Clinical Context

It should come as a surprise to no one that Black children experience the highest rates of homicide among major racial/ethnic groups in the United States and that systemic racism contributes to this terrible fact. A previous study by Priest and colleagues used an online survey to assess potential biases of 1022 White adults in the US who either volunteered or worked with children. Their research was published in the September 12, 2018, issue of PLoS One.^[1]

White adults held the highest bias against Black adults vs other racial/ethnic groups: 52% of participants felt that Black adults were violence prone and 36% and 19% felt that Black adults had unhealthy habits and were unintelligent, respectively. These negative attributes were maintained for Black adolescents, and the proportion of Black adolescents perceived as lazy actually increased compared with that for Black adults (24% for Black adults; 41% for Black adolescents). Other findings from the study included higher rates of perceived laziness among American Indian/Alaska Native adolescents and a higher perceived predilection for violence among Hispanic adolescents.

Although White adults were less biased against Black children compared with Black adolescents and adults, even younger children were perceived more negatively than White children. This work is important because these biases contribute to multiple negative health outcomes for Black and other minority children, including homicide.

Study Synopsis and Perspective

The mean homicide rate among children in the United States rose by more than 4% per year since 2013, but jumped nearly 27.7% from 2019 to 2020, new data show.

Although long-term trends varied by region and demographics, with some groups and areas seeing declines in killings, the increases were the highest among Black children and boys aged 11 to 17 years, according to the researchers, who attribute the surge in violent deaths to a recent rise in firearm-related killings in children.^[2] Gun violence is now the leading cause of death for children in the United States, claiming what the American Academy of Pediatrics has equated to a classroom-full of lives each day.^[3]

“There are troubling recent rate increases among several groups, warranting immediate attention, with some racial and ethnic disparities persisting for more than 20 years,” said Rebecca F. Wilson, PhD, from the Centers for Disease Control and Prevention, who helped conduct the study.

Dr Wilson and colleagues, whose findings appear this week in JAMA Pediatrics, examined data on 38,362 homicide victims in the United States aged 0 to 17 years who were killed between 1999 to 2020.^[4]

The nation’s overall homicide rate for youth fell by 5.6% per year from 2007 to 2013 before reversing course. Between 2013 and 2020, the overall rate rose 4.3% annually.

The figures show that not all children are affected equally. The rate of child homicide has fallen significantly for girls, infants, and children aged 5 years and younger, whose deaths often result from caregiver neglect or violence, as well as Asian or Pacific Islander populations, White populations, and those living in the Northeast.

But the child homicide rate in the South increased 6.4% per year between 2013 and 2020, and the rate for children both in rural America and in cities is also rising after years of decline, according to the researchers.

The suspected perpetrator was known in about 64% of child killings. Nearly 80% of those perpetrators were male.

Dr Wilson and colleagues also note that the COVID-19 pandemic appears to have precipitated a wave of gun-related violence among children, a link borne out by another paper published in JAMA Pediatrics.^[5] (Recent data suggest that intentional firearm injuries often are misclassified as accidental.)^[6]

The second JAMA Pediatrics study found that gun-related injuries in youth remained elevated through 2021, with non-Hispanic Black children and those with public insurance making up greater proportions of victims during the pandemic. The researchers identified 1815 firearm injuries per month before the pandemic and 2759 per month during the outbreak, for a 52% increase.

Although the 2 studies look at different data, both show that Black children are most affected by gun violence, experts said.

“This demonstrates a critical issue for the medical, public health, and legal communities: While homicide is often presented as a criminal justice problem, it is increasingly a racial justice problem,” said Katherine E. Hoops, MD, from the Center for Gun Violence Solutions at Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland.

In an editorial about the homicide study, researchers at the University of Pennsylvania Perelman School of Medicine in Philadelphia called the violent deaths “preventable and unacceptable.”^[7] Eliminating such deaths “must be among our first priorities,” they write.

The editorial authors also note that researchers know relatively little about nonfatal violent injuries such as those involving firearms. “These injuries are important not only because they may have life-altering consequences for children and families but also because understanding only the most severe form of any health condition (death) will hamper our ability to design and evaluate prevention strategies,” they write.

Dr Wilson’s group identified different causes of youth homicide for different age groups, and the potential interventions for each differ. Although the youngest children are more likely to die from abuse or neglect, those aged 6 to 10 years were most likely to die by firearm, often associated with abuse that ends in suicide. Meanwhile, adolescents aged 11 to 17 were more subject to peer violence.

For Dr Hoops, “each of these differences has important policy implications including the need for policies that address structural racism, poverty, and systematic disadvantage, but also firearm safe storage to prevent youth violence and suicide, reduction of access to lethal means such as through extreme risk protective orders when someone is at risk of harming themselves or others.”

Dr Wilson agreed. “We know child homicides are preventable,” she said. “The rate decrease for some groups is encouraging, yet more can be done to protect all children.”

JAMA Pediatr. Published online December 19, 2022.

Clinical Implications

• In a previous study, 52% of White adults felt that Black adults were violence prone and 36% and 19% felt that Black adults had unhealthy habits and were unintelligent, respectively. These negative attributes were maintained for Black adolescents, and the proportion of Black adolescents perceived as lazy actually increased compared with that for adults (24% for Black adults; 41% for Black adolescents). However, White adults were less biased regarding Black children. Other findings from the study included higher rates of perceived laziness among American Indian/Alaska Native adolescents and a higher perceived predilection for violence among Hispanic adolescents.
• In general, there was a decline in the US rate of child homicide between 1999 and 2013, but this reversed, particularly from 2018 to 2020. A higher number of deaths of Black male adolescents drove this latter trend. Rates of child homicide increased in urban and rural areas from 2018 to 2020, and only the Northeast did not experience a higher rate of child homicide during this period.
• Implications for the healthcare team: The healthcare team should screen children of all ages for the risk for violence that they face on a routine basis and intervene when necessary using an interprofessional approach.

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