Hopkins studies effect of violence on children

Particular attention paid to assent, consent

In a popular music video, the star is shot in one scene, then in the next, a small plastic bandage covers the purported wound as he continues singing with an arrogant swagger into the next verse. Guns and images of violence are popular entertainment in this country — featured in the plot lines of popular movies, music videos, TV shows, and video games.

A recent study by researchers at Johns Hopkins Medicine’s Hopkins Injury Prevention and Outreach Collaborative (HIPCOC) shows that countering these popular images with realistic images of the consequences of violence can significantly alter the attitudes young people have about aggression and violence.

The study subjects, participants in a Baltimore-area Police Athletic League after-school program, were given a specially designed pre-test to evaluate their existing attitudes about guns and violence. Following that test and then a special presentation by members of the research team, the subjects were taken to visit the emergency department at Johns Hopkins Hospital.

"Our study suggests that the kind of romanticized version of violence shown on television can be countered by more frank and open discussions and displays of what violence really does to the body," says David C. Chang, PhD, MPH, MBA, a coauthor of the study and a graduate fellow in the Department of Health Policy and Management in the Johns Hopkins Bloomberg School of Public Health, and in the Division of Adult Trauma at The Johns Hopkins Hospital.

Researchers at Hopkins, led by trauma surgeon Edward Cornwell, MD, conducted a controlled experimental study exposing a select group of young people, ages 7-17, to Hopkins patients injured as a result of gun violence, then assessed the impact on their attitudes about violence and aggression.

Getting consent

As expected, getting informed consent from a minor population proved challenging.

The IRB required researchers to get at least assent from all subjects. The parents of all of the children were required to give their consent in order for the children to participate in the project.

"We talked to the kids directly and told them what it was about," Chang explains. "In really simple language, we said, We are going to take you to the hospital, see these patients, talk about violence, we are going to ask you some questions about your attitudes before and after.’ So, that is the assent process and asking them to sign the assent form. We also sent home a more detailed consent form for parents to sign."

None of the parents objected to the children being taken to the hospital to visit victims of gun violence, he reports.

The biggest problem was getting the consent forms home with the potential subjects.

"The loss to follow-up was pretty high. We had about 97 kids initially, but only about 40 went through the post-test. There were only about 50% who were organized enough to remember to bring their consent slip. So, we had about a 50% completion rate," he notes. "That is actually where the missing link was, a lot of kids just lost the form on the way home. We had some parents come to pick up kids at the center and we asked them about the study at the center and consented them there — that is where we got a lot of the consent."

The study also was hampered somewhat by the loss of a planned control group for comparison. Originally, researchers planned to administer the pre-test and post-test questionnaires to a group of students of similar age and demographic distribution at a local alternative learning center, which at the beginning of the study had not yet opened and would not have had access to the research intervention — the visit to the hospital and specific exposure to images of the real-life consequences of violence.

However, the administrators of the center withdrew their consent for the research after the initial questionnaire and meeting, so researchers were unable to include those subjects in the study results.

Protecting privacy

At the beginning of the study, researchers gave the participants the pre-test questionnaires assessing the youths’ attitudes regarding interpersonal conflict, including their likelihood to act violently.

Only information about the participant’s age and gender were collected by the surveys. All pre-test surveys were assigned a number, with the researchers asking subjects to remember their number and use only the number on the post-intervention questionnaire.

In this way, the survey results were anonymous.

As the intervention researchers conducted educational sessions with the children, in addition to the ED visits, showing explicit photos of actual trauma patients treated for gunshot wounds.

The HIPCOC team compared the photos to rap videos that glamorize violence. For example, one music video shown portrayed a singer getting shot, and in the next scene he continued life as usual, wearing a small Band-Aid on his face. By contrast, the images Cornwell and colleagues offered to the participants included those of a man whose abdomen was torn open by a bullet wound, and a pregnant woman who was shot in the abdomen, killing her 8-month-old fetus.

A follow-up survey completed by 48 youths showed a significant reduction in quantified beliefs supporting aggression.

Beyond the study

Going forward, the research team is putting together a video, using footage from music videos and footage from the Hopkins 24/7 series, to be used by different groups as a violence prevention tool.

Once the video is finished, the researchers want to do another evaluation, similar to the original study using only the video as an intervention.

Portions of the youths’ visits there were captured on the ABC television miniseries Hopkins 24/7.

"On MTV, you see people get shot and get up with a bandage on their head. On Hopkins 24/7, you see a patient who was shot talking about his life and how it has permanently changed," Chang says. "The show did a good job of capturing the kids’ reaction. When they went into the room to see the patient, the wound was very clean, it was almost healing, it looked good for a clinical perspective, but many of the kids looked away and that was captured on camera. So, we actually contrast that to the cleaned-up image that MTV showed."