To examine how youth and their caregivers’ mental health risk factors for suicide are associated with youth firearm access inside and outside the home.
This study examines a cross-section of the Adolescent Brain and Cognitive Development Social Development study data collected from 2016 to 2021. The sample included 2277 children aged 10 to 15 years from 5 study sites across the United States. We estimated multilevel generalized linear models of household firearm ownership and the child’s reported firearm access (hard access or easy access). The primary exposures were the child’s and their caregivers’ mental health risk factors for suicide.
In the Adolescent Brain and Cognitive Development Social Development study sample, approximately 20% of children lived in a firearm-owning household and 5% of all children reported easy firearm access. In non–firearm-owning households, children with diagnosed lifetime suicidality were 2.48 times more likely (95% confidence interval [CI], 1.50–4.10) than their counterparts to report easy firearm access. In firearm-owning households, children of caregivers who self-reported any mental health history or externalizing problems were 1.67 times (95% CI, 1.10–2.54) and 2.28 times (95% CI, 1.55–3.37) more likely than their counterparts to report easy firearm access.
Youths with mental health risk factors for suicide may be just as likely or more likely to report firearm access as those without such risk factors. Youth suicide prevention efforts should address youths’ firearm access outside the home and caregiver mental health.
Previous research suggests that youths with mental health risk factors for suicide are just as likely to report in-home firearm access as those without such risk factors.
By analyzing novel data on youth mental health and firearm access, this study finds key mental health risk factors for youth firearm access in both firearm-owning and non–firearm-owning households.
As the United States grapples with the devastation of the COVID-19 pandemic, youth’s physical and psychological wellness remains a pressing public health concern. Between 2010 and 2020, firearm-involved suicide rates increased by 177% among children aged 10 to 14 years.1 Preliminary evidence also finds pandemic-related increases in firearm purchasing among adult populations,2,3 increases in household firearm accessibility,4 and increases in psychiatric risk factors for suicide (e.g., major depression) among youth populations.5,6 It is well-known that firearm access is a risk factor for youth suicide7–10 and that firearms are the most lethal means used in suicide attempts.11 A critical question is whether youth with psychiatric risk factors for suicide are as likely to access firearms as youth without these risk factors. Household firearm ownership and storage practices do not notably differ between children with and without mental health risk factors for suicide.10,12–14 One US study reported that histories of mental illness were not associated with a child accessing and shooting a gun.12 Thus, youth who struggle with mental health may have similar access to firearms as youth without mental concerns, posing a serious challenge for suicide prevention.
However, the evidence linking youths’ mental health to their firearm access remains nascent and faces 3 limitations. First, most studies focus on youth psychiatric risk factors of youth firearm access, whereas few studies examine caregiver psychiatric risk factors. Swanson et al found that maternal mental health was unrelated to whether youth (ages 13–18 years) lived in a firearm-owning home.10 Yet, other studies link poor caregiver mental health to a lower prevalence of safe storage practices in firearm-owning households and effect sizes for safe storage intervention programs.15–17 Examining the link between caregiver mental health and youth firearm access may help identify family-focused strategies for youth firearm violence prevention. Second, younger children (i.e., aged 14 years and younger) have limited representation in data on mental health and firearm access because most survey respondents are older adolescents (i.e., aged 15–18 years) or parents reporting on their child’s mental health.12,14,18 Identifying psychiatric risk factors for suicide and firearm access earlier in the life course may justify earlier points of assessment or intervention. Third, children can access firearms outside their homes,19,20 but how firearm access relates to this group’s psychiatric risk factors for suicide is poorly understood. Studying this population is critical because youth firearm access outside the home may be underestimated by both caregivers and health care providers.21
To address previous research limitations, our study examined youth’s reported access to firearms in relation to suicide risk factors measured in both children and their caregivers. Our analyses focused on the associations between youth’s reported firearm access and suicide risk factors and how they may differ between households that do and do not own firearms. Findings from this study inform potential opportunities for health care providers to discuss mental health and firearm risks with families and youth.
We examined a cross-section of baseline data collected by the Adolescent Brain and Cognitive Development (ABCD) study and the Social Development substudy (ABCD-SD).22 The ABCD study tracks the biological, physical, behavioral, and psychosocial development of a cohort of 11 874 children aged 9 to 10 years recruited from 21 nationally distributed study sites in the United States. ABCD baseline data were collected from 2016 to 2018. The ABCD-SD substudy collects information about child biopsychosocial development, delinquency, and victimization from 5 of the 21 ABCD sites (n = 2300 children). The ABCD-SD baseline data were collected from 2019 to 2021. Because the data are anonymous, they are exempt from IRB review.
Children’s Firearm Exposure
We examined 2 measures of children’s firearm exposure: household firearm ownership and the child’s reported firearm access. Household firearm ownership measured whether the child’s caregiver indicated any firearms kept in or around the child’s home. The child’s reported firearm access was measured by asking the child, “If you wanted to get a gun, how easy would it be for you to get one?” The responses included “very hard,” “sort of hard,” “sort of easy,” “very easy,” and “I don’t know.” We collapsed these responses into 3 categories: hard access, easy access, and I don’t know.
Child’s Mental Health
We measured the child’s mental health risk factors using the Child Behavioral Checklist (CBCL) completed by the child’s caregiver. We used CBCL T-scores to measure the child’s levels of social problems, thought problems, attention problems, rule-breaking, aggressive behavior, and internalizing and externalizing problems relative to the general population. We used the Achenbach System of Empirically Based Assessment (ASEBA) Diagnostic and Statistical Manual of Mental Disorders (DSM)-oriented T-scores to assess the child’s symptoms of depression, anxiety, attention deficit hyperactivity disorder, and oppositional defiant disorder relative to a normative sample. We used the CBCL and ASEBA T-score cutoff (≥65) to measure whether the child was in the borderline clinical range for any mental health diagnosis, a diagnosis of depression, or diagnosis of externalizing problems.23
Additionally, we used the Kiddie Schedule for Affective Disorders and Schizophrenia to code a dichotomous measure of the child’s lifetime passive or active suicidal ideation, planning, or behaviors based on DSM-V criteria.
Caregivers’ Mental Health
We measured caregivers’ mental health risk factors using the caregiver’s responses to the Adult Self Report (ASR). We used ASR T-scores to assess the caregiver’s levels of thought problems, aggressive behavior, rule-breaking behavior, intrusive thoughts, and internalizing and externalizing problems relative to a normative sample. Moreover, we calculated ASEBA DSM-oriented T-scores to approximate the caregiver’s symptoms of depression, anxiety, attention deficit hyperactivity disorder, and antisocial behavior relative to a normative sample. To calculate the exposure variables for our multilevel models, we used an ASR and ASEBA T-score cutoff (≥65) to measure whether the caregiver was in the borderline clinical range for any mental health diagnosis, a diagnosis of depression, or a diagnosis of externalizing problems.
We also measured the mental health histories of the child’s biological caregivers based on the responses of the caregiver (biological or adoptive) who brought the child to the study site. The biological caregivers were biologically related to the child and either (1) brought the child to the study site or (2) were involved in at least 40% of the child’s daily activities. The measures included the biological caregivers’ histories of alcohol use problems, drug use problems, depression, hospitalization for a mental health problem, and previous suicidal behavior.
Our analyses also included sociodemographic measures collected at the ABCD baseline assessment. These measures included the child’s age, sex at birth, and race and ethnicity. ABCD interviewers asked the caregiver about the child’s race and ethnicity, which included 16 racial groups and Hispanic origin. We collapsed these options into 5 categories (Hispanic, non-Hispanic Asian, non-Hispanic Black, non-Hispanic Other/mixed, and non-Hispanic white) because the granular racial categories led to the exclusion of cases in statistical models from a lack of variation in the outcome across racial groups. ABCD baseline assessments also included information about the child’s caregiver, including age, foreign-born status, marital status, and past-year history of financial hardship (e.g., unable to afford food). Some measures included information about the caregiver and the caregiver’s partner who was involved in at least 40% of the child’s activities, including the caregivers’ highest education, employment status, and total income.
We conducted 3 sets of analyses. First, we stratified the sample by household firearm ownership and calculated descriptive statistics of the sociodemographic measures. These analyses excluded 23 cases that were missing household firearm ownership information (n = 2277). Second, we calculated the proportions and means of the mental health measures by household firearm ownership and the child’s reported firearm access. When comparing the mean CBCL and ASR T-scores across strata, we considered a difference of 5 points to be clinically significant.24 These analyses excluded 29 cases that were missing either household firearm ownership or the child’s reported firearm access (n = 2271).
Third, we used Stata 13.1 and the gllamm package to specify multilevel generalized linear models of household firearm ownership and child’s reported easy access to firearms stratified by household firearm ownership. These models accounted for the ABCD data structure and sociodemographic covariates (Table 1). We specified the models using a Poisson distribution, a log link function, and robust standard errors. All coefficients and standard errors were exponentiated to estimate prevalence ratios of household firearm ownership and child’s reported easy access to firearms between children exposed and not exposed to suicide risk factors indicated by measures of the child’s and their caregivers’ mental health. We excluded cases with any missing data on the outcome, exposure, or covariates (Supplemental Table 8). In models estimating child’s reported firearm access, we excluded cases in which the child reported “don’t know.”
Table 1 presents descriptive statistics of this sample. In the study sample, approximately 5% of children lived with a firearm. Children who lived in firearm-owning homes were more likely to report easy access to firearms (12%) than children who did not live in firearm-owning homes (3%). Among children who reported easy access to firearms, 49% did not live with a firearm (Table 2). Children were mostly aged 11 to 12 years, and slightly more were female than male. Children who lived in firearm-owning homes were more likely than children who lived in non–firearm-owning homes to be non-Hispanic white (67% vs 43%), and their caregivers were more likely to have at least a 4-year degree (58% vs 51%), be married (79% vs 54%), and work full-time (92% vs 79%). Children who lived in firearm-owning homes were less likely than children who lived in non–firearm-owning homes to be non-Hispanic Black (14% vs 33%). Although caregiver income tended to be higher among firearm-owning households than nonfirearm households, nonfirearm households were more likely to be in the highest income group (ie, $200 000 or more).
Table 2 summarizes descriptive statistics of the children’s mean CBCL T-scores and the percentage of children who expressed suicidal ideation, planning, or behavior—as defined by the DSM-V—by household firearm ownership and child firearm access. In the study sample, we found no substantive mental health differences between children who lived and children who did not live in firearm-owning households. However, among children who lived in homes without firearms, we found that children who reported easy access to firearms (versus hard access to firearms) scored higher on CBCL measures of externalizing problems (mean = 52.5; SD = 12.2 versus mean = 45.6, SD = 10.8, respectively) and total problems (mean = 51.8, SD = 12.4 versus mean = 45.7, SD = 11.9, respectively). Additionally, these children had a higher prevalence of suicidal ideation, planning, or behavior (13% vs 7%, respectively).
We found little difference in the prevalence of caregiver mental health histories between children who lived and children who did not live in firearm-owning homes (Table 3). Among both groups, we found that children who reported easy access to firearms were more likely than those who reported hard access to firearms to have biological caregivers with mental health histories. The largest percentage point difference between these groups was for the biological caregivers’ histories of depression in only firearm-owning households (39% vs 27%, respectively). The 1 exception was that children who reported easy access to firearms were less likely than those who reported hard access to have biological caregivers with histories of alcohol problems (no firearm in home: 2% vs 8%; firearm in home: 2% vs 6%).
Table 4 presents the adjusted associations of mental health risk factors with household firearm ownership and child’s reported easy firearm access (stratified by household firearm ownership), as estimated by a series of multilevel quasi-Poisson models. In the total sample, we observed no associations between mental health risk factors and household firearm ownership. Among children who did not live in a firearm-owning household, children who expressed lifetime suicidal ideation, planning, or behavior were around 2.5 times more likely than their counterparts to report easy access to a firearm (prevalence ratio [PR] = 2.48; 95% confidence interval [CI], 1.50–4.10). It is important to note, however, that only 8 youth in the ABCD-SD data did not live in a firearm household, reported easy access to a firearm, and expressed lifetime suicidal ideation, planning, or behavior. Among children who lived in a firearm-owning household, we found that children with biological caregivers who reported any mental health history were approximately 1.7 times more likely than children with biological caregivers who reported no mental health history to report easy access to a firearm (PR = 1.67; 95% CI, 1.10–2.54). Additionally, children with caregivers who scored in the borderline clinical range for externalizing problems were approximately 2.3 times more likely than their counterparts to report easy access to a firearm (PR = 2.28; 95% CI, 1.55–3.37).
This study used ABCD-SD data to examine the links between children and their caregivers’ mental health risk factors for suicide and children’s reported firearm access in households with and without firearms. In the study sample, approximately 20% of the youth cohort lived in a firearm-owning home, and these youth were 4 times more likely than youth in nonfirearm homes to have easy access to a gun.
Even though the ABCD data are not nationally representative, our prevalence estimates of household firearm ownership were slightly lower than expected. From the National Comorbidity Survey’s Adolescent Supplement, Simonetti et al reported that approximately 29% of youth reported living in a firearm-owning home, and 40% of these youth reported the ability to access and shoot the firearm(s).12 Our firearm prevalence estimates were lower than Simonetti et al’s partly because the ABCD-SD cohort was younger than the National Comorbidity Survey’s Adolescent Supplement sample, and age is negatively associated with youth firearm access.25 In the ABCD data, we also found that a portion of youth do not live in firearm-owning homes but still report easy access to firearms. Previous research suggests these youth likely access guns through other relatives or friends.19,20,26
We found no differences in mental health risk factors between children who lived in firearm-owning homes and those who did not, but we observed positive associations between these factors and youth’s reported firearm access. Among nonfirearm households, children who expressed suicidality were significantly more likely than their counterparts to report easy access to firearms. Among firearm households, children with caregivers who reported any mental health history or who were in the clinical range for externalizing problems were more likely than their counterparts to report easy access to firearms.
Previous research claims that “adolescents with risk factors for suicide [are] just as likely to report in-home firearm access as those without such risk factors.”12 Our findings suggest that this conclusion could be expanded to include both in-home and outside-the-home firearm access. Additionally, we found that youth diagnosed with clinical suicidality or exposed to caregivers with histories of mental health problems were significantly more likely to report firearm access. This finding is consistent with previous research suggesting that internalizing problems, alcohol abuse, and lifetime substance abuse in adolescence are significant risk factors for youth knowing how to access a firearm.12,27 Thus, adolescents with mental health risk factors for suicide may be just as likely or more likely to report firearm access as those without such risk factors.
Our findings regarding youth firearm access outside the home have important implications for firearm suicide prevention. Research estimates that roughly 1 of 4 youth firearm suicides involved a firearm not owned by the victim or the victim’s family member.20 Parents and health care providers should inquire more broadly about youths firearm access outside the home (e.g., friends, neighbors). Moreover, clinicians may engage directly with youth to discuss their firearm exposure because youth may have access to sources of firearms unbeknownst to the parent.28–30 For example, clinicians may have separate discussions with youth and their parents about the danger of and alternatives to firearm access to “promote safer behaviors with respect to firearms.”21
Our study also motivates further research into caregiver mental health and youth firearm access. We provide preliminary evidence that children of caregivers with mental health histories or externalizing problems may have easier access to firearms in firearm-owning households.15 Researchers should further investigate whether safe storage practice mediates this relationship because evidence suggests poor caregiver mental health is linked to a lower prevalence of safe firearm storage practices.15 Additionally, clinicians may seek to inform families with histories of mental illness about extreme risk protection orders, which provide a civil court process to remove and restrict firearm access to caregivers who exhibit behaviors indicating a high risk of harming themselves or others.31
Our study has 3 limitations. First, the ABCD-SD sample is not nationally representative, and our findings may not be statistically generalizable to the US youth population. For example, the ABCD data underrepresent rural youth.32 However, the sociodemographic diversity of the cohort suggests that it provides valuable insight into US youth. Second, the ABCD-SD firearm access measures were somewhat vague. For example, what it means to have “easy” access to a firearm or to “get one” is subject to the youth respondent’s interpretation.8 The data measured whether the youth carried guns “other than for hunting…” and whether the household contained loaded and unlocked firearms. However, these outcomes were too rare to conduct statistical analyses. Third, we found that only 8 children did not live in a firearm-owning home, reported easy firearm access, and were in the clinical range for suicidality. Thus, the lifetime suicidality estimates from our youth firearm access models should be interpreted with this limitation in mind.
Concurrent increases in firearm purchasing and the dramatic rise in youth mental health problems have the combined potential to exacerbate the decade-long trend of rising youth suicide rates. Clinician conversations with families about youth firearm exposure can increase safe firearm storage practices,33 which may reduce youth firearm access overall. Knowledge about the intersections between youth mental health, caregiver mental health, and youth firearm access inside and outside the home may further help clinicians anticipate and investigate high-risk situations in which youth have ready access to firearms.
Dr Hullenaar conceptualized the paper, designed the methodology, executed the statistical analyses, interpreted the results, wrote the original manuscript draft, and prepared the final manuscript draft; Dr Rowhani-Rahbar conceptualized the paper, designed the methodology, interpreted the results, and revised manuscript drafts for publication submission; Drs Hicks and Morgan helped with the conception and design of the paper, contributed to the literature review, interpreted the results, and revised manuscript drafts for publication; Dr Rivara generated the original idea, conceptualized the paper, interpreted the results, and edited the manuscript drafts; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
FUNDING: This work was funded by the National Institute of Child Health and Human Development (5T32HD057822-11). The funder/sponsor did not participate in the work.
CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no conflicts of interest to disclose.