[Editor's note: Dr. Harise Stein at Stanford University edits a web site — abuseresearch.info — that focuses on the effects of abuse, and includes research articles on PACEs. Every month, she posts the summaries of the abstracts and links to research articles that address only ACEs, PCEs and PACEs. Thank you, Harise!]
Child Abuse
Kaferly J, Orsi-Hunt R, Hosokawa P, et al.
Health Differs by Foster Care Eligibility: A Nine-Year Retrospective Observational Study Among Medicaid-Enrolled Children.
Acad Pediatr. 2023 Dec 22:S1876-2859(23)00471-0. PMID: 38142889
Using data from over 1 million Colorado children using Medicaid, those in foster care had significantly higher rates of physical and behavioral health
conditions. “While children in foster care are impacted by health care, child welfare, and policy systems, these individual stakeholder systems operate with distinct priorities and obligations which, often, do not intersect. A broader understanding of health conditions among children in foster care provides opportunities to advance coordinated strategies to improve health across systems.”
Reddy J, Palmer L, Putnam-Hornstein E.
Three-Year Custody Outcomes Among Infants Investigated by CPS for Prenatal Substance Exposure in California.
Matern Child Health J. 2023;27(Suppl 1):94-103. PMID: 37256517
Of 22,855 infants investigated by CPS in 2017 in California, more than 26% had documentation of prenatal substance use. These infants were 2.2 times more likely to be in nonparental placement at age 3.
Ahn H, Williams K, Kim J, Moeller E.
Factors Associated With Permanency for Children in Out-Of-Home Placement: A Survival Analysis.
Child Maltreat. 2023:10775595231217278. PMID: 38018083
Using administrative data from one state during 6 years including 1,874 children, “Determinants associated with achievement of permanency were examined…The median length of time in days to achieve permanency was: 188 for reunification, 505 for guardianship, and 932 for adoption. Race/ethnicity, age at removal, number of placement changes, number of siblings, having a removal family team decision meeting, and placement type were significantly associated with achievement of permanency.”
Eg MB, Graesholt-Knudsen T, Madsen KB, et al.
Distinct age-related differences among victims in cases of suspected child abuse.
J Forensic Sci. 2024 Jan;69(1):252-263. PMID: 37792506
Of 756 children <15 years old suspected of experiencing child abuse 2001-2013 at a Dutch University Department of Forensic Medicine, “8% of children <4 years old died from child abuse, 36% through violence resulting in death, and 64% by manslaughter, whereas 1% > 4 years old died, solely by manslaughter. External injuries were mainly located to head and torso in children <4 years old, changing to the upper and lower extremities in older children. Child sexual abuse was suspected in 52% of cases with living children <4 years old, 83% of children 4-7 years of age, 88% of children 8-11 years of age, and 93% of children >12 years old.”
Leventhal JM, Asnes AG, Otterman GJ.
How Antiscience Creates Confusion About the Diagnosis of Abusive Head Trauma.
JAMA Pediatr. 2023 Dec 1;177(12):1257-1258. PMID: 37902740
“This Viewpoint exposes the antiscience and misinformation used to generate skepticism about abusive head trauma in young children, putting this vulnerable population at risk,” such as using flawed alternative explanations, cherry picking only some facts of a case, and requiring certain factors for a diagnosis while ignoring a comprehensive evaluation.
Alkan F, Sapmaz SY, Kardelen C, et al.
Should pediatric cardiologists refer all patients with unexplained chest pain to a psychiatrist?
Cardiology in the young. 2023:1-7. PMID: 38149344
For 43 Turkish children with unexplained chest pain and a control group of 33 children, the children with chest pain were more likely to have experienced “life events causing difficulties, derangement in the family, loss of a close person, and exposure to violence”. 67.4% were diagnosed with mental disorders, and these children were much more likely to also have other physical symptoms. Authors recommend psychiatric evaluation prior to possibly unnecessary medical diagnostic procedures in children with unexplained chest pain.
Thompson K, Svendsen S.
Analysis of Cases Presenting With Concern of Child Abuse or Neglect to a Child Protection Team.
Clin Pediatr (Phila). 2023:99228231219119. PMID: 38153048
“Data were collected for all referrals triaged by the Child Protection Program, a child abuse team located within an academic children's medical center. The program triaged a total of 928 cases and completed 345 in-person visits with a medical provider. Nearly half of all provider visits were for evaluation of children aged 3 years and younger (51%) and for a concern of physical abuse (49%). Of these visits, 26% were determined to be consistent with an accident or medical condition. This descriptive analysis highlights the burden of child abuse cases presenting to one small hospital-based child abuse program, as well as the structural and financial challenges faced by these programs.”
Tsang VMW, Verlinden E, Brilleslijper-Kater SN, et al.
A Longitudinal Study in Worrisome Sexual Behavior Following Sexual Abuse in Infancy or Early Childhood.
Journal of child & adolescent trauma. 2023;16(4):1053-63. PMID: 38045842
“We examined the sexual behavior, as reported by parents of 45 children who experienced early-age sexual abuse for a period of more than five years. Overall, we found that WSB [worrisome sexual behavior] is likely to be a CSA-specific and potentially long-term outcome for children who were sexually abused at a very young age. Despite the decrease in sexual abuse-specific behavior over time, the level of this behavior was still significantly high 8 years after the sexual abuse. This finding supports long-term monitoring and assessment and intervention for WSB over time. Despite these findings, it is important to note that WSB does not serve as proof of sexual abuse in children; likewise, when a child does not present with WSB, it does not indicate the absence of a substantiated history of sexual abuse.”
Callahan R, Johns A, Young A, Kelsey C, Gupta M, Bellino P.
Association between missed appointments and hospitalization for child physical abuse.
Heliyon. 2023;9(12):e22779. PMID: 38076151
Using a 20-year chart review for a single health system, of children 3 years or less hospitalized with high likelihood of child physical abuse (CPA) and a matched control group, the maltreated children were significantly more likely to have had a missed appointment (26% vs 9%). “We found an association between missed appointments and future admission for CPA. This finding has potential to assist clinicians with CPA risk stratification and future child abuse research.”
Seltzer RR, Thompson BS.
Pediatrician as Advocate and Protector: An Approach to Medical Neglect for Children with Medical Complexity.
Pediatr Clin North Am. 2024;71(1):59-70. PMID: 37973307
“For children with medical complexity (CMC), gaps in medical care can result in significant harm. When concerns for medical neglect arise for CMC, pediatricians may experience ethical challenges in attempting to simultaneously avoid harm, promote well-being, respect family goals and values, and maintain a positive therapeutic relationship. This article proposes an ethics-guided approach to identifying and addressing underlying modifiable risk factors for medical neglect through collaboration with family caregivers and other stakeholders (e.g. medical providers, school staff, and community resources). Pediatricians should recognize their critical role, beyond only as a mandated reporter, to be a mandated supporter.”
Lamela D, Pasion R, Costa R, et al.
Mother-child reporting discrepancies of child physical abuse: Associations with internalizing and externalizing symptoms.
Child Abuse Negl. 2023;147:106575. PMID: 38041965
Of 159 Portuguese mother-child pairs with exposure to IPV, of the pairs who were more divergent in reporting child physical abuse (with the child reporting significantly higher rates of their own physical abuse than did the mother), mothers reported more depressive and PTSD symptoms, and children showed the highest internalizing and externalizing symptoms.
Adult Manifestations of Child Abuse
Peterson C, Aslam MV, Niolon PH, et al.
Economic Burden of Health Conditions Associated With Adverse Childhood Experiences Among US Adults.
JAMA Netw Open. 2023 Dec 1;6(12):e2346323. PMID: 38055277
Using “estimated ACE-population attributable fractions (ie, the fraction of total cases associated with a specific exposure) for selected health outcomes (anxiety, arthritis, asthma, cancer, chronic obstructive pulmonary disease, depression, diabetes, heart disease, kidney disease, stroke, and violence) and risk factors (heavy drinking, illicit drug use, overweight and obesity, and smoking) among the 2019 US adult population, “An estimated 160 million of the total 255 million US adult population (63%) had 1 or more ACE, associated with an annual economic burden of $14.1 trillion ($183 billion in direct medical spending and $13.9 trillion in lost healthy life-years). This was $88,000 per affected adult annually and $2.4 million over their lifetimes…22% of adults had 4 or more ACEs and comprised 58% of the total economic burden -- the estimated per person lifetime economic burden for those adults was $4.0 million.”
Hanson JL, O'Connor K, Adkins DJ, Kahhale I.
Childhood adversity and COVID-19 outcomes in the UK Biobank.
J Epidemiol Community Health. 2023 Nov 1:jech-2023-221147. PMID: 37914378
Using data from a large UK biobank, “Childhood adversity was significantly associated with COVID-19-related hospitalisation and COVID-19-related mortality after adjusting for sociodemographic and health confounders. Further research is needed to clarify the biological and psychosocial processes underlying these associations to inform public health intervention and prevention strategies to minimise COVID-19 disparities.”
Boatman D, Kennedy-Rea S, Cottrell L, Hazard-Jenkins H.
Cancer Screening Behaviors and Associations with Childhood Trauma, Resiliency, and Patient-Provider Relationships: Findings from an Exploratory Study of Appalachian Cervical Cancer Survivors.
J Appalach Health. 2023;5(1):22-37. PMID: 38023113
Of 90 West Virginia cervical cancer survivors, ACEs were associated with weaker patient-provider relationships and fewer resilience protective factors. More protective factors were associated with stronger patient-provider relationships, earlier stage of cancer at diagnosis, and positive cancer screening behaviors.
Crișan Ş, Stoia M, Predescu E, Miu AC, Szentágotai-Tătar A.
The association between adverse childhood events and cluster C personality disorders: A meta-analysis.
Clin Psychol Psychother. 2023;30(6):1193-214. PMID: 37129438
From a research review, “ACEs were consistently associated with overall cluster C personality disorders, as well as each of the specific disorders in this cluster.” Disorders include avoidant, dependent, and obsessive-compulsive. (Figure from medium.com)
Airikka A, Lahti-Pulkkinen M, Tuovinen S, et al.
Maternal exposure to childhood maltreatment and mental and behavioral disorders in children.
Eur Child Adolesc Psychiatry. 2023;32(12):2463-75. PMID: 36181574
Following 2252 pregnant individuals until their children were 8-12 years old, “maternal exposure to childhood maltreatment [abuse but not neglect] is associated with mental and behavioral disorders in children…call for interventions to prevent intergenerational transmission.”
Alkema A, Marchi M, van der Zaag JAJ, et al.
Childhood abuse v. neglect and risk for major psychiatric disorders.
Psychol Med. 2023:1-12. PMID: 38018135
Combining three studies looking at major depressive disorder (MDD), bipolar disorder, and schizophrenia, childhood abuse was a stronger risk factor for schizophrenia (OR 3.51), and childhood neglect for bipolar disorder (OR 2.69). Combined abuse and neglect were related to increased risk exceeding additive effects of abuse and neglect for MDD. “Across disorders, abuse was associated with hallucinations (OR 2.16) and suicide attempts (OR 2.16) whereas neglect was associated with agitation (OR 1.24) and reduced need for sleep (OR 1.64).
Joannès C, Kelly-Irving M, Couarraze S, Castagné R.
The effect of smoking initiation in adolescence on the subsequent smoking trajectories of people who smoke, and the role of adverse childhood experiences: Results from the 1958 British cohort study.
Public Health Nurs. 2024 Jan-Feb;41(1):127-138. PMID: 37953700
Using data from a long-term British study, individuals who initiated smoking in adolescence were 3.66 times more likely to relapse, and 5.25 times more likely to persist, compared to those who started smoking in their twenties. “These effects were particularly pronounced in case of ACEs.”
Girard M, Fernet M, Godbout N.
"Like A Mouse Pursued By the Snake": A Qualitative Metasynthesis on the Experiences of Revictimization Among Women Survivors of Childhood Sexual Abuse and Partner Violence.
Trauma Violence Abuse. 2023:15248380231214783. PMID: 38049952
Based on qualitative studies of women who had experienced childhood sexual abuse and then adult IPV, “Results identified two main conceptual categories: (a) Barriers to action: A belief system reflecting learned helplessness that hinders women's abilities to protect themselves and prevent further abuses, and (b) Broken internal compass: Cognitive elements blurring women's risk evaluation capacities and reference points limiting their ability to break the cycle of revictimization. These findings support the need to examine cognitive distortions and false beliefs in intervention practices and suggest valuable guidelines for practitioners.”
Carr AL, Massou E, Kelly MP, Ford JA.
Mediating pathways that link adverse childhood experiences with cardiovascular disease.
Public Health. 2023;227:78-85. PMID: 38134567
From a long-term study of 4547 British participants (56% women), with a mean age of 64 years, 45% reported at least one ACE. 24% developed incident cardiovascular disease (CVD) over a median follow-up period of 9.7 years. After adjusting for potential confounders, experiencing ≥4 ACEs compared with none was associated with 1.55 times increased risk of incident CVD, but no statistically increased risk was found for 1-3 ACEs. “There were two statistically significant mediators of the association between ≥4 ACEs and incident CVD: CRP [a measure of inflammation] and depression...Targeting these factors may reduce the future incidence of CVD.”
Huang C, Peng J, Lee PMY, et al.
Sibling Death in Childhood and Early Adulthood and Risk of Early-Onset Cardiovascular Disease.
JAMA Netw Open. 2024 Jan 2;7(1):e2350814. PMID: 38190182
“In this cohort study, sibling death in childhood and early adulthood was associated with increased risks of overall and most type-specific early-onset CVDs, and the strengths of these associations varied by cause of death and age difference between sibling pairs. The findings highlight the need for extra attention and both social and mental support to bereaved siblings to reduce CVD risk later in life.”
Bussières A, Hancock MJ, Elklit A, et al.
Adverse childhood experience is associated with an increased risk of reporting chronic pain in adulthood: a systematic review and meta-analysis.
European journal of psychotraumatology. 2023;14(2):2284025. PMID: 38111090
From a research review, the odds of reporting chronic pain in adulthood were significantly higher among individuals exposed to a direct ACE (adjusted odds ratio 1.45). Individuals reporting childhood physical abuse were significantly more likely to report both chronic pain (1.50) and pain-related disability (1.46) during adulthood. The risk of chronic pain in adulthood significantly increased from one ACE (1.29) to four or more ACEs (1.95).
Voyer H, Aytur S, Tanda N.
Linking Adverse Childhood Experiences and Other Risk Factors to Subjective Cognitive Decline in an Aging Population.
Prev Chronic Dis. 2023;20:E115. PMID: 38127683
From a large national on-going survey, 8.1% of survey respondents reported subjective cognitive decline in the last 12 months. Associated conditions included: depression (adjusted odds ratio 2.85), arthritis (1.30), diabetes (1.33), >3 falls per year (2.95), sleeping more than 9 hours at night (2.06), physical inactivity (1.32), and 2+ ACEs (1.69).
Cascino G, Monteleone AM.
Early traumatic experiences and the hypothalamus-pituitary-adrenal axis in people with eating disorders: A narrative review.
Psychoneuroendocrinology. 2024;159:106665. PMID: 37944210
“Research evidence supports the idea that exposure to trauma in childhood may be responsible for long-lasting effects on the activity of the HPA axis [stress hormone system], which could contribute to biological vulnerability underlying a potential impaired ability to deal with stressful life events in the adulthood. This may favor the development/maintenance of psychiatric disorders, including eating disorders.” Authors review the state of research on eating disorders in this context.
Montague R, Canning SE, Thielking P, Qeadan F.
Adverse childhood experiences and psychotropic medication prescription among cancer patients.
J Psychosoc Oncol. 2023:1-15. PMID: 38127059
Of 178 adults receiving cancer care at a hospital in Utah, while the number of patients reporting at least 1 ACE was similar to the general population (67.4% vs. 63.6%), patients in this study had a much higher prevalence of 4+ ACEs (25.3% vs. 12.1%). In addition, there was a significant association between increasing ACEs and increasing prescriptions for mental health medications, with those reporting 3+ ACEs having 280% higher odds of these medications compared to those with 2 or fewer ACEs.
Corso A, Engel H, Müller F, et al.
Early life stress in women with autoimmune thyroid disorders.
Scientific reports. 2023;13(1):22341. PMID: 38102234
Of 78 women median age 53 with documented autoimmune thyroid disorders (AITD), compared to a control group, patients with AITD did not differ in regards to childhood sexual abuse, or physical abuse or neglect, but they did report significantly more emotional abuse and emotional neglect. “This study provides initial evidence for emotional neglect and abuse as potential risk factors for AITD.”
Korkmaz YN, Buyuk SK, Becet N.
Does childhood maltreatment play a role in temporomandibular disorders?
The British journal of oral & maxillofacial surgery. 2023;61(10):691-5. PMID: 37925310
Of 380 male and female adults mean age 27.63 years, there was an association between child maltreatment scores and level of temporomandibular disorders (TMD = pain or dysfunction of the jaw). “Dentists should be aware that possible collaboration with psychiatrists and/or psychologists when treating patients with TMD could increase the success of their treatment.”
Adolescents
Adams DR, Pérez-Flores NJ, Mabrouk F, Minor C.
Assessing Access to Trauma-Informed Outpatient Mental Health Services for Adolescents: A Mystery Shopper Study. Psychiatr Serv. 2023:appips20230198. PMID: 38018150
“In this mystery shopper study, three women (White, Latina, and Black voice actresses) called community mental health centers (CMHCs) and federally qualified health centers (FQHCs) in Cook County, Illinois, posing as mothers requesting a mental health appointment for their traumatized adolescent child…Callers could schedule an appointment in only 17% (N=78 of 451) of contacts. The primary reasons for denial were capacity constraints (67%) at CMHCs and administrative requirements to switch to in-network primary care providers (62%) at FQHCs…Non-White callers were significantly less likely (incidence rate ratio=1.18) to be offered an appointment than the White caller. The average wait time was 12 days.”
Bendall S, Eastwood O, Spelman T, et al.
Childhood trauma is prevalent and associated with co-occurring depression, anxiety, mania and psychosis in young people attending Australian youth mental health services.
Aust N Z J Psychiatry. 2023 Dec;57(12):1518-1526. PMID: 37243364
Of 775 Australian young adults being seen for mental health services including depression, anxiety, mania, and psychosis, “84% reported some form of abuse (emotional: 68%; physical: 32%; sexual: 22%) or neglect (emotional: 65%; physical: 46%). Exposure to multiple trauma types was common…More severe childhood trauma was more strongly associated with the co-occurrence of symptoms than with any one symptom domain in isolation…Childhood trauma is pervasive in youth mental health services and associated with a symptom profile that cuts across traditional diagnostic boundaries.”
Schlensog-Schuster F, Keil J, Von Klitzing K, et al.
From Maltreatment to Psychiatric Disorders in Childhood and Adolescence: The Relevance of Emotional Maltreatment.
Child Maltreat. 2024;29(1):142-54. PMID: 36426806
From detailed assessments of 778 German 3-16 year-olds recruited from CPS, mental health services, and the general community, “Besides confirming known relationships between maltreatment exposures and psychiatric disorders, emotional maltreatment exerted particularly strong effects on internalizing disorders in older youth and externalizing disorders in younger children…urging researchers and practitioners alike to prioritize future work on emotional maltreatment.”
Ackard DM, Eisenberg ME.
Verbal, physical and sexual dating violence among a population-based sample of teens: Does exposure to intimate partner violence in the home account for the association between dating violence and mental health?
Child Abuse Negl. 2023;147:106581. PMID: 38101101
Of 71,635 Minnesota 9th and 11th grade students, teen dating violence (TDV) was reported by 36.4% of those with exposure to IPV at home (eIPV), vs. 13.6% without such exposure. Each type of teen dating violence was significantly associated with adverse mental health, even after adjusting for demographic variables. “Education on healthy, consensual dating relationships is critical, alongside regular screening for eIPV and TDV, and referring affected youth for treatment.”
Koski A, Van Roost K, Reiss F.
State and sex-specific trends in the annual incidence of child marriage in the United States since the year 2000.
Child Abuse Negl. 2023;147:106566. PMID: 38043459
“Child marriage, defined as marriage before 18 years of age, is a violation of human rights with harmful consequences for population health, educational attainment, and economic opportunities. Child marriage is legal across most of the United States…The rate of child marriage declined substantially across the United States between 2000 and 2019. Over 75% of all married children in each state were girls who married men an average of 4 years older than they were.”
Schwartz A, Galera C, Kerbage H, Montagni I, Tzourio C.
Adverse Childhood Experiences and ADHD Symptoms Among French College Students.
Journal of child & adolescent trauma. 2023;16(4):1109-17. PMID: 38045835
Of 1062 French colleges students, mean age 20.3 years, “After controlling for potential confounders, every increase in ACE exposure heightened the risk of ADHD symptoms with the respective adjusted Odds Ratios: 1 ACE: 2.1, 2 ACEs: 4.5, ≥ 3 ACEs: 5.2. Estimates for ADHD symptoms were higher with sexual abuse, emotional and physical neglect, and bullying. Findings suggest that ACEs heighten the risk for developing ADHD symptoms among college students and bear important implications for prevention and clinical practice.”
Sebalo I, Königová MP, Sebalo Vňuková M, et al.
The Associations of Adverse Childhood Experiences (ACEs) With Substance Use in Young Adults: A Systematic Review.
Substance abuse: research and treatment. 2023;17:11782218231193914. PMID: 38025908
“This review provides clear evidence that exposure to ACEs, especially multiple ACEs, is a strong predictor for increased use of alcohol, cannabis, and other drugs by young adults. However, ACEs represent only one risk factor among many. As this effect was amplified by poor self-regulation and maladaptive coping strategies, these factors may represent initial targets for interventions…future research should identify protective factors that can reduce or eliminate the impacts of previous adverse experiences and buffer against future stressors.”
Wendler-Bödicker C, Kische H, Voss C, Beesdo-Baum K.
The Association Between Childhood Maltreatment and Body (dis)satisfaction in Adolescents and Young Adults.
J Trauma Dissociation. 2024;25(1):113-28. PMID: 37403492
Of 1001 German adolescents aged 14-21 years, “More than one-third of the participants reported experiences of childhood maltreatment (37.4%), in which emotional neglect and abuse were the most frequent subtypes. Individuals with a history of childhood maltreatment showed significantly less satisfaction with their physical appearance than participants without such adverse experiences…the role of potential mediator variables such as self-esteem warrants further prospective research.”
Rueb M, Rauen K, Koerte IK, et al.
Traumatic Encephalopathy Syndrome and Tauopathy in a 19-Year-Old With Child Abuse.
Neurotrauma Rep. 2023;4(1):857-62. PMID: 38156074
“This is the first case with TES [traumatic encephalopathy syndrome, brain damage seen in contact sport athletes] in a 19-year-old male patient with progressive cognitive decline after daily domestic physical violence through repeated hits to the head for 15 years…This report underlines child abuse as a relevant criterion in diagnosing TES in cases with repetitive hits to the head.” Authors used recently published diagnostic criteria for TES with brain and lab findings instead of autopsy findings.
Domestic Violence – Effects on Children
Herbert K, Xi Q, Feder G, et al.
Child maltreatment and parental domestic violence and abuse, co-occurrence and the effect on lifetime outcomes in the Avon Longitudinal Study of Parents and Children (ALSPAC).
SSM - population health. 2023;24:101555. PMID: 38073858
From a long-term UK study including 3 generations beginning with over 15,000 pregnant women 1991-1992, “Childhood exposure prevalences were estimated at 41.7% for any form of CM [child maltreatment], 19.3% for parental DVA [domestic violence and abuse], and 49.0% for exposure to at least one form of CM and/or parental DVA. Co-occurring parental DVA was reported in 21%-42% of CM-exposed households…Co-occurring CM and parental DVA exposures were associated with increased risks of drug use, anxiety, depression, smoking, unemployment, social welfare use, and perpetration of intimate partner violence as a young person - highlighting the intergenerational effects of exposure…The high cumulative prevalence of childhood exposure to CM and/or parental DVA, and the scale of the resulting adverse impacts, emphasise the need for policies and family interventions sensitive to the possibility of co-occurring forms of abuse.”
Lockington EP, Sherrell HC, Crawford K, Rae K, Kumar S.
Intimate partner violence is a significant risk factor for adverse pregnancy outcomes.
AJOG Glob Rep. 2023;3(4):100283. PMID: 38077225
In a study from one hospital in Australia, of 45,177 births, 3242 births (7.2%) were among women who were exposed to intimate partner violence. Those who identified as Indigenous or had refugee status experienced significantly higher rates of intimate partner violence, as well as worse birth outcomes. “Women exposed to intimate partner violence had greater odds of having a small for gestational age infant (adjusted odds ratio 1.17), preterm birth (1.21), preterm prelabor rupture of membranes (1.23), and an infant with severe neonatal morbidity (1.21)…also had higher odds of acute presentation to the obstetrical assessment unit (1.71) and admission to hospital (1.44).”
Human Trafficking
Hadjikyriakou M, Martinez-Sosa N, Harvey PD, et al.
Visit Data and Telehealth in a Clinic for Trafficked Persons: Virtual Care and Human Trafficking During the COVID-19 Pandemic.
J Health Care Poor Underserved. 2023;34(3):989-1002. PMID: 38015133
“THRIVE, a multidisciplinary University of Miami clinic for trafficked persons, transitioned to a hybrid telehealth model during the COVID-19 pandemic…There were 15% more scheduled and 8% more completed appointments per month early in the pandemic period with telehealth use compared to the pre-pandemic period. Telehealth was most used within psychiatry…Telehealth succeeded in connecting THRIVE patients during the pandemic, highlighting its potential for long-term use amongst trafficked persons.”
Raj A, Krass P, Hackett K, Green S, Wood JN.
Integrating Social Care Into a Specialized Medical Home for Sex-Trafficked Youth.
Pediatrics. 2024 Jan 1;153(1):e2023062394. PMID: 38124620
“The Children's Hospital of Philadelphia successfully launched the Adolescent Protection Collaborative in July 2021. This novel clinic created a specialized medical home for sex-trafficked youth. The clinic was staffed by a core team of child abuse pediatrics and adolescent medicine physicians and a social worker who provided coordinated evaluations and same-day services, followed by ongoing long-term care…Pilot data from the initial 21 months of clinical operations revealed that 88% of 43 referred patients (ages ranging from 13-22 years with a mean of 16 years) attended a scheduled appointment with 55% returning for follow up. All (100%) had past or present involvement with child protective services. Fifty percent of referrals tested positive for a sexually transmitted infection… Patient-desired contraception was facilitated for approximately 67% of referrals. Social care needs, such as referrals for educational support, case management, housing and employment resources, and mental health linkages, were offered alongside standard medical services.”
LGBTQ Concerns
Ethier KA, Jones SE, Kilbourn-Shear E, Dittus PJ.
Associations Between Verbal and Physical Abuse in the Home and Mental Health Indicators Among Heterosexual and Lesbian, Gay, Bisexual, and Questioning High School Students in the US-Adolescent Behaviors and Experiences Survey, 2021.
J Adolesc Health. 2024;74(1):198-201. PMID: 37791925
Using national CDC High School Student survey data, “Experiencing verbal or physical abuse in the home is strongly associated with poor mental health and suicidality among youth, regardless of sexual identity; however, among LGBQ students who experienced abuse, the prevalence of poor mental health and suicidality reached crisis levels…more than one in four LGBQ students who were verbally abused and half of LGBQ students who were physically abused had attempted suicide. That 75% of LGBQ young people indicated they had experienced verbal abuse in their home during the pandemic, suggests that concerns raised about the impact of increased time in unsupportive homes among LGBQ young people are well-founded.”
Race/Cultural Concerns
Mehta PM, Wang MC, Cameron NA, et al.
Association of Prepregnancy Risk Factors With Racial Differences in Preterm Birth Rates.
Am J Prev Med. 2023 Dec;65(6):1184-1186. PMID: 37552145
“The study sample included 509,890 live births to non-Hispanic Black individuals and 1,790,350 live births to non-Hispanic White individuals. PTB [pre-term birth] among non-Hispanic Black individuals occurred in 116.3 per 1,000 live births and 72.3 per 1,000 live births among non-Hispanic White individuals…Black individuals at the time of delivery were younger; more likely to have prepregnancy hypertension, diabetes, and obesity; and less likely to smoke, have a college education, or have private insurance than non-Hispanic White individuals…nearly one third of racial differences in PTB were explained by differences in a few select socio-economic and prepregnancy cardiovascular risk factors…these findings may inform public health interventions.”
Ellington L, Racine N, Mushquash C.
Indigenous youth wellbeing: Risk and resilience.
Child Abuse Negl. 2023:106580. PMID: 38065788
This editorial briefly reviews articles from a special issue on indigenous youth wellbeing around the world. Table of Contents
Saad F, Eisenstadt M, Liverpool S, Carlsson C, Vainieri I.
Self-Guided Mental Health Apps Targeting Racial and Ethnic Minority Groups: Scoping Review.
JMIR mental health. 2023;10:e48991. PMID: 38055315
“Considering the growing interest in MHAs [mental health apps], the available evidence for MHAs for racial and ethnic minority groups appears limited. Although the acceptability seems consistent, more research is needed to support the effectiveness of MHAs. Future research should also prioritize studies to explore the specific needs of racial and ethnic minority groups if MHAs are to be successfully adopted…Barriers to use included the repetitiveness of the MHAs, stigma, lack of personalization, and technical issues.”
Wolf RM, Hall M, Williams DJ, et al.
Disparities in Pharmacologic Restraint for Children Hospitalized in Mental Health Crisis.
Pediatrics. 2024 Jan 1;153(1):e2023061353. PMID: 38073320
“We performed a retrospective cohort study of children (aged 5-≤18 years) admitted for a primary mental health condition from 2018 to 2022 at 41 US children's hospitals. Pharmacologic restraint use was defined as parenteral [a shot or IV, not a pill] administration of medications for acute agitation.” Of 61,503 hospitalizations, children of non-Hispanic White, Asian, or other race and ethnicity, were less likely to receive pharmacologic restraint than non-Hispanic Black children. There was no significant difference with Hispanic children.”
Puls HT, Hall M, Boyd R, Chung PJ.
Public Benefit Programs and Differential Associations With Child Maltreatment by Race and Ethnicity.
JAMA Pediatr. 2023 Dec 18:e235521. PMID: 38109092
The association between total state spending for public benefit programs and CPS investigations “differed significantly by race and ethnicity: there was an inverse association between total state spending and CPS investigations for White children, but not for Black children or Hispanic children…These results raise concerns that benefit programs may add relative advantages for White children compared with Black and Hispanic children and contribute to racial and ethnic disparities in CPS investigations.”
Perpetrators
Koolschijn M, Janković M, Bogaerts S.
The impact of childhood maltreatment on aggression, criminal risk factors, and treatment trajectories in forensic psychiatric patients.
Frontiers in psychiatry. 2023;14:1128020. PMID: 38098623
Using data from two Dutch studies, of 128 patients residing in a Forensic Psychiatry [incarcerated mental health] facility, and 468 who had been released from such a facility, patients with higher child maltreatment (CM) scores had higher aggression scores. “Patients with histories of CM had a significantly longer length of stay in a forensic facility than patients without CM (respectively, 10.8 years and 9.3 years on average).”
Mathews B, Finkelhor D, Pacella R, et al.
Child sexual abuse by different classes and types of perpetrator: Prevalence and trends from an Australian national survey.
Child Abuse Negl. 2023;147:106562. PMID: 38061281
“Australian CSA prevalence was 28.5%, with the following prevalence by perpetrator classes: other known adolescents (non-romantic): 10.0%; parents/caregivers in the home: 7.8%; other known adults: 7.5%; unknown adults: 4.9%; adolescents (current/former romantic partners): 2.5%; institutional caregivers: 2.0%; siblings: 1.6%; unknown adolescents: 1.4%. Women experienced more CSA by all perpetrator classes except institutional caregivers. Age group comparison showed significant declines in CSA by parents/caregivers and other known adults; and increases in CSA by adolescents (current/former romantic partners)…Targeted prevention of CSA by adolescents must be prioritised.”
Police and Court Systems
Anillo I, Feldman D, Kennedy T.
A Global Outlook on Child Sexual Abuse and Sexually Explicit Material Online During COVID-19: Trends and Interdisciplinary Prevention Methods.
J Child Sex Abus. 2023;32(8):921-39. PMID: 37994473
“Globally, CSEM [child sexually explicit material] consumption increased dramatically during the pandemic, as well as trafficking of self-generated material. The hypothesized reasons for the increase in OCSA [online child sexual abuse] and CSEM included stay-at-home orders, COVID-19-related precautions, technology use increase, economic instability, and lack of available victim and legal resources. Current global and national law enforcement procedures to prevent the proliferation of online sexual abuse are reviewed with suggestions for preventing further increases in CSEM production, distribution, and consumption.
Islam MJ, Suzuki M, Mazerolle P.
Police responses to intimate partner violence incidents involving children: Exploring variations in actions and concerns in an Australian jurisdiction.
Child Abuse Negl. 2023;147:106568. PMID: 38039762
175 Australian police officers responded to 4 IPV scenarios about how they would proceed. Then they were asked if they would proceed differently if children were present. Differences for the 4 scenarios ranged from 48.9% to 22.0%, with those changing their process due to concerns about effects on children and ability of non-offending partner to keep children safe. “While children are acknowledged as secondary victims of IPV in research and practice, it appears that this concerning issue is sometimes being ignored by frontline officers…highlights the need for comprehensive training that accounts for the intricate interplay between standardized procedures and the unique contexts of IPV incidents involving children.”
Mitchell KJ, Gewirtz-Meydan A, Finkelhor D, et al.
The mental health of officials who regularly examine child sexual abuse material: strategies for harm mitigation.
BMC Psychiatry. 2023;23(1):940. PMID: 38093256
“Police investigators, forensic examiners, and others connected with the criminal justice system from across the United States who were exposed to CSAM [child sexual abuse materials] as part of their professions (N = 500) completed an anonymous online survey. Duration, frequency, amount, and content of CSAM exposure was not related to poorer mental health with the exception of exposure to violent CSAM which was related to elevated post-traumatic stress symptoms. Several agency-level practices and policies, such as the availability of an Officer Wellness Program and more frequently knowing the final case resolution, were related to better mental health and well-being. Harm mitigation strategies, such as talking to other officers investigating the case and taking breaks from the material being viewed, were also related to better mental health.”
Providers
Strauch KA.
Primary care nurse practitioners' perceptions and experiences communicating with adults about ACEs.
J Am Assoc Nurse Pract. 2024 Jan 1;36(1):48-56. PMID: 37882721
From interviews with 15 primary care nurse practitioners about discussing ACEs with patients, “Key themes described communication approaches and perceived barriers and facilitators to ACE-related conversations. Scope of practice, provider biases, diversity in practice models, and secondary trauma were factors NPs' perceived as positively or negatively influencing ACE-related communication in primary care.”
Garg A, LeBlanc A, Raphael JL.
Inadequacy of Current Screening Measures for Health-Related Social Needs.
JAMA. 2023 Sep 12;330(10):915-916. PMID: 37603327
“In 2022, the Centers for Medicare & Medicaid Services (CMS), along with standard-setting organizations such as the National Committee for Quality Assurance and The Joint Commission, established new quality measures aimed at promoting health equity. Many of these measures center around screening patients for health-related social needs (HRSN)…determining how HRSN screening is introduced to patients matters critically, and empathy, trust, respecting parents’ autonomy and dignity, and leveraging existing relationships are core factors necessary for patients to share their social needs willingly and openly. Unfortunately, health systems have paid little attention to these critical factors in implementing HRSN screening.” From experiences in Pediatrics, “Despite parental support for HRSN screening and an opportunity for parents to connect and receive support from their pediatrician, there is also great concern particularly from low-income minoritized parents. Their concerns include feelings of shame, being judged and discriminated against by the health care team, fear that disclosing needs will lead to filings with child protective services and removal of their children, and frustration with disclosing sensitive needs without getting acknowledgment and help.”
Elvir-Lazo OL, Yoshihara M, White PF, Yumul R.
Impact of Adverse Childhood Experiences on Health-Related Outcomes in Adults: Potential Implications for Perioperative Anesthetic Management.
Anesth Analg. 2024;138(1):210-5. PMID: 38100805
“Our intent in writing this Open Mind article is to stimulate interest in the anesthesia community regarding the potential role of ACEs in influencing clinical outcomes in the perioperative and post-discharge periods. Given both the prevalence of ACEs and the well-established relationships between ACEs and the subsequent occurrence of comorbidities in adults, we would speculate that the number of ACEs may be a predictor for certain types of postoperative morbidity (e.g. postoperative depression, prolonged fatigue, and chronic pain). An understanding of the relationship between ACEs and comorbidities in adults may also allow anesthesiologists to tailor their perioperative anesthetic and analgesic management. A better understanding of how ACEs influence subsequent health-related issues in adults might lead to significant improvements in perioperative care.”
Trockel MT, West CP, Dyrbye LN, et al.
Assessment of ACEs, Adverse Professional Experiences, Depression, and Burnout in US Physicians.
Mayo Clin Proc. 2023 Dec;98(12):1785-1796. PMID: 38043996
From a large national physician survey with a 30.6% response rate to mailed survey and 6.9% response rate to electronic survey, the proportion of physicians age 29-65 who had lived with a family member with substance misuse during childhood was marginally lower than that of workers in other professions (13.4% vs. 17.9%), while those who experienced childhood emotional abuse was similar to that of workers in other professions (16.3% vs. 16.2%). The average physician depression T-score was similar to the normed US average. Adverse occupational experiences (AOEs) were associated with mild to severe depression, including making a recent significant medical error (OR 1.64), being named in a malpractice suit (OR 1.30), and experiencing one or more coronavirus disease 2019-related AOEs (OR, 1.76). Having one or more ACEs was associated with mild to severe depression (OR 1.58). The ACEs, pandemic-related AOEs, and medical errors were also associated with burnout. “Assessing ACEs and AOEs and implementing selective primary prevention interventions may improve population health efforts to mitigate depression and burnout in physicians.”
Harding-Bremner M.
Overcoming barriers to recognizing and reporting child abuse.
JAAPA. 2024 Jan 1;37(1):22-27. PMID: 38051825
General review article for physician associates, including individual, interpersonal, organizational, and situational barriers to recognizing and reporting child abuse.
Haslam SK, Munroe A, Hamilton-Hinch B, et al.
Adverse childhood experiences and stress among oral health students: a descriptive correlational study.
Can J Dent Hyg. 2023;57(3):149-60. PMID: 38020077
From a survey of Canadian oral Health Students (OHS) with a 26% response rate, average ACEs score was 2.2, with 34.9% reporting 3+ ACEs (greater than the general population). The most common ACE was emotional abuse (41%). Associations were observed between numbers of ACEs and levels of stress, but not ACE type. “Faculty in dental and dental hygiene programs should recognize the prevalence of ACEs among OHS and the potential impact on their mental well-being.”
Najmabadi L, Agénor M, Tendulkar S.
"Pouring From an Empty Cup": Manifestations, Drivers, and Protective Factors of Occupational Stress Among Healthcare Providers of Trauma-Informed Care.
J Interpers Violence. 2023:8862605231215028. PMID: 38059411
“The DV workforce, including healthcare providers, social workers, advocates, and other providers, utilize trauma-informed care in a variety of settings to help DV survivors heal and recover from their traumatic experiences. Given the intensity of DV work and occupational stressors associated with navigating complex survivor cases and systems of care, health and mental health professionals can experience burnout, compassion fatigue, and secondary traumatic stress. The purpose of this qualitative study was to explore how professionals in the DV workforce, including healthcare and mental health professionals, experience and mitigate occupational stress.”
Hill Weller L, Tang J, Chen R, Boscardin C, Ehie O.
Tools for Addressing Microaggressions: An Interactive Workshop for Perioperative Trainees.
MedEdPORTAL 2023;19:11360. PMID: 38034501
“This workshop was developed with the primary aim of educating trainees on microaggressions, amplifying the role of allyship, and providing tools to respond to microaggressions as an ally” for anesthesia and surgical residents. “The facilitator and course feedback was remarkably positive…the strategies presented in this workshop could be applied across other graduate medical education programs.” Full article plus training materials.
Dimopoulos MP, Schnur JB, Adams RD, et al.
Identifying radiation therapists' perceptions of potentially triggering aspects of care for survivors of sexual violence undergoing radiotherapy.
Journal of medical imaging and radiation sciences. 2023;54(4s):S64-s76. PMID: 37482508
“Research shows that for survivors of sexual violence (SV), cancer procedures can be retraumatizing due to perceived similarities to the original SV. To date, there is no training program designed specifically for the radiation therapist (RTT) on how to deliver care sensitively to survivors of SV.” From surveys of 50 RTTs, “Relatively few trainees identified sensory/environmental triggers…Future research should identify a comprehensive list of triggers and then develop a training specific to the RTT…from the perspective of the patient in the often unfamiliar and frightening radiotherapy suite.”
McGrath E, Dwaihy M, Smitherman L, et al.
Treasure (Hunt for) Your Health! Addressing Pediatric Social Determinants of Health Through Child-Friendly Community Engagement Events.
Clin Pediatr (Phila). 2023:99228231218160. PMID: 38131315
“The ‘Wayne Pediatrics Health and Nutrition Expo’ held at Detroit's Eastern Market was an activity-based health and nutrition event addressing pediatric SDoH [social determinants of health]. Partnering with community organizations, the event had 10 stations addressing SDoH: access to a primary-care pediatrician; HIV-care and prevention; childhood literacy; clothing & winter coats; mental health and childhood development; nutrition; staying active; vaccination; and food insecurity. The free, public event featured a child-themed treasure hunt and map, music, giveaways, and live demonstrations, all in a family-friendly park atmosphere.”
Prevention
Kasimanickam MR, Kerr DCR, Killion RE, et al.
State Alcohol Policy Environments of U.S. Colleges.
Am J Prev Med. 2024;66(1):1-9. PMID: 38123257
Assessing data across 3 academic years at 1290 college institutions, higher state alcohol restrictions had direct associations with fewer alcohol-related arrests, alcohol-related disciplinary actions, and rape offenses. Alcohol restrictions were measured by the Alcohol Policy Scale, and included items such as laws regarding license revocation, blood alcohol concentration, restricted days or hours of sale, false ID, furnishing alcohol to minors, house party laws, ignition interlock laws, minimum drinking age, sales to intoxicated patrons, and taxes on alcohol.
Senn CY, Hobden KL, Eliasziw M, et al.
Testing the effectiveness of a sexual assault resistance programme in 'real-world' implementation.
European journal of psychotraumatology. 2023;14(2):2290859. PMID: 38109360
The EAAA (Enhanced Assess, Acknowledge, Act) program is a 12 hour, small-group, educational program designed to help college women resist acquaintance sexual assault, and was proven effective in a randomized trial. In this study of its real-world use at 5 Canadian universities, completed rape was significantly reduced by 57.3% at 6-months, and attempted rape was reduced by 32.9%.
Krause JT, Brown SM.
Mindfulness Intervention Improves Coping and Perceptions of Children's Behavior among Families with Elevated Risk.
Int J Environ Res Public Health. 2023;20(23). PMID: 38063522
“A mindfulness-informed intervention improved coping strategies and perceptions of children's behavior among 53 families with elevated risk…intervention participants demonstrated improvements in positive refocusing coping, positive adaptation coping, and perceptions of children's behavior problems compared to participants in the waitlist control group.”
La Charite J, Khan M, Dudovitz R, et al.
Specific domains of positive childhood experiences (PCEs) associated with improved adult health: A nationally representative study.
SSM - population health. 2023;24:101558. PMID: 38034480
From a national survey including 7105 adults, “Experiencing childhood peer support, a healthy school climate, and neighborhood safety were especially protective against multiple adult health conditions, including for ACE exposed individuals. Interventions that promote PCEs may yield population health gains.”
Hoffmann F, Linz R, Steinbeis N, et al.
Children with maltreatment exposure exhibit rumination-like spontaneous thought patterns: association with symptoms of depression, subcallosal cingulate cortex thickness, and cortisol levels.
J Child Psychol Psychiatry. 2024;65(1):31-41. PMID: 37402634
Of 183 children aged 6-12 years, 96 of whom were exposed to maltreatment, maltreated children exhibited fewer positive thoughts or future-oriented thoughts, and more rumination thought patterns, all of which were associated with depressive symptoms and brain scan correlates of depression. “Targeting thought patterns in children with maltreatment exposure may be an effective strategy to effectively mitigate depression risk early in life.”
Researchers
Chung J, Pecora PJ, Sinha A, Prichett L, Lin FY, Seltzer RR.
A gap in the data: Defining, identifying, and tracking children with medical complexity in the child welfare system.
Child Abuse Negl. 2023;147:106600. PMID: 38118290
“Among nearly 400,000 children in US foster care, an estimated 10% are medically complex. Yet, population-level data about children with medical complexity (CMC) served by the child welfare system, both for prevention and foster care services, are largely unavailable…The majority of agencies could not easily identify CMC or access CMC-related data within data systems. Agencies described lack of a clear definition as a barrier to collecting population level data.”
Hunt GR, Higgins DJ, Willis ML, Harris L.
Scoping Review of the Definitions Used to Describe and Understand Harmful Sexual Behaviors in Children and Young People.
Trauma Violence Abuse. 2023:15248380231218294. PMID: 38153115
“There was disagreement and inconsistency across the included papers in their conceptualization of harmful, abusive, or problematic sexual behavior in children and adolescents. Although the term HSB [harmful sexual behavior] has been adopted as an umbrella term in many policy, practice, and research settings, there is a large variance in behaviors, treatment needs, etiology, and harms. Relying solely on one term to describe a wide range of sexual behaviors may limit the understanding of this issue and imply similarities between groups that are not present.” Authors note the need for clearly defined subsets of HSB.
Kerr-Davis A, Hillman S, Anderson K, Cross R.
Introducing Routine Assessment of Adverse Childhood Experiences For Looked-After Children: The Use and Properties of the Trauma and Adverse Life Events (TALE) Screening Tool.
Journal of child & adolescent trauma. 2023;16(4):981-94. PMID: 38045847
“The present study aims to illustrate the process of developing, implementing, and clinically validating a new assessment measure, the Trauma and Adverse Life Events (TALE) screening tool, to assess Adverse Childhood Experiences (ACEs) among looked-after children [children in foster or group care]…Adverse and traumatic experiences were highly prevalent in this population and appeared to be closely related with children's psychosocial wellbeing. Results emphasise the importance of routine assessment of past experiences within trauma-informed psychological care and intervention planning for looked-after children.”
Winquist A, Leiker CB, Landis T, Fraser J, Eddy LL, Burduli E.
Development and psychometric evaluation of the reporting suspected child abuse and neglect (RSCAN) scale for United States registered nurses.
J Pediatr Nurs. 2023 Nov-Dec;73:e319-e326. PMID: 37863784
The Reporting Suspected Child Abuse and Neglect (RSCAN) tool, with 8 items, “is the first US instrument to reliably measure nurses' professional knowledge and self-efficacy of reporting suspected CAN…Future research can build upon these findings to recognize and support nurses in their mandated role to report CAN.”
Other of Interest
Wilson RF, Mintz S, Blair JM, Betz CJ, Collier A, Fowler KA. Unintentional Firearm Injury Deaths Among Children and Adolescents Aged 0-17 Years - National Violent Death Reporting System, United States, 2003-2021.
MMWR Morb Mortal Wkly Rep. 2023 Dec 15;72(50):1338-1345. PMID: 38096119
“In the United States, unintentional injury is the fourth leading cause of death among infants (i.e., children aged <1 year) and is the top cause of death among children and adolescents aged 1-17 years; firearms are a leading injury method…Data recorded during 2003-2021 by the National Violent Death Reporting System (NVDRS) identified 1,262 unintentional firearm injury deaths among children aged 0-17 years: the largest percentage (33%) were among children aged 11-15 years, followed by 29% among those aged 0-5 years. Overall, 83% of unintentional firearm injury deaths occurred among boys. The majority (85%) of victims were fatally injured at a house or apartment, including 56% in their own home. Approximately one half (53%) of fatal unintentional firearm injuries to children were inflicted by others; 38% were self-inflicted. In 9% of incidents, it was unknown whether the injury was self- or other-inflicted. Approximately two thirds (67%) of shooters were playing with or showing the firearm to others when it discharged. Overall, firearms used in unintentional injury deaths were often stored loaded (74%) and unlocked (76%) and were most commonly accessed from nightstands and other sleeping areas (30%). Unintentional firearm injury deaths of children are preventable. Secured firearm storage practices (e.g., storing firearms locked, unloaded, and separate from ammunition) have been identified as protective factors against child firearm injuries and deaths, underscoring the importance of policymakers, health care professionals (e.g., pediatricians), and others partnering with parents, caregivers, and firearm owners to promote secure firearm storage.”
Barnard LM, Wright-Kelly E, Brooks-Russell A, Betz ME.
Characterization of Mass Shootings by State, 2014-2022.
JAMA Netw Open. 2023 Jul 3;6(7):e2325868. PMID: 37494046
“The US has more than 10 times the number of mass shooting events as other developed countries. Mass shootings in the US have increased in frequency, with more than half occurring since the year 2000. These events have a direct toll on individuals injured or killed, as well as a psychological impact on families, friends, and society…From 2014 to 2022, there were 4011 mass shootings, ranging from zero events in Hawaii and North Dakota to 414 events in Illinois. For these 9 years, 27.3% were social-related mass shootings, 15.8% were crime related, 11.1% were domestic violence (DV) related, 1.4% were school or work related, and 52.0% were not a part of these categories. A total of 21,006 people were killed or injured…Crime-, social-, and DV-related mass shootings followed a similar pattern, while mass shootings that were not part of these categories were more evenly distributed across the US.
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