The Effects of Gun Violence on Children’s Mental Health with Dr. Chelsea Grefe McCann and Dr. Cristin McDermott

Healthy Minds Monthly and Annual Public Opinion Polls | American Psychiatric Association

Firearm Violence Prevention | Centers for Disease Control and Prevention

Firearm Deaths Grow, Disparities Widen | CDC Vital Signs

Current Causes of Death in Children and Adolescents in the United States | NEJM

Injury Prevention: Firearm Safety | CHP.edu

Behavioral Health | CHP.edu

Empowering Teens to Thrive (ET3) Program | CHP.edu

Be Smart for Kids

The National Child Traumatic Stress Network

Adverse Childhood Experiences (ACEs) | CDC

Talking to Children About Gun Violence | UPMC Healthbeat

Tips for Managing Mass Shooting Anxiety | UPMC Healthbeat

The War-Zone Mentality — Mental Health Effects of Gun Violence in U.S. Children and Adolescents | NEJM

The Impact of Gun Violence on Children and Teens | Everytown for Gun Safety

What Gun Violence Does to Our Mental Health | The New York Times

Mitigating the Effects of Gun Violence on Children and Youth | U.S. Department of Justice

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Voiceover: This podcast is for informational and educational purposes only. It is not medical care or advice. Clinicians should rely on their own medical judgements when advising their patients. Patients in need of medical care should consult their personal care provider. Welcome to "That's Pediatrics", where we sit down with physicians, scientists, and experts to discuss the latest discoveries and innovations in pediatric healthcare.

Dr. Arvind Srinath: From UPMC Children's Hospital of Pittsburgh, welcome to That's Pediatrics. I'm Arvind Srinath, Associate Professor of Pediatrics in the Division of Pediatric Gastroenterology.

Dr. Amanda Poholek: And I'm Amanda Poholek, Assistant Professor of Pediatrics and Immunology.

Dr. Srinath: Today's topic is children and the effects of gun violence. We have Doctors Grefe McCann and McDermott here to speak with us. Dr. Chelsea Grefe McCann is a licensed psychologist at UPMC Children's Hospital of Pittsburgh and certified clinician in trauma-focused cognitive behavioral therapy. She currently serves as the Program Director of the Behavioral Science Division. Dr. Grefe McCann earned her bachelor’s degree from Dickinson College and her Master of Science and Doctoral degrees from St. John’s University. Dr. Grefe McCann has extensive experience treating patients who present with mood concerns, behavioral problems, and trauma histories in school, outpatient, and hospital settings.

Prior to joining UPMC Children’s, Dr. Grefe McCann worked as a school psychologist in Connecticut and staff psychologist at New York Presbyterian/Columbia University Medical Center in New York. Dr. Grefe McCann is a trained in Cognitive Behavioral Therapy and Dialectical Behavioral Therapist. She is a National Registrar Health Service Psychologist and a member of the American Psychological Association and Association for Behavioral and Cognitive Therapies. Welcome, Dr. McCann.

Dr. Cristin McDermott graduated from the UPMC Triple Board Program in 2017 and joined the faculty as Assistant Professor in the department of Pediatrics and Psychiatry at the University of Pittsburgh and UPMC Children's Hospital of Pittsburgh. Today she splits her clinical time between inpatient pediatrics as part of the CHP Paul C. Gaffney Division of Pediatric Hospital Medicine, and Pediatric Consult Liaison Psychiatry on the CHP Behavioral Health Consultation and Liaison service. She also serves as a co-attending for the UPMC Triple Board Clinic.

Outside of her clinical work, Dr. McDermott's interests include physician wellbeing and women in medicine. She has presented nationally and regionally on physician wellbeing and served as a member of the ACGME Physician Well-Being Task Force. Dr. McDermott is an Associate Program Director for the Triple Board Program at UPMC. Welcome, Dr. McDermott, and thank you again to both of you for speaking.

Dr. Cristin McDermott: Thank you for having us.

Dr. Chelsea Grefe McCann: Thank you for having us.

Dr. Srinath: So this is obviously a hugely important and devastating topic to discuss. We so appreciate both of your time and willingness to share your expertise and describe your services to our audience. Can we start off with an overview of the psychological effects of gun violence on children?

Dr. McDermott: Yes. This is a challenging topic to discuss and I think, in doing so, we need to really provide some context about gun violence in America. The CDC has all kinds of statistics out there. I think one of the most devastating ones is that, in 2020, gun violence is now the number one cause of death in children and adolescents from zero to 19. This is ahead of motor vehicle accidents, which used to be number one, and ahead of poisonings and ingestions, which is number three. What this translates to is about 32 kids a day being injured by gun violence, and seven dying each day, which is absolutely unacceptable.

Dr. Srinath: Wow, wow.

Dr. Poholek: Those are staggering numbers.

Dr. McDermott: Additionally, firearms account for about 20% of deaths in children throughout the US. Only 1 to 2% of that is from mass shootings. Those get the most press because they are truly devastating events, but the loss of any child, any person, particularly to gun violence, is devastating. But that 20%, that is largely due to suicide and homicide. So we have a long way to go to work on protecting our children, adolescents, and adults in this country.

Dr. Srinath: Those are absolutely devastating statistics. Gosh.

Dr. McDermott: I think when we were preparing for this, actually last night, so this is hot off the press, the American Psychiatric Association published their results. They do a Healthy Minds Monthly poll, which goes out to about 2,000 parents, and they ask about a wide range of topics and this was kind of preparing for the school year, and 55% of those 2,000 parents ranked fear of gun violence impacting their K-12 students. 70% of the respondents to that survey reported that they were anxious about gun violence moving forward. So, this is something that affects all of us, and how it affects us as adults impacts how it affects our kids and teenagers. So I think, with that context, we can talk a bit more about what are the psychological effects of gun violence on kids.

Dr. Grefe McCann: And I think to start to answer that question is, it can depend. And I think when we're thinking about the psychological effects of gun violence, or trauma in general on kids, we need to take it into consideration of the developmental stage the child is in, the age of the child, and the family context.

Some of the most common reactions we can see from gun violence can include difficulty paying attention or concentrating, some irritability or defiance, trouble separating from caregivers or difficulty with interpersonal relationships, change in sleep and appetite. Sometimes we see our kids, teens, preteens have increase in their anxiety. Sometimes avoidance of certain situations, certain people, certain places. And especially in our teenagers, we may see an increase in risky behaviors, as well as substance use as well, to be able to keep in mind.

Dr. Poholek: So the statistics you gave on gun violence are, of course, incredibly heartbreaking to hear. One of the things that I noticed when I was looking into some of the data prior to this conversation was not just the statistics on who's impacted as a victim, but how many kids are experiencing or witnessing violence, and I believe the statistic that I saw was basically about one in four, which is just incredible. That's so many kids. Right? So you have these effects, not just on victims of gun violence, but on the kids that are witnessing violence, which is a very broad category, I can imagine.

So I guess I really kind of wanted to go from there and talk about, with such a large number of children experiencing violence, we have these important psychological effects to look for, but how do we think about this in the broader community aspect of, what can we do to think about how many children are impacted by violence in America today?

Dr. McDermott: That's a really important question, and I think it's challenging to answer for a lot of reasons, but the safety and security of our children is first and foremost. And so, there are ways that we as parents, as godparents, as friends, as pediatricians, psychologists, providers, teachers can educate kids about violence, all kinds of violence, not just gun, but really providing not only the education, but perhaps some of the words and ways to express themselves in those contexts.

I think ending violence would be the goal. That's hard to do, again, for a variety of reasons. And so I think when we're talking about educating kids, it starts first with families, making sure that the homes are safe. When we talk about gun safety, we're talking about something very specific.

Dr. Grefe McCann: Which is guns being stored and locked when they're not loaded, as well as ammunition being stored and locked separately. What we do know from the statistics is that 40% of American households have a gun in them, and I think when we're talking about, how do we make changes on a community level? How do we make changes on an individual level? It can be really starting with parents and caregivers, as Cristin mentioned, as well as pediatricians, behavioral health providers. But I think we also need to think about gun violence in terms of safety for our kids, even in going to other kids' homes for play dates. What kind of conversations can parents have with other parents or caregivers? Just like they may ask, "Does your kid have any allergies? Do you have a pool or a trampoline at your house?" Parents can ask other parents, "Do you have any firearms at your house? And if so, how are they stored?" It is in every parent or caregivers right to know what type of environment they're sending their child to.

I think it's also important to teach kids at a young age about gun safety and what they should do if they're in a situation where ... any situation outside of guns as well, where they may be uncomfortable or feel unsafe and how they can advocate and tell a trusted adult what their concerns are.

Dr. Poholek: Yeah, you raise a really interesting point, because when you think about this in the context of the other top two things that you mentioned in terms of child death, motor vehicle accidents and ingestions and poisonings, we have ... It's easy to lock away the poisons, or even say to your child, "This is where the things are that are not safe. Don't touch these things." And with motor vehicles, obviously we have all these safeties that we put in place, and kids learn at a young age that you have to have your seatbelt on because that's what keeps you safe. But it doesn't feel like this conversation is happening at the same level related to guns and to gun safety. And especially, like you say, for children, do children have this information so that they know, in the same way that they know a seatbelt keeps them safe or in the same way that they know that that's the cabinet where all the poisons are kept, and how do we kind of create an environment where that's a broader scale knowledge, not just among parents and adults, but also for children as well?

Dr. Srinath: We appreciate you taking a step back and noting these horrible, horrible statistics. I mean, Amanda, you brought up the one in four, right? And 32, and then seven deaths per day, which has just, Amanda, been just staggering. Staggering. And then Chelsea, you brought up ... You're getting at what parents can do, because I think that's what a lot of listeners in this podcast are wondering. What can we as parents do? What can providers do? And what other resources do we have? And that's where my next set of questions kind of stems from here is, starting at normalizing the situation and asking those questions, but if even with all those precautions a child were to be witnessing gun violence or hear about it, how can parents approach those situations? How do they start the conversation, if a child doesn't start a conversation? Because as you mentioned, some of their effects may not necessarily be classic adult-presenting effects. "I'm nervous, I'm scared," right?

Dr. McDermott: Chelsea has a great saying, which is, "Avoid the avoidance." So avoid not talking about it, right? If a child experiences violence, be it gun or otherwise, at some point they will process that information and they will process it in different ways. Part of a job as a parent is to take the lead from your child, but also to observe and make note of when someone is kind of standing a little close to you, maybe a little closer than usual, they're hovering more, they're giving you signals that either they're seeking reassurance or they may be looking for an opportunity to start talking to you. Little kids may not know how. They may not have the language to say, "I'm worried. I'm scared." So again, their behaviors may shape a little bit more of your guide. Whereas our older teenagers, more of them will have the language, and so may be more forthcoming in what they want to talk about. But the key is to take the lead from the child.

Dr. Srinath: And along those lines, because I'm sure everybody ... We have an argument with someone, right? Everybody handles things differently. I'm a person who likes to talk it out in the moment, and a lot of other people like to cool off, process their thoughts, and then be able. So how can parents respect that and recognize those type of factors, know children and recognize when's a good time versus when pushback from their child and then, "I don't want to talk about it," is, okay, guess what, need to wait?

Dr. Grefe McCann: I think parents and caregivers know their kids best, and certainly they have to be the ones to make the judgment call as to maybe their child or children need some space, but there's some natural quiet times during the day. Even when we talk to parents and caregivers about talking to their children about any challenging topic, is it that wind down time before bed, or other times where there's just not a whole lot of distractions going on. Maybe a parent can bring up, "I know something really scary happened. Do you have any questions?"

And I think it's really important for parents and caregivers to let their children and teens know that they're able to answer questions that their kids and teens have. As Cristin said, we don't want to avoid these hard topics because then we're sending the message to our kids and to our teens that we shouldn't talk about scary things, that it's not okay to express our feelings. And then as a result, we see kids and teens maybe internalizing that and acting out in different ways.

So want to offer a listening ear to our kids, want to be able to answer any questions they have to the best of our knowledge as adults, and empower parents and caregivers to also say, "I don't know." If they don't know information, it's okay to be honest with our kids and teens and to make sure that they are getting the information from a trusted adult, and parents and caregivers are also correcting any misinformation that our kids or teens may have.

Dr. Poholek: So then on that note, what kind of resources are available for parents who may not feel like they actually know what to say or how to say it, or what is appropriate or not appropriate for their child's age? I think that it's not always that clear as a parent what you should say or shouldn't say, and yes, I think most of us do feel like we know our children and we know kind of what they might be sensitive to, but I think guidelines or helpful information to try and steer that conversation would be incredibly valuable to so many people who are still unsure exactly what is and isn't age appropriate or how much information to share or not. Are there resources available?

Dr. Grefe McCann: I would say a great go-to resource that even those of us in the behavioral health field used quite frequently is the National Child Traumatic Stress Network, nctsn.org. It has a tremendous amount of information on all different types of traumas, a tremendous amount of education for parents, caregivers, physicians, school personnel, and also provide some great feedback as to how to start some conversations, this is the verbiage you can use for your child, and this is how to monitor a child's symptoms to see how they're reacting to a certain traumatic event or events, and what to do if a parent or caregiver has ongoing concerns.

Dr. Poholek: And so then as a follow-up, at what point does a parent maybe say, "I've had the conversation and I still think my child is struggling. What should I do now? Where do I go?" Can they turn to their pediatrician? And then what are the next steps after that, that they could expect?

Dr. McDermott: So you can always turn to your pediatrician in these situations, or in any situation. But I think this is a great next step, is going and having more of a conversation to see how the child is actually doing in terms of mood, anxiety, depending on their age, right? Being able to get at those symptoms. And very likely, if those symptoms are really impacting the child, and we look at an impact on their family life, on their friends, on their schooling and social events, if it's impacting all of those things, they may then need some additional support, and that's absolutely okay.

Additional support may look like a therapist or a counselor. There are lots of places, certainly within Pittsburgh, where that is an option. Some kids may need to see somebody once a month, or maybe just once to kind of process and talk through. Other kids may need more intensive therapy on a weekly basis or potentially more than that. And so your pediatrician can help kind of guide into the next steps.

Here at UPMC Children's and within our Children's Community Pediatrics, we do have some embedded therapists within various practices, but our pediatricians here are also great about referring to resources that are certainly within and without UPMC, but we also have access to Western Psychiatric Hospital and Clinic, which has a variety of outpatient services as well.

Dr. Srinath: I really appreciate you bringing that up, Amanda, about when it gets to the point when a parent has tried their best and is identifying some barriers, which they're recognizing their limitations and they want to help their child, what resources they have. And the other point I want to just pivot to is, I'm sure you see this a lot, there's fear, particularly with school shootings and school drills, right? Which I'm sure we all see on a regular basis. How can parents address those fears? What resources can they ask the school about to help address those fears? And what things can they be looking for in their child's behavior, or what can they be asking for with teachers that may clue them into like, guess what, this is post-traumatic stress manifesting in a different way?

Dr. Grefe McCann: I think this is a great area where parents can feel empowered to ask for open communication with their school administrators and leaders and teachers, for parents and caregivers to understand what their school safety protocols are. Even on a day to day, including locked doors or vestibules or security guards, things like that. So when a child may have questions about school safety, a parent, a caregiver, school personnel can give very succinct concrete answers as to what safety looks like.

It is also helpful for the school to communicate to parents, or parents to ask the school and have this two-way conversation, if there are any active shooter drills going on in the school building, for parents to be aware of when that is happening. And oftentimes, schools will send out information of what they are telling children and how parents can reiterate that information and use similar language at home to explain what is going on, why it's happening, and again, be able to answer questions that their kids may have.

Any concerns about traumatic stress symptoms, again, we're really looking more broadly at changes in mood, behavior, sleep, appetite. If a parent or caregiver has concerns that they're noticing changes in their kids, the first stop would be to go to their pediatrician and talk to their pediatrician about these concerns.

Dr. Srinath: That's super helpful. Thank you.

Dr. McDermott: I think the other important thing to remember is that a child or teenager can experience traumatic stress but not develop post-traumatic stress disorder.

Dr. Poholek: Can you maybe clarify those two differences a little bit?

Dr. Srinath: Yeah.

Dr. McDermott: Sure. So post-traumatic stress disorder is really a clinical syndrome that, again, impacts children in a variety of settings. So we look for impacts in more than one setting. PTSD, post-traumatic stress disorder can be diagnosed six months out from an event. So it's not something that, if you witnessed violence tomorrow, you'd be diagnosed with PTSD the next day. It takes some time to evolve, and kids and teenagers can experience things like nightmares, flashbacks about the event that occur during the day or at nighttime. They may seek reassurance quite frequently. They may be very vigilant about where they go, who they go with, when they go places. And again, it has impacts in multiple areas of their life. Traumatic stress, it can be similar symptoms, but they aren't as pervasive.

Dr. Poholek: So it's-

Dr. McDermott: It's a spectrum of-

Dr. Poholek: And it sounds like, to some extent, it's related to the period of time at which the person is experiencing stress post an event.

Dr. McDermott: Mm-hmm.

Dr. Poholek: So then, obviously we talked about the goal being to end violence, which ... end gun violence, specifically, and that is a huge and lofty goal. And so it feels likely that that will take time, and so therefore it suggests that there's a lot of children who will continue to experience gun violence, probably, maybe, not just one time. So then when does sort of long-term effects of traumatic stress that is persistent in a child's life, how does that differentiate itself from PTSD and what are the potential areas that clinicians like yourselves can do to address kids in those categories?

Dr. Grefe McCann: So I think when you're asking or talking about gun violence and repeated almost instances of trauma or exposure to violence, we can reference the literature on adverse childhood events or ACEs. So there is research about ACEs stemming from the early '90s, looking at various traumatic events, death and violence being one of them, on the long-term impact of kids, on teens, and adults.

Initially, these studies started at looking at adults who had experienced childhood trauma. And what we know from a tremendous amount of research at this point is that adults who have experienced repeated traumas as a child have worsening physical health issues, they are more likely to have cancer diagnoses, heart problems, be a smoker. They have poor interpersonal relationships. They struggle in their professional jobs and are not typically making the same amount of money as their peers.

We know there's also a lot of research about the impact of ACEs on children. So for example, in the Fragile Families and Child Wellbeing Study, children who experience three or more ACEs we know are at a higher risk for behavior problems, such as aggression or defiance, mood disorders, such as anxiety, depression, and ADHD by age nine. Additionally, they may struggle in school academically. They'd be more likely to have an individualized education plan, or be more likely to repeat a grade.

So we know from working with the pediatric population, the earlier you intervene and the earlier these kids receive evidence-based intervention for trauma, we can really mitigate those effects that they may still experience in adolescence or adulthood. Not only we're talking evidence-based treatments for trauma, but also thinking about family environment in terms of how the caregiver's wellbeing is, how the caregiver is responding and modeling coping, what the child's school environment is like, their community environment. Thinking about other protective factors that our kids and teens may have, too.

Dr. McDermott: We also know that having just one, even just one safe trusted adult, can change the course of a child's life. If they have someone to go to and talk to who they feel safe and secure with, that can help mitigate the risks and the potential effects of these adverse childhood events, be it gun violence or other.

Dr. Poholek: Wow, that's incredible.

Dr. Srinath: Well, Doctors Grefe McCann and McDermott, we so appreciate you talking about this hugely important topic today. Not only the devastating facts, but what the effects are in children and what we as parents and as providers, and the resources we have, what we can do to help. So, thank you both.

Dr. Poholek: Thank you.

Dr. McDermott: Thank you for having us.

Dr. Grefe McCann: Thank you for having us.

Dr. Poholek: Thanks so much for your time today.

Voiceover: You can find other episodes of That's Pediatrics on Apple Podcast, Google Podcast, Spotify and YouTube. For more information about this podcast or our guests, please visit chp.edu/thatspediatrics. If you've enjoyed this episode, please be sure to rate, review, and subscribe to keep up with our new content. You can also email us at podcast.upmc@gmail.com with any feedback or ideas for topics you'd like our experts to cover on future episodes. Thank you again for listening to That's Pediatrics. Tune in next time.