Youth violence is the intentional use of physical force or power to threaten or harm others by young people ages 10−24 years; a young person can be involved with youth violence as a victim, offender, or witness.¹ Youth violence has significant long-term effects on the physical, social, and emotional health of youth and families.² In 2020, there were over 6,500 homicides and over 300,000 emergency departments (ED) for nonfatal assault injuries among U.S. youth ages 10−24 years, each representing an substantial and long-term societal cost for individuals, families, and communities including schools.³ The annual economic burden of U.S. youth violence is an estimated $120 billion in medical spending, lost productivity, reduced quality of life, and avoidable mortality.⁴ More information on the most frequent assault mechanisms—or, causes (e.g., firearms, cut/pierce, etc.)—affecting youth can support the development and implementation of effective public health strategies. Information on the burden of firearm injuries specifically, is critical but analysis requires an intentional method with available data. Using nationally representative data, this study estimated the annual health and economic burden of U.S. youth violence by injury mechanism.

In 2023, the number of homicides and nonfatal assault intent ED visits by disposition (treat and release or hospitalized) in 2020 among U.S. youth aged 10−24 years and the average economic cost of those injuries were obtained from CDC’s publicly available Web-based Injury Statistics Query and Reporting System (WIS-QARS). Institutional review was not required. Underlying surveillance and cost methods for the data source are described elsewhere.⁵ Information on youth homicides came from the National Center for Health Statistics mortality files.⁶ Information on ED visits came from the National Electronic Injury Surveillance System-All Injury Program, a U.S. nationally representative probability sample of hospitals.⁷ Medical spending and lost work costs due to nonfatal injuries were assessed using regression-based cost of illness methods applied to the Healthcare Cost and Utilization Project National Emergency Department Sample (HCUP-NEDS) (which can produce survey-weighted national estimates of community hospital encounters) and MarketScan Commercial Claims and Encounters Databases (which demonstrate medical payments to providers from approximately 350 health insurance payers—employers, health plans, and public organizations).⁸⁻¹⁰ The monetary value of injury morbidity and mortality was determined based on quality of life loss estimates for injuries by mechanism and intent (e.g., assault). It also considered recommended methods for estimating the value of statistical life (VSL), a monetary measure of the collective value placed on reducing the risk of mortality. This estimate is derived from research studies of revealed preferences (e.g., observed wage differences for dangerous occupations) or from stated preferences obtained through surveys of individuals’ willingness to pay for mortality risk reduction.¹¹⁻¹³ VSL is higher for children than adults.¹⁴ Cost estimates as 2020 USD used the societal perspective, including tangible and intangible costs to multiple payers and a 1-year time horizon for nonfatal assaults.

WISQARS reporting on nonfatal ED visits for some injury mechanisms—including firearm assaults—is not available due to small sample sizes in the underlying surveillance source data. To comprehensively present the health and economic burden of youth violence injuries by mechanism, when 2020 WISQARS estimates by injury mechanism were unavailable for the 10–24 age group, data were supplemented with annualized estimates from WISQARS and HCUP-NEDS for the years 2018–2020. Nonfatal injuries in HCUP-NEDS were identified using recommended ICD-10-CM codes (Appendix Table 1, available online).¹⁵ The number and cost of nonfatal firearm assault ED visits were not available even with combined 2018–2020 WISQARS data and such injuries are known to be undercounted in administrative data sources including HCUP-NEDS.^16,17 To estimate the annual number of youth firearm assault-related ED visits more accurately, the authors multiplied the percentage of nonfatal firearm ED visits with assault intent among patients aged 10–24 years, as found in the 2018–2020 National Electronic Injury Surveillance-Firearm Special Study (NEISS-FISS), by the total number of nonfatal firearm ED visits (regardless of intent) in 2018–2020 HCUP-NEDS.¹⁶ NEISS-FISS data come from a probability sample of U.S. hospitals; medical records for firearm injuries are validated by medical coders.⁷ Nonfatal firearm injury average costs were applied from previous studies.^5,12,18

Of the $86B estimated annual economic burden of youth homicide, $78B was caused by firearms, $4B by cut/pierce injuries, and $1B by unspecified causes (Table 1). Most of the economic burden of youth homicide came from lost life years valued using VSL (approximately $12–13M per homicide—variation due to victim age) rather than medical spending (not all homicide victims received medical care—$3,000–$25,000 average per homicide by injury mechanism). Of the $36B billion estimated economic burden of nonfatal youth violence injuries, $19B was caused by struck by/against injuries, $3B by firearm injuries, and $365M by cut/pierce injuries (Table 2). Each nonfatal assault ED treat and release visit among youth cost approximately $8,000 in medical spending, $800 in work loss costs, and $97,000 in morbidity-related reduced quality of life over the follow 1 year. Those costs were higher—$96,000, $9,000, and $105,000—for injuries requiring hospitalization (13% of ED visits overall and highest for firearm injuries—52%).

In 2020, the estimated economic cost of homicides and nonfatal assaults affecting U.S. youth was $86 billion in fatal injury costs and $36 billion in nonfatal injury costs. Firearms (homicides, assaults), cut/pierce weapons (homicides), and struck/by against an object (assaults) were the most frequent injury mechanisms. Firearms are involved in over 90% of homicides, nearly 10% of ED visits for assault injuries among youth, and a combined estimated annual economic burden of $81 billion. Avoidable mortality based on VSL was the largest contributing element to the economic burden, reflecting the substantial number of life years lost to violence in this young population. Findings point to the lethality of injuries among youth when a weapon was explicitly or likely involved—firearms and cut/pierce injuries combined accounted for 96% of youth homicides compared to 13% of nonfatal assault ED visits.

In addition to pain and suffering at the individual, family, and community levels youth violence causes a substantial economic burden. Firearm injuries contribute significantly to this burden. Addressing risk and protective factors across various levels is crucial for preventing youth violence. Implementing evidence-based programs, policies, or practices like home visitation programs, pre-school enrichment with family engagement, mentoring or afterschool programs, street outreach, and community norm change campaigns, for example, has been shown to effectively reduce youth violence.¹