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The State Of Our Children 360: November 2023

In this month's edition, get an in-depth look and perspectives from subject matter experts about injury prevention and safety.

Articles in this issue:

Preventing Injuries: The Importance of Recognizing and Reporting Concerning Behavior

Two children pushing a younger childOne of the infrequent but devastating situations affecting our youth today involves instances of targeted violence. There are a number of well-known phrases that embody these situations, such as school shootings, school violence, mass shootings and active shooter incidents. In addition to acts of targeted violence, some of our youth today will experience other situations that lead to serious injury, such as drug abuse, dating violence and suicide attempts. There are many different types of intervention mechanisms in place that seek to prevent these types of occurrences, but one of the critical components to these preventive measures is often overlooked – the reporting piece. One of the hard truths about violence prevention programs is that they rely heavily on people coming forward when they observe behavior of concern, and this is often one of the most difficult pieces to achieve.

Most, if not all, instances of targeted violence are preceded by warning signs or concerning behaviors on the part of the would-be perpetrator. People don’t just “snap,” they make a decision that violence is the only way they can address their grievance. Although a person’s grievance may not make sense to others, it makes sense to them, and in extreme situations, they start moving along a pathway towards violence. This pathway has identifiable stages in most cases and presents opportunities for intervention if brought to the attention of someone who can help.

In so many cases of targeted violence and other situations leading to injuries, when looking back after the act, there were a number of warning signs that were observed by different people, yet not reported or not acted upon. There seems to be a wide variety of reasons people don’t report concerning behavior, including not wanting to get involved, not wanting to be labelled a “snitch,” fear of causing problems for someone who might be innocent, fear of retaliation, assuming that someone else will report, not wanting to waste the time of law enforcement, or because of fear or mistrust of law enforcement or other authorities.

“One of the hard truths about violence prevention programs is that they rely heavily on people coming forward when they observe behavior of concern, and this is often one of the most difficult pieces to achieve.”

A number of reporting mechanisms have emerged to address the need for obtaining information about behaviors of concern while addressing the apprehension of those who have information to share. Many reporting systems are based for school environments and advertised to help prevent acts of harm to self, harm to others, bullying and suicidality. Most of these types of reporting mechanisms advertise anonymity as a key feature. The ability to report suspicious behavior anonymously seems to encourage more people to do so; however, there are some disadvantages, such as not being able to contact the reporting party for more information and an increased potential for hoax or malicious tips.

In addition to school-based programs, the U.S. Department of Homeland Security launched the “If You See Something, Say Something” campaign in response to the terrorist attack on September 11, 2001 and many other law enforcement and intelligence organizations have initiated Suspicious Activity Reporting programs where people are encouraged to report concerning behavior potentially related to terrorism or criminal activity. Many jurisdictions have regional tip lines for anonymous reporting of suspicious activity. In the Central Valley of California, Valley Crime Stoppers has been providing an anonymous reporting service with the goal of deterring, reducing, and solving crimes since the 1990s.

Once a concern is reported, there should be a multi-disciplinary response to assess and mitigate any potential threat that is discovered. The groups that work to prevent violence are often called “threat assessment teams” or “threat assessment and management teams,” although other terms such as “behavioral intervention teams” are also used. These types of teams are becoming far more common, and while they have been evolving for several decades, they are still not well known in many areas. Many more schools are now employing these types of teams to mitigate student threats, and while there has been some concern that students will be dealt with in a much more punitive manner when engaged by one of these teams, the goal of threat assessment and management is to prevent violence and provide intervention and support to students who are encountering difficulties.

While there is a growing number of multi-disciplinary threat assessment and management teams, there is also a greater need than ever for our young people to be able to recognize and report concerning behavior. Prevention of violence and harm is the goal, and in order for this to be accomplished, we need to have a population willing to report when they see something concerning.

About the Author

Bill Ward is the operations commander for the Madera County Sheriff's Office.

More Than Just an Injury: The Greater Impact

A little girl pulling down a pot from on top of a stoveAs a pediatric trauma surgeon, while a large part of my job is in treating injuries after they occur, I have come to understand the immense significance of injury prevention in safeguarding the well-being of our children. Injuries are a leading cause of morbidity and mortality among pediatric populations, capable of causing long-lasting physical and emotional consequences. By prioritizing injury prevention measures, we can significantly reduce the burden of trauma on children and their families, ultimately promoting a healthier and safer future.

Injury prevention is crucial because it addresses the root causes of child injuries, which are the number one case of death of children and teens. Many childhood injuries are predictable and, most importantly, preventable. Taking proactive measures such as car seat usage, childproofing homes, and promoting safe sports practices can significantly reduce the incidence of injury. Valley Children’s Trauma Program participates in a wide range of education on helmet use, car seat safety, firearm safety and more. Implementing safety regulations in schools, community spaces, and public areas further strengthens prevention efforts. By proactively addressing risk factors, we have the opportunity to spare countless children from the pain and suffering associated with preventable injuries.

Additionally, injury prevention promotes the overall well-being and development of children. Injuries can have a profound impact on a child's physical, cognitive and emotional development. A serious injury not only requires medical intervention, but also necessitates significant rehabilitation and psychological support, disrupting the normal trajectory of a child's life. Preventing injuries allows children to focus on their education, social interactions, and exploration of the world, ultimately enabling them to reach their full potential.

Finally, injury prevention is not only beneficial for the child but also for the entire community as a whole. When children remain safe from injuries, families experience reduced stress and financial burden. Additionally, the healthcare system benefits from a decreased demand for emergency services and long-term care. This allows us to allocate resources more effectively, ultimately driving down healthcare costs. A community that prioritizes injury prevention fosters a culture of safety, where parents, educators, and healthcare providers work together to protect and nurture the well-being of our children.

Overall, injury prevention plays a vital role in ensuring the safety, development and overall well-being of our children. By implementing proactive measures, addressing risk factors, and creating a culture of safety, we can significantly reduce the incidence and impact of child injuries. Together, as a community, we have the opportunity to create a safer and healthier environment for our children, fostering their potential and securing a brighter future.

About the Author

Dr. Shannon L. Castle, FACS, FAAP joined Valley Children’s as a pediatric surgeon in 2018. She serves as medical director of trauma at Valley Children's Hospital.

Be SMART: Safe Firearm Storage Saves Lives

Little girl reaching into drawer where a handgun is storedMany people may not realize it, but injuries account for the majority of child deaths in the United States. Over the past several decades, we have seen significant reductions in child deaths from falls, motor vehicle collisions and sleep-related deaths in infants. In each case, this has been due to comprehensive, multilayered advocacy which employed public safety messaging, community outreach, improvements in product design and regulation, and legislative efforts.

At the same time, we have seen significant increases in both fatal and nonfatal injuries in children from firearms. In fact, firearm injuries are now the leading cause of death of U.S. children. These deaths are comprised of three intent types: unintentional shootings, which typically involve toddlers and younger children, suicides and homicides. Regardless of the intent type, though, these injuries and deaths are preventable.

One of the most effective tools we have to keep our kids safe is also the simplest: safe storage, also known as secure storage, which is storing firearms in a way that prevents kids from gaining access to them. One of the main reasons safe storage is so effective at preventing child firearm injury and death is because it addresses all three categories of intent.

In fact:

Unfortunately, many people don’t realize the danger unsecured firearms pose to children. Often times, caregivers believe that kids either don’t know they own firearms or don’t know where they are, but studies have shown that up to 87% of kids know where their parents’ firearms are secured, and 60% report having handled them, even when parents have told them not to.

That’s why the safest way to store firearms is to ensure they are unloaded and locked in a device like a safe, separate from the ammunition, which should also be locked up. However, depending on a family’s reason for owning firearms, it is important to know about other options, such as biometric safes, lock boxes, or even cable locks, all of which can keep a firearm close at hand if that is important to the owner, but still inaccessible to kids.

While many caregivers may think of keeping firearms away from toddlers and small children, it is important to know that older kids are still at risk. Suicide is now the third leading cause of death of U.S. children, and guns are the most common fatal means used. This is because firearms are fatal 90% of the time when used in a suicide attempt.

Most school shooters also use firearms from their or a relative’s home. Oftentimes the firearms in a home are an important part of family traditions like hunting or sport shooting. It’s important to know that even if an older teen might behave responsibly around the firearm when an adult is there, the data show us that kids really shouldn’t have access to firearms when adults aren’t around.

One really helpful resource for understanding and spreading awareness of the importance of secure storage is Be SMART:

  • S: Secure all firearms in your homes and vehicles
  • M: Model responsible behavior around firearms
  • A: Ask about the presence of unsecured firearms in other homes where your kids stay and play
  • R: Recognize the role of firearms in suicide
  • T: Tell your peers to Be S-M-A-R-T

Pediatric firearm violence is a public health epidemic, and there are proven strategies that work. Safe storage is the easiest and most accessible, and that’s why it’s so important that people who work with children and caregivers, like community organizations and schools, spread awareness about safe storage. In 2022, California passed AB 452, Pupil Safety, which requires schools to notify parents or guardians of all students of California’s child access prevention laws and laws relating to the safe storage of firearms.

Child access prevention laws hold caregivers civilly or criminally liable for leaving firearms accessible to unsupervised minors. States which have enacted these laws see significantly lower rates of child firearm injury and death. However, notifying caregivers of the existence of these laws is only likely to be helpful if it is paired with guidance regarding secure storage and why it is effective.

This is why it’s so important for all of us to work together to spread awareness about the prevalence of pediatric firearm violence in the U.S. and what we can all do to help prevent it. Just like with motor vehicle collisions, sleep-related deaths and child passenger safety, pediatric firearm injury is preventable, and it requires a comprehensive, layered approach. Firearm safety and secure storage is a very critical first step.

Together, we can all Be SMART to keep kids safe.


About the Author

Dr. Webb joined Valley Children's in August 2012 as a pediatric hospitalist. Board certified in both general pediatrics and pediatric hospital medicine, Dr. Webb enjoys managing a wide variety of conditions from birth to early adulthood, and working with children and families during often difficult times in their lives. Dr. Webb is very active in medical education, as the academic co-chief for hospital medicine within the Valley Children’s Pediatric Residency Program and the chair of the Valley Children’s Medical Staff Education Committee. Dr. Webb’s scholarly interests include curricular development, quality improvement, health literacy and communication and pediatric firearm injury prevention. 

Resources for Safe Storage:

Resources for Pediatric Firearm Epidemiology:


Our Kids: 10 Common Injuries and How to Prevent Them

Did you know that the number one killer of Americans ages 1 to 44 is unintentional injury, or what some people call “accidents?” This is more than all illnesses and diseases combined, yet we often do not talk about it.

As a pediatric trauma nurse with more than two decades of emergency and trauma experience, I have seen the devastating effects of these injuries first hand. As a result, I truly believe that knowledge and awareness is essential to preventing accidents, so I would like to share with you 10 common ways that children get injured and simple ways to prevent them.

  1. Children's hands in the air with "safety" written on their handsFirearm injuries are currently the #1 killer of American children. You can keep children safe from firearm injuries by using Be SMART for secure gun safety and storage. Always keep firearms unloaded, locked up, away from children and with ammunition stored separately. When visiting others, do not be afraid to ask the question, “Where do your keep guns in your home?”
  2. Falls are one of the most common reasons that children are brought to emergency rooms. Simple additions in your home such as installing protective rails on bunkbeds and lofts, and gates at the top and bottom of stairs can prevent many of them. Avoid placing cribs, beds and furniture near windows and purchase window guards. An important thing to remember is that screens are designed to keep bugs out, not children in.
  3. Furniture injuries are another common reason children are injured. Mount flat screen TVs and secure furniture to the walls with an anti-tip strap. Keep heavier items on lower shelves and drawers. Avoid placing remote controls, toys and food in places where kids may be tempted to reach for them.
  4. Drowning can happen at any age so active supervision without distractions such as cellphones, reading, visiting with another person is essential. Pools should be surrounded by a 4-sided, self-closing, self-latching gate. Children and adults should learn to swim by taking swim classes. Adults and caregivers should also consider learning CPR. You can learn more about water safety here.
  5. Motor vehicle crashes are another reason why children and teens are injured each year. Always use seatbelts, car seats and booster seats that are appropriate in height, weight and developmental level for the child. I really encourage every parent with a child of car or booster seat age, to meet with a child passenger safety technician for education on proper use and installation -- doing so is free and you will never regret doing so. Learn more about car seat safety here and/or locate a car seat technician in your area. Adults should also always model safe driving behaviors such as wearing a seatbelt, driving distraction-free and using safe driving contracts with teens.
  6. Fire/burn related injuries are among the leading ten causes of unintentional injury in children ages 0 to 5, with children 2 and younger being at greatest risk. Use smoke alarms where people sleep and on every level of the home and make sure to check smoke alarm batteries once a month. In case of a fire, create and practice a fire escape plan so every member of your family knows what to do and where to go should the unthinkable occur.
  7. Let's face it, sometimes kids get into things that they probably shouldn't such as everyday household items including but not limited to cleaning products and personal care products which can be harmful to kids. Keep medicines up and away from children and teens. Keep cleaning solutions and other toxic products in their original packaging and where children cannot get them.
  8. For our littlest of children, having a safe sleep environment is key. Make sure infants sleep alone, placed on their backs on a firm surface. Avoid sleeping with them on places like couches and recliners. Be sure their crib or play yard meets safety standards and avoid loose bedding, blankets, pillows or soft toys in the crib. Learn more about how to keep your baby safe while they sleep >>
  9. There are many reasons to ride bikes, scooters and skateboards and it is encourage for children and families to get out and get active. When doing so, it is important that children and adults wear a properly fitted helmet as it is the best way to prevent a head injury. Encourage children to follow the rules of the road and ride on sidewalks whenever possible and dress your children in bright clothing so they can be easily seen by drivers.
  10. Whether children are walking to school, the park or a friend’s house, we want them to get there safely. Teach children to look left, then right, then left again and always cross the street at a corner or crosswalk. Teach kids to put phones, headphones and devices down when crossing the street. It is particularly important to reinforce these safety habits with teenagers. Whenever possible, walk on sidewalks and paths, and if there are no sidewalks, walk facing traffic as far to the left as possible.

Always remember simple safety. In my experience, many traumatic events and injuries could have been prevented by simple changes we are all too familiar with such as using a car seat or seatbelt properly, wearing a helmet, having active adult supervision, putting a fence around a pool, securing firearms and more. Injury prevention is everyone’s job, so remember to think twice

There are no accidents and our homes and communities can be much safer with just small changes. Children are our future and it takes a village to raise them. We encourage you to join us in our mission to keep them safe and make injury prevention “your job” too.

About Safe Kids Central California

Safe Kids Central California is led by Valley Children's Hospital, which provides dedicated and caring staff, operation support and other resources to assist in achieving our common goal: keeping your kids safe. Based on the needs of the community, this coalition of agencies in Fresno and Madera counties work together to implement evidence-based programs, such as car-seat checkups, safety workshops and sports clinics, that help parents and caregivers prevent childhood injuries.

About the Author

Kristina Pasma, BSN, RN, CPSI, is a trauma nurse liaison at Valley Children's Healthcare. She is also the Safe Kids Central California Coalition Coordinator and is passionate about educating children and their families about injury prevention at home and in the community.