Each year, approximately 33,000 Americans die by a firearm, among those are more than 2,500 (about seven every day) children and teens younger than age 20 years.1 Furthermore, 2 to 3 times as many are hospitalized every year for a nonfatal gunshot injury. Over one-half are homicides, one-third are suicides, and less than 200 are considered unintentional.1 A study comparing firearm deaths in the United States to several other developed nations revealed that American children younger than age 15 years are 12 times more likely to be killed by a gun—including 10 times more likely to commit suicide with a gun and 9 times more likely to die of an unintentional gun injury.2
Guns in American Homes
Guns are ubiquitous in the US; there is nearly one firearm for each person in America.3 About one-half of all homes contain at least one gun, including those with children;4 therefore, most American children have a high probability of being in an environment with a gun at some point during their childhood or adolescence. The American Academy of Pediatrics (AAP) has made firearm injury prevention a high priority and has emphasized the importance of anticipatory guidance in clinical practice—in addition to advocating for better regulation of the use of and sale of firearms.5 This article focuses on unintentional and suicide-related firearm injury prevention, and the critical role that clinicians play in framing a message to convey to families in terms of child development and safety.
Those who provide child health care are accustomed to giving anticipatory guidance for a variety of potential home hazards such as medicines, cleaning products, swimming pools, and unsecured furniture. As part of prevention guidance, pediatricians emphasize the developmental vulnerabilities that put children at risk for injury. Guns are no different in this respect; children are at risk due to their cognitive, emotional, and physical immaturity. However, guns are different from most other home hazards due to their high incidence of fatality. Often there are no second chances. An impulsive teenager or a curious toddler plus an unsecured and loaded gun creates a potentially highly lethal situation.
Numerous studies have demonstrated that a gun in the home increases the risk of adolescent suicide, even when there is no known psychiatric diagnosis. In one study, handguns and loaded guns in the home were specific risk factors.6 This fact is particularly concerning given that large national studies have shown that suicidal thinking is common among teens. The 2015 Youth Risk Behavior Survey found that 14.6% of students nationwide had planned a suicide attempt in the 12 months preceding the survey and 8.6% had actually attempted a suicide in that time frame.7 Teens are naturally impulsive and may seek permanent solutions for temporary problems. And, it matters whether there is a means readily available. If a teen opts to use pills in a suicide attempt, in less than 5% of the time will death result; however, with a gun, that probability is greater than 80%.8 A discussion with families on firearms in the home is especially important as guns used by young people to commit suicide are most often owned by a parent.9
A large case-control study by Grossman et al.10 found that safe storage (ie, guns that are locked, unloaded, and ammunition locked separately) significantly reduces the risk of both suicide and unintentional injury for children and teens. However, nearly 1 in 10 families with guns admit to keeping at least one gun loaded and unlocked, and nearly one-half keep at least one gun unlocked.4 Thus, promotion of safe firearm storage is significant in my view and should be considered a vital part of injury prevention addressed during anticipatory guidance at well-child visits. As part of safety planning for children with mental or behavioral health problems, guns in the home must be addressed.5 Parents who worry about their child's mental stability should be encouraged not to store guns in their home or to practice safe storage as defined previously.
Does Teaching Children Not To Touch Guns Work?
What about teaching children “not to touch” or “tell an adult” if they find a gun? Do these gun-avoidance programs (eg, Eddie Eagle and STAR [Straight Talk About Risks], gun-safety programs for children) work? Although it is difficult to argue with teaching children to not touch guns, current evidence indicates that these programs are not effective in preventing children from handling guns.11-13 Children can be taught the knowledge and the proper response to “what would you do if you saw a gun” but at the time of greatest risk, when a curious child finds a gun (usually with friends or siblings), the behavior does not reflect this teaching.11–13 For older children who are depressed and seeking to harm themselves, teaching them not to touch a gun is likely not to work, as suicide in this age group is most often an emotional and impulsive act with deliberation lasting less than 10 minutes.14
Politics and Guns
Unfortunately, the topic of guns is highly politicized and can be a polarizing and an emotional discussion subject. Some physicians may feel uncomfortable asking about guns in the home for a variety of reasons. They may fear being perceived as intrusive or offensive or they may believe they are legally prohibited from doing so. “Gag” law legislation, which prohibits physicians from asking about guns in the home, has been introduced in several states, including Florida, where it gained the most traction.15 However, a recent final ruling by the US Court of Appears for the 11th Circuit blocked such legislation on First Amendment grounds, thus upholding physicians' right to counsel patients about firearm safety. Confounded media coverage, mass shootings, an upsurge in gun sales, ongoing public debate regarding gun regulation, increasingly relaxed conceal carry regulations, and the failure of child access prevention legislation all affect how we as pediatric clinicians attempt to prevent our patients from being killed or injured by firearms.
Does counseling in clinical settings work in getting parents to store guns safely? A large nation-wide, randomized controlled trial study by Barkin et al.16 found that, in combination with distribution of gunlocks, brief counseling by a physician is effective in promoting safe storage. Whether universal screening for firearms in the home leads to an increase in safe storage is an unanswered question. Past research17 has demonstrated that parents are receptive to screening, but there may be some caveats. A recent study by Garbutt et al.18 surveyed parents to determine if they are receptive to discussing firearm safety with their pediatricians. They further examined whether attitudes differed based on gun ownership. A secondary aim was to ascertain whether parents had been asked by their child's doctor about firearms in the home and their storage. They found that although many parents were supportive when asked about guns in the home during their child's health care visit, a small number had never been asked. Interestingly, and perhaps not surprisingly, parents who owned guns were less likely to be receptive to such screening than parents who did not own guns (58% vs 71%). But, the majority of both owners and nonowners thought pediatricians should advise on the safest way to store firearms in the home.18
Although the study results are seemingly supportive of addressing firearm injury prevention in practice, the best approach is not clear. One consideration is to provide firearm safety information universally rather than directly screening for guns in the home. Given that guns are so common in the US, asking about a gun in the child's home does not address the dangers surrounding children and teens who are affected, so providing information on firearm injury prevention to everyone might be the best approach. However, providing information universally (and only information) has not been demonstrated to be an effective intervention for other childhood injuries.19 Future research comparing universal information provision to a more focused approach may help settle this question. Having gunlocks available to families at the time of providing information may be especially effective. Partnerships with local law enforcement agencies to implement such a program may be possible in many areas through Project ChildSafe, a comprehensive firearm safety education program.20
The ASK (Asking Saves Kids) program,21 promoted by the AAP, focuses on increasing the number of parents who ask about guns in the homes where their children visit. Recommending that parents do this is a good start but to realistically help families, specific guidance should be given, as asking can often feel awkward or uncomfortable. In my view, offering language that parents can use (Table 1) and encouraging them to think about this as they would other concerns such as child safety seats is a step in the right direction.
Examples of How Parents Can Ask About Guns in Homes Their Children Visit
A Call to Action
As experts in child development, pediatricians have a unique advantage in taking on firearm injury prevention in the clinical setting. By framing family discussions with a focus on the developmental capabilities of the child and underscoring the fact that safe activities must align with those abilities, pediatric providers can speak with credibility and authenticity. Emphasizing child safety (as opposed to gun safety) keeps the focus squarely on the child and allows an approach to home injury prevention that is consistent across injury mechanisms.
An emphasis on the curiosity of small children and the impulsiveness of older children (teenagers) can help parents make sound developmentally based decisions. Furthermore, when case fatality is high and second chances are few, it is best to think about “layers” of protection. Yes, it is important to teach children not to touch a gun, but like swimming lessons alone such education is far from sufficient to protect a child. A physical separation (ie, gunlock, fencing around a pool) is required to prevent tragic outcomes that cannot be prevented by child education or supervision alone.
- Centers for Disease Control and Prevention. Fatal injury data. http://www.cdc.gov/injury/wisqars/fatal.html. Accessed March 21, 2017.
- Centers for Disease Control and Prevention. Rates of homicide, suicide, and firearm-related death among children--26 industrialized countries. MMWR Morb Mortal Wkly Rep. 1997;46(5):101–105.
- US Department of Justice, Bureau of Alcohol, Tobacco, Firearms and Explosives, Firearms Commerce in the United States, 2011. https://www.atf.gov/firearms/docs/report/firearms-commerce-united-states-2011/download. Accessed March 21, 2017.
- Schuster MA, Franke TM, Bastian AM, Sor S, Halfon N. Firearm storage patterns in homes with children. Am J Public Health. 2000;90:588–594. doi:10.2105/AJPH.90.4.588 [CrossRef]
- Dowd MD, Sege RDCouncil on Injury, Violence, and Poison Prevention Executive CommitteeAmerican Academy of Pediatrics. Firearm-related injuries affecting the pediatric population. Pediatrics. 2012;130(5):e1416–1423. doi:10.1542/peds.2012-2481 [CrossRef]
- Brent DA, Perper JA, Moritz G, et al. Firearms and adolescent suicide. A community case-control study. Am J Dis Child. 1993;147(10):1066–1071. doi:10.1001/archpedi.1993.02160340052013 [CrossRef]
- Kann L, McManus T, Harris W, et al. Youth risk behavior surveillance – United States, 2015. MMWR Surveill Summ. 2016;65(6):1–174.
- Spicer RS, Miller TR. Suicide acts in 8 states: incidence and case fatality rates by demographics and method. Am J Public Health. 2000;90(12):1885–1891. doi:10.2105/AJPH.90.12.1885 [CrossRef]
- Johnson RM, Barber C, Azrael D, Clark D, Hemenway D. Who are the owners of firearms used in adolescent suicides?Suicide Life Threat Behav. 2010;40(6):609–611. doi:10.1521/suli.2010.40.6.609 [CrossRef]
- Grossman DC, Mueller BA, Riedy C, et al. Gun storage practices and risk of youth suicide and unintentional firearm injuries. JAMA. 2005;293:707–714. doi:10.1001/jama.293.6.707 [CrossRef]
- Hardy MS. Teaching firearm safety to children: failure of a program. J Dev Behav Pediatr. 2002;23(2):71–76. doi:10.1097/00004703-200204000-00002 [CrossRef]
- Himle MB, Miltenberger RG, Gatheridge BJM, Flessner CA. An evaluation of two procedures for training skills to prevent gun play in children. Pediatrics. 2004;113(1 Pt 1):70–77. doi:10.1542/peds.113.1.70 [CrossRef]
- Jackman GA, Farah MM, Kellermann AL, Simon HK. Seeing is believing: what do boys do when they find a real gun?Pediatrics. 2001;107(6):1247–1250. doi:10.1542/peds.107.6.1247 [CrossRef]
- Deisenhammer EA, Ing CM, Strauss R, Kemmler G, Hinterhuber H, Weiss EM. The duration of the suicidal process: how much time is left for intervention between consideration and accomplishment of a suicide attempt?J Clin Psychiatry. 2009;70(1):19–24. doi:10.4088/JCP.07m03904 [CrossRef]
- News AAP Gateway.Journals Federal court strikes down ‘physician gag law’ on guns. http://www.aappublications.org/news/2017/02/16/FloridaGun021617. Accessed April 3, 2017.
- Barkin LS, Finch SA, Ip EH, et al. Is office-based counseling about media use, time-outs, and firearm storage effective? Results from a cluster-randomized, controlled trial. Pediatrics. 2008;122(1):e15–e25. doi:10.1542/peds.2007-2611 [CrossRef]
- Haught K, Grossman D, Connell F. Parents' attitudes toward firearm injury prevention counseling in urban pediatric clinics. Pediatrics. 1995;96(4 Pt 1):649–653.
- Garbutt JM, Bobenhouse N, Dodd S, Sterkel R, Strunk RC. What are parents willing to discuss with their pediatricians about firearm safety? A parental survey. J Pediatr. 2016;179:166–171. doi:10.1016/j.jpeds.2016.08.019 [CrossRef]
- DiGuiseppi C, Roberts IG. Individual-level injury prevention strategies in the clinical setting. Future Child. 2000;10(1):53–82. doi:10.2307/1602825 [CrossRef]
- Project ChildSafe website. http://www.projectchildsafe.org/. Accessed March 21, 2017.
- ASK (Asking Saves Kids) website. http://askingsaveskids.org/. Accessed March 21, 2017.
Examples of How Parents Can Ask About Guns in Homes Their Children Visita
Focus on yourself
“Ok I might be a bit nervous, but I do worry about the safety of my children when I'm not around. So, I've got to ask you…Do you have any guns in the house?”
Focus on your child“I need you to know my kid is really curious and can be mischievous. He gets into everything! So, I've got to ask you… Do you have any guns in the house?”
Focus on the news“I just read a news story about a little boy who found an unlocked gun in his grandfather's house and ended up shooting his little sister. That really scares me... So, I've got to ask you… Do you have any guns in the house?”