Elsevier

Preventive Medicine

Volume 102, September 2017, Pages 112-119
Preventive Medicine

Violent firearm-related conflicts among high-risk youth: An event-level and daily calendar analysis

https://doi.org/10.1016/j.ypmed.2017.07.011Get rights and content

Highlights

  • Among a sample of drug-using youth, ~ 25% of violent conflicts involved a firearm.

  • 42% of the sample reported substance use prior to a violent conflict.

  • Marijuana, but not alcohol use, was uniquely associated with firearm conflicts.

  • Firearm conflict was motivated by retaliation & arguments over personal belongings.

  • Alcohol, marijuana, & prescription drugs were associated with firearm conflict days.

Abstract

Firearm homicide is the leading cause of violence-related youth mortality. To inform prevention efforts, we analyzed event-level data to identify unique precursors to firearm conflicts. Youth (ages:14–24) seeking Emergency Department (ED) treatment for assault or for other reasons and reporting past 6-month drug use were enrolled in a 2-year longitudinal study. Time-line follow-back substance use/aggression modules were administered at baseline and each 6-month follow-up. Violent non-partner conflicts were combined across time-points. Regression analyzed: a)antecedents of firearm-related conflicts (i.e., threats/use) as compared to non-firearm conflicts; and b)substance use on conflict (vs. non-conflict) days for those engaged in firearm conflict. During the 24-months, we found that 421-youth reported involvement in violent non-partner conflict (n = 829-conflicts;197-firearm/632-non-firearm). Among firearm conflicts, 24.9% involved aggression and 92.9% involved victimization. Retaliation was the most common motivation for firearm-aggression (51.0%), while “shot for no reason” (29.5%) and conflicts motivated by arguments over “personal belongings” (24.0%) were most common for firearm-victimization. Male sex (AOR = 5.14), Black race (AOR = 2.75), a ED visit for assault (AOR = 3.46), marijuana use before the conflict (AOR = 2.02), and conflicts motivated by retaliation (AOR = 4.57) or personal belongings (AOR = 2.28) increased the odds that a conflict involved firearms. Alcohol (AOR = 2.80), marijuana (AOR = 1.63), and prescription drugs (AOR = 4.06) had a higher association with conflict (vs. non-conflict) days among youth reporting firearm conflict. Overall, we found that firearm conflicts are differentially associated with substance use and violence motivations. Addressing substance use, interrupting the cycle of retaliatory violence, and developing conflict resolution strategies that address escalation over infringement on personal belongings may aid in decreasing and preventing adolescent firearm violence.

Introduction

Firearm homicide is the leading cause of violence-related mortality for U.S. youth aged 14–24 (Centers for Disease Control and Prevention (WISQARS), 2004). In fact, youth firearm homicide rates are twice those of U.S. adults (Centers for Disease Control and Prevention (WISQARS), 2004) and forty-nine times those of youth in other high-income countries (Grinshteyn and Hemenway, 2015). Health disparities persist, with 68% of firearm-related homicides among youth occurring among Black youth (Centers for Disease Control and Prevention (WISQARS), 2004). Non-fatal firearm injuries resulting from assault have accounted for an average of > 58,000 visits to U.S. Emergency Departments (EDs) annually in the past five years, almost half involving youth aged 14–24 (Centers for Disease Control and Prevention (WISQARS), 2004). The Institute of Medicine (Leshner et al., 2013) has responded to this public health issue by emphasizing the need for additional firearm research, especially research informing prevention initiatives.

Research has identified aggregated risk factors associated with an increased risk for firearm violence among high-risk youth, including prior violence involvement, firearm possession, attitudes favoring retaliation, higher severity substance use, and several specific mental health diagnoses (Carter et al., 2015). Among youth seeking ED treatment for assault, 25% report owning or carrying a firearm in the prior 6 months, with those youth who endorse firearm possession also reporting higher rates of firearm victimization and aggression (Carter et al., 2013). Substance use has also been identified as a key risk factor for a series of high-risk firearm behaviors, including illicit firearm possession (Carter et al., 2013), unsafe weapon storage (Wintemute, 2011), weapon carriage (Wintemute, 2011, Steinman and Zimmerman, 2003), and firearm threats against others (Casiano et al., 2008). In addition, it is estimated that 50% of high-risk youth involved in firearm violence meet criteria for a recent mental health diagnosis (e.g., depression), with PTSD predictive of future firearm violence risk (Carter et al., 2015).

While studies using aggregated measures (e.g., past 6-month substance use) have identified important risk factors for firearm violence (Carter et al., 2015, Cunningham et al., 2015), such research is limited — it does not characterize the unique set of factors that directly precedes firearm-related conflicts or the specific motivations underlying a conflict (Chermack et al., 2010, Epstein-Ngo et al., 2014). Research employing timeline follow-back (TLFB) methodology collects data on daily behaviors using an event calendar, allowing for a detailed examination of factors influencing behaviors at the incident level (Chermack et al., 2010, Epstein-Ngo et al., 2014). To date, TLFB studies have focused on factors influencing daily substance use (Chermack et al., 2010), or have explored the relationship between substance use and intimate partner violence (Epstein-Ngo et al., 2014) or adolescent peer violence (Stoddard et al., 2015). No TLFB studies have focused on understanding the distinctive contextual factors differentiating non-partner conflicts involving a firearm from other forms of non-partner conflict. Such data has the potential to influence the design of evidence-based firearm violence interventions addressing upstream factors related to this more lethal form of violence.

The Flint Youth Injury (FYI) Study (Carter et al., 2015, Cunningham et al., 2015, Bohnert et al., 2015) is a two-year longitudinal study examining violence and substance use outcomes among drug-using youth seeking ED care for assault and a comparison cohort of youth with drug use seeking care for other (non-violence) reasons. In addition to aggregate measures, participants completed TLFB calendars at each time point. The primary objective of this analysis is to utilize TLFB data to characterize the circumstances surrounding non-partner firearm violence, both in terms of contrasting firearm with non-firearm conflicts, and contrasting firearm conflict days with non-conflict days among those engaging in non-partner firearm conflict.

Section snippets

Study design and setting

Data for this secondary analysis are from the FYI Study (Cunningham et al., 2015, Bohnert et al., 2015). The UM and Hurley Medical Center (HMC) IRBs approved all study procedures; A NIH Certificate of Confidentiality was obtained. The study was conducted in Flint, Michigan at HMC. Flint crime and poverty rates are comparable to other urban centers (Federal Bureau of Investigation, 2011). The study population reflects the ethnic/racial characteristics of Flint (U.S. Census Bureau, 2016), which

Sample characteristics

Overall, 599 youth (AIG = 349; CG = 250) were enrolled in the longitudinal study. Baseline characteristics and the study flowchart have been previously published (Cunningham et al., 2015, Bohnert et al., 2015). Of note, we found no differences between cohorts with regards to baseline age, sex, race, or socio-economic status. Follow-up rates were > 80% at each time-point, with no differential follow-up (Cunningham et al., 2015). Within the longitudinal sample (n = 599), 421 (70.3%) youth reported a

Discussion

This is the first study to characterize firearm-related conflicts using a TLFB approach; results have significant potential to inform violence prevention strategies. Data characterizing firearm conflict motivations is particularly novel. Retaliation, power/respect, and protection/retrieval of personal belongings were identified as key motivations. In particular, conflicts where retaliation was the motivating factor were almost five times more likely to involve a firearm. This is consistent with

Conclusions

Firearm violence remains a complex, but preventable public health problem. Findings confirm the need for interventions that address multiple socio-ecological levels and a variety of settings (e.g., ED/hospital based, neighborhood), as well as the need for prevention initiatives to incorporate tailored content that addresses factors unique to youth conflicts involving firearms.

Role of the funding source

This work was funded by NIDA R01 024646 and in part, by CDC IPA 16IPA605200. In addition, this project was also supported, in part, by NIH/NIDA K23DA039341 and NIH/NIAAA K23 AA022641. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Dr. Carter authored the first draft of this manuscript. No honoraria, grants or other form of payment were received for producing this

Conflict of interest

None of the authors has any financial interests or relationships relevant to the subject of this manuscript.

Acknowledgements

The authors wish to acknowledge project staff, including Bethany Buschmann, MPH, Jessica Roche MPH, Linping Duan, MS, Sonia Kamat, and Wendi Mohl, BS, for their assistance in data and manuscript preparation. Finally, special thanks are owed to the patients and medical staff of the Hurley Medical Center (HMC) for their support of this project.

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      Further, our results also highlight the importance of considering healthcare settings for primary prevention approaches early before A/EAs progress in the trajectory of violence involvement to more severe behaviors. Predictors associated with firearm possession within the full sample, including male sex, pro-firearm attitudes, peer firearm carriage, and community violence exposure largely mirror the findings of prior analyses examining firearm possession, as well as risky firearm behaviors (e.g., threats/use), among healthcare (Carter et al., 2013; Carter et al., 2017, Carter et al., 2020, Cunningham et al., 2010, Loh, 2010) and non-healthcare-based samples (Cao et al., 2008; Steinman and Zimmerman, 2003; Vaughn et al., 2012; Hemenway et al., 2011). In contrast to prior analyses (Carter et al., 2013; Cunningham et al., 2010; Reid et al., 2017; Spano and Bolland, 2011), we did not find an association between prior violence involvement (i.e., victimization, violent offending) and firearm possession.

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    Prior Presentations: Society for Academic Emergency Medicine (Spring 2015); Conference for Problems on Drug Dependence (CPPD; Spring 2015).

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