Violent Youth Mortality (15-24) in 21 st Century-Suicides, Assaults, Transport Deaths in USA and other Western Countries.

Introduction: Adolescence is characterized by impetuosity, which can lead to fatalities- suicide, assault, and transport deaths, the key being access to lethal means. This population- based study examines violent deaths in the 21st Century by comparing America with nineteen Other Western Countries’ (OWC). Method: All mortality data is drawn from WHO latest report, comparing bases- line years 2000-02 to index years 2013-15 for Youth (15-24years) of both sexes. Changes in Youth rates per million (pm) of these three types of violent deaths are calculated and for Total mortality the Age-Standardized-Deaths-Rates (ASDR). Chi square test are used to compare each OWC with the USA outcomes. Based upon the world- small- arms survey national gun ownership per thousand persons (ptp) are examined and rank order correlations used to determine any possible association. Results: Over the period USA Suicide rates increased for Youth by 16%, the average in OWC was a 22% fall. American Youth Assault rate was almost double the Total ASDR (99pm to 55pm respectively) and Youth and ASDR rates were more than fight times the OWC average. USA Youth Transport deaths at 158pm were double the average of other countries. USA gun ownership far exceeded OWC, correlating with Youth suicide. Conclusions: USA Youth Violent death rates are worse compared with most OWCs, especially increased suicide, which correlated with gun ownership. Youth Assaults and Suicide this century numbered 142,784 or 8,924pa. There is a specific need for specific public health focus on American Youth violent deaths which are even higher than recent US military losses.


Introduction
Of the many facets of adolescence is the intensity of the present-when NOW feels like forever. This is wonderfully portrayed in Romeo and Juliet, where youth's bravado with play-full use of lethal weapons unintentionally ends in a fatal duel and at the crisis point of seemingly unbearable anguish, Romeo and Juliet kill themselves. In modern times the impetuosity of youth is reflected in the high motor insurance premiums of Youth (15)(16)(17)(18)(19)(20)(21)(22)(23)(24) as they are disproportionately over-represented in motor accidents, be it the bravado of the cyclist or the less experienced driver, almost attracted by the risk [1][2][3]. This population-based comparative study explores the outcomes of these risks. We build upon an earlier study that examined the extent of gun violence in the USA, with a special focus upon Youths aged 15-24 years old [4], as it is known this is an age of peak violence both as victims and perpetrators [5][6]. Moreover, it is known firearms are a major method of completed could be argued that many Youth suicides and assault deaths were not primarily intentional but a result of a situation that had got out of control.
Furthermore, due to the relatively high rates of transport casualties in every Western country, this form of `violent' category should not be ignored. One feature often ignored is that Youth (15)(16)(17)(18)(19)(20)(21)(22)(23)(24) deaths, be they suicides, homicides or transport deaths all have a sequel, namely life-long grieving parents. This is the nightmare of every parent-that their child should predecease them, more horrendous when their child dies by their own hand [13][14][15], especially when the child used the parent's own weapons [12].
Given the above, it is imperative that we need to confront the extent to which Youth are vulnerable to violent death and for society to respond with adequate public health measures. This is an annual toll that seems to go on virtually unremarked by either media or policy makers. This population-based study examines the three violent Youth death categories in the USA and nineteen Other Western Countries (OWC). It provides an up-to-date analysis of the situation during the 21st century 2000-2015 to explore whether Youth (15)(16)(17)(18)(19)(20)(21)(22)(23)(24) violent deaths in the USA are markedly different from Other Western Countries (OWC). There is one working null-hypothesis.
That there will be no significant differences in the patterns of suicide, assault, and transport deaths since the beginning of the century in America compared with the OWC.

Methodology
A key limitation to a comparative international study of adolescence, is that adolescence is usually defined as those aged between 13-18, however scientifically informed definitions based on neurocognitive, social, and emotional factors suggest a definitional period up to mid-20s is more appropriate. [16][17].
Moreover, international WHO data is only available in specific decade groupings hence we transpose adolescence into mortality of Youths aged 15-24 for this international analysis. All mortality data is drawn from WHO [6]. The three civil forms of violent death consist of suicide defined in the WHO category `Intentional Self-Harm', coded X60-84 Y870 [928]; homicide is Assault coded X81-Y09, Y871 and Transport deaths coded VB01-V99. Transport deaths include every form of transport but mainly road accidents.
Youth (15-24years) death rates are calculated from the numbers of deaths amongst those aged 15-24years, divided by that country's Youth (15)(16)(17)(18)(19)(20)(21)(22)(23)(24) population from which a rate per million can be calculated. As a comparator, we also analyze WHO Age-Standardized-Deathrates (ASDR) per million (pm), which is the total death rate that controls for age, gender and population thus allowing us to compare countries of differing population sizes.
The study examines 3year average baseline rates; 2000-02 to be To compare differences between the mortalities of each country and the USA, chi-square tests are calculated using SPSS to determine any statistical difference, the probability level of <0.05 being taken as significant. As Assault rates are relatively very low, we calculate a ratio of each OWC to the USA Assault rates. A selfevident key feature in Youth risk of violent outcomes in conflict and psycho-social stress situations, is the availability and use of lethal methods, which can end fatally. The presence of firearms is highly lethal whenever or wherever used and known to be associated with young adult suicides in the USA, [7][8][9][10][11]. Moreover, this link between suicide and easy access of guns has long been known to be associated with gun bearing occupations in other Western countries [18][19][20] made especially dangerous by the impetuosity of Youth.
Hence, we juxtapose gun ownership in the each of the countries, based upon the world small arms survey of the number of firearms per thousand persons (ptp) [21]. Spearman rank order correlations
Youth rates were highest in New Zealand at 204per million [pm], followed by Finland 130pm, and Ireland at 125pm, the USA was fifth highest at 116pm. Down to lows of 26pm in Greece, 27pm Portugal and 34pm in Italy. The overall Western average, minus the USA, fell from 99pm to 81pm a fall equivalent of 18% over the period, whilst Youth suicides in the USA increased from 100pm to 116pm -an increase of 16% over the period. Youth suicide rates also rose in Greece, the Netherlands and Sweden, increasing substantially (>10%). Comparing the average OWC suicide rate with the USA yielded an odds ratio of 1:1.43. Chi square results showed that rates in Austria, Belgium, Denmark, Ireland, Finland, Norway, Switzerland fell significantly more than the USA (<0.05).

Total Suicides ASDR
Total suicides, Age-Standardized-Deathrates were highest in Belgium 135pm, Finland 129pm and the USA120pm. Greece, Italy Portugal and Spain were lowest ranging from 39pm to 60pm. The OWC average was 92pm, which produced a OWC to USA ratio of

Assault Deaths
Youths: The highest Youth homicide deaths were in the USA at 99pm, followed by Canada 21pm and Sweden 18pm, the lowest being the UK at 2pm, Switzerland 3pm and Norway 4pm, indeed fifteen countries had rates of less than 10pm. It is noteworthy that every country rate fell over the period except in Sweden and Greece. American Youth assault deaths at 99pm, were a substantial fall of 23% over the period. However, with such small actual rates, percentages exaggerate relatively small absolute differences and have a disproportionately high impact on the ratios. Youth average OWC assault deaths were 8pm, which produces an OWC to America ratio of 1: 13.4.

Total Assaults
The highest ASDR assaults rates were the USA at 55pm, Finland 14pm, and Canada and New Zealand at 13pm, whilst the UK 2pm and Switzerland 3pm were lowest, with thirteen countries having rates of less than 10pm. The overall OWC average of 7pm gives an OWC to USA ratio of 1:7.86. Total ASDR and Youth assaults rates in all countries strongly correlated (Rho=0.7027 p<0.001) ( Table 2). It should be noted that every country's Youth rates were higher than ASDR and in eighteen countries were 30% higher. Seventeen countries had significantly greater reduction over the period than the USA. Total and Youth transport deaths of all countries positively correlated (Rho=+0.9280) ( Table 3).  The big concern is the rise in American Youth suicides. Conversely the decline of Youth transport deaths in during this century can be framed as a public health success story; evidence that governments have responded to the issue of road deaths with policy changes in several areas-e.g., legislation, infrastructure, incentivization of car safety, education, and law enforcement. Whilst the USA transport death rates remained relatively high there were still substantial reductions. Another matter of concern is the assault death rate in the USA, which is ten times higher than the mean assault rate of the  [9,[23][24]. Whilst in most American States eighteenyears old can legally purchase guns [10,25]. which reflects the fact that there are more guns in the USA than people-1205per 100,000

Gun Ownership
persons [21]. Whilst there are some early encouraging signs of a public health approach to access to firearms in a new initiative for proper domestic care of firearms where children are present, in response to the number of accidental gun-deaths at home [26][27].
Nonetheless these results show there are significant differences in the patterns of suicide, assault, and transport deaths, appear to reflect an innate cultural factor as there were strong positive correlations between all mortality categories and Youth and Total deaths rates, and the differences found between the USA and the other nations regarding violent deaths means the null hypothesis is rejected.
It is beyond the scope of this study to explain causal factors that contributed to differences between the USA and all the other countries, though based on our findings we would suggest that there is a specific need for further public health focus on Youth violence in the USA. Averaging over 10,000 p.a indicates more than 5,000 deaths would be from by firearms, higher than recent USA military losses in the Afghan and Iraq wars, surely demands serious public health attention [4]. But there is another `public health' aspect. Most 15-24-year-old suicide and homicide victims will have parents, who will have experienced the reality of every parent's nightmarethat their child should pre-deceases them, creates a massive mental health burden [10,[13][14][15]. To evoke change in the USA strong factbased language is needed. As a recent American study calculated, that if the firearm death-toll continues at the present rate, then one in five of today's adolescents by adulthood will have had a family member or close friend who died by gunfire [28]. Until such an ongoing toll is more widely realised by the public-that their Youths are dying annually to virtually match the annual Vietnam war American death-toll, then there will be little political will to stem the tide of these young lives lost [29][30][31].
required. Both authors shared equally in the design development and final write-up of the project.