another clinician. A “disclosure” is a term used to describe the confidential sharing of instances of abuse to a healthcare professional. Healthcare professionals are mandated reporters to the state’s protective services body, to ensure disclosures are followed by an objective investigation into the concern, and that children are kept safe. Star shared another event during her time in the PST clinic. The police had arrived at her school the week before because a kid had been hurt. How had this school friend gotten hurt? A boy brought a gun to the school, and he used it to hurt this kid. Did she see the kid get hurt? No, she had only seen the blood.

There is a term in pediatrics, “non-accidental trauma,” or NAT, which is code in medical circles for child abuse. It is a clinical term that allows distance from the visceral reaction generated by the word “abuse.” It is a term that allows physicians to perform the duty of care without becoming overwhelmed by the horror that is the mistreatment of a child. The term is no accident; to continuously serve in a clinical faculty as a child abuse specialist, it is necessary to shield yourself as you face the awful reality that there are people who wish harm upon kids, and there are kids who must now process the devastation caused by this harm.

Often this harm is of a physical nature, and physicians use a variety of evidence-based measures to assess the possibility that NAT has occurred. From guidelines regarding bruising presentation to radiographic assessments, to multi-system level agencies dedicated to child safety, there are innumerable tools in the arsenal of front-line clinicians and consulting teams when meeting a child who bears physical signs concerning for abuse. Things can and will be done to aid a child in recovery from NAT of a physical nature.

In the last decade, however, children across the nation are experiencing a different kind of non-accidental trauma: trauma caused by gun violence. Since the tragedy of Sandy Hook in December 2012, 980 school shootings have occurred in America¹. Children are being drilled on individual safety tactics to employ in the event of a school shooting, and teachers are being requested to place their lives in danger not if, but when they are faced with a shooter. The ubiquity of guns is only facilitating this crisis that is uniquely American. And the unmitigated violence is not only touching the lives of those already mourning the effects of gun violence. All around the nation, children are questioning their safety in the classroom, as well as in the grocery store, in the church, and in the hospital. They are bearing witness to the ceaseless cycle of gun violence which is being met with inaction by those with the political capital to make change. They are reporting increasing levels of anxiety in pediatrician offices, and they are arriving at the hospital doors with thoughts of self-harm and suicide in unprecedented numbers. They are showing signs of trauma. And while there are steps to take when signs of trauma are concerning for physical abuse, and there are steps to ensure that kids are kept safe, no such measures are available to protect children from the effects of gun violence.

As pediatricians, we address the fears and stresses of our small patients, with listening ears and lists of coping mechanisms. We offer counseling as much as we are able, to allow children to manage the emotions surrounding visualizing death and facing near death experiences. But the bottleneck of child psychiatric and psychologic services in the nation means a lot of children are navigating these challenges on their own. And while one of the key principles of child protective services is to remove danger from the child’s environment, the pervasiveness of gun violence makes this impossible. Efforts to reduce gun violence are supported by a multitude of organizations, including the American Academy of Pediatrics², Everytown³, Moms Demand Action⁴ and the Association of American Medical Colleges. However, it is clearly not enough.

As physicians, we take an oath to do no harm. Any silence in the face of this crisis, is doing harm. All medical organizations should take the issue of gun violence as one of critical priority. Columbine was our sentinel event. Sandy Hook was our repeated event. Gun violence is causing non-accidental trauma. Gun violence is child abuse.

1. Naval Postgraduate School’s Center for Homeland Defense and Security. K-12 School Shooting Database. (2020, August 27). Retrieved June 8, 2022, from https://www.chds.us/ssdb/data-map/
2. AAP: Gun safety campaign toolkit. Retrieved June 8, 2022, from https://www.aap.org/en/news-room/campaigns-and-toolkits/gun-safety/
3. Everytown For Gun Safety. Everytown. (2022, June 7). Retrieved June 8, 2022, from https://www.everytown.org/
4. Moms Demand Action. (2022, June 6). Retrieved June 8, 2022, from https://momsdemandaction.org/