Firearm Injury and Mortality Prevention in Pediatric Health-care Settings.

Abstract

After completing this article, readers should be able to: Understand the epidemiology of firearm injury and mortality in the United States.Recognize risk factors associated with firearm injury and mortality.Define the role that pediatric providers have in screening for firearm injury risk among patients and families and counseling about firearm safety when appropriate.Understand provider-level barriers to firearm safety counseling and how to overcome these barriers (education, stakeholder buy in, collaborations with gun owners and community-based organizations to increase cultural competence).Develop strategies to build cultural competence in advising patients and families with firearms.Compared with other high-income countries, the United States has the highest rate of firearm-related injury and mortality in the world. (1) In 2016, the rate of firearm deaths in children and adolescents in the United States was 36.5 times higher than the rate in other high-income countries and 5 times higher than the rate in middle-income countries. (2) According to 2016 death certificate data collected by the Centers for Disease Control and Prevention (CDC), the second leading cause of death among children and adolescents (age 1–19 years) in the United States was firearm injury. (3)(4) International studies indicate that 91% of firearm deaths in children aged 0 to 14 years in high-income countries worldwide occur in the United States. (5) According to data from the National Trauma Data Bank from 2010 to 2016, 13% of firearm injuries occurred in children younger than 15 years and 50% occurred in 18- and 19-year-olds. (3) Of all injuries and illnesses in children, firearm injuries have one of the highest case fatality rates, particularly if intent is self-harm. (5)(6) Surprisingly, the rates of firearm injury across the country during the COVID-19 pandemic have increased, and 2020 was the deadliest year on record, with more than 40,000 Americans killed by firearms. (7)One-third of homes in the United States in which children reside have at least 1 gun in the household, and a surge in firearm purchases among Americans during the past 2 years has resulted in a significantly higher number of firearms in households across the country. (8) Although the safest way to store a gun is locked and unloaded, (9)(10) many are stored unlocked and loaded. (11)(12)(13) During the past 2 decades, the safe storage of weapons in homes has declined, with 21% of homes storing firearms unlocked and loaded in 2015 compared with only 8% in 2002. (13)(14) As a result, at least 4.6 million American children live in a home with an unlocked and loaded gun. (13) Interestingly, the most common reason for owning a firearm among Americans is the perceived belief that it makes the home safer, with 35% of Americans saying it makes the household safer in 2000 and 63% with this same belief in 2014. (13) However, guns in the home do not correlate with safety, (15) with the odds of firearm-related homicide, suicide, or accidental injury being higher in gun-owning homes. (13)Deaths and injuries related to firearms are considered unintentional or intentional. Unintentional injuries from firearms are more common in children, whereas intentional injuries, such as suicide or homicide, are more likely seen in adolescents. (2) Unintentional firearm-related deaths in children commonly occur when a child happens upon a loaded and unsecured firearm in their household and shoots a sibling or themselves. (6) Suicide accounts for most firearm-related deaths in the United States (>55%), followed by homicides. (5)(7) In the pediatric population, homicides are the leading cause of firearm-related deaths. (6) Younger children are more likely to be shot by adults they know and in the house in which they live, whereas adolescents aged 13 to 17 years are more likely to be killed by someone similar in age as the victim and are equally as likely to die in a home or in the streets. Although homicide rates in children and adolescents have been decreasing, firearm suicide rates in the pediatric population have had the opposite trend with a rapid increase, and firearm-related suicide is now one of the leading causes of death in adolescents. (4) In 2019, suicide was the 10th leading cause of death in the United States among all Americans, and about half of all suicides were by firearms. (4) Most suicides are completed with handguns; however, long gun use for suicides is higher in rural counties and in adolescents. (16) Regardless of the intention, overall, firearm injury has one of the highest case fatality rates of any illness or injury in pediatrics. (3)Firearm injury and mortality vary across the country by geographic location and across states. From 2010 to 2014, Louisiana and the District of Columbia had the highest rates of child firearm mortality in the nation (4.5 and 4.2 per 100,000, respectively). (6) In addition, firearm-related homicide deaths are more prevalent in southern and midwestern states. (6) This variability may be in part due to varying firearm safety legislation by state, as there has been an association between strict firearm safety laws (safe storage, background checks) and lower rates of childhood and all-age resident firearm-related deaths. (17)Firearm injury and violence disproportionally affects Americans based on their race, sex, age, and socioeconomic status. In the United States, African Americans, males, and adolescents aged 13 to 17 years are particularly at risk. (6) From 2012 to 2014, firearm-related homicides primarily affected African Americans, whereas firearm-related suicide primarily affected White and American Indian children. (6) In addition, males and adolescents are also more likely to experience nonfatal firearm injuries. (6) Firearm injury trends also show that young African American children (<5 years) have firearm mortality rates 3 times as high as young White children. (18) Given these disparities, gun violence has to be addressed via a community-based approach with emphasis placed on neighborhood- and hospital-based violence interrupter programs. (19)(20) Efforts to develop more hospital-based violence intervention programs and other important community-based organizations should be considered.Policies and laws geared toward safe storage have been shown to improve firearm safety in the household. Child access prevention (CAP) laws requiring safe storage of weapons within the household have been associated with lower rates of firearm-associated suicide (21) and reduced self-inflicted injuries and unintentional firearm injuries in youth. (17)(22) Background checks have been shown to decrease violent crime, whereas stand-your-ground laws have resulted in higher rates of homicide. Extreme risk protection orders (ERPOs), also known as red flag laws, are important means that empower families and law enforcement to temporarily restrict firearm access for loved ones who are at risk for harm to self or others. After implementation in Indiana and Connecticut, it is estimated to have prevented at least 1 suicide for every 10 to 20 ERPOs issued, with 7.5% and 13.7% reductions in suicides, respectively. (23) For pediatricians providing guidance to patients and families on firearm safety, an understanding of state firearm safety laws such as ERPOs and CAP laws empowers practitioners to provide families information on these lifesaving resources during counseling.Most health-care providers believe that discussing firearm safety with their patients is important and that implementing already existing evidence-based firearm injury and mortality prevention strategies into health-care settings can be impactful. Most pediatric providers believe that counseling on firearm safety is beneficial and that firearm injury prevention should be discussed with all families. (24)(25) Despite widespread belief that counseling is necessary to prevent injuries, few health-care providers routinely screen and counsel patients about firearm safety. In a survey conducted in the 1990s, 33% of providers reported ever having counseled about gun safety and 20% reported actively performing firearm safety counseling, despite 80% finding it beneficial. (23) In a more recent survey of pediatric residents, most (96%) believed that physicians have a duty to counsel on firearm risks; however, 63% never provide counseling during health supervision visits, and of those who did, most report that they provided it less than 5% of the time. (26) Of the respondents, most (85%) felt uncomfortable with counseling on safety storage devices. In a survey from outpatient pediatric practices in St Louis, Missouri, only 0.5% of parents reported that their firearm safety education was received through a pediatrician; yet, 75% of the respondents thought that pediatricians should advise about safe firearm storage. (27)Both gun-owning and non–gun-owning parents underestimate how much their kids know about where guns are stored or whether the child has ever handled a gun. (28) A survey found that 39% of parents who reported that their children did not know the location of the firearm in the home were contradicted by their children, and 40% of children who reported having handled a firearm were not identified by their parents as having done so. (28)Although some physicians are concerned about the legality of confidentially screening and counseling patients on firearm injury risk, there are no federal or state laws that prohibit physicians from asking about firearms in the home. (29) Parental willingness to engage in discussions with providers about firearm safety is also important to consider. Several studies have shown parental willingness to hear advice from their pediatrician on this topic. One study found that 75% of parents thought that pediatricians should advise about safe storage of firearms and two-thirds thought that pediatricians should screen for guns in the home. (27) Although gun owners were less likely to feel that their physician should ask about firearms in the home compared with non–gun owners, still, most agree that it would be appropriate to do so. (27)(30)(31) Furthermore, most gun owners reported that physicians should advise about safe gun storage (71%), despite fewer feeling that physicians should ask. (27) By approaching screening and counseling about firearm safety in the context of injury prevention as part of routine care, concurrently with discussions about other injury prevention topics, such as motor vehicle safety and drowning avoidance, providers can help normalize conversations around firearm injury prevention in the health-care setting.There are gaps in knowledge in our understanding of the most effective approach for pediatric providers to screen and counsel patients and families on firearm injury prevention, highlighting the need for further research. However, several studies to date do provide valuable insights into a variety of approaches. (32)(33)(34)(35) In 2000, a national study on the effectiveness of a 1-time, 1-minute counseling session on firearm safety and safe storage was found to have no effect on gun acquisition, removal of firearms, or use of safe storage devices. (32) Although this trial did not find significant differences in removal of firearms from the home, there was a moderate increase in the purchase of gun safety locks after this short 1-minute counseling intervention. More recent studies found that firearm safety intervention significantly increases the use of safer storage practices. (33)(34)(35) In a randomized controlled trial in a large health-care setting, pediatricians administered an intervention to at-risk families termed the Safety Check that involves screening for firearm access, counseling on safe storage and motivational interviewing, and providing a gun lock. Patients and families who received the Safety Check had a 21.4% increase in storing their firearms locked, unloaded, and separately from ammunition. (33) Based on this study, the Safety Check is a common evidence-based approach that is used in health-care settings. (33) Differences in the intervention of this latter study included screening for exposure, assessing parents’ interest and openness to changing their child’s exposure, and providing a physical tool (ie, the cable lock) compared with previous studies, which consisted of only scripted counseling dialogue and a brochure. (32)(33) Another study found that a clinical team member–administered firearm safety intervention, which included safe storage counseling, a brochure, and a free gun safety lock, among families with access to a firearm resulted in a 61% increase in the safe storage of firearms compared with 26% in the control group. (35) These studies suggest that a more nuanced approach in discussing firearm safety rather than screening all patients, counseling based on individual risk factors, and providing physical preventive tools—such as gun safety locks—may be the most effective in improving safe storage practices and promoting positive behavior change.For pediatric providers, where the focus is on child safety, in addition to the safety of everyone in the household, safe storage counseling should clearly emphasize that the safest way to store a gun is locked, unloaded, and separately from ammunition. (9)(10) Context for screening is important; hence, questions about firearm access inside or outside of the household and subsequent counseling can be incorporated into broader discussions about injury prevention that are already part of routine care, such as counseling pertaining to motor vehicle safety, helmet use, and drowning avoidance. (31) A simple technique to start the screening is to ask “Are any firearms kept in or around your home?” within the context of questions about home safety hazards. (31) If the answer is yes, a strategy that adult providers use for follow-up questions includes use of the 5 Ls: Locked, Loaded, Little children, feeling Low, Learned owner, many of which can be applied to children as well. (29)(31) These screening questions can prompt deeper discussions on education about safe storage practices, provisions of resources such as gun locks and firearm safety courses, referrals for underlying health risk factors such as mental health or substance use, and community resources. (36) Ideally, discussions should be had in the context of a physician–patient relationship (29); however, if a physician is encountering a patient who is at particularly high risk for firearm violence (harm to self or others) it is important to intervene regardless of the previously established relationship—hence why screening is important especially for acute care physicians seeing patients in emergency care settings. Table 1 outlines a variety of other firearm safety measures that can be used as part of provider-administered counseling, and Table 2 outlines a list of additional resources that can be offered to patients.All patients and families are potentially at risk for firearm injury, particularly those with access to firearms within or outside of the household (eg, family or friend’s house); hence, the importance of universally screening all patients cannot be understated. Yet, in addition to screening for firearm access, concomitant screening for health risk factors that pose a heightened risk of firearm injury and mortality and may require more targeted intervention is critical. (37) Patients with suicidal or homicidal ideation, previous substance abuse or active substance use, or a history of violence have a higher risk of firearm-related injury and mortality. (29)(38) Sixty percent of firearm-related deaths are suicides (39); hence, suicidal ideation warrants particular attention. Despite the elevated risk of firearm injury in patients with suicidal or homicidal ideation, pediatricians rarely document screening for firearm access in these high-risk patients. (40) It is imperative that behavioral health professionals are involved for patients with suicidal ideation to provide lethal means counseling, which is an intervention that includes education about the lethality of guns in the setting of suicides and routine counseling on removal of access to firearms for patients deemed to be at higher risk for suicide. (5) Other risk factors for firearm injury and mortality, such as a history of violence, alcohol or drug abuse, or a history of other mental illnesses, are important to screen for as well. (29) One recent study in a pediatric trauma center found that firearm safety discussions were held in only 10% of patients after presenting with gunshot wounds, (41) despite this being a risk factor for future gun violence. Screening for these additional risk factors will allow for specialty behavioral health and substance use referrals as needed, as well as the provision of community resources such as violence interrupter programs. (31) Although particular health risk factors as listed previously herein can increase one’s risk of firearm injury, it is critical to reemphasize that screening for firearm injury risk should be universal and nontargeted, particularly when it comes to firearm access, because all children and family members are potentially at risk regardless of associated health risk factors.Another important consideration is the effect of firearm-related violence on the mental health of children who witness it. Exposure to firearm-related violence generally is also related to mental health in the development of posttraumatic stress. (42) In addition, as mass shootings are becoming more commonplace, the mental health toll taken on survivors of the mass shooting, the families and friends of the victims, and the community of the event has led to posttraumatic stress disorders, depression, and other psychological symptoms. (43) However, there are a significant number of factors involved in the development of mental health disorders following violence and in particular gun-related violence. Significantly more research is required to better understand the effects of firearm injury and mortality on survivors, although, it does highlight the importance and need to involve mental health professionals for children who witness gun violence in their communities.Studies have identified several provider-level barriers with respect to having conversations related to firearm injury prevention with patients and families, including lack of comfort, education, knowledge, and time and fear of offending or harming the doctor–patient relationship. It is important that clinicians are aware of these potential barriers because education in itself can serve to overcome many of these barriers to the implementation of firearm injury and mortality prevention strategies. The most common reason cited for lack of firearm safety counseling during office visits is unfamiliarity with firearms and safety devices. (26)(44) Another review reported that clinicians who lacked formal training or felt that their patients were unlikely to follow their advice were least likely to provide firearm safety counseling. (45) Given the impact that firearm safety counseling has on improving safe storage practices and thereby preventing firearm injury, it is imperative that providers are educated on this topic to feel comfortable discussing firearm safety with their patients. (24)(25)(32)(33)(34) Studies demonstrate that education does improve clinical team members’ ability to counsel on firearm safety. Workshop courses can be especially effective in increasing rates of firearm safety counseling among providers and trainees. Until recently, data on the effectiveness of educating providers on firearm injury and mortality prevention screening and counseling has been limited, with a systematic review in 2016 finding only 4 papers pertaining to this. (46) However, 2 institutions recently published their findings with respect to the effectiveness of educational workshops on improving resident comfort with firearm safety counseling. (47)(48)(49) One residency program found that after implementing a firearm safety counseling training session with their pediatrics residents they were 5 times more likely to discuss firearm safety than previously at 6-month follow-up. (47) This course consisted of training from a police officer on safe handling of firearm devices with videos and demonstrations, didactic discussion on the epidemiology of firearm injuries in children, and principles of counseling with role play practice scenarios. (47) The interactive nature of this workshop is especially helpful as the residents learn directly about guns and safety measures to improve their knowledge and comfort with the topic. Another institution completed a similar workshop course with didactics on epidemiology, lessons on firearm parts and safety features, and an interactive workshop. Residents report an increase in knowledge and skill, and there is significant improvement in documented counseling in office visits. Surveys of residencies in pediatrics, psychiatry, and family medicine report low rates of actual training for their residents, (45) indicating a need for more training and better resources. However, recent papers on quality improvement strategies such as recurrent resident education via noon conferences and grand rounds (49) and electronic medical record prompts (50) have shown that these strategies resulted in a better rate of firearm screening among pediatric residents at their hospitals. Hence, education can certainly serve to improve provider comfort in screening and counseling for firearm injury prevention.For providers to become confident in screening and counseling those at risk for firearm injury and violence, the acquisition of a new skill set of cultural competence around firearm-related injury prevention is also necessary. To build on this level competence, it is critical that health-care providers engage gun owners and community leaders throughout the process of educating and developing and implementing firearm injury prevention strategies. Collaboration with gun owners to learn effective storage strategies for different types of guns may help build physician confidence in counseling, encourage better rapport with gun-owning patients, and help promote change in patient behavior with credible suggestions. (5)(35)(38) Increased knowledge on the types of firearms, how they are operated, and how safety devices are used will undoubtedly increase provider comfort and confidence in talking about firearm safety. Similarly, engaging community voices, including schools, faith-based organizations, and members from communities that experience high rates of firearm violence, is a crucial component of developing the cultural competence necessary to talk to patients about firearm safety and firearm injury prevention. (51) Community-based collaborations serve to empower and educate clinical team members on how to have conversations with patients about gun violence while also serving to ensure that appropriate bridges are built to provide at-risk patients with community resources they may need.Although health-care–driven screening and counseling to prevent firearm injury and mortality is critical, it is only 1 piece of a much larger strategy involving health-care organizations and communities of physicians, clinicians, patients, and advocates to address this public health issue. Important steps in approaching firearm injury prevention as a health-care issue include surveillance, the identification of risk and protective factors, the implementation of preventive strategies, and their subsequent evaluation. (52) The benefit of framing firearm injury and violence as a public health issue is that it allows for a clear framework to study this epidemic, the implementation of preventive strategies that improve community health as a whole, and a multipronged approach to this crisis from an apolitical, harm reduction viewpoint focused solely on injury prevention and safety.Many large medical associations have published position statements on firearm injury and mortality prevention, emphasizing the importance of approaching this as a health-care issue. (5) In 2012 the American Academy of Pediatrics updated its policy statement on firearm-related injuries to children, (53) and in 2018 the American Pediatric Surgical Association updated its position statement. (54) Both organizations provide statements on governmental policies and regulations as well as statements focusing on empowering physicians to address firearm-related injury and mortality as an injury prevention health-care issue and strategies to do so. These statements are summarized in Table 3.For the first time in decades, federal funding for research on firearm injury and mortality prevention is available. This presents a unique opportunity for pediatric providers to conduct firearm injury prevention research to address the many knowledge gaps that exist with respect to risk factors for firearm injury, the effectiveness of preventive strategies, and facilitators and barriers to the implementation of firearm injury and mortality prevention strategies in health-care settings. Although research priorities are wide reaching, a focus on the study of implementation of firearm-related injury and mortality prevention strategies concurrently with evaluating outcomes and effectiveness of evidence-based strategies is paramount.Research is required to further evaluate the effectiveness of safe storage counseling and other health-care firearm injury prevention strategies with respect to not only positive behavior change but also downstream reductions in firearm injuries. A multicenter safety intervention by pediatric surgeons showed that 63% of parents who viewed a firearm safety module would change the way they stored their firearm. (12) Studies comparing firearm storage practices across regions that rigorously evaluate how these practices correlate with firearm-related injury rates are lacking and would help inform best practices.There is also an opportunity to screen patients for their firearm and interpersonal violence risk using violence risk prediction models such as the SaFETy (serious fighting, friend weapon carrying, community environment, and firearm threats) score. (55) One study found that 59% of assaulted drug-using adolescents and young adults (age 14–24 years) who received care in an emergency department reported firearm aggression, victimization, or injury within 2 years of the initial visit. (56) Implementing brief intervention techniques during their initial hospital encounter that focus on mental health, drug use, and violence prevention may deter future events associated with firearms.Immediate actionable steps for pediatricians include awareness of the health issue of firearm injury and its incorporation into their practice to learn about prevention strategies and counseling. Physicians can, and should, educate themselves on their role in firearm injury prevention with their individual patients. Medical governing organizations, academic hospitals, and residency training programs can develop teaching and coaching for physicians to be able to better incorporate firearm safety into their daily practice. Importantly, common sense policy measures will be critical to achieve long-term success in preventing firearm injuries as part of a holistic public health approach. Further evaluation of the effectiveness of CAP laws and ERPOs to promote firearm safety and prevent firearm injury would lend further weight to having these policies be a part of the education offered to patients.Integrate screening for firearm access and firearm injury risk into your routine practice by incorporating this conversation into home safety hazard and injury prevention discussions about risk factors such as motor vehicle safety, drowning avoidance, and helmet wearing.Use the 5 Ls—locked, loaded, little children, feeling low, and learned owner—to guide counseling on firearm safety.Approach all discussions about firearms empathetically and without judgment to encourage open discussion with patients.Attend workshops and training programs to learn more about firearm injury and mortality prevention, firearm safe storage practices, and firearm safety counseling tips.Work collaboratively with colleagues and stakeholders in the health-care setting to improve chances for successful implementation.Collaborate with community members, such as gun owners and members from communities at risk, in developing the culturally competent education needed to increase provider comfort in talking to patients about firearm injury prevention. This will also allow for the provision of community resources to those at risk.You can find the teaching slides that accompany this article on the Views>Supplementary Data option in the online article toolbar.