A 16-year-old with a history of depression tells you he has thoughts of suicide but does not have a specific plan.
Parents bring a 4-year-old child with an 8-year-old sibling to a well-child visit.
Both scenarios offer opportunities for pediatricians to provide anticipatory guidance on decreasing access to firearms, which now are the leading cause of death for U.S. children and youths ages 0-24.
The updated AAP policy statement Firearm-Related Injuries and Deaths in Children and Youth: Injury Prevention and Harm Reduction and accompanying technical report provide guidance, updated information and resources for pediatricians. They also provide evidence on the importance of safe storage of firearms, anticipatory guidance, lethal means counseling, violence intervention programs and legislation.
The documents, from the AAP Council on Injury, Violence, and Poison Prevention, are available at https://doi.org/10.1542/peds.2022-060070 and https://doi.org/10.1542/peds.2022-060071. They will be published in the December issue of Pediatrics.
Scope of the problem
In 2020, use of firearms resulted in 10,197 deaths among those from birth to age 24 years, and they are the leading cause of pediatric deaths, including for homicides and suicides. There also are disparities when considering the race, ethnicity, sex and socioeconomic status of victims.
Among pediatric firearm deaths, homicides account for 58%, suicides 37%, unintentional shootings 2% and legal intervention (i.e., by law enforcement) 1%. School and mass shootings account for less than 1% of pediatric firearm deaths.
Increased access to firearms at both the household and state level are associated with increased firearm deaths in the pediatric population. Providing barriers to firearm access can help. Interventions at the primary care, emergency department, psychiatric, hospital and community levels can decrease the likelihood that at-risk individuals will harm themselves or others. Stronger legislation also is associated with decreases in firearm deaths.
Firearm-related injury prevention anticipatory guidance, coupled with provision of safety equipment (e.g., trigger locks, gun locks, gun safes), improves firearm safe storage. If families keep firearms in the home, they should be counseled to store them unloaded, with the firearm and ammunition locked separately where children can’t access them.
One method to decrease a child’s unauthorized access to a firearm while allowing fast access by an authorized adult is to use the authorized user’s fingerprint to open trigger locks and gun safes.
Firearms have the highest lethality of any means of suicide with a greater than 90% fatality rate. Given this high rate and the impulsivity associated with suicidal ideation, removing firearm access from at-risk individuals is essential to decrease suicide risk. It is important to counsel families about removing firearms and other lethal means of self-harm, including medications and poisons. Families can be advised on keeping firearms temporarily in someone else’s home or at a firearm dealer, gun club/shooting range or with the local police.
Some states have extreme risk protection order (ERPO) laws (https://americanhealth.jhu.edu/implementERPO) that allow a family, clinician (depending on the state) or law enforcement to ask a judge to temporarily prohibit an at-risk individual from possessing or purchasing a firearm.
Stronger state firearm injury prevention laws are associated with lower firearm fatality rates. Child access prevention (CAP) laws, for example, hold gunowners liable for how firearms are stored when children are in the home.
The Bipartisan Safer Communities Act, passed by Congress in June 2022 after the shooting deaths at Robb Elementary School in Uvalde, Texas, is the first federal firearm-related legislation passed in over 25 years. However, continued advocacy will be needed for additional firearm laws, including those addressing universal background checks, assault weapons bans, safer storage and ERPO.
Recommendations for pediatricians
- Provide anticipatory guidance to families about the importance and effectiveness of barriers to prevent access to firearms in the home.
- Encourage parents and caregivers to ask about firearms and their storage where the child may spend time, including relatives’ and friends’ homes.
- Discuss risks and removal of firearm access for those at risk for suicide and homicide.
- Know state CAP and ERPO laws.
- Learn about hospital- and community-based violence intervention and prevention programs.
Pediatricians interested in advocacy related to decreasing pediatric firearm injuries and deaths can contact their AAP chapter or firearm injury prevention advocacy organizations (see resources).
Dr. Lee is a lead author of the policy statement and technical report. She is chair of the AAP Council on Injury, Violence and Poison Prevention and a liaison from the Society for Pediatric Research to the AAP Committee on Federal Government Affairs and Committee on Pediatric Research.