The Florida Times-Union // October 12, 2018

Caught In The Crossfire

UF Health says children in poor areas more often gun violence victims

By Tessa Duvall  // The Florida Times-Union

CHILDREN WHO AREN’T PHYSICALLY SCARRED BY GUNFIRE but grow up surrounded by it also suffer the mental and emotional effects of that environment.

Children living in some of Jacksonville’s most challenged neighborhoods consistently have been victims of gun violence more often than kids elsewhere in Duval County, a new study from UF Health Jacksonville found.

Even as the number of shootings fluctuated over the 20-year study period, a constant remained: ZIP Code 32209 in Northwest Jacksonville always had the highest incidence of firearm violence.

“Despite policing efforts and other really well-intentioned efforts, it didn’t really change the endemic nature of the shootings in the most distressed communities,” said Dr. Marie Crandall, a UF Health Jacksonville surgeon and one of the study’s authors. “We haven’t really made a difference in our community in regards to gun violence in our areas with higher deprivation.”

The study has implications far beyond the bodily injury of gunshot wounds.

Children who aren’t physically scarred by gunfire but grow up surrounded by it also suffer the mental and emotional effects of that environment.

Dr. Mikah Owen, a pediatrician who works with a high percentage of youths involved in the criminal justice and foster care systems, said the human brain develops in a way to prepare a child for the environment that it is in. If a child has a safe and fulfilling environment, the brain will respond one way.

Conversely, exposure to gun violence can lead to a heightened, constant sense of “fight or flight,” he said, eventually leading to toxic stress.

That stress, he said, can physically change the brain.

“Situations that you or I may not consider threatening ... they may perceive things to be threat,” Owen said. “If someone puts them on the spot in front of other people, or makes fun of them in front of other people ... that may be a serious trigger for them.”

Crandall said seeing these kids and adolescents — mostly black young men — being shot, hurt, disabled and dying takes a psychological toll on the communities they hail from. She said it would be an understatement to say there’s “insufficient” mental health support available to deal with the fallout.

“This is a whole generation of kids who see people shot,” Crandall said.

INEQUITIES PERSIST

The UF Health study looked at 898 instances of patients up to and including age 18 who had gunshot wounds between 1996 and 2016 and were treated at UF Health Jacksonville’s trauma department.

When looking at factors associated with the gun violence, Crandall said she and her colleagues looked beyond just low socioeconomic status. They also included other indicators of neighborhood deprivation, such as the employment rate, percent of population with a high school diploma and the number of female heads of household.

What the analysis found is that the highest rates of gunshot wound incidents occur in the same neighborhoods that have high scores on the deprivation scale.

Crandall said because of the limited sample size, she couldn’t divulge how many patients lived in a given ZIP Code, but that 32209 was “dramatically” over-represented every year of the study and in the overall sample.

As the study points out, Duval County is the state’s most violent urban county. In 2017, there were 112 murders in the county, which equates to 12 murders per 100,000 residents, according to the Florida Department of Law Enforcement. Among major urban counties, Duval County had the worst rate by far. Miami-Dade County had 188 murders for a murder rate of 6.9 murders per 100,000 residents.

ZIP Code 32209 has long accounted for the largest share of the county’s homicides. From 2008 through 2016, 190 homicides were reported in 32209, according to Times-Union records. The next closest ZIP Code — 32208 — had a total of 80 homicides during the same time.

According to a Times-Union database, 26 out of the county’s 136 homicides in 2017 took place in 32209. And out of the 96 so far in 2018, 19 have been in 32209.

Also located in 32209: UF Health Jacksonville, the area hospital where most shooting victims receive treatment.

‘THAT’S THEIR NORM’

There are parts of Jacksonville where growing up hearing gunshots and knowing people who were shot is normal.

Just ask Monique Gillins-Highsmith, a clinician with Children’s Home Society who provides mental health services at Ribault High School in Northwest Jacksonville. Gun violence — and the fallout from it — is one of the top issues she sees again and again with students.

“It’s so common that that’s their norm. They don’t mind talking about it,” she said. “They’ll say something like, ‘I see it all the time. I’m used to it. I hear it all the time. There was a shooting.’ ”

Losing a loved one happens frequently enough that Gillins-Highsmith started a grief counseling group for Ribault students.

“These kids are dealing with so much,” she said.

After the late August shooting after a Raines High School football game, Gillins-Highsmith said one of the young women she sees was crying every day.

“She was with the guy that got killed,” Gillins-Highsmith said. “She literally held him in her arms as he took his last breath.”

Elizabeth Sanson, a clinician who supervises the Children’s Home Society’s transitional trauma team and the acute intervention team, said her therapists are called in any time, day or night, there’s a child involved in a shooting.

In the immediate aftermath, Sanson says her therapists must meet the client where they’re at, mentally. What can they do to support them in that moment?

Sometimes it means bringing a stuffed animal and showing that they care, but it can also mean just being physically there to provide a feeling of safety.

Reactions among kids can vary.

Detachment from the people and places around them is common, Sanson said.

“There’s a violation of bodily safety, a loss of a sense of goodness in the world,” she said. “They’ve gone from a place where they feel safe to a place where they’re on edge.”

Trauma can also manifest itself in ways that are frequently mislabeled.

Sanson said kids may be diagnosed as having behavioral disorders when really aggression, a lack of conflict resolution and acting out are normal reactions to trauma.

Gillins-Highsmith and Sanson both said teaching children about relaxation, coping techniques and regulating their emotions can help them process the violence they’ve been exposed to. The earlier a child can be reached, Sanson said, the better.

Some older teens may be resistant to getting help because all they’ve seen is a lifetime of people who have wronged them.

“Even if they don’t speak to you for months,” Sanson said, “you’ll still be a positive person in their life, and consistent.”

INVESTMENTS REFLECT PRIORITIES

Owen said the idea that violence is a serious public health problem is not new. But, the understanding of violence and the impact of toxic stress is expanding to include historic, community and generational perspectives, he said.

“When we think about community violence, we think just about the adolescents who experience it or know someone who was shot. But it can also change parenting,” Owen said. “There’s a generation of parents who grew up in violent communities and who didn’t get the trauma-informed care that would have helped them cope.”

Crandall said this cycle of ongoing gun violence is not a problem without a solution, but the solution is more complicated than some people would like.

“I feel like we know what the solutions have to be, but there are reasons that they’re not as palatable,” she said. “It’s because we want to feel safe.”

Solutions that will actually work have to go beyond just putting bad people in jail, she said. There needs to be money invested into struggling communities in order to increase access to health care, improve schools, provide more jobs and help the neighborhoods develop.

“Prevention strategies should strive to correct the inequalities that have contributed to 20 years of structural violence that has predisposed our pediatric population to repeatedly fall victim to the gun violence epidemic,” the study says. “Current law enforcement programs and hospital based trauma prevention programs through patient and family education and counseling efforts are not sufficient. Policy change needs to be community based, look to protect resources that alleviate poverty, and limit our children’s access to firearms.”

Owen said how a city invests in its communities is a reflection of its priorities. As an example, he pointed out that teachers are some of the lowest-paid professionals in the country. What if schools were designed to be responsive to students’ traumas and the voices of young people were a part of the solutions?

There are already evidence-based methods for reducing young violence, Owen said, citing Boston and Philadelphia as examples Jacksonville could look toward.

“And they all say the same thing,” he said. “Take an approach that meets the needs of the city, that’s holistic, that meets the needs of the children and their families.”

When in school in California, Owen said he saw patients who were shot as teens. While each person was different, he said common symptoms — beyond any physical injuries — were Post-Traumatic Stress Disorder, nightmares and flashbacks. He said studies have shown that between 40 and 60 percent of gun violence victims will have symptoms of PTSD.

Some kids he worked with had such high exposure to gun violence in adolescence that they expected to be shot at some point.

“They kind of thought of it as always coming,” Owen said, “so they were happy to be alive.”

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