OBJECTIVES:

Access to firearms among youth can increase the risk of suicide or other injury. In this study, we sought to estimate the population prevalence of adolescent perception of firearm access by demographic, geographic, and other individual health characteristics.

METHODS:

The 2019 Healthy Kids Colorado Survey was an anonymous survey administered to a representative sample of high school students in Colorado. The survey was used to assess health behaviors and risk and protective factors. Analysis was conducted with weights to the state population of public high school students.

RESULTS:

In total, 46 537 high school students responded (71% student response rate; 83% school response rate). One in 5 students said it was “sort of easy” (11.1%) or “very easy” (8.8%) to access a handgun, with higher prevalence among male and older-aged youth and differences in racial and/or ethnicity groups. There were geographic differences such that students in schools in more rural areas were more likely to report perceived easy access. Students who had felt sad or hopeless, attempted suicide, or been in a fight were more likely to say they had access to a handgun.

CONCLUSIONS:

A relatively high proportion of youth have easy access to a firearm, with differences across age, sex, race and/or ethnicity, and geography. This highlights the need for efforts to address ways to reduce firearm access for youth, including secure storage at home, for the prevention of youth firearm suicide and other firearm injuries.

What’s Known on This Subject:

Suicide is a leading cause of death among adolescents, and firearms are implicated in a majority of those deaths. Safe storage of firearms can prevent adolescent suicide, homicide, and unintentional firearm injuries and deaths.

What This Study Adds:

In a representative sample of high school students in Colorado, 20% reported easy access to a handgun. Students with mental health concerns or who had been in a fight were more likely to say they could access a handgun.

Suicide is the second leading cause of death for adolescents aged 15 to 19 years,1  and firearms are the leading method of these deaths.2  Furthermore, adolescent suicide rates have increased 76% for adolescents aged 15 to 19 years from 2007 to 2017, with a 10% annual increase for each year from 2014 to 2017.3  Especially concerning is the rise in firearm suicide among Black youth, a group that for many years had lower suicide rates compared with white youth.46  Among those younger than age 13 years, Black youth are now twice as likely as white youth to die by suicide. Among adolescents aged 15 to 19 who die by suicide, 51% used a firearm, which is approximately the same for white and Black youth.6 

Reducing firearm access is an evidence-based, recommended strategy to prevent suicide deaths, as well as to prevent other intentional or unintentional firearm injuries.7  In the United States, youth may have easy access to firearms in their homes: 1 in 3 adults has a gun in their home, and 2 in 10 of these gun owners keep at least 1 gun loaded and unlocked.8  Firearms located in the home are the most common source for youth access, but youth may also access firearms at the homes of relatives of friends9  or may obtain firearms illegally.10  Yet the lack of consistent national surveillance means relatively little is known about firearm access among adolescents. Existing evidence about home access and storage of firearms is largely about adults11,12  or specific adolescent subpopulations,13  such as those seen in emergency departments.10,14 

The purpose with this study was to (1) examine the population prevalence of perception of handgun access among adolescents in Colorado and (2) explore individual and geographic characteristics, as well as related health factors, associated with perceptions of handgun access. Understanding youth perceptions about ease of access has implication for injury prevention efforts related to reducing legal or illegal firearm access.

Data were from the Healthy Kids Colorado Survey (HKCS), a biennial cross-sectional survey of Colorado public high school students. Schools were sampled and the survey was administered consistent with methods for Centers for Disease Control and Prevention Youth Risk Behavior Survey (YRBS).15  The HKCS sampling used a 2-stage stratified cluster design by using a sampling frame of all public high schools in Colorado.

The survey was self-administered in classrooms during a regular class period by using either a machine-scannable paper booklet or online, with mode of administration determined by the school. Teachers oversaw survey administration and were directed to read a script and show a short video providing instructions for students. Teachers were instructed not to circulate the room while students were completing the survey so that they could not see student responses. Participation was voluntary and approved by parents; no identifying information was collected from students. The study was approved by the Colorado Multiple Institutional Board.

The HKCS instrument consists primarily of questions from the YRBS, with additional questions added for Colorado from validated sources. There are 2 modules, consisting of a total of 123 and 126 questions. Because firearm access is a risk factor for suicide,16  the 2019 HKCS administration include a single new question: “If you wanted to get a handgun, how easy would it be for you to get one?” (response options: very hard, sort of hard, sort of easy, and very easy). For ease of presentation and analysis, we combined sort of easy and very easy.

Students were asked about their mental health with the YRBS question “during the past 12 months, did you ever feel so sad or hopeless almost every day for 2 weeks or more in a row that you stopped doing some usual activities?” with response options of yes or no. Students were also asked, “during the past 12 months, how many times did you actually attempt suicide?” and collapsed responses of 1 time and >1 vs 0 times. Physical fighting was assessed with the question “during the past 12 months, how many times were you in a physical fight?” and collapsed responses of 1 time and >1 vs 0 times.

Students were asked about demographic characteristics, including their sex, grade level in school, race and/or ethnicity, sexual orientation, gender identity, and highest level of their mother’s education. Schools were characterized as urban, suburban, and rural on the basis of classifications from the National Center of Education Statistics.

Students were weighted to state enrollment in public high schools. The weights accounted for sampling design, school and student nonparticipation and nonresponse, and discrepancies in grade, sex, and race and/or ethnicity between the sample and the population. For analysis, we examined student characteristics among responding and nonresponding schools and found comparable distributions of sex and grade (Supplemental Table 3). Although the distribution of race and/or ethnicity differed between responding and nonresponding schools, there was no evidence of systematic differences. Among responding schools, ∼5% more were in urban areas versus nonresponding schools, and nonresponding schools tended to have lower student enrollment.

We conducted analyses in SAS (SAS Institute, Inc, Cary, NC) using design and poststratification weights to represent Colorado public high school enrollment. First, we examined weighted prevalence of perceived handgun access by student demographic characteristics and school location using the Rao-Scott χ2 test.17  We then examined perceived handgun access by indicators of suicidality or violence, adjusting for demographic and school characteristics.

In total, 46 537 high school students responded (71% student response rate; 83% school response rate). In weighted analysis, students reported it was very hard (60.6%), sort of hard (19.4%), sort of easy (11.1%), and very easy (8.8%) to get a handgun, totaling 20.0% reporting ease of access (collapsing easy or very easy).

Observed differences among demographic groups included that more male than female high school students reported ease of access to a handgun, and there was an increasing prevalence of perceived access by grade (Table 1). There was no significant difference in reported ease of access to firearms by sexual orientation, and a significantly higher proportion of transgender youth (compared with cisgender youth) reported easy access to a handgun.

TABLE 1

Description of the Overall HKCS Sample and the Weighted Prevalence of Colorado High School Students Who Perceived it Was Very Easy or Sort of Easy to Get a Handgun by Demographic Factors (Weighted N = 209 036; Unweighted N = 41 067)

Description of Sample DemographicsPerceived Easy Access to a Handgun by Demographic Factors
Unweighted NWeighted NPrevalence (95% CI)Prevalence (95% CI)P
Total 46 537 240 568 — 20.0 (19.2–20.8) — 
Sex     <.0001 
 Male 22 898 120 846 51.1 (50.4–51.7) 22.0 (21.0–22.9)  
 Female 22 831 115 713 48.9 (48.3–49.6) 18.1 (17.2–18.9)  
Grade     <.0001 
 Ninth 12 413 63 828 26.8 (25.9–27.7) 16.3 (15.3–17.4)  
 10th 12 467 61 413 25.8 (24.7–26.9) 18.9 (17.9–19.9)  
 11th 11 548 57 259 24.1 (23.1–25.0) 19.8 (18.6–20.9)  
 12th 9557 55 469 23.3 (22.4–24.2) 25.0 (23.8–26.1)  
Race and/or ethnicity     <.0001 
 Native American 567 1547 0.7 (0.6–0.7) 19.6 (15.6–23.6)  
 Asian American 1237 7099 3.0 (2.6–3.5) 12.2 (10.1–14.3)  
 Black or African American 1349 10 150 4.3 (3.5–5.2) 16.9 (14.5–19.3)  
 Native Hawaiian or Pacific Islander 195 943 0.4 (0.3–0.5) 23.8 (16.3–31.3)  
 White 23 969 128 679 55.1 (51.7–58.4) 21.3 (20.2–22.5)  
 Hispanic 15 620 75 260 32.2 (29.0–35.5) 18.2 (17.5–18.9)  
 Multiracial 2199 9984 4.3 (3.9–4.6) 23.3 (21.0–25.5)  
Sexual orientation     .10 
 Heterosexual 37 502 193 297 12.2 (11.5–12.9) 19.6 (18.7–20.5)  
 Gay, lesbian, or bisexual 5084 26 884 87.8 (87.1–88.5) 21.3 (19.9–22.6)  
Gender identity     — 
 Cisgender 42 688 222 040 98.6 (98.5–98.8) 19.5 (18.7–20.4)  
 Transgender 587 3080 1.4 (1.2–1.5) 35.3 (31.2–39.5)  
Mother’s education     .0003 
 High school or less 13 750 65 438 31.6 (28.9–34.2) 20.6 (19.7–21.6)  
 Some college 6048 31 292 15.1 (14.4–15.7) 23.7 (21.8–25.6)  
 College and/or graduate school 20 106 110 665 53.4 (50.4–56.4) 19.3 (18.4–20.3)  
Urban and/or rural     <.0001 
 Urban 13 746 96 428 40.1(32.1–48.0) 17.1 (16.3–17.9)  
 Suburban 12 771 88 391 36.7 (29.3–44.2) 18.7 (17.7–19.7)  
 Rural 20 020 55 749 23.2 (17.2–29.2) 26.8 (24.4–29.2)  
Description of Sample DemographicsPerceived Easy Access to a Handgun by Demographic Factors
Unweighted NWeighted NPrevalence (95% CI)Prevalence (95% CI)P
Total 46 537 240 568 — 20.0 (19.2–20.8) — 
Sex     <.0001 
 Male 22 898 120 846 51.1 (50.4–51.7) 22.0 (21.0–22.9)  
 Female 22 831 115 713 48.9 (48.3–49.6) 18.1 (17.2–18.9)  
Grade     <.0001 
 Ninth 12 413 63 828 26.8 (25.9–27.7) 16.3 (15.3–17.4)  
 10th 12 467 61 413 25.8 (24.7–26.9) 18.9 (17.9–19.9)  
 11th 11 548 57 259 24.1 (23.1–25.0) 19.8 (18.6–20.9)  
 12th 9557 55 469 23.3 (22.4–24.2) 25.0 (23.8–26.1)  
Race and/or ethnicity     <.0001 
 Native American 567 1547 0.7 (0.6–0.7) 19.6 (15.6–23.6)  
 Asian American 1237 7099 3.0 (2.6–3.5) 12.2 (10.1–14.3)  
 Black or African American 1349 10 150 4.3 (3.5–5.2) 16.9 (14.5–19.3)  
 Native Hawaiian or Pacific Islander 195 943 0.4 (0.3–0.5) 23.8 (16.3–31.3)  
 White 23 969 128 679 55.1 (51.7–58.4) 21.3 (20.2–22.5)  
 Hispanic 15 620 75 260 32.2 (29.0–35.5) 18.2 (17.5–18.9)  
 Multiracial 2199 9984 4.3 (3.9–4.6) 23.3 (21.0–25.5)  
Sexual orientation     .10 
 Heterosexual 37 502 193 297 12.2 (11.5–12.9) 19.6 (18.7–20.5)  
 Gay, lesbian, or bisexual 5084 26 884 87.8 (87.1–88.5) 21.3 (19.9–22.6)  
Gender identity     — 
 Cisgender 42 688 222 040 98.6 (98.5–98.8) 19.5 (18.7–20.4)  
 Transgender 587 3080 1.4 (1.2–1.5) 35.3 (31.2–39.5)  
Mother’s education     .0003 
 High school or less 13 750 65 438 31.6 (28.9–34.2) 20.6 (19.7–21.6)  
 Some college 6048 31 292 15.1 (14.4–15.7) 23.7 (21.8–25.6)  
 College and/or graduate school 20 106 110 665 53.4 (50.4–56.4) 19.3 (18.4–20.3)  
Urban and/or rural     <.0001 
 Urban 13 746 96 428 40.1(32.1–48.0) 17.1 (16.3–17.9)  
 Suburban 12 771 88 391 36.7 (29.3–44.2) 18.7 (17.7–19.7)  
 Rural 20 020 55 749 23.2 (17.2–29.2) 26.8 (24.4–29.2)  

P values are calculated from second-order Rao-Scott χ2 test. CI, confidence interval; —, not applicable.

By race and/or ethnicity, reported ease of access was highest among Native American (23.8%) and multiracial students (23.3%), followed by white students (21.3%); reported prevalence was significantly higher in these groups than among Hispanic (18.2%), Black or African American (16.9%), or Asian American students (12.2%). Perceived ease of handgun access was lowest among Asian American students, which was significantly lower than all other groups (Table 1).

Reported handgun access varied by reported level of maternal education, with the highest prevalence among those who reported their mother completed some college, which was significantly higher than the other 2 categories of less education or more education. There was also a significant difference by geography, with perceived access highest in rural areas, followed by suburban and then urban areas.

In Table 2, we present the prevalence of perceived access to a firearm by feeling sad or hopeless for ≥2 weeks, having attempted suicide in the past 12 months, and having been in a physical fight in the past 12 months. Students were significantly more likely to report easy handgun access if they felt sad or hopeless almost every day for 2 weeks (24.2%), had attempted suicide (30.1%), or had been in a physical fight in the past 12 months (31.8%; Table 2). For example, among the 7.6% (weighted n = 15 058) of high school students who reported attempting suicide in the past 12 months, 30.1% reported easy access to a handgun. After adjusting for individual and school characteristics presented in Table 1, there was a significant association between feeling sad or hopeless, having attempted suicide, and having been in a physical fight and perceived easy access to a handgun. Students who attempted suicide in the past 12 months were 1.83 times as likely to report easy access to a handgun, and students who had been in a physical fight were 2.21 times as likely to report access to a handgun.

TABLE 2

The Weighted Prevalence of Colorado High School Students With Mental Health Concerns or Fighting Involvement and the Relationship Between Mental Health and Fighting Involvement Indicators and Perceptions That it is Very Easy or Sort of Easy to Get a Handgun (Past 12 Months)

Prevalence of Mental Health and Fighting Involvement FactorsPerceived Easy Access to a Handgun by Mental Health and Fighting Factors
Prevalence (95% CI)Unweighted FrequencyWeighted FrequencyPrevalence (95% CI)OR (95% CI)aOR (95% CI)a
Sad or hopeless almost every day for 2 wk, past 12 mo 34.7 (33.9–35.5) 14 854 71 510 24.2 (23.1–25.2) 1.48 (1.38–1.58) 1.50 (1.40–1.61) 
Attempted suicide 1+ times, past 12 mo 7.6 (7.2–8.0) 3238 15 058 30.1 (28.2–31.9) 1.82 (1.65–2.01) 1.83 (1.62–2.07) 
In a physical fight 1+ times, past 12 mo 19.9 (19.2–20.6) 8277 39 467 31.8 (30.5–33.0) 2.24 (2.10–2.40) 2.21 (2.03–2.41) 
Prevalence of Mental Health and Fighting Involvement FactorsPerceived Easy Access to a Handgun by Mental Health and Fighting Factors
Prevalence (95% CI)Unweighted FrequencyWeighted FrequencyPrevalence (95% CI)OR (95% CI)aOR (95% CI)a
Sad or hopeless almost every day for 2 wk, past 12 mo 34.7 (33.9–35.5) 14 854 71 510 24.2 (23.1–25.2) 1.48 (1.38–1.58) 1.50 (1.40–1.61) 
Attempted suicide 1+ times, past 12 mo 7.6 (7.2–8.0) 3238 15 058 30.1 (28.2–31.9) 1.82 (1.65–2.01) 1.83 (1.62–2.07) 
In a physical fight 1+ times, past 12 mo 19.9 (19.2–20.6) 8277 39 467 31.8 (30.5–33.0) 2.24 (2.10–2.40) 2.21 (2.03–2.41) 
a

OR adjusted for sex, gender identity, grade, race and/or ethnicity, mother’s education, and school location. aOR, adjusted odds ratio; CI, confidence interval; OR, odds ratio.

Efforts to estimate youth access to firearms are infrequent and inconsistent despite firearms representing a major source of mortality for adolescents.18  In this population-based study, 1 in 5 public high school students in Colorado reported easy access to a handgun. There was higher perceived ease of handgun access among male and older adolescents, consistent with firearm suicide fatality rates and overall firearm fatality rates.2  Given the increased risk of suicidal despair among lesbian, gay, bisexual, and transgender students identified in previous studies,1921  the reported ease of handgun access observed among the transgender students in this study is particularly troubling.

In addition to differences by demographic characteristics, the most striking difference was that those youth at greater risk of harm to themselves or others were significantly more likely to report perceptions of easy access. This may reflect a more accurate perception of access, increasing the prevalence of easy access to >1 in 5 youth, or perhaps the increased perception of access among those at risk may reflect a greater willingness to contemplate accessing a firearm. In future research, researchers should seek to validate self-reports of firearm access with methods such as parental reports or home audits.

Reducing access to lethal means of suicide, such as access to firearms, is an evidence-based strategy to prevent suicide.2224  Prevention approaches that address the risk and protective factors related to suicide, including reducing the accessibility of firearms for those at risk for suicide, have the potential to reduce suicide rates at the population level.25  Raising awareness about suicide risk factors and secure firearm storage as part of suicide prevention will be particularly important for firearm-owning parents. A newly released joint effort from the National Shooting Sports Foundation (trade association for the firearms industry) and American Foundation for Suicide Prevention may help fill this need.26  Engagement of firearm owners and organizations in the development of materials for parents may increase the credibility of the messaging and likelihood of actions to secure storage.25  Pediatricians and other health care providers also have a role to play, given evidence that provider-delivered counseling to parents about reducing firearm access for suicidal youth may result in changes in home storage.27,28 

Firearms may also be accessible to youth outside of their own home. This may include other homes where they spend time (eg, legally owned firearms belonging to neighbors, relatives, or friends) or avenues for illegal firearm acquisition or access.9,10,29  In a rural county in Colorado, a broad coalition of law enforcement, public health professionals, schools, and other community services recently initiated a program targeting firearm theft as an avenue for youth firearm access, as well as promoting responsible, safe storage of firearms; encouraging youth reporting of guns at schools; and working with youth in the criminal justice system.29  Within urban areas, multifaceted strategies are necessary, such as reducing the diversion of firearms, improving relations between police officers and communities of color, and changing social norms related to firearms and violence.30 

A limitation of this study was that students were not asked where the handgun was located, such as where within a home or even if it was in the child’s home or another location. The specifics of the firearm location, as well as attempts to access a firearm, should be explored in future research. Given the question asked about perception of access, the adolescent may have an accurate or inaccurate perception of actual ease of access for firearms. In future studies, researchers should validate the accuracy of firearm availability and access.

These findings highlight the common perception among high school students in Colorado that it is relatively easy to access a handgun. This perception, combined with the high prevalence of feeling sad or depressed and suicide attempts, is concerning for the safety of adolescents. We can use these findings to inform strategies to educate parents on the importance of secure home firearm storage, particularly if an adolescent is at risk for suicide.

Dr Brooks-Russell conceptualized the study and drafted the initial manuscript; Dr Ma conducted the analysis and reviewed and revised the manuscript; Ms Brummet and Drs Kelly and Betz critically reviewed the manuscript for important intellectual content; and all authors contributed to data interpretation and revision the manuscript and approved the final manuscript as submitted.

FUNDING: Data used for this study were collected under contracts with the Colorado Department of Public Health and Environment (Brooks-Russell, principal investigator).

     
  • HKCS

    Healthy Kids Colorado Survey

  •  
  • YRBS

    Youth Risk Behavior Survey

1
Heron
M
.
Deaths: Leading Causes for 2017
, vol.
68, No. 6
.
Hyattsville, MD
:
National Center for Health Statistics
;
2019
2
Centers for Disease Control and Prevention
.
Web-Based Injury Statistics Query and Reporting System (WISQARS): Fatal Injury Reports, 2018
.
National Center for Injury Prevention and Control
;
2018. Accessed November 11, 2020
3
Curtin
SC
,
Heron
M
.
Death Rates Due to Suicide and Homicide Among Persons Aged 10–24: United States, 2000–2017. NCHS Data Brief, No. 352
.
Hyattsville, MD
:
National Center for Health Statistics
;
2019
4
Bridge
JA
,
Horowitz
LM
,
Fontanella
CA
, et al
.
Age-related racial disparity in suicide rates among US youths from 2001 through 2015
.
JAMA Pediatr
.
2018
;
172
(
7
):
697
699
5
Gordan
J
;
The National Institute of Mental Health
.
Addressing the crisis of Black youth suicide. 2020. Available at: https://www.nimh.nih.gov/about/director/messages/2020/addressing-the-crisis-of-black-youth-suicide.shtml. Accessed November 11, 2020
6
Centers for Disease Control and Prevention
.
Web-Based Injury Statistics Query and Reporting System (WISQARS), Leading Causes of Death
.
Atlanta, GA
:
National Center for Injury Prevention and Control Centers for Disease Control and Prevention
;
2010
.
Available at: www.cdc.gov/injury/wisqars/leading_causes_death.html. Accessed November 11, 2020
7
Grossman
DC
,
Mueller
BA
,
Riedy
C
, et al
.
Gun storage practices and risk of youth suicide and unintentional firearm injuries
.
JAMA
.
2005
;
293
(
6
):
707
714
8
Azrael
D
,
Cohen
J
,
Salhi
C
,
Miller
M
.
Firearm storage in gun-owning households with children: results of a 2015 national survey
.
J Urban Health
.
2018
;
95
(
3
):
295
304
9
Johnson
RM
,
Barber
C
,
Azrael
D
,
Clark
DE
,
Hemenway
D
.
Who are the owners of firearms used in adolescent suicides?
Suicide Life Threat Behav
.
2010
;
40
(
6
):
609
611
10
Carter
PM
,
Walton
MA
,
Newton
MF
, et al
.
Firearm possession among adolescents presenting to an urban emergency department for assault
.
Pediatrics
.
2013
;
132
(
2
):
213
221
11
Crifasi
CK
,
Doucette
ML
,
McGinty
EE
,
Webster
DW
,
Barry
CL
.
Storage practices of US gun owners in 2016
.
Am J Public Health
.
2018
;
108
(
4
):
532
537
12
Berrigan
J
,
Azrael
D
,
Hemenway
D
,
Miller
M
.
Firearms training and storage practices among US gun owners: a nationally representative study
.
Inj Prev
.
2019
;
25
(
suppl 1
):
i31
i38
13
King
A
,
Simonetti
J
,
Bennett
E
, et al
.
Firearm storage practices in households with children: a survey of community-based firearm safety event participants
.
Prev Med
.
2020
;
131
:
105952
14
Carter
PM
,
Mouch
CA
,
Goldstick
JE
, et al
.
Rates and correlates of risky firearm behaviors among adolescents and young adults treated in an urban emergency department
.
Prev Med
.
2020
;
130
:
105891
15
Brener
ND
,
Kann
L
,
Shanklin
S
, et al.;
Centers for Disease Control and Prevention (CDC)
;
Centers for Disease Control and Prevention (CDC)
.
Methodology of the youth risk behavior surveillance system–2013
.
MMWR Recomm Rep
.
2013
;
62
(
RR
):
1
20
16
Anglemyer
A
,
Horvath
T
,
Rutherford
G
.
The accessibility of firearms and risk for suicide and homicide victimization among household members: a systematic review and meta-analysis
.
Ann Intern Med
.
2014
;
160
(
2
):
101
110
17
Rao
JNK
,
Scott
AJ
.
On simple adjustments to chi-square tests with sample survey data
.
Ann Stat
.
1987
;
15
(
1
):
385
397
18
Cunningham
RM
,
Walton
MA
,
Carter
PM
.
The major causes of death in children and adolescents in the United States
.
N Engl J Med
.
2018
;
379
(
25
):
2468
2475
19
Kann
L
,
Olsen
EO
,
McManus
T
, et al.;
Centers for Disease Control and Prevention (CDC)
.
Sexual identity, sex of sexual contacts, and health-risk behaviors among students in grades 9-12–youth risk behavior surveillance, selected sites, United States, 2001–2009
.
MMWR Surveill Summ
.
2011
;
60
(
7
):
1
133
20
Perez-Brumer
A
,
Day
JK
,
Russell
ST
,
Hatzenbuehler
ML
.
Prevalence and correlates of suicidal ideation among transgender youth in California: findings from a representative, population-based sample of high school students
.
J Am Acad Child Adolesc Psychiatry
.
2017
;
56
(
9
):
739
746
21
Toomey
RB
,
Syvertsen
AK
,
Shramko
M
.
Transgender adolescent suicide behavior
.
Pediatrics
.
2018
;
142
(
4
):
e20174218
22
Stone
D
,
Holland
K
,
Bartholow
BN
,
Crosby
AE
,
Davis
SP
,
Wilkins
N
.
Preventing Suicide: A Technical Package of Policies, Programs, and Practices
.
Atlanta, GA
:
National Center for Injury Prevention and Control, Centers for Disease Control and Prevention
;
2017
23
Simonetti
JA
,
Rowhani-Rahbar
A
.
Limiting access to firearms as a suicide prevention strategy among adults: what should clinicians recommend?
JAMA Netw Open
.
2019
;
2
(
6
):
e195400
24
Gunnell
D
,
Miller
M
.
Strategies to prevent suicide
.
BMJ
.
2010
;
341
:
c3054
25
Barber
CW
,
Miller
MJ
.
Reducing a suicidal person’s access to lethal means of suicide: a research agenda
.
Am J Prev Med
.
2014
;
47
(
3
suppl 2
):
S264
S272
26
Project Child Safe
.
A guide for parents: understanding youth mental health and preventing unauthorized access to firearms. 2018. Available at: https://projectchildsafe.org/parents-resources. Accessed November 11, 2020
27
Miller
M
,
Salhi
C
,
Barber
C
, et al
.
Changes in firearm and medication storage practices in homes of youths at risk for suicide: results of the SAFETY study, a clustered, emergency department-based, multisite, stepped-wedge trial
.
Ann Emerg Med
.
2020
;
76
(
2
):
194
205
28
Roszko
PJ
,
Ameli
J
,
Carter
PM
,
Cunningham
RM
,
Ranney
ML
.
Clinician attitudes, screening practices, and interventions to reduce firearm-related injury
.
Epidemiol Rev
.
2016
;
38
(
1
):
87
110
29
Larimer County Colorado
.
Juvenile gun safety: gun safety for juveniles begins with responsible ownership by adults. 2020. Available at: https://www.larimer.org/cjs/juvenile-gun-safety#:∼:text=The%20Larimer%20County%20Sheriff's%20Office,at%20970%2D498%2D5159. Accessed November 11, 2020
30
Bieler
S
,
Kijakazi
K
,
La Vigne
N
,
Vinik
N
,
Overton
S
.
Engaging Communities in Reducing Gun Violence: A Road Map for Safer Communities
.
Washington, DC
:
Urban Institute
;
2016

Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.