Introduction
Violence is a major public health concern, affecting many people’s lives and having devastating long-term impacts, especially for children. Children and young people can be victims of violence, witnesses of violence, perpetrators of violence or a combination.
Box 1 contains a definition of violence from the WHO.
Definition of violence
The WHO defines violence as ‘the intentional use of physical force or power, threatened or actual, against oneself, another person or against a group or community that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation’.
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There are many types of violence, that is, child maltreatment, violence against children and young people, abuse of older people, sexual violence, criminal exploitation, domestic abuse and homicide, many of which overlap. There are known risk factors and protective factors for violence, and it is recognised that violence is predictable and, therefore, preventable.1
Many children with injuries caused by violence are likely to present to paediatricians and other healthcare professionals, yet they may not present to police, social care or other public sector workers. Injuries caused by violence may range from minor to fatal and from acute to chronic, and therefore paediatricians and healthcare professionals have an ideal opportunity to reduce violence.
It is not just those children and young people who present with injuries caused by violence that we should be looking out for. During clinical practice, paediatricians will also encounter other children and young people who are at risk of or have been victims or perpetrators of violence but who present with other health concerns. Professional curiosity is vital to ensure that these risks are identified and acted on with the same rigour that a paediatrician would apply if they noticed an unusual pattern of bruising on a non-mobile infant.
This article explores the public health approach to violence reduction and considers how paediatricians can help reduce and prevent violence while supporting children and their families. Actions for paediatricians range from health promotion to early recognition, partnership working, supporting data collection and contributing to the evidence base.
Background
Violence increases morbidity and mortality, severely lowers life expectancy and has a wide impact on health and well-being. In the UK, 160 children died due to violence and maltreatment over a 3-year period (2019–2022), of which 44% were aged 14–17 years.2 Nearly half (48.75%; n=78) of these deaths were caused by stabbings or firearms. Children living in the most deprived quintile were twice as likely to die due to violence and maltreatment compared with those in the least deprived area.2 Across England and Wales in the year ending March 2024, there were 64 homicides of children aged 13–19 years, with most of these victims being killed by a knife or sharp instrument.3
There were 1438 hospital admissions in England and Wales for assault with sharp objects for young people (0–24 years) from October 2021 to September 2022.4 Many children present to the emergency department (ED) with assault-related injuries, and yet many more will not seek medical attention.
A quarter (25%) of all firearm victims (excluding air weapons) were aged 0–19 years.5 The Youth Endowment Fund survey found that 16% of teenage children had been a victim of violence in the last 12 months, of which 68% experienced physical injury as a result, and 47% said that they had either been a victim or witnessed violence.6
There is a disproportionate impact of violence in more disadvantaged areas and population groups. Children with lived experience of the care system are more likely to be involved in the criminal justice system, as are black children.7 Boys engaged with the youth justice system are one of our most vulnerable groups, with histories of social exclusion, poor education, exposure to trauma and time spent in care.
Violence affecting children and young people is harmful, often having serious effects on health and well-being, where it can manifest into mental health conditions, that is, depression and anxiety, post-traumatic stress disorder, assault and even suicide. Violence can also cause various injuries, that is, burns, fractures and head injuries, and its impact can result in health-harming behaviours such as alcohol dependency, smoking, drug taking and unsafe sexual practices, thereby increasing the risk of sexually transmitted infections, HIV and unintended pregnancy.8 Such outcomes directly impact health and care, demonstrating the importance that paediatricians and healthcare professionals can contribute to reducing violence and its impact.
Public health approach
Public health is defined by the Faculty of Public Health (2016) as ‘the science and art of promoting and protecting health and well-being, preventing ill-health and prolonging life through the organised efforts of society’.9 Prevention of violence can be considered in three phases (figure 1).
Three phases of prevention.
A similar approach can be taken when considering how and when paediatricians may be able to recognise and intervene to reduce violence.
Early identification of children at risk of being involved in violence
Paediatricians need to be inquisitive and yet remain open-minded about the children and young people they encounter, whether they directly report violence or whether exploration of their life, home and family circumstances reveals a risk of violence.
Professional curiosity is critical, with opportunities to explore the patient’s history, delve a little deeper and understand why injuries, behaviour or disengagement may happen. It may not be for the paediatrician to provide all the support, but they must be able to recognise risks and refer to other professionals who can also help.
Community paediatrics and primary care
Community paediatricians see a wide range of children and young people with a variety of medical conditions. With the advantage of seeing children within their own community, there is an opportunity to gain insight into family structure and home circumstances. For example, paediatricians should consider the risk and/or impact of violence during routine medicals for looked after children.
Hospital paediatrics
Safeguarding
Traditional child protection approaches have focused on the identification of non-accidental or deliberately inflicted injuries on infants and very young children. There has been less rigour applied to teaching paediatricians about the impact and risk of violent injuries on older children. If an infant is suspected of being a victim of child maltreatment, having been shaken or hit, then there would usually be no hesitation about admitting them to a paediatric ward as a place of safety while further investigations and enquiries about their social circumstances and home environment are made and liaison with other agencies such as social care and police. If a 15-year-old boy presents to the hospital with a stab injury inflicted by a peer, then the response may be different, and in some hospitals in England, he may be denied admission to a paediatric ward, citing safety concerns for other children.
Children and young people affected by violence may be victims of criminal exploitation who need care and support to help them stop being exploited. This perspective is not always recognised, and they may be labelled as ‘gang members’ or perpetrators of violence, abuse or crime.
There is a complex relationship and overlap between victims and perpetrators of violence which can present challenges to professionals working with them. Furthermore, children aged under 18 years could be in an intimate relationship and be subject to domestic abuse by their partner and/or witness domestic abuse at home.
As always in paediatric practice, the need to safeguard a child is balanced with their right to confidentiality. The General Medical Council has provided clear guidance to doctors that for patients with gunshot injuries or knife injuries caused by interpersonal violence, information should usually be shared with the police in the public interest. For children aged under 18, wounds due to gunshots or attacks with knives or bladed/sharp instruments would raise child protection concerns, and relevant guidance should be followed.10
Paediatric trauma and injury
Paediatric emergency medicine doctors, paediatric surgeons and trauma specialists will treat children who have been injured as a result of violence. While the risk here is easy to identify, professionals may not know how best to support the child and their family to reduce the risk of future violence.
Clinicians should take a non-judgemental, trauma-informed approach and need to recognise that the interplay between victim and perpetrator is complex.
Some areas and hospitals have youth workers who specifically support children and young people who are affected by or are at risk of violence, often referred to as navigators. Hospital-based violence intervention programmes have been shown to be capable of reducing violent reinjury and arrests due to violence perpetration.11
Box 2 describes the effect of a youth worker intervention following a referral from hospital staff.
Case study
Sean, aged 15 years, was referred to a youth work ‘navigator’ project run by Oasis UK when he attended hospital with an injury following an assault. During the initial assessment, Sean spoke about carrying weapons, drug use and involvement in organised fights between two local groups. Sean found school difficult and left with no qualifications. Relationships with his family had broken down due to his behaviour.
Over 12 months, he was supported by a youth worker with positive activities, qualifications and rebuilding his family relationships. This included finding suitable accommodation with an extended family member. During the initial assessment, Sean mentioned that he really loved playing football, so the navigator linked him with a local grassroots team. Having the structure of attending training and playing games on Saturday morning helped to begin putting a bit of structure into Sean’s week. Building on this, Sean was supported to enrol in a 12-week programme with Street League based on sports and employability skills. Through this, he gained a certificate in football coaching and a Sports Leader Award. Sean showed huge commitment throughout the 12 weeks, taking two buses and a train each day to attend the course 4 days a week. Following this course, he was put forward for football trials at a professional club and has been successful in gaining a place on the team. As part of this, he has also been enrolled in an education programme which will give him a BTEC qualification in sports coaching.
‘I couldn’t have done this without you. When other people let me down you (the Navigator) were always there’. Sean
Neurodiversity, adversity and trauma-informed practice
When taking a public health approach to violence prevention, paediatricians must consider the potential for undiagnosed neurodiversity as well as the effects of intergenerational adversity and trauma.
Neurodiversity
Neurodiversity covers many different conditions, that is, attention deficit hyperactivity disorder, autism spectrum condition, developmental coordination disorder, dyscalculia, dyslexia and developmental language disorder and people often have more than one condition.12 Unfortunately, a neurodivergent diagnosis is often associated with an increased risk of violence. While an estimated one in six adults is neurodivergent, this increases to one in three for adults within the criminal justice system, many of whom will not have been diagnosed during their childhood, thereby missing out on appropriate support and medication.12 Neurodiverse children are particularly vulnerable to both sexual exploitation and criminal exploitation. They are also more likely to be misdiagnosed, often having a social, emotional and mental health diagnosis rather than a specific neurodiverse diagnosis.12 Furthermore, neurodiverse children are at increased risk of being victims of violence. Paediatricians need to consider whether an assessment for neurodiversity is required and work with professionals to ensure that the most appropriate support and treatment are offered.
Adverse childhood experiences and trauma
It is widely recognised that adverse childhood experiences (ACEs) are associated with poor health and social outcomes in adulthood. With an increasing number of ACEs, there is an increased risk of violence (victim and/or perpetrator), teenage pregnancy, attending a hospital within the past 12 months and having a cancer diagnosis or heart condition. Being exposed to adversity can have a behavioural impact, leading to an increased risk of illicit drug use, suicidal ideation, violence perpetration and school absenteeism. Often, the behaviours, that is, smoking, alcohol use, drug use and self-harm, are the victim’s way to self-medicate from the adversity and trauma that they have experienced. There is evidence that investing in a safe and secure childhood results in positive outcomes, and having a trusted adult with a strong attachment in a child’s life is one way to mitigate the negative impacts.8
Paediatricians and other healthcare professionals are in a strong position to understand the impact of adversity and trauma on children as well as to identify such adversity. And while paediatricians cannot necessarily prevent them, they can understand the risks that they pose and the potential future impact. We should ask about ACEs within assessments because by identifying children with adversity and trauma early enough, appropriate support and interventions could be put in place to help prevent further abuse and violence, and we are potentially providing more opportunities for positive change for the child.
Training and education
To enable the best management and support for our children and young people and to create the most effective professional care, it is important that training is considered; that is, ACEs are part of the Royal College of Paediatrics and Child Health curriculum for paediatric trainees. However, many report a lack of confidence and knowledge in this area,13 and the implementation of being ACE and trauma-informed should be considered and reviewed across the profession, not just for trainees.
Given the complexity of violence, healthcare professionals working with children often feel that they do not have adequate training or knowledge about certain aspects of violence, such as criminal exploitation and, in particular, county lines and their safeguarding implications.14
Another consideration for paediatric training is the use of language and to ensure that appropriate and supportive language is used so that victim blaming can be avoided and the risks of adultification bias reduced (see boxes 3 and 4 below).
Language
It is important to consider how health professionals describe children and young people, how we describe their behaviour and how we safeguard them, especially if there is any chance that the child is being exploited or they are a victim of violence. The more we listen to children and young people and understand what is happening in their lives, it can help shift our mindset and decision-making, which influences our approach and those of our partners. By shifting away from (unintentional) victim-blaming language, it is possible to further help the child away from violence.
Adultification bias
Adultification bias is about how adults perceive children and their childlike behaviour and is rooted in anti-black racism.19 Adultification bias occurs when children are perceived to be or are expected to act like adults before reaching adulthood. Through adultification bias, humanity and childhood are easily dismissed.20 Research suggests black children are most likely to experience adultification bias, although there are other contexts in which adultification bias occurs. For example, children who live in homes where domestic abuse is present are more likely to be adultified, both within the home and externally. The professionals may consider the child to be more resilient and ‘streetwise’ and potentially overlook the vulnerability of the child, resulting in the child being more at risk.
Support with data and evidence
A public health approach to violence reduction needs to start with a clear understanding of the situation and the scale of the problem, especially at a population level. Health data is a key component of building this knowledge. In the National Health Service, there is a large amount of data collected about violence, including people attending EDs as a result of violence, hospital admissions data and domestic abuse data. If we know how, where and when people are injured due to violence, it is possible to identify trends and where to intervene to prevent violence.
The England and Wales information sharing to tackle violence initiative aims to help reduce violence15 and demonstrates how those working in ED play a critical role.
However, data quality is only as good as the information that is recorded at the source. To enhance data quality and to help prevent violence, paediatricians could start by asking to see the assault-related data from their hospital or service, checking that children are included and sense checking the numbers to see if they seem correct. They could also talk to their staff to discuss why it is important for all staff members to record information on assaults and violence and what it is used for, as well as undertaking clinical audits on data collection and deep dives into understanding the epidemiology of violence within their service, department or hospital. Local initiatives to improve coding and data collection can be valuable. There is evidence that collecting and sharing health data with police, social care and community safety partnerships (CSPs) can lead to a 30% reduction in assaults.16 17
Causes of the causes
Violence is multicausal and results from various factors, including social and cultural as well as current situational influences. Violence is influenced at individual, family, community and wider society levels.1 Understanding such factors, that is, adverse childhood adversity, intergenerational violence, trauma, abuse and neglect, as well as witnessing family abuse and harmful use of drugs and/or alcohol, as well as understanding trusted adults, is important to help prevent violence.18 This is so that we can find the best solution to stop the violence from happening rather than only treating its symptoms.
Partnerships
Working in partnership with CSPs, police, public health, communities and social care is an integral part of violence prevention. Sharing expertise and insight from a paediatrician’s perspective can help shape interventions as well as models of care that focus on prevention and early identification as well as widen people’s awareness and knowledge.
The role of paediatricians and healthcare professionals and how they play into the wider picture is critical. Working in partnership, both with health colleagues and wider networks, for example, general practitioners, school nurses, health visitors and child and adolescent mental health practitioners, is much broader than sharing individual patient details at key multidisciplinary meetings, although this is critical. It may include sharing cohort trends and sharing emerging situations that may be starting to happen within community paediatric clinics or paediatric ED. It can include leadership, influencing policies and plans to implement interventions and applying evidence-based practice. By taking such a public health approach, intelligence can be shared with partners where joint solutions can be found.
For example, in one area, police received intelligence that children were sustaining deliberately inflicted injuries to their hands as part of ‘punishments’ meted out by criminal gang leaders. Working directly with local hospital staff and paediatric emergency medicine specialists, this information was shared with frontline practitioners. In some areas of the UK, doctors with paediatric expertise are taking leadership roles in local Violence Reduction Partnerships and Violence Reduction Units.
Box 5 summarises key learning for paediatricians.
Summary of key learning
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The respect and trust placed in paediatricians allows them to provide leadership and influence in this important area of public health.
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Professional curiosity is important to really understand the underlying risk factors and to ensure that correct diagnoses are made and assessments that incorporate childhood adversity and other trauma.
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Language is important—so that the child is not blamed for any risky behaviours—so how to describe events and write up notes is really critical—and also to reduce adultification bias.
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Understanding the importance of data and intelligence and sharing the knowledge enables joint solutions to be more targeted and focused.
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Training and education, especially around adverse childhood experiences, trauma and domestic abuse for paediatricians, are vital to help them identify and manage the risk of violence in the children they encounter.