Firearm-Related Injuries and Deaths in Children and Youth: Injury Prevention and Harm Reduction

The majority of deaths (85%) from firearms in younger children (0–12 years of age) occur in the home. Older children (13–17 years of age) are equally likely to be killed at home (39%) or on the street or sidewalk (38%).¹⁴  Therefore, providing barriers to access to firearms in the home is a crucial mechanism to decrease the risks of unintentional firearm shooting as well as suicide and homicide.¹⁵  Removal of firearms from the home, which is the most protective measure¹⁶  and may be strongly advisable in some scenarios, may not be acceptable or achievable for many firearm-owning families. However, families should be informed that firearms can be temporarily transferred to other people (ie, family, friends, firearm dealers), stored at gun clubs or shooting ranges, or stored with the local police in many localities.^17–19  In households with firearms, it is important to discuss the safer storage of firearms in the home, which includes the following:

1. Store the firearm unloaded.

2. Store the firearm locked.

3. Store the ammunition separated from the firearm.

4. Store the ammunition locked separately from the firearm.^20,21 

Clinician-initiated firearm safety anticipatory guidance to patients and families can increase household safe firearm storage behaviors.^14,22  Many families are interested in discussing firearm injury prevention.^23,24  Families underestimate how children will behave when they encounter a firearm^25–27  and, thus, miscalculate the risk of having a firearm in the home.^28,29  The application of successful behavioral economics principles³⁰  to firearm injury prevention includes addressing parental beliefs regarding their child’s firearm injury risk and the immediate inconvenience versus likely future benefits of safe firearm storage.³¹ 

Anticipatory guidance is an important component of every well-child visit, with firearm-related anticipatory guidance included in the American Academy of Pediatrics (AAP) Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescent, Fourth Edition for well-child care.³²  Several interventional studies have examined the effectiveness of firearm safety anticipatory guidance,^22,33–35  and overall, provision of firearm safety storage devices is associated with safer storage practices.³³  Anticipatory guidance should also include asking about firearms in the homes of relatives and friends where the child(ren) may visit.^36,37  However, because conversations involving firearms can be challenging, culturally appropriate messaging is important.²⁴ 

Firearms have the highest fatality rate (>90%) compared with other methods of suicide.³⁸  Lethal means counseling in households with individuals at risk for self-harm and suicide should include discussions to prevent access to lethal agents of harm, including firearms and other means.³⁹  In addition to the primary care office, this type of counseling can occur in the emergency department (ED)⁴⁰  or mental health professional’s office.^41,42 

In addition to decreasing firearm access, policies should be implemented that focus on the safety of firearms themselves. Currently firearms, even though they are sold as a consumer product, are not regulated for safety.^43,44  Firearms should also be designed with affordable technologic barriers to prevent firing in the hands of an unauthorized user, like cellphone biometric technology.²¹ 

For community-level intervention strategies, the National Academy of Medicine stated that successful interventions must involve health and public safety organizations, educators, and community groups.⁴⁵  Hospital-based violence intervention programs are 1 example of a violence prevention program engaging both hospitals and community groups. Hospital-based violence intervention programs identify youth injured from violence, including firearms, at the index ED visit and enroll them in community-based programs to decrease recidivism.^46,47  Violence intervention advocacy programs are community-based programs that include interventions at the individual and community level to address risk and protective factors for firearm injuries and deaths.^46,48,49  These programs include multidimensional interventions focused on improving public transportation, environmental safety, and housing.^50,51  Increased funding to support and expand these programs is essential, especially to address the inequities associated with firearm violence.

Greater firearm availability is associated with increased risks of firearm suicide and unintentional deaths in youth 0 to 24 years of age.^52–54  Increased state-level firearm household ownership and prevalence has been associated with higher state-level rates of firearm suicides, homicide, and unintentional deaths in children 5 to 14 years of age.⁵⁵  Stronger state-level legislation is associated with lower state-level firearm prevalence and access⁵⁶  and decreased firearm deaths in children and youth.⁵⁷ 

Research funding is vitally needed for firearm injury prevention, with an estimated $120 million needed annually to close the research funding gap.⁵⁸  The passage of the Dickey amendment in 1996 led to a nearly 25-year prohibition of federal funding. Not until 2020 was Congressional federal funding appropriated again for research on firearm injury and violence prevention. Between 2008 and 2017, on average, $597 was spent on research per pediatric firearm death. In comparison, motor vehicle-related research received $26 136 per pediatric death, whereas cancer, the third leading cause of death, received $195 508 per death in funding.⁵⁹  Consequently, research and publications addressing firearm-related injuries, deaths, and interventions remain far behind other areas of research. This lack of funding and research has impeded our ability to apply evidence-based approaches to decrease firearm injuries and deaths in US children and youth.^59,60 

In 2013, the Institute of Medicine issued a summary of research priorities to reduce the threat of firearm-related violence, including characteristics of violence, risk and protective factors, intervention strategies, the impact of gun safety technology, and the influence of media.⁶¹  Better data sources for research are also critical. The National Highway Transportation Safety Administration has detailed databases on motor vehicle crash deaths and injuries,⁶²  which have been vitally important in implementing interventions and ultimately decreasing motor vehicle-related deaths.⁶³  As of 2020, funding has been appropriated for the first time for all 50 states to provide data for the National Violent Death Reporting System⁶⁴ —a very important start. However, this database only provides information about deaths and is not available in real-time for surveillance of firearm deaths. To truly understand the changing dynamic of firearm injuries and deaths, a real-time data surveillance system for injuries, including those caused by firearms, is necessary.

• Firearm anticipatory guidance and lethal means counseling

  • Educate clinicians about firearm epidemiology, anticipatory guidance, and lethal means restriction: clinicians, including trainees, should be provided training on the importance of, and how to have, these discussions with patients and families to decrease firearm injuries and deaths.⁶⁵ 

  • Mental health screening: age-appropriate, evidence-based screening for depression and suicide risk should be conducted in the primary care, subspecialty care, and ED settings to identify youth at risk for self-harm or for harming others.^39,66 

  • Anticipatory guidance: anticipatory guidance regarding safer firearm storage, including “smart” gun safety technology, or removal of firearms from the home, should be provided as part of routine injury prevention discussions.³³  These open, nonjudgmental conversations should be normalized and personalized to the specific situation of the family to foster shared decision making. For families with toddlers and older children, the focus should be on the prevention of an unintentional shooting event. For families with adolescents and young adults, the focus should also include the prevention of suicide, while acknowledging many teenagers who attempt suicide do not have a known history of depression or suicidal ideation. When counseling, consider direct messages such as:

    • “Having a loaded or unlocked firearm in your house increases the risk of injury or death to all family members, including children, whether by accident or on purpose. I urge you to store your unloaded firearms in a locked box or safe, separate from the locked ammunition, and out of the reach of children.”⁶⁷ 

    • Safer storage includes having the firearm unloaded and locking the firearm and ammunition away separately.

    • Anticipatory guidance on safety storage can be provided, preferably with a safety device (eg, trigger lock, firearm lock box),²¹  or at least with resources on how to obtain these devices.

  • Asking Saves Kids (ASK): the Asking Saves Kids (ASK) campaign advocates for greater awareness about the risks of unintentional firearm shootings and asking about firearms in the homes of others. As part of anticipatory guidance, parents and caregivers should also be counseled on asking about firearms in the homes where their child(ren) are visiting.³⁶ 

  • Lethal means counseling: this counseling should be provided to young adults and families of individuals at risk for self-harm or harming others (eg, individuals with suicidal ideation, history of intimate partner violence in the household, individuals with history of violent acts or substance use disorders) in primary care, mental health, ED, or other health care settings (https://www.hsph.harvard.edu/means-matter/recommendations/clinicians/). Counseling about firearms should be included in the context of the removal of other lethal means, including medications, toxic substances (eg, cleaners), and sharp objects.^68,69 

• Hospital and community-level interventions

  • Violence intervention programs: advocate for increased funding⁷⁰  for and disseminate best practices for the development of hospital- and community-based violence intervention advocacy programs, tailoring resources to needs of the community.

  • Location restrictions for firearms: as smoking is restricted in certain public places, firearms should have similar restrictions (eg, airlines, hospitals, sports stadiums, schools, and other public places).¹² 

  • Neighborhood environment interventions: advocate for community development, including cleaning and greening of open neighborhood land spaces and mitigation of abandoned houses (by securing the doors and windows), as these practices have been associated with decreased firearm violence.⁵⁰ 

  • Community investment in addressing the social determinants of health: because poverty is associated with increased firearm deaths, decreasing the poverty level of the community by increasing affordable housing and educational and employment opportunities may be another strategy to decrease firearm violence on the community level.^71,72 

  • Law enforcement: address policies and practices in law enforcement that have led to greater policing of youth from marginalized racial and ethnic communities and reform laws (eg, minimum mandatory sentence drug laws, repeat offender laws) that may influence the frequency of contact with the police and the criminal justice system.^71,73,74 

• Firearms as a consumer product

  • Consumer product regulations: firearms should be regulated for safety like other consumer products. Similar to motor vehicles, firearm regulations could be enacted so national requirements are established for training, licensing, insurance coverage, and registration of individuals purchasing firearms and requirements for safe storage.⁷⁵ 

  • Establish a federal agency to regulate firearms: comparable to the National Highway Transportation Safety Administration that regulates motor vehicles for safety, a similar organization could be established for firearms to make policies and respond efficiently to changes in technology. This agency would be focused on safety standard setting, recalls, and collecting data on firearms.⁷⁵ 

  • Firearm safety design and regulation: advocate for the design and sale of affordable personalized “smart” gun and safety technology, which allow only authorized users to pull the trigger on the firearm. Safety mechanisms, like trigger locks, should be required.²¹  There should be regulations for privately made firearms (“ghost guns”), which are untraceable, including those printed by 3D printers, with requirements for background checks for purchase of key components and for identifying markings.⁷⁶ 

• Legislation

  Stronger, effective legislation should be enacted and enforced at the state and federal level, including the following laws.

  • Universal background checks: background checks, using both federal databases, as well as information from local law enforcement, should be performed before all firearm purchases. These background checks should be applied not only to firearms sold at federally licensed firearm dealers but for all transactions resulting in firearm sales. These transactions include those at gun shows, private sales and transfers, and online purchases, similar to how privately sold motor vehicles still must be legally registered.^77,78 

  • Buyer regulations: buyer regulations include laws increasing age limits for certain types of firearms (eg, semiautomatic, military-style weapons), requiring buyers to obtain a permit or license, and a waiting period before firearm purchase. Standardized, evidence-based safety training should be mandatory for all buyers. Waiting periods may reduce the risk of impulsive acts (eg, suicide, intimate partner violence) and allow sufficient time for background checks to be conducted.^77,79 

  • Child access prevention laws: these laws hold firearm owners liable if a child can or does access a firearm. The degree of rigor of these law vary by state.⁷⁷  More stringent child access prevention laws are associated with decreased firearm deaths in children 0 to 14 years of age.⁸⁰ 

  • Extreme risk protection order laws: also known as “red flag laws,” these laws prohibit individuals at risk from harming themselves or others from purchasing or owning a firearm by a court order. These laws also allow for the temporary removal of firearms already owned by the at-risk individual. These laws are associated with decreases in firearm violence.^81–84 

  • Semiautomatic military-style weapons and high-capacity magazine bans: these weapons can fire multiple rounds of ammunition without reloading the firearm, increasing the morbidity and mortality of shooting events. Banning these weapons would restrict access to the types of weapons most often used in mass shootings.^75,77 

• Data and research

  Better data sources are needed to be able to develop targeted interventions.

  • A comprehensive data system for firearm injuries and deaths, including real-time surveillance, should be developed at the national level.⁵⁸ 

  • State firearm registration files, including handguns and rifles, should be made accessible to researchers to better understand firearm ownership and purchasing. The 2003 Tiahrt amendment prohibits the release of firearm tracing data for research.⁸⁵ 

  • Increased research funding is essential to develop effective and impactful injury prevention strategies. Better understanding of the risk and protective factors for firearm injuries and interventions at the individual, household, community, state, and federal level is essential for designing focused interventions.^45,47,61 

  • Firearm injury and prevention research should be expanded. Important areas of research include, but are not limited to, the following:^86,87 

  1. Risk and protective factors for firearm injuries and deaths.

  2. Epidemiology of fatal and nonfatal firearm injuries, including inequities existing among communities, and for legal intervention shootings, school shootings, adolescent intimate partner violence, health care utilization and cost, and long-term consequences.

  3. Parental and young adult attitudes and behaviors regarding firearms, including safer storage.

  4. Effective approaches to firearm safety anticipatory guidance and lethal means counseling.

  5. Implementation, effectiveness, and dissemination of school-, hospital-, and community-based firearm violence prevention programs.

  6. Development and impact of firearm safety technologies.

  7. Effectiveness of firearm-related legislation.

  8. Linking data systems for firearm surveillance and research.

• Clinician advocacy

  For clinicians interested in advocacy to advance firearm injury prevention, there are multiple ways to become involved.

  • Join the AAP and your local chapter or other professional medical society (eg, AAP, American Medical Association, American College of Physicians, American College of Emergency Physicians, American College of Surgeons) and grassroots firearm violence prevention organizations (eg, https://www.everytown.org/, https://momsdemandaction.org) to support their efforts against firearm violence.

  • Engage in advocacy. These efforts can focus on advocacy for community approaches to decreasing the impact of firearm injuries, including legislation and increasing research funding. This advocacy can be at the institutional, municipal or county, state, or federal level. Pediatricians should work with their AAP state chapter to advance state and local policy change.

  • Assess institutional policies around firearm possession and gun-free zones, including use of force by police and security officers in clinical settings.

  • Encourage health system investment by working with payers, institutional leadership, media, injury prevention or wellness departments, and government affairs teams to ensure firearm injury prevention is a priority with their provision of financial and personnel resources. Advocate for adequate payment for health risk assessments and care coordination services as necessary as well as payment for gun safety devices, like durable medical equipment.

  • Write op-eds, letters to the editor, or blog posts specific to your community.

  • Identify and support the work of local community-based organizations (eg, community associations, culturally specific organizations) around firearm injury prevention.

  • Engage your elected officials to educate them about the impact of firearm injury.

  • When applicable, support policy change efforts through written and/or oral testimony at the local, state, and federal level to advance firearm safety legislation, including participating in state lobby days throughout your institution, AAP chapter, or other professional medical organization.⁸⁸ 

As with motor vehicle safety, we must acknowledge a multipronged approach, including principles of the Haddon matrix^8,10  and focusing on harm reduction, is essential to decrease firearm deaths and injuries in the United States. Clinicians should educate themselves and their patients and families about the increased risks of unintentional and intentional firearm injuries and deaths with increased access to firearms in the home and in the community. Firearms should be regulated and designed to decrease the risk of unauthorized users being able to use the firearm. Federal and state legislation must be enacted to increase the safety of firearms and decrease access to those at risk for harming themselves or others. Better data sources and robust and sustained research funding are also critical to advance the science of firearm injury prevention. We must resolve to make progress and work collaboratively. This public health approach must engage individuals, the health care sector, communities, corporations, and the government to address the persistent epidemic and inequities of firearm violence among children and youth in the United States.

Lois K. Lee, MD, MPH

Eric W. Fleegler, MD, MPH

Monika K. Goyal, MD, MSCE

Kiesha Fraser Doh, MD, FAAP

Danielle Laraque-Arena, MD

Benjamin D. Hoffman, MD

Benjamin D. Hoffman, MD, FAAP, Chairperson

Alison Culyba, MD, MPH, PhD, FAAP

James Dodington, MD, FAAP

Brian D. Johnston, MD, MPH, FAAP

Sadiqa Kendi, MD, CPST, FAAP

Andrew Kiragu, MD, FAAP

Lois K. Lee, MD, MPH, FAAP

Terri McFadden, MD, FAAP

Kevin C. Osterhoudt, MD, MS, FAAP

Milton Tenenbein, MD, FAAP

Kyran Quinlan, MD, MPH, FAAP, Immediate Past Chairperson

Cinnamon Dixon, DO, MPH – National Institute of Child Health and Human Development

Suzanne Beno, MD – Canadian Paediatric Society

Bonnie Kozial

Allison Delgado, MPH

AAP

American Academy of Pediatrics

ED

emergency department