Aditi Vasan is an associate fellow at the Leonard Davis Institute of Health Economics (LDI) at the University of Pennsylvania and a pediatrician and researcher at PolicyLab at Children’s Hospital of Philadelphia. Eugenia South is a senior fellow at LDI, an assistant professor at the University of Pennsylvania and faculty director for the Urban Health Lab.

Every night, children in cities across the United States wake up to the sound of gunfire. They hide in their homes, lying on the ground, waiting to hear sirens. Many fear for their own safety. Some think about loved ones lost to gun violence. But all of them will be affected by this violence in some way.

In our hometown of Philadelphia, 2021 is on pace to be the most violent year in the city’s history, with more than 1,800 people, including more than 170 children under age 18, killed or injured by a gun since January. These numbers are staggering, but they tell only part of the story. Each of these 1,800 victims has family members, neighbors and friends who have also been affected. At one pediatric primary care clinic in West Philadelphia, 70 percent of patients — all of them children or young adults — had one or more shootings on their block in the past year.

So when we consider how gun violence affects children, we must think not only about shooting victims and their families, but also about the many children who grow up listening to gunshots at night, bearing witness to neighborhood violence and seeing newly empty seats in their classrooms.

As physicians, we know that trauma and adverse childhood experiences, including exposure to violence, have long-term negative effects on children’s mental health. Children exposed to trauma have higher rates of anxiety, depression and post-traumatic stress disorder. They are also more likely to be withdrawn, irritable and display disruptive behaviors in school in the following years.

But what happens to these children in the days and weeks immediately after a shooting? Our experiences caring for children exposed to violence motivated us to study the relationship between shootings and immediate mental health symptoms among children living nearby. We mapped shootings in West, Southwest and South Philadelphia between 2014 and 2018, and then looked to see how children living in the surrounding blocks used the local pediatric hospital emergency room.

We found that in the two weeks after a shooting, children living in the surrounding two to three blocks were almost twice as likely to come in to the ER for mental health symptoms such as anxiety, depressed mood, insomnia and intentional self-harm. This association was even stronger for children exposed to multiple shootings.

Unfortunately, these secondary traumatic effects of gun violence often go unrecognized and untreated. Children do not always recognize their symptoms as related to this trauma, or disclose them to their caregivers, teachers or physicians. Many children who do recognize and disclose symptoms still have trouble accessing the mental health support they need.

For health-care providers, schools, social agencies, law enforcement agencies and community-based organizations working in neighborhoods with high levels of gun violence, our findings underscore the importance of providing all children with universal trauma-informed care.

This includes recognizing preexisting trauma and acute traumatic stress reactions in children. Instead of punishing or reprimanding children who act out or become withdrawn, all adults who interact with these children should validate their feelings and behaviors as appropriate responses to trauma, help them identify and cope with their emotions, and provide referrals to mental health support — including trauma-focused therapy, if needed. We must also provide resources and support to their caregivers, who have likely experienced trauma as well.

It’s also essential to recognize that in Philadelphia and many other cities, gun violence disproportionately impacts Black children and families living in poverty. This is due to the effects of structural racism, including practices such as redlining and discriminatory bank lending, which have led to persistent racial segregation and concentrated poverty.

Reducing neighborhood gun violence must therefore be a priority for health-care providers, health systems, policymakers and others broadly working toward health equity. This should include evidence-based public health interventions, such as safe storage and background check laws, vacant lot greening, and violence prevention programs. There is also a pressing need for local governments to allocate additional funding to community-based mental health services for children and families. One approach might be to divert funds previously allocated to law enforcement to instead provide support for such services and for violence prevention programs.

Reducing neighborhood gun violence exposure is particularly urgent now, given the surge in depression and anxiety symptoms among teenagers during the pandemic. Black children are particularly at risk, as they are 2.4 times more likely to have lost a parent or caregiver to covid-19.

Gun violence is a public health crisis, and children are suffering. No child should have to wake up to the terror of gun violence. We must do all we can to keep our children healthy and safe.