CHARGE (Children’s Hospital Association Research in Gun-Related Events): Building a Research Home for Children Who Survive Firearm Injury

The Stories That Aren’t in the Data — How CHARGE Began

Every year, thousands of children in the United States experience firearm injuries. In 2023, children and adolescents were victims of 4,470 firearm fatalities and an estimated 28,711 firearm injuries, representing increases of 34% in fatalities and 73% in injuries in just five years.¹Centers for Disease Control and Prevention, Web-Based Injury Statistics Query and Reporting System (WISQARS) [Online], accessed July 12, 2026, www.cdc.gov/injury/wisqars Despite the outsized burden on children who experience a nonfatal firearm injury, a paucity of research informs interventional efforts to support children and families who survive firearm injuries.

As a pediatric emergency medicine fellow, it was too common to treat children and adolescents with gunshot wounds. The care followed a set routine and moved quickly. They would often “get patched up” and go home the same day. What struck me wasn’t just the injury itself but its ripple effects. Many children were admitted with new medical complexities, while others returned to the ED with new chronic conditions, mental health diagnoses, and patterns of health care use that hadn’t existed before they were shot. Yet almost no one has studied this phenomenon nor identified the most effective and important ways to intervene.

At the time—circa 2019—firearm injury research about children was thin. The literature focused overwhelmingly on death by firearms. That work matters enormously, but it left an entire population invisible: the survivors. Kids who live with bullet fragments still in their bodies, kids who stopped walking to school because the walk itself became terrifying, kids whose grades collapsed because they couldn’t concentrate in class anymore. Their stories were not in any dataset we could find.

This raised questions without apparent answers. That’s how CHARGE, the Children’s Hospital Association Research in Gun-Related Events research consortium, came together. We built a close partnership with the Children’s Hospital Association (CHA), which gave us access to the infrastructure, data, and expertise to study this population at scale. What began as a handful of interested fellows, junior and senior faculty has grown into a multi-institutional collaborative with impressive diversity geographically (including UCLA, Harvard, Vanderbilt University, Emory University, the University of Colorado, the University of Vermont, and others) and in terms of disciplines (such as pediatric emergency medicine, pediatric surgery, child and adolescent psychiatry, and pediatric hospital medicine).

What the Data Showed Us

Our first major study, published in 2021, looked at 1,821 children with Medicaid coverage who survived a firearm injury.²Christian Pulcini et al., “Nonfatal Firearm Injuries: Utilization and Expenditures for Children Pre- and Postinjury,” Academic Emergency Medicine. 28, no. 8 (2021):840–847, doi:10.1111/acem.14318 We compared their health care use one year before and one year after the injury. The results were stark. Across our sample, health care encounters rose from about 22,000 to nearly 28,000. Health care expenditures increased by $16.5 million across the cohort: roughly $9,000 per child. These encounter and expenditure totals are combined across the full cohort of 1,821 children, and they reflect overall health care use; the mental health service patterns described in the next section followed a different course. Most striking to us: The share of children who qualified as having a complex chronic condition—meaning a condition expected to last more than a year and that required ongoing, intensive care—rose by 50% after the injury. These weren’t children who were already sick. Almost all of them had been perfectly healthy before they were shot.

We then turned to mental health and expected a straightforward story of increased need and increased care. What we found was more complicated and, frankly, more troubling. Overall, mental health service use didn’t change much in the year after injury. But when we looked closely at specific groups within our larger sample, a pattern emerged: Children who had no documented mental health needs before their injury saw mental health encounters jump 131%.³Christian Pulcini et al., “Mental Health Utilization and Expenditures for Children Pre–Post Firearm Injury,” American Journal of Preventive Medicine 61, no. 1 (2021):133–135, doi:10.1016/j.amepre.2021.01.024

Children who already had high mental health needs before their injury saw their care drop by nearly half. The kids who most needed ongoing mental health support after surviving a shooting were the ones least likely to get more of it. What’s driving that drop, isn’t yet clear from our data, and it’s a question we’re actively investigating. Is it cost, resource strain, treatment triaging, gaps in follow-up, or some combination? That finding pushed our group to dig further into who falls through the cracks and why—and this has shaped a lot of our subsequent work. What’s more, when our group and other researchers reviewed the full body of literature on this topic in 2025 (15 studies in all, a paltry number given the scope of the problem), we found the same trend. Hospitalizations, readmissions, emergency visits, mental health diagnoses, and health care spending all rose after a nonfatal firearm injury, regardless of how a study measured it or which database the authors used.⁴Joseph Du et al., “Pediatric Nonfatal Firearm Injury Health Care Utilization,” Pediatrics 156, no. 1 (2025):e2024070424, doi:10.1542/peds.2024-070424

Putting a Face on the Numbers

Survey and hospital data can tell only part of this story. A few years ago our group wrote about a patient we called Nick to give a face to a seemingly invisible problem.⁵Christian Pulcini et al., “A Holistic Approach to Childhood Firearm Injuries,” Pediatrics 153, no. 1 (2024):e2023063322, doi:10.1542/peds.2023-063322 Nick was 12 years old when gunshots came through his backyard fence. He survived without major injury and was discharged from the emergency department that day. But he started hearing phantom gunshots. He had panic attacks. He was afraid to walk to basketball practice. He came back to the emergency department three times over the following year before anyone connected him with mental health care. By then Nick was actively suicidal. After his injury, 14 months passed before he received the care he needed.

Nick’s story isn’t rare. Between 47% and 70% of children who survive a firearm injury are discharged straight from the ED. This means there is a only narrow window to catch what comes next. We established a set of recommendations for hospitals, researchers, and policymakers to address that gap.⁶Christian Pulcini et al., “A Holistic Approach to Childhood Firearm Injuries,” Pediatrics 153, no. 1 (2024):e2023063322, doi:10.1542/peds.2023-063322 We suggested strengthening the handoff between trauma teams and mental health providers, training ED staff to screen for trauma symptoms before discharge, and funding the kind of longitudinal research that can tell us not only whether children struggle after these injuries, but when and how—and which children the health care system fails to identify and support in time.⁷Christian Pulcini et al., “A Holistic Approach to Childhood Firearm Injuries,” Pediatrics 153, no. 1 (2024):e2023063322, doi:10.1542/peds.2023-063322

Why This Work Matters Now

None of this research changes how a bullet enters a child’s body. But it makes visible a population that health systems, insurers, and policymakers have largely overlooked: the children who survive. If a child’s care costs rise by thousands of dollars in the year after a shooting, if their odds of a new mental health diagnosis jump by more than 50 percent, if the ones with the highest need are the ones least likely to get help, that’s not a set of statistics to file away.

We started CHARGE because we wanted answers when families asked us what came next for their child. Years later, we still don’t have all of them. But we know a lot more than we did, and we understand better where the gaps remain: longer-term outcomes beyond that first year; the impact on siblings and parents; disparities by race, ethnicity, geography, and income that none of the current data sources fully capture; and which interventions work best for different populations after a firearm injury. Building the evidence base to close those gaps is the next chapter of this work, and it’s one we hope more researchers, clinicians, and advocates will help us write.