Title: Working With Victims of Gun Violence Series: Bulletin Author: Judith Bonderman Published: July 2001 Subject: victims -- general, victim services, gun violence 30 pages 73,728 bytes ---------------------------- Figures, charts, forms, and tables are not included in this ASCII plain-text file. To view this document in its entirety, download the Adobe Acrobat graphic file available from this Web site or order a print copy from Office for Victims of Crime Resource Center at 800-627-6872. ---------------------------- U.S. Department of Justice Office of Justice Programs Office for Victims of Crime OVC Bulletin July 2001 ---------------- About This Bulletin Gun violence in America crosses the demographic lines of age, race, ethnicity, religion, gender, and class--very few Americans have not been affected by the scourge of gun violence. Gun violence corrodes the fabric of our communities, traumatizing victims, witnesses, families, communities, and even our Nation, as recent high-profile school shootings have shown. To understand and respond effectively to violence in our society, we must build on many disciplines, including the victim assistance and criminal justice fields, health care, social services, education, and the clergy. To guide our efforts in serving victims of gun violence, the Office for Victims of Crime (OVC) sponsored a multidisciplinary group of national experts in March 2000 to identify key victim issues and needs, develop recommendations for using federal funds to address victims' needs, and identify promising practices to serve victims of gun violence. Not surprisingly, this bulletin indicates that some demographic groups are disproportionately victimized by gun violence and that many victims never receive needed services. And while we typically think of gun violence victims as victims of homicide, we were reminded that there are many more victims who survive their injuries, often with long-term physical and psychological disabilities. Addressing the needs of secondary victims, including children and adults who witness violence, is another challenge for practitioners, and one that we are just beginning to address systematically in the victim assistance and compensation fields. This bulletin not only outlines the many challenges before us but also describes some promising practices in communities across our Nation to serve victims and stop the violence. We believe that the information provided in this bulletin will advance the field's understanding of how gun violence affects victims and their communities and will help OVC identify and support improved services for victims of gun violence. ---------------------------- Working With Victims of Gun Violence by Judith Bonderman Introduction On March 3, 2000, the Office for Victims of Crime (OVC) sponsored a roundtable discussion about the effects of gun violence on individual victims, their families, and their communities. This 1-day meeting in Washington, D.C., brought together a diverse group of professionals who work with victims of gun violence: physicians, social workers, mental health providers, prosecutors, nurses, lawyers, teachers, school principals, victim compensation administrators, and judges. Several gunshot victims and survivors who lost family members to gun violence also participated. This interdisciplinary discussion was designed to o Identify key victim issues stemming from firearm violence. o Increase understanding of the full range of gun victims' needs and how they differ from the needs of other crime victims. o Identify promising or successful assistance programs for victims of gun violence. o Develop recommendations for how federal and state crime victims' funds could be used to address unmet needs. The 18-person group reflected a wide range of expertise--from a trauma surgeon who operates on gun victims to a counselor who accompanies families to the morgue to a judge who hears victim impact statements. Although each participant's contribution to the discussion was shaped by his or her unique experience, the major concerns raised by all participants were remarkably consistent and supported by the growing literature on gun victimization. This bulletin highlights the issues raised and the recommendations developed by the roundtable. While our focus was victims of gun crime, as mandated by the Victims of Crime Act (VOCA) administered by OVC, we recognize that victims of all types of gun trauma--including unintentional shootings and suicides--have many of the same needs that can be met with help from victim service providers. Who Are the Victims of Gun Violence? The Death Toll When confronted with the question, "Who are the victims of gun violence?" we usually think first about the fatalities. According to death certificate data compiled by the National Center for Health Statistics, a part of the Centers for Disease Control and Prevention (CDC), a total of 32,436 persons died from firearm injuries in the United States in 1997. The majority of these deaths--54.2 percent--were suicides, 41.7 percent were homicides, and the remaining 4.1 percent were unintentional shootings or deaths of an undetermined nature.[1] The effects of gun violence cross all socioeconomic and geographic boundaries--from inner cities to remote rural areas to upscale suburbs and in homes, public housing communities, schools, workplaces, recreational areas, bars, and on the street. Gun violence victims are young and old, male and female, African-American and white. In some cases, the shooter and victim are strangers, but in many others, they are intimately related. In spite of the pervasive nature of gun violence, some demographic groups are disproportionately represented in the gun crime victim population. The 13,252 gun homicide victims recorded in the mortality statistics for 1997 included 5,110 who were 15 to 24 years old. Firearm homicide[2] was the second leading cause of death for the 15- to 24-year-old group. In the 25- to 34-year-old group, there were 3,706 deaths from gun homicide; at younger ages (5-14), there were 284 firearm homicides. In fact, firearm homicide was within the top 10 causes of death for all age groups from 5 to 44 years. Gun homicide victims are disproportionately young and predominantly male. According to CDC, 84 percent were male in 1997. At ages 15 to 19 years, the gun homicide rate for males was 8 times the rate for females in 1997.[3] The Bureau of Justice Statistics (BJS) reports that males of all ages were 3.2 times more likely than females to be murdered in 1998. Moreover, the circumstances of firearm violence differ significantly for men and women. In contrast to men, women are far more likely to be killed by a spouse, intimate acquaintance, or family member than by a stranger.[4] Firearm homicide also disproportionately affects African-Americans. Approximately 52 percent of gun homicide victims are African-American, even though they represent less than 13 percent of the total population. African-American males between the ages of 15 and 24 have the highest firearm homicide rate of any demographic group. Their firearm homicide rate of 103.4 deaths per 100,000 is 10 times higher than the rate for white males in the same age group (10.5 deaths per 100,000). In 1997, 92 percent of homicides of young African-American men occurred by firearms, compared to 68 percent of homicides by firearms in the general population.[5] Even though violent crime rates, including crimes committed with guns, have declined each year since 1993, according to Federal Bureau of Investigation trend reports,[6] guns remain the leading cause of death for young African-American males.[7] ---------------------------- If all Americans were killed with firearms at the same rate as African-American males between the ages of 15 and 24 (103.4 per 100,000), there would be 276,843 firearm homicide victims annually in the United States. (Based on 1997 CDC numbers and a total population of 267,636,061.) ---------------------------- The Nonfatal Gun Crime Victimization For every firearm death, there are approximately three nonfatal firearm injuries that show up in hospital emergency rooms. With no mechanism, such as a national registry, to collect uniform national data on nonfatal firearm injuries, this is, at best, an estimate based on a sample of hospitals.[8] There may be many more nonfatal firearm victims who do not go to hospital emergency rooms for treatment. Others have estimated four to six nonfatal injuries for each gun death.[9] In addition, many crime victims may be traumatized by the presence of a gun during a crime, whether or not the gun was fired. According to the National Crime Victimization Survey (NCVS) in 1998, victimizations involving a firearm represented 23 percent of the 2.9 million violent crimes of rape and sexual assault, robbery, and aggravated assault. In 1998, 670,500 crime victims reported facing an assailant with a gun.[10] Secondary Victims The number of deaths and injuries is just a crude index of the effects of gun violence in the United States. There is an even greater number of secondary victims, sometimes called covictims or survivors of homicide. These are the parents, children, siblings, spouses, and others who have lost a loved one or friend to gun homicide. In the aftermath of a homicide, covictims must deal with law enforcement, the medical examiner, the press, and the court system, among others. They may have to clean up a crime scene, pay the homicide victim's medical bills, and arrange for a funeral and burial. Secondary victims also include those who are touched by or witness gun violence in their homes, schools, or workplaces or on the street. In the Nation's largest public housing projects, the damage goes well beyond the lives lost and injuries inflicted. According to a report from the U.S. Department of Housing and Urban Development, public housing residents are more than twice as likely as other members of the population to suffer from firearm victimization, one in five residents reports feeling unsafe in his or her neighborhood, and children show symptoms of posttraumatic stress disorder (PTSD) similar to those seen in children exposed to war or major disasters.[11] This is consistent with numerous studies finding high rates of exposure to violence particularly among youth in urban communities. In one study, almost two-thirds of high school students had witnessed a shooting, and in another, 70 percent of the youth ages 7 to 18 in a public housing project had witnessed a shooting and 43 percent had seen a murder.[12] Recent data also indicate substantial exposure to gun violence among suburban school-age children.[13] ---------------------------- "It is estimated that each homicide victim is survived by an average of three loved ones for whom the violent death produces a painful and traumatic grief." --Deborah Spungen Homicide: The Hidden Victims Sage Publications, 1998 ---------------------------- Multiple-Victim Shootings While the number of crimes committed with firearms has been falling to levels not seen since the mid-1980s,[14] media coverage and public awareness of gun crime are increasing. In the past few years, a rash of multiple-victim tragedies has erupted in schools, workplaces, churches, nursing homes, fast food restaurants, shopping malls, and transportation. These are very public venues--places that we frequent on a daily basis and where we should feel safe. When a gun massacre interrupts play in a daycare center, prayer in a church, or commuters going home from work, it shatters our most basic sense of security. Consequently, even though the percentage of homicides involving five or more victims was less than 0.05 percent in 1998,[15] these are the ones that receive the overwhelming majority of the media's attention. In addition, the multiple-victim shootings in public places may be ones that create the most secondary victims as whole classrooms of first graders, cafeterias full of teenagers, and hundreds of fellow workers witness a mass shooting. The media coverage alone multiplies the number of persons victimized by the crime. ---------------------------- "Even those who have never encountered a gun are aware of the widespread presence of guns in our communities, witness news reports of gun-related crime, domestic murders, and high-profile shootings at schools, churches and other public places. The ever-present fear that someone we love might be killed or injured is another form of gun trauma." -From The Bell Campaign's World Wide Web site at www.bellcampaign.org The Bell Campaign is now referred to as The Million Mom March Foundation. -------------- Needs of Gun Victims The roundtable participants were asked to consider how gun victims may be different from other crime victims and how the differences might affect the services they need or receive. The main themes that emerged were 1) the gun as the weapon of violence, 2) the young age of the victims, 3) the high cost of gun violence, and 4) the extraordinary media attention given to a small subset of gun crimes. 1. The Gun as the Weapon of Violence Much has been written on why gun use increases the deadliness of attacks; for example, because guns inflict more damage than other instruments, they can be fired multiple times with little effort, firearms have a greater range, and assailants intending to kill choose the most efficient instrument.[16] Whatever the impact of these different factors, it is clear that the fatality rate from gun assaults is much higher than that from other weapons. This is true regardless of the relationship between the victim and shooter, as the presence of a gun can turn a robbery, an argument, or an abusive relationship into a homicide.[17] According to a 1996 BJS report, 29 percent of firearm homicide victims were killed because of an argument; 21 percent were killed during the commission of another crime, such as a robbery or drug crime; and 6 percent died as a result of a gang-related shooting.[18] Offenders report firing a gun within 15 seconds of brandishing it, even when they had not intended to shoot the victim.[19] Gun victims include those shot during traffic altercations, gambling disputes, and verbal disagreements. The lethality effect is not lost on the victims. Participants repeatedly spoke of the nature of the weapon used. "An important difference is the gun itself. Guns are the only instrument developed to kill; victims facing a gun suffer the trauma of death or the fear of death," said family bereavement counselor Kevin O'Brien. Meanwhile, participant DeLano Foster, an OVC Program Specialist and survivor of multiple homicides, offered that "the difference between an armed robbery and a homicide could be the time it takes the victim to hand over his wallet." Eyewitness accounts frequently report victims putting their hands in front of them and "holding up articles of all kinds in their last moments in the magical belief that even a sheet of paper might save them."[20] ---------------------------- Bystander Victims Durham, North Carolina: April 7, 1998. While walking with his mother, a 5-year-old boy was hit by a stray bullet from a gunfight. The bullet severed his spine, and Taquan Mikell may never walk again. The bullet struck him more than half a block away from the gunfight. Nashville, Tennessee: July 2, 1999. Nashville teenager Eric Harvey Hazelitt was fatally shot in the chest when gunfire erupted at the John Henry Hale public housing complex in Nashville. Just 14 years old, he was caught in the crossfire of two groups shooting at each other. Referenced from In the Crossfire: The Impact of Gun Violence on Public Housing Communities, published by the U.S. Department of Housing and Urban Development, February 2000. Washington, D.C.: June 21, 1999. Helen Foster-El, a 55-year-old grandmother, was outside her home in the 100 block of 56th Place SE. watching neighborhood children play when gunfire erupted between two groups. On hearing the gunfire, Ms. Foster-El began to shepherd the children into one of the neighborhood homes for their safety. As she was doing so, she was struck in the back by a stray bullet and died instantly. Harrisburg, Pennsylvania: June 10, 1999. Raphael Rivera, 14, was in the immediate area of an altercation involving several individuals. When the altercation escalated into gunfire, Raphael, who was not involved in the argument, sustained a fatal wound to the chest. Referenced from The Death Toll Since Columbine, a report of the U.S. Conference of Mayors, Washington, D.C., January 2000. ---------------------------- Gun violence also is frequently more random than other types of criminal victimization. One participant noted that "bullets don't always have a name on them. You can be shot from a great distance even with a bullet meant for someone else." Young men can be "casualties of a war they did not partake in" when gang members intent on retaliating shoot at random victims when they can't find the rivals they intended to kill.[21] Other participants talked about small children sleeping in bathtubs to hide from stray bullets penetrating bedroom walls at night. The bystander victim represents the most impersonal type of crime. But participants commented that, even when the shooter targets a particular victim, the gun crime is somewhat impersonal. The gun, as an instrument of both power and detachment, allows the shooter to remain physically and emotionally distanced from his or her victims. When the victims are shot in the back, as many are, they never even see the shooter's face. This may increase the "Why me?" response of so many gun victims, similar to the feelings of victims of drunk driving. The ability of mentally disturbed individuals to kill at a distance, together with the enormous firepower of semiautomatic weapons, may have facilitated the gun rampages that have taken so many lives in recent years. Participant Michelle Scully Hobus was shot and her husband killed when a crazed gunman armed with two semiautomatic TEC-9 pistols roamed a San Francisco, California, law firm, shooting 15 people, killing 9 before taking his own life. It was a long time before she could shake the feeling of danger. "Even though I knew that the gun massacre at the law firm was an extremely rare event, I kept having the feeling that it would happen again. I couldn't sit with my back to the door; I thought someone would come in and blow everyone away." o Just as Larry Gene Ashbrook did on September 15, 1999, when he shot 14 people (7 dead) in the Wedgwood Baptist Church in Fort Worth, Texas. o Just as Mark Barton did on July 29, 1999, when he shot 22 people (9 dead) at two brokerage firms in Atlanta, Georgia. o Just as Kip Kinkel did on May 21, 1998, when he shot 24 people (2 dead) at Thurston High School in Springfield, Oregon. o Just as George Hennard did on October 16, 1991, when he drove his truck into Luby's Cafeteria in Killeen, Texas, and opened fire on the lunchtime crowd, killing 23 people before shooting himself.[22] Moreover, gun victims face constant reminders of their trauma from the ever-present gun seen on television programs and commercials and in films and videos. Even American slang, for example, "one shot," "take aim," and "set your sights," takes its toll on some victims. Some participants reported that any loud noise, like balloons popping and cars backfiring, could "trigger" a response. The exorbitant media attention paid to each new multiple-victim shooting also is retraumatizing for gun victims of similar tragedies. Security changes, such as metal detectors in schools, hidden cameras, dress codes, and guards in the halls, are constant visual reminders of school shootings. Like other crime victims, gun victims seek redress against their shooters through the criminal justice and civil justice systems. Many victims, like participants Scully Hobus and Jaquie Algee, have become activists. RECOMMENDATION: Clinical evidence supports the therapeutic value of victims working as change agents, in grassroots or church activities, informal support groups, and anticrime organizations.[23] 2. The Young Age of the Victims As previously noted, gun crime disproportionately affects young people. Their injuries and grief must be understood in this context. The participants who work with adolescents spoke of the pessimism and despair, particularly in the inner cities, where communities are losing children to gun violence daily. Youngsters whose relatives and friends have been shot automatically think that sooner or later it will happen to them. They plan their funerals, write their obituaries, and specify the clothing in which they want to be buried. A psychological counselor for teenagers in Baltimore, Maryland, Dr. Rosetta Graham, spoke of the need to do much more for this age group: "Around age 14 or 15 they become more private and hold in their grief. They are caught between adults who know how to make their needs known and young children whose caregivers speak for them." Studies of urban youth show a high correlation between exposure to violence and depression and PTSD.[24] The hopelessness of this population was a recurring theme. The participants agreed that one major shooting, or the daily loss of friends and classmates, can have a profound effect on young people just beginning to explore their independence and develop plans for their future. While some hold in their grief, others become suicidal or act out their feelings on the street. Even in suburban settings where violence is rare, a highly publicized school gun massacre can have a significant impact. Counselors working with students at Columbine High School in Littleton, Colorado, worried about kids who were somewhat depressed and doing drugs before the shooting. In the months since the shooting, they have seen an increase in drunk driving, suicide attempts, and fighting. Disaffected students--or those who feel alienated or rejected--don't trust anyone, don't feel safe, and don't do well in school. Similarly, after the 1998 shooting of 22 students at Thurston High School in Springfield, Oregon, there was a 600-percent increase in referrals to the school nurse and a 400-percent increase in arguments and fights reported to the principal. Many students, even some who were not present at the school but who watched the news coverage, experienced a loss of control, a feeling of being violated, and a sense of guilt that they survived. For many students, the fear of gun violence is strong enough to interfere with the quality of their lives and their performance in school; they also may suffer from increased absentee, truancy, and dropout rates. Participants who work with children explained the importance of getting them to talk about their fears. They are hungry for information and may distort facts and think they could have prevented the shooting. They need to understand that the school shootings on the evening news are rare events and that schools are safe places. Although exposure to violence will affect all adolescents to some extent, different services are needed when the shooting is an isolated tragedy versus when there is a daily threat of violence in the community.[25] In the high-profile school and workplace shootings, crisis response teams "debrief" the victims and witnesses, often in a group setting. The interventions for schools and communities that witness violence are based on the assumption that the incidents they witnessed are one-time horrific events. Participants who had the benefit of this type of crisis response service felt a sense of security while the teams were there and a great void when they left. In the absence of organized training, teachers, school administrators, and guidance counselors are scrambling to get up to speed on crisis response. Many professionals who helped care for the students who were shot or witnessed a massacre of their classmates also became depressed and suicidal. According to School Superintendent Jamon Kent, the shooting at Thurston High took place May 21, 1998, and the aftershocks still occupy one-third of his time in the office. RECOMMENDATION: Participants recommended that communities victimized by gun massacres be offered long-term assistance and training so they can more effectively be involved in the healing process. Different problems arise and different types of interventions are needed to address chronic gun violence. For the past 10 years at least, young African-American males have experienced violent crime at a rate significantly higher than the rate for other age groups.[26] Sandra DeLeon, Director of the Rise Above It violence prevention program in West Orange, New Jersey, reported that 60 percent of the students they serve know someone who has been shot. In their neighborhoods, gun violence is more predictable than random. They come to school worrying about the gunshots they heard the night before. The students need to hear, preferably from peer counselors, that there is a future to look forward to and they are not destined to be either buried or behind bars in jail. But the participants also agreed that this is an uphill battle. The strong correlation between poverty and violent crime means that those with the fewest resources are the most vulnerable. In some cases, the parents of homicide victims are very young. An enormous amount of preventive counseling is needed to keep them from exacting retribution while they struggle to get daycare, buy food, and arrange for the burial of a loved one. The literature on children and adolescent victims reinforces the group's findings about the vulnerabilities of young gun victims. A Task Force on Adolescent Assault Victim Needs, convened by the American Academy of Pediatrics, recommends addressing the psychosocial needs of young victims along with their physical injuries.[27] To do this effectively, the task force noted that health care providers must acknowledge and address three myths: 1) that all adolescent victims are "bad" kids who probably deserve what they got, 2) that it is dangerous to care for adolescent victims who may be members of a gang, and 3) that it is hopeless to help them because of the high risk of reinjury and subsequent acts of violence by the victim. The myth that all adolescent victims are "bad" kids is particularly harmful for young African-American men growing up in neighborhoods rife with drugs and gun violence. Generalizations about "predator youth" cause added grief for gun victims and stigmatize them and their families unfairly. Future employers may refuse to hire a young man with a bullet in his arm, assuming that he was a gang member or a bad person because he'd been shot.[28] On the other hand, the tendency to use violence is considered a serious potential consequence of being a young victim of gun violence. In fact, "a new study by the National Center on Crime and Delinquency finds that one of the best predictors of whether a teenager will commit a crime is whether he or she has been a victim."[29] Siblings of gunshot victims are frequently preoccupied with revenge fantasies and may be encouraged and assisted by their peers in exacting vigilante justice. Once having resorted to violence, young men engage in more risk-taking behavior. Thus, a cycle of violence continues, and being shot once becomes the greatest predictor for being targeted again.[30] However, the risk factors for this group are often overcome by the resourcefulness and determination of families surviving in the inner city. RECOMMENDATION: Participants agreed that assistance for gun victims, particularly young African-American men, must include programs designed to teach victims to regain their self-respect and status in the community without resorting to more violence. Quick outreach and support to newly bereaved families can help redirect their grief toward positive efforts to honor the memory of their loved ones. ---------------------------- "After my 19-year-old son was shot in Chicago, I went to many support groups, community organizations, and church-affiliated meetings, but I really wasn't getting what I needed. I needed to be more active in the movement to reduce gun trauma. I found comfort in joining The Bell Campaign, a grassroots victim-based organization, modeled after Mothers Against Drunk Driving." --Jaquie Algee, Southeast Regional Director for The Bell Campaign ---------------------------- Although much of the roundtable discussion centered on teenage youth, elementary school-age children also are frequent witnesses to gun violence and often display symptoms of PTSD and other trauma-related disorders.[31] Some children are afraid of school, and many become fatalistic. Some engage in aggressive play and perform poorly in school,[32] while others become desensitized to violence and lose the ability to recognize and avoid dangerous situations. The few research studies that were available to participants suggested that witnessing gun violence affects children in many different ways, depending on the type of wound, the proximity to the shooter, the relationship of the shooter and victim, and whether the shooting took place in a context generally considered safe, among other things. Different reactions can be expected from boys and girls. Child witnesses who have been raised in a subculture of violence in the home may have additional risk factors for long-term psychosocial consequences.[33] Effects also can be seen in somatic disturbances. According to participant Marianne Z. Wamboldt, M.D., a child psychiatrist in Denver, Colorado, clinicians have noted a relationship between the general stress in the community after the shooting at Columbine High and an increase in asthma cases and deaths among preschoolers. RECOMMENDATION: The roundtable consensus was that much more research is needed to develop services that take into account the full range of effects that gun violence has on children. OVC should work with other offices in the Office of Justice Programs (OJP), such as the National Institute of Justice, the Office of Juvenile Justice and Delinquency Prevention (OJJDP), the Violence Against Women Office (VAWO), and BJS, to develop a research agenda concerning the needs of gun violence victims. The evaluation of promising direct service programs for child victims of gun violence should be encouraged and funded by OJP. 3. The High Cost of Gun Violence Gunshot injury and death place a burden on the health care system in the United States that far exceeds the toll of other types of criminal victimization. Because of the traumatic nature and extent of their injuries, gunshot victims are more likely than other crime victims to require overnight hospitalization and followup care. BJS reports that gunshot victims represented only 5 percent of the estimated 1.4 million hospital emergency department patients treated in 1994 for violence-related nonfatal injuries. But while the majority of crime victims are treated and released, gunshot victims represent a third of those requiring hospitalization.[34] The average cost of acute care treatment ranges from $14,850[35] to $32,000[36] per hospital admission. Because of the young average age of the victims and the frequent need for rehospitalization, the lifetime medical costs are very high, around $35,500 per victim. For all victims of firearm injuries (assaults) and deaths (homicides) in 1994, the lifetime medical costs totaled $1.7 billion. Government programs, primarily Medicaid, are the primary payers for 50 percent of hospitalized gunshot injury cases due to violence.[37] The growing cost of gun violence can affect the trauma care available for all community members. At King/Drew Medical Center in Los Angeles, California, hospital expenses, not including professional fees, were more than $270.7 million for the 34,893 patients hospitalized for gunshot injuries from 1978 to 1992.[38] Some 96 percent of these costs were paid with public funds.[39] Between 1983 and 1990, the financial strain of treating uninsured patients contributed to the closure of 10 out of 23 trauma centers in Los Angeles County.[40] In addition to direct health care and related expenditures, gun violence exacts a substantial economic toll on its victims and society in general in terms of lost productivity, use of the criminal justice system, pain and suffering, and diminished quality of life. Economists and public health statisticians estimate an annual bill of more than $100 billion for all of these gun violence costs. An examination of more than 1,000 jury awards in cases involving shooting victims yields an average loss of more than $3 million for a single family of a homicide victim.[41] The economic loss is even more staggering for victims who sustain spinal cord injuries (SCIs) from gunshot wounds. These relatively rare catastrophic cases account for the lion's share of the medical costs for gun injuries. Each year, approximately 10,000 persons suffer an SCI and require hospitalization. Nearly a quarter of these injuries are caused by acts of violence, primarily gunshot wounds. Violence-related SCIs have increased dramatically since the early 1970s, overtaking falls as the second leading cause of SCIs (after motor vehicle accidents) in the past 4 years.[42] The average first-year expenses have been estimated at $217,868 (in 1995 dollars) for violence-related SCIs, although the amount varies considerably depending on the extent of neurological damage. With recurring annual charges for violence-related SCIs calculated at $17,275, the lifetime charges are estimated to be more than $600,000 for each victim. This includes charges incurred as a direct result of the injury, such as emergency medical services, hospitalizations, attendant care, equipment, supplies, medications, environmental modifications, physician and outpatient services, nursing homes, household assistance, vocational rehabilitation, and similar miscellaneous items. It does not include indirect costs, such as lost wages, fringe benefits, productivity, pain and suffering, and diminished quality of life, which could be twice as much as the direct costs.[43] A handful of gunshot SCI victims have fared better than most. For example, the SCI students from the Columbine shootings have had the benefit of a communitywide effort to raise funds for remodeling living areas, paying for medical and living expenses, specially equipped vans, and even college scholarships. But these are atypical cases. The majority of people with violence-related SCIs are young African-Americans with low socioeconomic status. Many in this group have been targets of gun violence and have sustained most of their injuries because of drug- or gang-related activity. Those who return to their communities after surviving months with tubes in their bodies face a daunting challenge in school. Paralyzed for life, they never will be the same active teenagers again. The practical and social problems like calling ahead and waiting hours for transportation, wheelchair access to classrooms, and dealing with colostomy bags are difficult enough without the added fears of testifying in court and being targeted again by the shooter. Those with violence-related SCIs are more likely than other SCI patients to have intractable pain and commit suicide. For others, the cost of acute care and rehabilitation, among other things, can lead to the dim prospect of constant dependence on the Government or family.[44] 4. The Extraordinary Media Attention to a Small Subset of Gun Crimes On April 20, 1999, the world watched as two high school students, armed with automatic weapons and shotguns, killed 12 students and a teacher and wounded 23 others before turning the guns on themselves. The tragedy at Columbine High School is considered a defining moment in the public's consciousness about gun violence. The nonstop realtime media coverage of this horrendous massacre, both on the air and in print, was traumatizing to the victims' families and friends, the community, the state of Colorado, the United States, and the world. The roundtable participants discussed this media coverage, focusing on its impact on children and its message for those haunted by the unpublicized loss of a loved one to gun violence. RECOMMENDATION: Participants agreed that the media should be more sensitive to how their coverage of gun violence affects victims and children. OVC should develop training materials and guidelines for media coverage of gun massacres. School shootings in particular are traumatizing for children because they all go to school.[45] After Columbine, preschoolers in Colorado began talking about where they would be going to school as the place where they would die. School systems around the country saw the phenomenon of school-phobic kids, as both the news media and talk shows exaggerated a child's risk of being shot at school. Although participants thought that such news coverage should carry a warning caption for parents about the possible adverse effects on young children, they also felt that older children are hungry to know what has happened and have a great need for information. In all cases, parents and teachers need to help children process the information they see on television, so they can realistically assess their own safety in school. Unfortunately, the misconceptions about the risk of school shootings are pervasive in all age groups. A recent analysis of opinion polls taken after the shootings in Jonesboro, Arkansas, and Littleton found a 49-percent increase in parents' anxiety about children's safety in the classroom, even though statistical studies by the U.S. Department of Justice (DOJ) and the National School Safety Center showed a 40-percent decrease in school-associated violent deaths in 1998-1999, the school year including the Columbine shooting. These tragic events are truly rare--with 52 million students enrolled in public school, the chance that a school-aged child would die in school in 1998-1999 was 1 in 2 million.[46] The gap between public fear and reality is not surprising, as media coverage is focused on less than 1 percent of homicides--those with multiple victims. Even within a group of multiple-victim gun homicides, the rarest events get the most media attention. For example, o December 4, 1999: Sacramento, California. A 31-year-old Asian man shot and killed his daughter and four sons, reportedly after having an argument with his wife. A shotgun and a high-powered rifle were found in the apartment. o December 5, 1999: Baltimore, Maryland. Five women were found shot to death in their Northeast Baltimore row house. Police said the women, who were not involved in drug activity, were shot to send a message to a relative who was involved in the drug trade. o December 6, 1999: Fort Gibson, Oklahoma. Five students were injured when a 13-year-old opened fire at a middle school with a 9 mm handgun he took from his home. The family homicide, an all-too-common occurrence, was reported only by the California press. The Baltimore shooting was prime-time news for a day and then was eclipsed by the middle school shooting in a rural community in Oklahoma. Even among victims of the same shooting, the media may focus on one or two to represent the face on the story. Perhaps because of their pronounced activism on the gun issue or because of some other special attribute, these chosen victims become the story of the massacre. In Homicide: The Hidden Victims, A Guide for Professionals, Deborah Spungen describes how individual victims of multiple-victim shootings "tend to get lost in the scale of the horror," while "covictims who have had a loved one selected for the [poster victim] may experience feelings of reluctance, exploitation, loss of control, and anger."[47] Services for Gun Victims The roundtable participants were asked to consider how VOCA-funded programs, both compensation and direct services, are useful for gun violence victims. Two points made throughout the day were reiterated in this discussion: o Communities most at risk for gun violence need ongoing prevention work. Even though the Federal VOCA Victim Assistance Final Program Guidelines preclude the use of Crime Victims Fund moneys for "activities exclusively related to crime prevention," direct services and compensation for gun victims could have a secondary preventive effect by minimizing the risk of retaliation and repeat victimization. Comprehensive programs that provide direct services and help break the cycle of violence in the community typically have more than one funding source. For example, a program could receive VOCA funding to support direct victim services and funding from another federal agency, such as DOJ's OJJDP or the U.S. Department of Health and Human Services, to support prevention initiatives. o Gun violence disproportionately affects young African-American men. The health care, criminal justice, and media response to these victims may be less sympathetic than responses to other crime victims. Whatever the reason for the disparate treatment of these victims, we must not ignore them. Assumptions about the blameworthiness of young African-Americans and Hispanics shortchange a large segment of the population and perpetuate racial stereotyping. Crime Victim Compensation Crime victim compensation programs--operating in all 50 states, the District of Columbia, the Commonwealth of Puerto Rico, the U.S. Virgin Islands, the Commonwealth of Northern Mariana Islands, American Samoa, and Guam-- provide financial assistance to victims for crime-related out-of-pocket expenses, such as medical care, mental health counseling, lost wages, and, in cases of homicide, funerals, loss of support, and counseling for secondary victims. Many programs also pay for crime scene cleanup, durable medical equipment like wheelchairs and hospital beds, transportation to medical providers, rehabilitation, physical therapy, and ramps or modifications to homes for paralyzed victims. All state victim compensation programs are "payors of last resort," covering losses not recouped from other sources such as public or private insurance, employee benefits, offender restitution, or civil judgments. The state programs set their own administrative rules and reimbursement maximums, which average $25,000 and range from a low of $10,000 to no limit for medical expenses (as in New York). A few states set higher limits for catastrophic or permanent injuries that could be used for special home and health aids. In view of the large medical, rehabilitative, and counseling expenses faced by gun victims, participants agreed that VOCA- and state-funded compensation programs provide much-needed financial assistance. Although there is no available estimate of the number of gun victims who benefit from these programs,[48] Program Director of the D.C. Superior Court's Crime Victims Compensation Program Laura Banks Reed stated that 30 percent of claims paid by her program are to gun victims. We are in a new era of crime victim compensation: program funding is more secure than ever before, and state administrators are more responsive to the needs of crime victims and flexible in administering their programs. Participants identified special needs of gun violence victims and made the following recommendations for state crime victim compensation programs. o Survivors of serious gunshot injuries may require long-term mental health counseling. Currently, the states impose many different limits on mental health claims, for example, limits on the total dollar amount and the number of sessions. As a result, the percentage of compensation dollars spent by the states on mental health claims varies enormously. Nearly all states pay for grief counseling for survivors of homicide, and some pay for mental health counseling for family members who witness the crime. RECOMMENDATION: Where necessary, state compensation caps and limits should be raised for mental health counseling to permit long-term counseling. States should consider extending benefits to more secondary victims, such as students or coworkers who witness a shooting, even if they are not family members and were not threatened by the shooter. o In addition to medical and mental health expenses, victims whose brains have been damaged or spinal cords have been injured as a result of gun violence may require long-term care, special transportation services, housing modifications, and occupational therapy. For the most severely injured victims, durable medical equipment such as a powered wheelchair can cost anywhere from $20,000 to $25,000, in addition to other equipment that may be needed. Many have living arrangements that can't be modified to meet their needs--their third- or fourth-floor walk-up apartments are not wheelchair accessible, and they cannot afford to move. In many cases, the parents or family members don't have the resources or services to stay home and care for the injured person; there are a large number of 21-year-olds on ventilators in nursing homes being covered by Medicaid. RECOMMENDATION: Limits on medical expenses should be raised for catastrophic injuries, and programs should be flexible in defining eligible expenses as the needs of gun victims become clear to them. For example, New Jersey pays for childcare and daycare services along with domestic help at a rate of $50 a day. This type of innovative benefit allows family members to continue working rather than having to stay home to care for a minor victim or an adult. o Although eligibility requirements vary somewhat from state to state, they all require victim (or claimant) cooperation with police and prosecutors. These requirements may be difficult for gun violence victims in some cases and may discourage them from applying for compensation benefits. RECOMMENDATION: Encouraging victim cooperation with law enforcement is a valid goal of state compensation programs. However, the Federal VOCA Victim Compensation Final Program Guidelines encourage program administrators to be flexible about cooperation requirements in cases where they may present special barriers for the victim. Law enforcement personnel, prosecutors, and compensation program staff should be trained to understand and be sensitive to the fears of these victims. o Most compensation programs have time limits for filing compensation applications. Although many states have specific exceptions or will waive filing limits for minors, the time limits may still disqualify some teen and young adult gun victims who need mental health counseling but are embarrassed to come forward at first and admit they need help. RECOMMENDATION: Compensation programs should waive time limits for filing applications to avoid penalizing young victims. Direct Victim Services OVC makes annual VOCA crime victim assistance formula grants to all 50 states to support the provision of direct services to victims of crime. The state VOCA administrators, in turn, subgrant the funds to victim service providers. Ten percent of each VOCA state grant must be allocated to victims of violent crime who have been previously underserved in that state. Underserved victims include, but are not limited to, victims of federal crimes, survivors of homicide victims, and victims of assault, robbery, gang violence, hate and bias crimes, intoxicated drivers, and elder abuse. States also may define underserved victims according to their status as senior citizens, persons with disabilities, racial or ethnic minorities, and residents of rural areas or inner cities. Eligible direct services include programs that 1) respond to the emotional and physical needs of crime victims, 2) assist primary and secondary victims of crime to stabilize their lives after a victimization, 3) assist victims to understand and participate in the criminal justice system, and 4) provide victims of crime with a measure of safety and security, such as boarding up broken windows and replacing or repairing locks. Many of the current VOCA subgrantees may provide services that are used by victims of gun violence, such as homicide support groups and victim advocates in prosecutors' offices. Because there are no data on how many existing programs serve gun victims and no service directory of gun victim programs, the roundtable participants identified a few promising practices and discussed the types of programs they would like to see funded under VOCA to benefit gun victims. Clearly, many innovative programs are not known outside their limited geographical area. RECOMMENDATION: Participants recommended that a database of providers serving gun victims be established and that OVC increase efforts to publicize promising programs and encourage states to fund them. RECOMMENDATION: If gun violence victims have been underserved, states should be encouraged to fund programs that serve gun victims as part of their required 10-percent minimum allocation of VOCA subgrants for underserved victim populations. 1. Holistic Care for Families of Homicide Victims Participants who counsel surviving family members spoke of the need to assist with day-to-day problems to reduce the immediate, ongoing, and long-term effects of traumatic loss. Programs that operate at the community level and provide a range of free services and referrals are preferred. They might be administered by the law enforcement or prosecutor's office, a hospital, a church, or an independent private agency. Three multiservice programs were discussed in detail at the roundtable. The Recover program in Washington, D.C., has a professional grief counselor in the Office of the Chief Medical Examiner to offer emotional support before, during, and after the process of identification of a loved one. Recover staff do an early assessment of needs, including inquiring about children who may be affected, and set up case management services. Staff or trained volunteers are available for practical and emotional support, including planning a funeral, explaining the grieving process, talking to children about death, driving the family to the store, helping with paperwork, or simply listening. Recover also makes referrals to mental health counseling and other services but recognizes that these may be premature and/or insufficient for victims having trouble getting out of the house, getting food on the table, and dealing with funeral homes and police investigators. The Family Bereavement Center in Baltimore, Maryland, is funded by a VOCA subgrant and administered by the state's attorney's office. The center reaches out to every homicide victim's family by sending a letter encouraging them to call for services. Center staff provide liaison services with the police department, the medical examiner, and the state's attorney's office. They offer crime scene cleanup services, court support and escort services, notification of case status and victims' rights, assistance in applying for victim compensation, and individual and group grief counseling sessions. They also sponsor educational and support activities such as memorial services, weekend camps for adolescents and younger children who have lost family and friends to violence, and a quarterly newsletter. The Family Advocacy Program at the Washington Hospital Center in Washington, D.C., also provides coordinated services for family members of gun homicide victims. Program staff are available to assist families of all emergency patients at the hospital. If the patient dies, the program advocates help the decedent's family navigate the next steps--decisions about organ transplant, hospital procedures, meeting with police officers, answering media inquiries, and referrals to counseling or pastoral services. This program is staffed primarily with retired D.C. homicide detectives. RECOMMENDATION: OVC should support the development of promising multiservice programs that reach families of gun victims within 24 hours after the shooting and remain available to assist with longer term needs. State VOCA administrators should be encouraged to fund programs like Recover, the Family Bereavement Center, and the Family Advocacy Program. Evaluation studies for these and similar programs should be encouraged and funded by OJP. 2. Support Groups for Nonfatal Gunshot Victims Victims who had been shot and survived their wounds spoke of the need to tell their stories many times. They stressed the importance of peer support groups. But unlike for rape victims, victims of domestic abuse, victims with severe SCIs, and parents/friends of murdered children, there are few, if any, specialized services or organized support groups for "plain, old-fashioned assault." These victims, who are shot, one by one, day in and day out, have bullets removed in emergency rooms and then are released to carry on with their lives. Participants recommended developing gun violence assistance centers modeled on the Thurston High Assistance Center in Springfield. This center was established in the aftermath of the Thurston High shootings and functions as a clearinghouse for services, activities, and resources related to healing individuals and the community. The proposed centers could be located within a YMCA or recreation center already functioning in the community and should be available to secondary victims like friends, neighbors, and family. They would be safe-haven drop-in sites where victims could meet with each other and with a multidisciplinary support team. Ideally, the centers would coordinate all services for gun victims in the community, such as medical and mental health evaluations, counseling services, family assistance, help with schoolwork or job applications, referrals to other programs, applications for victim compensation, emergency housing, and victim/witness protection. The centers also could be integrated with prevention efforts, such as community policing and afterschool programs. Participants who worked with young gun violence victims felt that the support of other victims would help reduce the stigma associated with talking to the police and testifying against an accused shooter. The centers could encourage cooperation with the criminal justice system and nonviolent ways of solving disputes. RECOMMENDATION: OVC should fund the development of model gun violence assistance centers that could be replicated in communities across the country. 3. Multidisciplinary Hospital-Based Programs for Adolescent Gun Victims Although virtually all U.S. trauma centers have some sort of counseling and referral services for victims of violence and violence prevention clubs exist in a majority of SCI units, there are fewer than a dozen hospital centers nationwide that offer comprehensive counseling, intervention, and inpatient treatment programs to victims of gun violence. Participants agreed that this should be a high priority for DOJ funding. Urban trauma centers have reported the recurrent nature of assaultive trauma, with hospital readmission rates as high as 44 percent in some areas and subsequent homicide rates as high as 20 percent. Medical personnel working with social workers and counselors could turn the crisis of injury into an opportunity to intervene and interrupt this pattern of violence. According to participant Dr. Caesar Ursic, Director of Trauma Services for the Alameda County Medical Center in Oakland, California, there are anecdotal evidence and some data suggesting that such programs diminish the psychological impact of the injury, prevent retaliatory violence, minimize violent injury recidivism, decrease future involvement with guns, and increase the likelihood of success in school. The Caught in the Crossfire (CC) program in Oakland has been hailed as a model program. It maintains a hotline for the Alameda County Medical Center to call when a youth between the ages of 12 and 19 is admitted to the emergency room with a gunshot wound. CC crisis intervention specialists visit the patient at bedside and o Review the violent incident. o Explore alternative strategies for conflict resolution. o Provide information on risk factors for violence. o Explore coping skills and safety plans. o Arrange for followup contacts. The recovery period in a hospital and rehabilitation center offers victims an opportunity to be exposed to supportive services. After victims have been discharged, followup visits are scheduled for a minimum of 12 months. The CC program uses trained peer counselors, many in wheelchairs because they too were victims of gun violence. RECOMMENDATION: OVC should continue to recommend that VOCA subgrants be awarded to hospital-based gun victim programs.[49] The elements critical to a model program should be identified for replication. Where funding is not available for comprehensive programs, emergency rooms should implement protocols to assess the risk of recurrent injury and provide counseling services for young gunshot victims and their families. ---------------------------- Recover, a program of the William Wendt Center for Loss and Healing 4880-A MacArthur Boulevard NW., Washington, DC 20007-1557 202-333-4880, www.lossandhealing.org Family Bereavement Center, a program of the State's Attorney's Office for Baltimore City 10 South Street, Suite 502, Baltimore, MD 21202 410-396-7351 Family Advocacy Program Office of Decedent Affairs, Washington Hospital Center 110 Irving Street NW., Washington, DC 20010 202-877-8351 ---------------------------- 4. School-Based Peer Counseling for Violence Prevention The power of peer counseling, evident in the hospital-based programs, also is an important component of school-based violence prevention programs. The Rise Above It program was launched in 1995 in direct response to an increasing number of severe SCIs and gunshot wounds in young people in the Newark, New Jersey, area. Program presenters, like Hashim Garrett, the Violence Prevention Coordinator for Rise Above It, are individuals who were paralyzed as a result of violent acts. They are teamed with able-bodied peer educators to let the students see the long-lasting effects of gunshot wounds and to teach them skills to deal with anger and prevent fights. The classes are part of the public school health sciences curriculum and have reached more than 10,000 students. The program has been posttested--meaning that the program surveyed students before and after they participated in the program, asking questions about their behavior and their beliefs about the consequences of fighting--and shows positive results as both students and teachers report a decrease in arguments and violent incidents. School-based peer counseling programs like Rise Above It are designed as violence prevention initiatives. But roundtable participants found it difficult to draw a line between the victim services provided and the prevention aspects of the programs. The victim presenters are empowered by their ability to speak in front of an audience and become whole again by sharing their stories and acting as change agents for a violent school-age community. And many in the classroom are also victims, suffering physical or emotional harm from the violence they experience daily. These types of programs could be part of more comprehensive victim service initiatives, including crisis intervention, age-specific courses on victim trauma, and stress reaction training.[50] As Dr. Enid Margolies with the New York City public school system observed, violence prevention and victim response issues must be folded into a school's core curriculum, as funding for separate programs is difficult. RECOMMENDATION: OVC should recommend that VOCA subgrants be awarded to qualifying school-based victim services programs. School boards should be encouraged to include victim services and violence prevention as part of a school's core curriculum. ---------------------------- Caught in the Crossfire Youth Alive 3300 Elm Street Oakland, CA 94609 510-594-2588 Rise Above It Kessler Anti-Violence Program Kessler Institute for Rehabilitation 1199 Pleasant Valley Way West Orange, NJ 07052 973-731-3600, ext. 2253 ---------------------------- Next Steps This roundtable was the first time that OVC focused exclusively on the needs of victims of gun violence. Participants found the process extremely useful and were satisfied that many key victim issues stemming from firearm violence were identified. As indicated in this bulletin, gun violence victims have some unique concerns and needs that differ from those of other crime victims. By sponsoring this roundtable, OVC has opened the door for a full and frank discussion of these issues. Participants expressed the hope that there would be other opportunities to continue this discourse. For example, o Once a national-scope search of providers and programs serving the needs of gun trauma victims is concluded, OVC should reconvene this or a similar group to identify unmet needs and make additional recommendations for funding new programs. o Smaller focus groups of gun victims should be held regionally to identify their needs and learn about the services they used to meet those needs. o Focus groups should be held on particular topics that were not fully covered in the roundtable. For example, we know that guns and domestic violence terrorize, injure, and kill women every day. On average, in 1997, more than one woman a day (393 women total) was shot and killed by her husband or intimate acquaintance during an argument.[51] The use of guns in domestic violence situations and its impact on victims should be explored further by both OVC and VAWO. Some key issues were raised during OVC's September 2000 Intimate Partner Homicide Forum. These issues and recommendations on how to identify trends and factors associated with intimate partner homicide will be addressed in a future OVC bulletin. o OVC should develop training materials and sponsor training and technical assistance programs for state VOCA administrators and compensation programs to help them identify the diverse needs of victims of gun violence and how to respond to them. Notes 1. Hoyert, D.L., K.D. Kochanek, and S.L. Murphy, "Deaths: Final Data for 1997," National Vital Statistics Reports, 1999; 47 (19). 2. The terms "gun homicide" and "firearm homicide" have the same definition and are used interchangeably throughout the bulletin. 3. Available online at the National Center for Injury Prevention and Control's database at www.cdc.gov/ncipc/wisqars. 4. Kellermann, A.L., and J.A. Mercy, "Men, Women, and Murder: Gender- Specific Differences in Rates of Fatal Violence and Victimization," The Journal of Trauma, 1992; 33:1-5. 5. Hoyert, D.L., K.D. Kochanek, and S.L. Murphy, "Deaths: Final Data for 1997," National Vital Statistics Reports, 1999; 47 (19). 6. Available online at www.ojp.usdoj.gov/bjs/glance/guncrime.htm. 7. Available online at www.cdc.gov/ncipc/wisqars. 8. "Nonfatal and Fatal Firearm-Related Injuries--United States, 1993-1997," Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, 1999; 48:1029-1034. 9. Annest, J.L., J.A. Mercy, D.R. Gibson, and G.W. Ryan, "National Estimates of Nonfatal Firearm-Related Injuries: Beyond the Tip of the Iceberg," The Journal of the American Medical Association, 1995; 273:1749-1754. 10. Available online at www.ojp.usdoj.gov/bjs/guns.htm. 11. In the Crossfire: The Impact of Gun Violence on Public Housing Communities, U.S. Department of Housing and Urban Development, February 2000. 12. Bell, C.C., and E.J. Jenkins, "Exposure and Response to Community Violence Among Children and Adolescents," in Children in a Violent Society, Osofsky, ed., The Guilford Press, 1997. 13. Campbell, C., and Donald F. Schwarz, "Prevalence and Impact of Exposure to Interpersonal Violence Among Suburban and Urban Middle School Students," Pediatrics, 1996; 98:396-402. 14. Available online at www.ojp.usdoj.gov/bjs/guns.htm. 15. Available online at www.ojp.usdoj.gov/bjs/homicide/multiple.htm. 16. See, e.g, Reiss, A.J., and J.A. Roth, Understanding and Preventing Violence, National Academy Press, 1993, pp. 260-261; Zimring, F.E., and G. Hawkins, Crime Is Not the Problem: Lethal Violence in America, Oxford University Press, 1997, pp. 106-123. 17. Saltzman, L.E., J.A. Mercy, P.W. O'Carroll, M.L. Rosenberg, and P.H. Rhodes, "Weapon Involvement and Injury Outcomes in Family and Intimate Assaults," The Journal of the American Medical Association, 1992; 267:3043-3047. (When a gun is involved in a domestic dispute, it is at least 12 times more likely that the dispute will end in death.) 18. Zawitz, Marianne, Firearm Injury From Crime, U.S. Department of Justice, Bureau of Justice Statistics, 1996. 19. "Firearm-Associated Homicides Among Family Members, Relatives, or Friends--Ohio," Epidemiologic Notes and Reports, Morbidity and Mortality Weekly Report, 1989; 38 (15):253-256. 20. Larson, Eric, Lethal Passage, Vintage Books, 1995, p. 86. (Describing student holding up French textbook to ward off bullets from a Cobray M 11/9 semiautomatic pistol shot by a fellow student.) 21. Slevin, Peter, "District Teen Gets 127 Years in Random Shooting of Four," The Washington Post, Jan. 6, 2000, p. B2. 22. A list of multiple-victim shootings in the United States is available online at www.millionmommarch.com (formerly www.bellcampaign.org). 23. Temple, Scott, "Treating Inner-City Families of Homicide Victims: A Contextually Oriented Approach," Family Process, 1997; 36 (2):133-149. 24. Schwab-Stone, Mary E., Tim S. Ayers, Wesley Kasprow, Charlene Voyce, Charles Barone, Timothy Shriver, and Roger P. Weissberg, "No Safe Haven: A Study of Violence Exposure in an Urban Community," Journal of the American Academy of Child and Adolescent Psychiatry, 1995; 34 (10):1343-1352. 25. Duncan, David, "Growing Up Under the Gun: Children and Adolescents Coping With Violent Neighborhoods," Journal of Primary Prevention, 1996; 16:343-356. 26. Bastian, Lisa, and B. Taylor, Young Black Male Victims, U.S. Department of Justice, Bureau of Justice Statistics, 1994. 27. "Adolescent Assault Victim Needs: A Review of Issues and a Model Protocol," Pediatrics, 1996; 98:991-999. 28. Slevin, Peter, "District Teen Gets 127 Years in Random Shooting of Four," The Washington Post, Jan. 6, 2000, p. B2. 29. Jackman, Tom, "Group Urges More Help for Victims of Crimes," The Washington Post, Dec. 15, 2000, p. B5. 30. Christoffel, K.K., "Youth Violence Prevention: The Physician's Role," medical student Journal of the American Medical Association (msJAMA). 31. Nader, Kathi, Robert Pynoos, Lynn Fairbanks, and Calvin Frederick, "Children's PTSD Reactions One Year After a Sniper Attack at Their School," The American Journal of Psychiatry, 1990; 147:1526-1530. 32. Bell, C.C., and E.J. Jenkins, "Exposure and Response to Community Violence Among Children and Adolescents," in Children in a Violent Society, Osofsky, ed., The Guilford Press, 1997. 33. Richters, John E., and Pedro Martinez, "The NIMH Community Violence Project: I. Children as Victims of and Witnesses to Violence," Psychiatry, 1993; 56:7-21. 34. Rand, M.R., Violence Related Injuries Treated in Hospital Emergency Departments, U.S. Department of Justice, Bureau of Justice Statistics, 1997. 35. Cook, P.J., B.A. Lawrence, J. Ludwig, and T.R. Miller, "The Medical Costs of Gunshot Injuries in the United States," The Journal of the American Medical Association, 1999; 282:447-454. 36. Kizer, K.W., M.J. Vassar, R.L. Harry, and K.D. Layton, "Hospitalization Charges, Costs, and Income for Firearm Related Injuries at a University Trauma Center," The Journal of the American Medical Association, 1995; 273:1768-1773. 37. Cook, P.J., B.A. Lawrence, J. Ludwig, and T.R. Miller, "The Medical Costs of Gunshot Injuries in the United States," The Journal of the American Medical Association, 1999; 282:447-454. 38. Ordog, G.J., J. Wasserberger, and G. Ackroyd, "Hospital Costs of Firearm Injuries," The Journal of Trauma, 1995; 38:291-298. 39. Ibid. 40. Klein, S.R., I.J. Kanno, D.A. Gilmore, and S.E. Wilson, "The Socioeconomic Impact of Assault Injuries on an Urban Trauma Center," The American Surgeon, 1991; 57:793-797. 41. Goldman, H., "Gun Violence in the U.S. Costs More Than $100 Billion a Year," Bloomberg News, available online through Deseret News Archives at deseretnews.com. 42. Available online at www.spinalcord.org/resource/Factsheets/factsheet2.html. 43. DeVito, M.J., "Causes and Costs of Spinal Cord Injury in the United States," Spinal Cord, 1997; 35:809-813. 44. Holicky, R., "Violently Acquired SCI: A Recipe for Inequity." Available online at www.spinlife.com (reprinted from New Mobility, March 2000). 45. The National Education Association has issued Advice for Journalists covering school shootings. See www.nea.org/issues/safescho. 46. Brooks, K., V. Schiraldi, and J. Zeidenberg, School House Hype: Two Years Later, Justice Policy Institute/Children's Law Center, 2000. Available online at www.cjcj.org/schoolhousehype/shh2.html. 47. Spungen, Deborah, Homicide: The Hidden Victims, A Guide for Professionals, Sage Publications, 1998, pp. 110-111. 48. While a recent survey conducted for OVC indicates that 23 percent of the programs enter information into their databases about whether the crime was gun related, OVC does not require states to report the number of claimants who were victims of gun violence, although states do report categories of "assault" (34 percent of claims) and "survivors of homicide" (11 percent of claims). 49. In October 1996, OVC recommended that hospital-based counseling and prevention programs be established in medical facilities that provide services to adolescent gunshot victims and victims of gang violence. In May 1998, OVC made the same recommendation in New Directions From the Field: Victims' Rights and Services for the 21st Century. 50. Gregorie, Trudy, School Violence--Are You Prepared To Respond? National Center for Victims of Crime, 1999. Available online at www.ncvc.org/newsltr/schvio.htm. 51. Brock, K., When Men Murder Women: An Analysis of 1997 Homicide Data: Females Murdered by Males in Single Victim/Single Offender Incidents, Violence Policy Center, 1999. ---------------------------- Judith Bonderman, J.D., M.P.H., teaches a course on gun violence prevention at the George Washington University School of Public Health and Health Services. She thanks the roundtable participants for sharing their experiences and for their candid and full discussion of the issues. ---------------------------- This document was prepared under the direction of the Office for Victims of Crime, Office of Justice Programs, U.S. Department of Justice. The opinions, findings, conclusions, and recommendations expressed in this document are those of the author and do not necessarily represent the official position or policies of the U.S. Department of Justice. The Office for Victims of Crime is a component of the Office of Justice Programs, which also includes the Bureau of Justice Assistance, the Bureau of Justice Statistics, the National Institute of Justice, and the Office of Juvenile Justice and Delinquency Prevention. ---------------------------- NCJ 186155