Firearm injury has recently become the leading cause of death among American children and adolescents.1  Although the home is the most common place for school-aged children to be injured by firearms,2  firearm injuries are occurring in schools at a rate that exceeds those of other high-income countries.3  What do we know about school shootings and what can pediatricians do to address these tragedies?

In this issue of Pediatrics, Rapa et al4  present trends in kindergarten through 12th grade school shootings from 1997 through 2022. The authors look at 2 categories of events: school shootings and school mass shootings. Data on school shootings were taken from the Center for Homeland Defense and Security’s School Shooting Safety Compendium,5  with “school shooting” defined as “every instance a gun is brandished, is fired, or a bullet hits school property for any reason, regardless of the number of victims, time of day or day of week.” Rapa et al find that the frequency of school shooting events has increased significantly in the past 5 years compared with the prior 20 years. Data on school mass shootings were taken from the Mother Jones U.S. Mass Shootings database.6  The authors find that the frequency of school mass shootings remained steady throughout this period but that incidents became more deadly.

It is worth noting that the databases used in this study are created and maintained by individuals and organizations using publicly available data with little funding support.7  These are valuable databases for the public and for academic researchers. But the leading cause of childhood death should warrant federal resources commensurate to its burden. Progress has been made in dedicating federal funds to firearm injury research but remains inadequate; medical organizations including the American Academy of Pediatrics continue to advocate for needed federal funding for firearm research and data infrastructure.8 

The most common school shooting situation involves a student,9  a handgun,10  and an “escalation of dispute.”9  It is no surprise that these events are becoming more prevalent; youth handgun carrying is increasing and occurs in both rural and urban populations.11  Witnessing community violence increases high school students’ risk for handgun carrying.12  Community-based prevention systems have shown reduction in youth handgun carrying in some populations13  but little is known about how pediatricians can best address this during clinical encounters. Research is needed to determine effective strategies for pediatricians in direct counseling of youth on handgun carrying.

Most school shooters obtain their firearm from the home of a parent or close relative,14  underscoring the importance of secure home storage. The most secure way to store a firearm is locked up, unloaded, with the ammunition locked and stored separately.15  Pediatricians can play an important role in firearm storage counseling, but many lack training in how to have these conversations with families. In recent years, pediatricians have created educational resources including the online module Safer: Storing Firearms Prevents Harm16  available through the American Academy of Pediatrics at no cost. Pediatricians who have taken the course report improved firearm storage counseling self-efficacy and increased counseling frequency.17 

As pediatricians counseling families on secure firearm storage, we may recommend temporary removal of firearms from the home. Some states have followed Colorado’s lead by creating firearm storage facility maps for families seeking to voluntarily and temporarily store firearms outside of the home.18 20  Pediatricians should know about these local resources and, if not available, should collaborate with law enforcement and state agencies to create out-of-home firearm storage programs.

For those at elevated risk of harming themselves or others, use of an Extreme Risk Protection Order (ERPO) can be lifesaving. ERPO laws, sometimes referred to as “red flag” laws, allow courts to issue an order temporarily restricting an individual at increased risk of harming themselves or others from possessing a firearm. A thwarted school shooting in Vermont in 2018 led to the passage of a state ERPO law that has since been used in subsequent instances of school shooting threats.21  Pediatricians should know the details of the ERPO laws in their state and advocate for passage in the 29 states that have yet to enact them.22  There is growing interest in ERPO laws with many states having enacted them in the past 5 years. The Bipartisan Safer Communities Act of 2022 set aside federal grant funding for states to support ERPO implementation.23 

Additional areas of policy advocacy include restricting access to weaponry like semiautomatic military-style firearms24  and large-capacity magazines that are associated with increases in the incidence and fatality rate of mass shootings.25  Child-access prevention (also known as safe storage) laws reduce firearm homicides and firearm assault injuries among youth.26  The legal landscape regarding firearm laws has become more disruptive and uncertain since the 2022 Supreme Court decision in NYSRPA v Bruen, with an unprecedented number of Second Amendment challenges to gun laws in the past year.27  However, the courts have upheld gun laws in the vast majority of decisions.28  Pediatricians should feel bolstered by this and continue to advocate for evidence-based policy.

It has been 25 years since the shooting at Columbine High School. Since that time, billions of dollars have been poured into school security efforts.29,30  Despite this, Rapa et al show that school-related gun incidents are growing, and the fatality rate of school mass shootings has increased. The data are clear that these tragedies cannot be prevented by focusing on school security alone. Schools are extensions of our homes and communities and cannot be expected to be secure fortresses amid the easy availability of firearms. Pediatricians’ efforts to make homes and communities safer also make schools safer. Intensifying our counseling and community collaboration efforts and advocating for research funding and policy change are critical measures to stem the tide of increasing gun violence in schools.

COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2023-064311.

FUNDING: No external funding.

CONFLICT OF INTEREST DISCLOSURES: The author has indicated she has no conflicts of interest to disclose.

ERPO

Extreme Risk Protection Order

1
Lee
LK
,
Douglas
K
,
Hemenway
D
.
Crossing lines—a change in the leading cause of death among U.S. children
.
N Engl J Med
.
2022
;
386
(
16
):
1485
1487
2
Ordoobadi
AJ
,
Wickard
A
,
Heindel
P
,
Raykar
N
,
Masiakos
PT
,
Anderson
GA
.
Quantifying pediatric gun violence by location, time of day, and day of week
[published online ahead of print November 7, 2023].
J Pediatr Surg
. doi: 10.1016/j.jpedsurg.2023.11.002
3
Rowhani-Rahbar
A
,
Moe
C
.
School shootings in the U.S.: what is the state of evidence?
J Adolesc Health
.
2019
;
64
(
6
):
683
684
4
Rapa
LJ
,
Katsiyannis
A
,
Scott
SN
,
Durham
O
.
School shootings in the United States: 1997–2022
.
Pediatrics
.
2024
;
153
(
4
):e2023064311
5
Riedman
D
,
O’Neill
D
.
Naval Postgraduate School, Center for Homeland Defense and Security, Homeland Security Advanced Thinking Program (HSx).
K-12 School Shooting Database
.
6
US Mass Shootings
.
1982–2023: data from Mother Jones’ Investigation
.
7
IPVM
.
K-12 School Shooting Database examined
.
Available at: https://ipvm.com/reports/k-12-school-shooting-database. Accessed January 11, 2024
8
Lee
LK
,
Fleegler
EW
,
Goyal
MK
, et al
; THE COUNCIL ON INJURY, VIOLENCE, AND POISON PREVENTION.
Firearm-related injuries and deaths in children and youth: injury prevention and harm reduction
.
Pediatrics
.
2022
;
150
(
6
):
e2022060070
9
Riedman
D
,
O’Neill
D
.
Naval Postgraduate School, Center for Homeland Defense and Security, Homeland Security Advanced Thinking Program (HSx).
K-12 School Shooting Database. Shooting incidents at K-12 schools
.
Available at: https://www.chds.us/sssc/charts-graphs/. Accessed January 2, 2024
10
Klein
BR
,
Trowbridge
J
,
Schnell
C
,
Lewis
K
.
Characteristics and obtainment methods of firearms used in adolescent school shootings
.
JAMA Pediatr
.
2024
;
178
(
1
):
73
79
11
Schleimer
JP
,
Gause
E
,
Dalve
K
,
Ellyson
A
,
Rowhani-Rahbar
A
.
Rural-urban variation in the association of adolescent violence and handgun carrying in the United States, 2002-2019
.
JAMA Netw Open
.
2023
;
6
(
2
):
e231153
12
Harper
CR
,
Li
J
,
Sheats
K
, et al
.
Witnessing community violence, gun carrying, and associations with substance use and suicide risk among high school students - youth risk behavior survey, United States, 2021
.
MMWR Suppl
.
2023
;
72
(
1
):
22
28
13
Rowhani-Rahbar
A
,
Oesterle
S
,
Gause
EL
, et al
.
Effect of the Communities That Care Prevention System on adolescent handgun carrying: a cluster-randomized clinical trial
.
JAMA Netw Open
.
2023
;
6
(
4
):
e236699
14
U.S. Secret Service National Threat Assessment Center
.
U.S. Secret Service protecting America’s schools
.
15
Lee
LK
,
Fleegler
EW
,
Goyal
MK
, et al
; THE COUNCIL ON INJURY, VIOLENCE, AND POISON PREVENTION.
Firearm-related injuries and deaths in children and youth
.
Pediatrics
.
2022
;
150
(
6
):
e2022060071
16
Barkin
S
.
Safer: storing firearms prevents harm
.
Available at: https://www.aap.org/Safer-Storing-Firearms-Prevents-Harm. Accessed January 11, 2024
17
Gastineau
KAB
,
Bell
R
,
Hanes
A
, et al
.
One step closer to safer: counseling outcomes from American Academy of Pediatrics firearm safe storage education training
.
J Pediatr
.
2024
;
264
:
113767
18
Colorado Firearm Safety Coalition.
Gun storage map
.
Available at: https://coloradofirearmsafetycoalition.org/gun-storage-map/. Accessed January 9, 2024
19
NC S.A.F.E
.
Safe storage 101
.
Available at: https://www.ncsafe.org/safestorage/. Accessed January 9, 2024
20
Vermont State Police, Department of Public Safety
.
Firearms storage program
.
Available at: https://vsp.vermont.gov/firearmstorage. Accessed January 9, 2024
21
Vermont Department of Public Safety
.
Extreme Risk Protection Orders (ERPOs). A guide for prosecutors, law enforcement, families and household members, and community members
.
22
American Academy of Pediatrics
.
Extreme Risk Protection Orders (ERPO) or “red flag” laws
.
23
Everytown for Gun Safety and Johns Hopkins Center for Gun Violence Solutions
.
2023
.
Promising approaches for implementing extreme risk laws: a guide for practitioners and policymakers
.
24
DiMaggio
C
,
Avraham
J
,
Berry
C
, et al
.
Changes in US mass shooting deaths associated with the 1994-2004 federal assault weapons ban: analysis of open-source data
.
J Trauma Acute Care Surg
.
2019
;
86
(
1
):
11
19
25
Klarevas
L
,
Conner
A
,
Hemenway
D
.
The effect of large-capacity magazine bans on high-fatality mass shootings, 1990-2017
.
Am J Public Health
.
2019
;
109
(
12
):
1754
1761
26
Smart
R
,
Morral
A
,
Ramchand
R
, et al
The Science of Gun Policy: A Critical Synthesis of Research Evidence on the Effects of Gun Policies in the United States
, 3rd ed.
RAND Corporation
;
2023
27
Clark
W
.
Giffords Law Center
.
Second Amendment challenges following the Supreme Court’s Bruen decision
.
28
Charles
JD
.
Pepperdine Caruso School of Law.
The dead hand of a silent past: Bruen, gun rights, and the shackles of history
.
Available at: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=4335545. Accessed January 31, 2024
29
Caffrey
M
.
Spending on school security tops $3 billion, with focus on new surveillance and tech
.
30
Avila-Acosta
M
,
Sorensen
L
.
Urban Institute
.
Contextualizing the push for more school resource officer funding
.