Mass shootings receive substantial media coverage and capture the public’s attention for days, even weeks. The United States has witnessed more than 290 mass shootings in 2019 so far [1]. Even more worrisome, the number of school shootings in the U.S. far exceeds that of several other high-income nations, even after accounting for population size [2]. Over the past decade, there were at least 180 shootings and 356 victims at K-12 schools across the U.S., 43 incidents this year alone [3]. They happened in big cities and in small towns, at homecoming games and during art class. Shootings have become a part of daily conversation around kids, in places that used to be considered “safe”, and the real cost of this crisis to the youth remains unknown. Pediatricians need to advocate and raise awareness that this generation may be facing increased levels of stress, decreased perception of safety, and higher prevalence of depression and anxiety than previous generations. We need to encourage routine screening for mental health problems in well-child visits, as well as empower parents with resources on how to approach conversations about this sensitive topic and how to manage their kids’ exposure to the media during catastrophic events.

Limited research has begun to elucidate the short-term direct and indirect effects of mass shootings on survivors and the broader community. Individual responses of survivors can include anxiety, depression, PTSS, grief, sleep problems, anger, demoralization, catastrophic thinking, and somatization symptoms [4]. Moreover, media coverage of mass shootings and their aftermath reaches far beyond the affected communities to the entire nation and beyond. As shown in the aftermath of the September 11 terrorist attacks (9/11), such indirect exposure can have mental health consequences. For example, in the National Epidemiologic Survey of Alcohol and Related Conditions, indirect exposure to 9/11 through the media was associated with increased risk for mood, anxiety, substance use disorders, and PTSD, relative to no reported 9/11 exposure [5]. Children may similarly associate schools with tragedy, violence and death, and they must go there daily.   

In the span of two weeks in March 2019, two students who survived the mass shooting that occurred in February 2018 at Marjory Stoneman Douglas High School in Parkland, Florida, died by suicide. Drawing direct individual-level causal connections between mass shootings and suicide deaths cannot be done with certainty; however, these deaths painfully underscore the potential long-lasting consequences of gun violence, mass shootings specifically [4]. 

Pediatricians have a responsibility to acknowledge the magnitude of the problem and urge that appropriate research be done to better understand the influence of direct and indirect exposure to mass shootings on the mental and physical health, social functioning and development in the pediatric population. We can also  bring this topic up in our health visits, especially right after a mass shooting with broad media coverage or one close to our area of practice. In Texas, two mass shootings with broad media coverage have occurred in the past month. We can start with a simple question about mood and anxiety in our well visits. This can offer a teaching opportunity for patients and their families and identify those who may benefit from other resources or therapies.

Fear, insecurity and anxiety can be transmitted to children from adults around them, even if they don’t fully understand the situation. This is why it is crucial that pediatricians educate parents and other members of the community that work directly with children (such as teachers) about the importance of having “the talk about mass shootings.”  It can be done appropriately with 4 basic steps: (1) initiate the conversation, (2) answer their questions, (3) correct any misconceptions and (4) limit media exposure. 

To find more information on how to have a conversation with children about shootings according to age group, visit the following resources:

• The National Child traumatic Stress Network: https://www.nctsn.org/resources/talking-children-about-shooting

• Healthy Children from the American Academy of Pediatrics: https://www.healthychildren.org/English/family-life/Media/Pages/Talking-To-Children-About-Tragedies-and-Other-News-Events.aspx

• National Education Association: http://www.nea.org/home/72279.htm​

Elisa Geraldino, MD

References

1. Gun Violence Archive. https://www.gunviolencearchive.org
2. School Shootings in the U.S.: What Is the State of Evidence?AliRowhani-RahbarM.D., M.P.H., Ph.D.^abCaitlinMoeM.S.^ahttps://doi.org/10.1016/j.jadohealth.2019.03.016
3. CNN. 10 years of School Shootings. https://www.cnn.com/interactive/2019/07/us/ten-years-of-school-shootings-trnd/
4. Rowhani-Rahbar A, Zatzick DF, Rivara FP. Long-lasting Consequences of Gun Violence and Mass Shootings. JAMA. Published online April 12, 2019321(18):1765–1766. doi:10.1001/jama.2019.5063 https://jamanetwork-com.foyer.swmed.edu/journals/jama/fullarticle/2731087?resultClick=1
5. Lowe, S. R., & Galea, S. (2017). The Mental Health Consequences of Mass Shootings. Trauma, Violence, & Abuse, 18(1), 62–82. https://doi.org/10.1177/1524838015591572