Firearm injury is a leading cause of death among children and adolescents.1–3 Approximately 33 000 children were killed by firearms in the decade between 2012 and 2021, with an annual rate that increased 50% between 2019 (1732) and 2021 (2590).4 For every 1 of these lives tragically lost, 4 children survive their firearm injuries.4 This substantial rise in preventable death and injury among children by firearms underscores the need for firearm injury reduction to be a national priority area for policymakers, community leaders, clinicians, advocates, and researchers.
The authors of recent studies estimate that 40% of children who survive firearm injuries suffer chronic, complex medical conditions, with an associated $100 million in additional health care expenditures in the year after the injury.5 Of children who survive firearm injuries, between 47% and 70% are discharged directly from the emergency department (ED), resulting in only a brief window to recognize and begin to address the consequences of traumatic injury.4,6 In addition, there are well-described racial, ethnic, and socioeconomic disparities in firearm injury patterns.7 For example, children from disinvested neighborhoods are more likely to be affected by firearm injury and return to the same neighborhoods in which their injury occurred.8,9 Non-Hispanic Black males and females are 19-fold and 13-fold, respectively, more likely to experience nonfatal firearm assaults compared with non-Hispanic white males and females.7
These findings only begin to describe the experiences of firearm-injured children and their families. To illustrate this, we describe a real patient vignette (name changed). The elements of the vignette are familiar to many clinicians, given similar stories unfold daily across the United States.
Patient Vignette
Nick, a 12-year-old male, was in his backyard with his friends. Suddenly, multiple gunshots rang out, penetrating the wood fence separating the street from his yard. All he remembered was the pain in his neck and thinking he was going to die. He also remembered sirens and his friends yelling. An ambulance arrived, and Nick was transferred to the local children’s hospital. His airway remained clear without hemorrhage, and he remained stable. The gunshot did not penetrate any major structures, and the medical team decided not to remove the bullet to prevent injury to vital structures of the neck. He was discharged from the ED after an evaluation by the trauma team.
Nick was persistently haunted by phantom gunshot sounds and the bullet lodged in his neck. He experienced frequent palpitations and diaphoresis and had periods in which he was too afraid to leave his home. He subsequently presented 3 more times to the ED with these symptoms and was eventually diagnosed with anxiety, posttraumatic stress disorder, and depression. Multiple school absences led to a drop in his grades, he quit the local basketball team because he feared walking to practice, and he spent less time with his friends because it reminded him of the incident. During the first 2 ED visits, he was deemed in no immediate danger to himself or others, and he was discharged from the hospital. He was advised to seek mental health support through a trained professional, and this was even scheduled, albeit 8 months after the injury because of limited access to mental health resources. It was not until Nick’s third presentation to the ED with active suicidal thoughts that his mounting crisis received appropriate recognition and support, 14 months after his injury.
Coalition Building to Identify and Address Current Gaps
Patient and family experiences, such as the one described above, inspired us to establish a multidisciplinary research collaborative through the Children’s Hospital Association Research in Gun-Related Events. Instead of a focus solely on the biomedical impact of firearm injuries, we deliberately chose research questions that aligned with a more holistic approach to nonfatal firearm injuries in children.10 Our initial evaluation of health service utilization and expenditures among children after nonfatal firearm injuries quickly led us to identify a research gap in our knowledge of mental health service use after firearm injuries.5,6,11 We directed our attention to this area and found that children who suffer from firearm injuries have 50% greater odds of a new mental health diagnosis within a year of injury compared with children involved in motor vehicle crashes.12 We have also found that up to two-thirds of children do not access mental health services after a firearm injury, and there are racial disparities in rates of mental health service use after firearm injuries.13
These are among the first studies, to our knowledge, to characterize the mental health needs of children after nonfatal firearm injuries. Nick’s story, and the stories of many children who receive limited psychosocial support after injury, clearly reveal a need for more definitive recommendations and actions, which includes further research efforts and funding. Table 1 outlines a nonexhaustive list of recommended actions and anticipated outcomes, intended to guide multidisciplinary efforts to address this issue based on our collective expertise.
Recommended Actions and Anticipated Outcomes to Address Childhood Firearm Injury
| Domain . | Action . | Anticipated Outcome . |
|---|---|---|
| Advocacy: to bring attention to pediatric firearm injury and increase support for funding and programmatic interventions to assist children and families affected by firearm injury. | 1. Advocate for more local, state, and federal funding to support programmatic efforts focused on firearm injury recovery and firearm injury prevention, such as Medicaid reimbursement for community violence intervention, expanded victim of crime act, etc. | 1. Increased funding will lead to more sustainable interventions that address the full range of effects of nonfatal firearm injury on children and families. |
| 2. Advocate for more public health and health care-based efforts to address the ongoing needs of survivors of pediatric firearm injury and their family members (eg, hospital-based violence intervention programs). | 2. More public health and clinical care programmatic efforts will contribute to enhanced comprehensive wraparound care for survivors of childhood firearm injury. | |
| 3. Leverage the experiences of patients, their families, and health care organizations to share their experiences through various forms of advocacy. | 3. Raise awareness among key partners, such as policymakers and decision makers, about the substantial need for family-centered mental health care for children after a firearm injury, which will lead to the development of solutions that use a partnered approach to address unmet needs for holistic care. | |
| 4. Continue efforts to ameliorate and reduce stigma and bias among clinicians, patients, and families related to recovery needs after firearm injury. | 4. Timely, equitable referrals and connections to care for children after firearm injuries will facilitate increased recognition of trauma symptoms. | |
| 5. Support increased access to evidence-based programs and therapies, such as trauma-focused cognitive behavior therapy, including but not limited to, the expansion of training opportunities for community-based providers and colocation of services (eg, school-based health centers) to reduce the pragmatic barriers to care experienced by patients and families. | 5. Increased access to evidence-based care, notably within the communities most affected by firearm injuries, will reduce disparities and mitigate short- and long-term effects of firearm injury. | |
| Clinical care/quality improvement: to initiate interdisciplinary clinical and quality improvement initiatives to build and sustain best practices for holistic care for children and their families after nonfatal firearm injuries. | 1. Establish or strengthen local communication and collaboration between trauma teams, medical homes, and community-based mental health providers for children with firearm injuries, including navigation of follow-up needs. | 1. Enhanced coordination of care will ensure children affected by firearm injury are not lost to follow-up or experience delayed connection to care. |
| 2. Enhance emergency department and inpatient-specific resources for children with nonfatal firearm injuries. Examples include strengthening staffing in EDs for mental health consultations and social care resources and providing discharge instructions that describe potential mental health effects and where to seek assistance. | 2. These resources will empower families to recognize immediate and long-term sequelae of pediatric firearm injury, which will result in improved access and timelier holistic care for children affected by firearm injury. | |
| 3. Engage information technology and digital health care support to prompt providers of the importance of connecting children with firearm injury to medical home and mental health resources | 3. These supports will increase children’s and families’ access to services and, therefore, provide the best opportunity for a positive outcome after the firearm injury | |
| Research: to advance the knowledge of the sequalae of pediatric nonfatal firearm injury, and further, how to prevent such injuries. | 1. Local and regional interdisciplinary research to identify and describe the biopsychosocial morbidity of pediatric firearm injury. | 1. This research will increase our understanding of the individual and longitudinal care needs after pediatric firearm injury, which include interventions to improve access, timeliness, and quality of follow-up of care. |
| 2. Develop community-engaged research partnerships to increase understanding of the sequelae of nonfatal firearm injuries as experienced by children, families, friends, and neighborhoods. Interventions should be developed and implemented across the care continuum (prevention, early detection, treatment, and recovery) with a specific focus on historically disinvested communities. | 2. These partnerships will promote the investigation of effects on children, families, and communities and will begin to identify locally relevant solutions to support recovery and prevent pediatric firearm injury. | |
| 3. Continue to advocate for more local, state, and federal funding to support research and program evaluation efforts focused on firearm injury prevention, holistic early treatment, and recovery. More specifically, fund research that investigates the medium- and long-term impact of enhanced mental illness identification and timely connection with mental health services for children and their families after firearm injury. | 3. Increased research funding will lead to an improved understanding of the full range of effects of nonfatal firearm injury on children and families and inform prevention and treatment programs for children and their families. |
| Domain . | Action . | Anticipated Outcome . |
|---|---|---|
| Advocacy: to bring attention to pediatric firearm injury and increase support for funding and programmatic interventions to assist children and families affected by firearm injury. | 1. Advocate for more local, state, and federal funding to support programmatic efforts focused on firearm injury recovery and firearm injury prevention, such as Medicaid reimbursement for community violence intervention, expanded victim of crime act, etc. | 1. Increased funding will lead to more sustainable interventions that address the full range of effects of nonfatal firearm injury on children and families. |
| 2. Advocate for more public health and health care-based efforts to address the ongoing needs of survivors of pediatric firearm injury and their family members (eg, hospital-based violence intervention programs). | 2. More public health and clinical care programmatic efforts will contribute to enhanced comprehensive wraparound care for survivors of childhood firearm injury. | |
| 3. Leverage the experiences of patients, their families, and health care organizations to share their experiences through various forms of advocacy. | 3. Raise awareness among key partners, such as policymakers and decision makers, about the substantial need for family-centered mental health care for children after a firearm injury, which will lead to the development of solutions that use a partnered approach to address unmet needs for holistic care. | |
| 4. Continue efforts to ameliorate and reduce stigma and bias among clinicians, patients, and families related to recovery needs after firearm injury. | 4. Timely, equitable referrals and connections to care for children after firearm injuries will facilitate increased recognition of trauma symptoms. | |
| 5. Support increased access to evidence-based programs and therapies, such as trauma-focused cognitive behavior therapy, including but not limited to, the expansion of training opportunities for community-based providers and colocation of services (eg, school-based health centers) to reduce the pragmatic barriers to care experienced by patients and families. | 5. Increased access to evidence-based care, notably within the communities most affected by firearm injuries, will reduce disparities and mitigate short- and long-term effects of firearm injury. | |
| Clinical care/quality improvement: to initiate interdisciplinary clinical and quality improvement initiatives to build and sustain best practices for holistic care for children and their families after nonfatal firearm injuries. | 1. Establish or strengthen local communication and collaboration between trauma teams, medical homes, and community-based mental health providers for children with firearm injuries, including navigation of follow-up needs. | 1. Enhanced coordination of care will ensure children affected by firearm injury are not lost to follow-up or experience delayed connection to care. |
| 2. Enhance emergency department and inpatient-specific resources for children with nonfatal firearm injuries. Examples include strengthening staffing in EDs for mental health consultations and social care resources and providing discharge instructions that describe potential mental health effects and where to seek assistance. | 2. These resources will empower families to recognize immediate and long-term sequelae of pediatric firearm injury, which will result in improved access and timelier holistic care for children affected by firearm injury. | |
| 3. Engage information technology and digital health care support to prompt providers of the importance of connecting children with firearm injury to medical home and mental health resources | 3. These supports will increase children’s and families’ access to services and, therefore, provide the best opportunity for a positive outcome after the firearm injury | |
| Research: to advance the knowledge of the sequalae of pediatric nonfatal firearm injury, and further, how to prevent such injuries. | 1. Local and regional interdisciplinary research to identify and describe the biopsychosocial morbidity of pediatric firearm injury. | 1. This research will increase our understanding of the individual and longitudinal care needs after pediatric firearm injury, which include interventions to improve access, timeliness, and quality of follow-up of care. |
| 2. Develop community-engaged research partnerships to increase understanding of the sequelae of nonfatal firearm injuries as experienced by children, families, friends, and neighborhoods. Interventions should be developed and implemented across the care continuum (prevention, early detection, treatment, and recovery) with a specific focus on historically disinvested communities. | 2. These partnerships will promote the investigation of effects on children, families, and communities and will begin to identify locally relevant solutions to support recovery and prevent pediatric firearm injury. | |
| 3. Continue to advocate for more local, state, and federal funding to support research and program evaluation efforts focused on firearm injury prevention, holistic early treatment, and recovery. More specifically, fund research that investigates the medium- and long-term impact of enhanced mental illness identification and timely connection with mental health services for children and their families after firearm injury. | 3. Increased research funding will lead to an improved understanding of the full range of effects of nonfatal firearm injury on children and families and inform prevention and treatment programs for children and their families. |
A Collaborative Step Forward
As researchers and clinicians from around the nation who care for children with nonfatal firearm injuries and their families, we recommend a biopsychosocial approach to pediatric nonfatal firearm injuries rooted in health equity.14 We have just begun to delve into health care utilization, expenditures, and mental health service use after nonfatal firearm injury among children, and we are recognizing numerous gaps in our understanding of Nick’s story. For example, where and when could we have intervened to prevent the exacerbation of his mental health issues? Who should intervene? Is the timing and intensity of intervention important? How did community health equity factors, including (but not limited to) systemic racism, poverty, housing instability, high rates of crime/violence, inadequate school systems, and food insecurity impact Nick’s story? What support should we provide for his family? What support is necessary for the community? And most importantly, how can we meaningfully prevent childhood firearm injuries entirely? Many questions such as these remain to be answered. Given the overwhelming impact of firearm injury among children, coupled with the paucity of research on firearm injuries in comparison with other causes of childhood injury and death,1,15 it is our collective goal as a pediatric clinical research and advocacy community to study and subsequently implement a biopsychosocial model that comprehensively addresses the needs of children, families, and communities after firearm injuries.
Dr Pulcini designed the manuscript, drafted the initial manuscript, and critically reviewed and revised the manuscript; Dr Hargarten conceptualized the manuscript, drafted the initial manuscript, and critically reviewed and revised the manuscript; Drs Alpern, Chaudhary, Ehrlich, Fein, Goyal, Hall, Hoffman, Jeffries, Fleegler, Myers, Sheehan, Zamani, and Zima drafted the initial manuscript and critically reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
FUNDING: Funded by the National Institutes of Health (NIH). Dr Pulcini was supported by the NIH Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) (K23HD109469-01). The other authors received no additional funding. The NIH had no role in the design and conduct of the study.
CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts of interest to disclose.
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