Firearms, Physicians, Families, and Kids: Finding Words that Work

Abstract

In 2020, firearm injuries were the leading cause of death in Americans 18 years old and younger, accounting for 3230 children's deaths (63.2% homicide; 30.0% suicide; 4.2% unintentional injury, 2.2% undetermined, and 0.4% legal intervention).1Web-based Injury Statistics and Query and Reporting System (WISQARS) [internet]. Centers for Disease Control and Prevention.https://www.cdc.gov/injury/wisqars/index.htmlDate: March 3, 2020Date accessed: February 16, 2022Google Scholar This has increased over the last 2 years,2Gun Violence Archive.https://www.gunviolencearchive.org/Date: 2021Date accessed: December 10, 2021Google Scholar concurrent with a surge in firearm purchases and the onset of the coronavirus disease 2019 pandemic.3NICS Firearm Checks.https://www.fbi.gov/file-repository/nics_firearm_checks_-_month_year.pdf/viewDate: 2021Date accessed: December 10, 2021Google Scholar Firearms are the most lethal method of suicide attempt, with a case fatality rate of 90%; they account for 42% of suicide deaths among those <19 years of age.1Web-based Injury Statistics and Query and Reporting System (WISQARS) [internet]. Centers for Disease Control and Prevention.https://www.cdc.gov/injury/wisqars/index.htmlDate: March 3, 2020Date accessed: February 16, 2022Google Scholar Triple-safe storage practices (storing firearms locked and unloaded with ammunition stored separately) are protective, with simulation models demonstrating that even a modest increase in safe storage could lead to decreased rates of suicide and unintentional injury among children and adolescents.4Monuteaux M.C. Azrael D. Miller M. Association of increased safe household firearm storage with firearm suicide and unintentional death among US youths.JAMA Pediatr. 2019; 173: 657-662Crossref PubMed Scopus (67) Google Scholar The role of safe storage in preventing assaultive injuries has not been established, although we would also expect these to decrease if youth have decreased access to firearms in the home.Health care providers (HCPs) are well positioned to discuss evidence-based strategies to reduce unauthorized children's access to firearms and minimize the risk of firearm injury. HCPs caring for children are particularly poised to have these conversations, given their role in safety conversations with parents on other topics. Caregivers generally accept firearm safety discussions in pediatric settings5Knoepke C.E. Allen A. Ranney M.L. Wintemute G.J. Matlock D.D. Betz M.E. Loaded questions: internet commenters' opinions on physician-patient firearm safety conversations.West J Emerg Med. 2017; 18: 903-912Crossref PubMed Scopus (23) Google Scholar, 6Garbutt J.M. Bobenhouse N. Dodd S. Sterkel R. Strunk R.C. What are parents willing to discuss with their pediatrician about firearm safety? A parental survey.J Pediatr. 2016; 179: 166-171Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar, 7Hinnant A. Boman C.D. Hu S. Ashley R.R. Lee S. Dodd S. et al.The third rail of pediatric communication: discussing firearm risk and safety in well-child exams.Health Commun. 2021; 36: 508-520Crossref PubMed Scopus (3) Google Scholar; however, many pediatricians do not counsel about firearm injury prevention.6Garbutt J.M. Bobenhouse N. Dodd S. Sterkel R. Strunk R.C. What are parents willing to discuss with their pediatrician about firearm safety? A parental survey.J Pediatr. 2016; 179: 166-171Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar,8Olson L.M. Christoffel K.K. O'Connor K.G. Pediatricians' involvement in gun injury prevention.Inj Prev. 2007; 13: 99-104Crossref PubMed Scopus (34) Google Scholar Although they believe that counseling may reduce firearm-related injury and death,8Olson L.M. Christoffel K.K. O'Connor K.G. Pediatricians' involvement in gun injury prevention.Inj Prev. 2007; 13: 99-104Crossref PubMed Scopus (34) Google Scholar they cite their lack of knowledge, self-efficacy, and ability to have productive conversations as limitations.7Hinnant A. Boman C.D. Hu S. Ashley R.R. Lee S. Dodd S. et al.The third rail of pediatric communication: discussing firearm risk and safety in well-child exams.Health Commun. 2021; 36: 508-520Crossref PubMed Scopus (3) Google Scholar The political climate around firearms, lack of HCP training, and absence of a shared language between firearm owners and nonfirearm owners are other barriers that HCPs face.7Hinnant A. Boman C.D. Hu S. Ashley R.R. Lee S. Dodd S. et al.The third rail of pediatric communication: discussing firearm risk and safety in well-child exams.Health Commun. 2021; 36: 508-520Crossref PubMed Scopus (3) Google ScholarThe challenge to discussing safe firearm storage lies in finding a common language and navigating a productive discussion. The American Academy of Pediatrics recommends that HCPs discuss with parents of children and adolescents the need to secure firearms to avoid unauthorized access,9Dowd M.D. Sege R.D. Council on Injury, Violence, and Poison Prevention Executive Committee; American Academy of Pediatrics. Firearm-related injuries affecting the pediatric population.Pediatrics. 2012; 130: e1416-e1423Crossref PubMed Scopus (165) Google Scholar based on evidence that brief counseling may improve storage practices in homes with children.10Barkin S.L. Finch S.A. Ip E.H. Scheindlin B. Craig J.A. Steffes J. et al.Is office-based counseling about media use, timeouts, and firearm storage effective? Results from a cluster-randomized, controlled trial.Pediatrics. 2008; 122: e15-e25Crossref PubMed Scopus (147) Google Scholar Specific recommendations include asking about access inside the home and off property and exploring strategies to minimize access.9Dowd M.D. Sege R.D. Council on Injury, Violence, and Poison Prevention Executive Committee; American Academy of Pediatrics. Firearm-related injuries affecting the pediatric population.Pediatrics. 2012; 130: e1416-e1423Crossref PubMed Scopus (165) Google Scholar An online educational module based on these principles is available and contains simulations with sample language and strategies to address potential obstacles to such a conversation.11American Academy of PediatricsSafer: Storing Firearms Prevents Harm [online course].https://shop.aap.org/safer-storing-firearms-prevents-harm/Date: 2021Date accessed: June 15, 2021Google Scholar Expert suggestions for “culturally respectful, conversation-promoting language” regarding firearm discussions in the general population were described.12Betz M.E. Harkavy-Friedman J. Dreier F.L. Pincus R. Ranney M.L. Talking about “firearm injury” and “gun violence”: words matter.Am J Public Health. 2021; 111: 2105-2110Crossref PubMed Scopus (7) Google Scholar Here, we build on this knowledge and propose a framework for firearm safety discussions in families with children. We review current evidence and expert opinion, and we suggest best practices for pediatricians to engage families in a patient-centered manner when discussing firearm safety. We suggest specific terminology that can be used during these conversations (Table), recognizing that these have not yet been tested in the real-world setting, and that future refinement is needed as research in the field advances.13Ngo Q.M. Sigel E. Moon A. Stein S.F. Massey L.S. Rivara F. et al.State of the science: a scoping review of primary prevention of firearm injuries among children and adolescents.J Behav Med. 2019; 42: 811-829Crossref PubMed Scopus (21) Google ScholarTableRecommended terminology to engage with families in conversations about safe firearm storageInstead of…Try to…RationaleSet the stage for a nonjudgmental conversation Starting a conversation with “do you have firearms?”Start with a normative statement such as “I ask everyone about firearms” or “many of my patients have firearms.”Parents may feel judged if asked about firearm ownership. This can be allayed by explaining that you have these conversations with all patients.7Hinnant A. Boman C.D. Hu S. Ashley R.R. Lee S. Dodd S. et al.The third rail of pediatric communication: discussing firearm risk and safety in well-child exams.Health Commun. 2021; 36: 508-520Crossref PubMed Scopus (3) Google Scholar Focusing your safety conversation solely on firearms.Address other age-appropriate injury prevention issues in the same conversation.Including other injury prevention topics is more acceptable and effective, framing the conversation as a safety issue rather than a firearm issue.14Wojtowicz A. French M. Alper J. Health systems interventions to prevent firearm injuries and death. Proceedings of a workshop. National Academies Press, US, Washington (DC)2019Google Scholar Asking “are your firearms locked up with ammunition stored separately?”Ask what the owner is doing to prevent access by children or adolescents.This reinforces that the conversation is about child safety. It also provides a starting point for a conversation about decreasing access using shared decision-making, if keeping firearms locked separately from ammunition is not feasible for their intended purpose.Universal delivery of firearm messaging Asking whether there are firearms in the home and only providing education to those who say “yes.”Speak to all families about safe firearm storage and asking about guns where their children spend time.Caregivers may be worried about their privacy and not disclose that they have firearms in the home. This ensures that the necessary information still reaches them. Asking “Would you like a storage lock?”Ask “How many locking devices would you like?”15Wolk C.B. Van Pelt A.E. Jager-Hyman S. Ahmedani B.K. Zeber J.E. Fein J.A. et al.Stakeholder perspectives on implementing a firearm safety intervention in pediatric primary care as a universal suicide prevention strategy: a qualitative study.JAMA Netw Open. 2018; 1: e185309Crossref PubMed Scopus (17) Google ScholarThis normalizes firearm ownership and may make the parent more receptive to safety education and to take a device. Using terminology you are unfamiliar with or attempting to answer questions that are beyond your scope.Provide educational materials and discuss safe storage practices.The HCP is not expected to be a firearm expert, but is a child safety expert.Tailoring the discussion Discussing only firearms when addressing limiting access to lethal means for suicide.Discuss strategies for limiting access to firearms, medications, and other potentially lethal means.Providing this context reinforces that you are counseling best on best practices for suicide prevention and not “picking on guns.16Pallin R. Siry B. Azrael D. Knoepke C.E. Matlock D.D. Clement A. et al.“Hey, let me hold your guns for a while”: a qualitative study of messaging for firearm suicide prevention.Behav Sci Law. 2019; 37: 259-269Crossref PubMed Scopus (24) Google Scholar,17Betz M.E. Knoepke C.E. Siry B. Clement A. Azrael D. Ernestus S. et al.‘Lock to Live': development of a firearm storage decision aid to enhance lethal means counselling and prevent suicide.Inj Prev. 2019; 25: i18-i24Crossref PubMed Scopus (22) Google Scholar Excluding youth from firearm safety discussions.Ask both parents and youth about their access to firearms.Parents may underestimate their child's access to firearms, and access is more relevant than the specific storage strategy.18Salhi C. Azrael D. Miller M. Parent and adolescent reports of adolescent access to household firearms in the United States.JAMA Netw Open. 2021; 4: e210989Crossref PubMed Scopus (12) Google Scholar Just providing safe firearm storage information to a youth who reports carrying a firearm.Ask about reasons the adolescent feels unsafe and determine whether it is within their own home or in the community. Engage child services, a trusted adult, or community resources depending on the situation.Carrying a firearm for protection is a sign that the youth may be involved with drug activities, street gangs, feel threatened by others, or may feel unsafe in their own home. Open table in a new tab Setting the Stage for a Nonjudgmental Conversation on Safe Firearm StoragePatient-centered care, which is more effective at increasing parental satisfaction and follow-through with treatment plans,19Nobile C. Drotar D. Research on the Quality of Parent-Provider Communication in Pediatric Care: Implications and Recommendations.J Dev Behav Pediatr. 2003; 24: 279-290Crossref PubMed Scopus (95) Google Scholar generally entails reserving judgment, listening to the patient, building partnership, sharing information, and showing empathy.20Fernández-Ballesteros R. Sánchez-Izquierdo M. Olmos R. Huici C. Ribera Casado J.M. Cruz Jentoft A. Paternalism vs. autonomy: are they alternative types of formal care?.Front Psychol. 2019; 10: 1460Crossref PubMed Scopus (21) Google Scholar,21Erickson S.J. Gerstle M. Feldstein S.W. Brief interventions and motivational interviewing with children, adolescents, and their parents in pediatric health care settings: a review.Arch Pediatr Adolesc Med. 2005; 159: 1173-1180Crossref PubMed Scopus (201) Google Scholar HCPs are trained in how to talk with their patients about sensitive topics like sexual activity, substance use, and end-of-life care; similarly, HCPs can learn to discuss firearm safety based on these principles.Nonjudgmental communication is a necessary precursor to any effective conversation about safe firearm storage. To be credible safety messengers, providers need to recognize their own verbal and nonverbal expressions of judgment and implicit biases22Dobscha S.K. Clark K.D. Newell S. Kenyon E.A. Karras E. Simonetti J.A. et al.Strategies for discussing firearms storage safety in primary care: veteran perspectives.J Gen Intern Med. 2021; 36: 1492-1502Crossref PubMed Scopus (3) Google Scholar and avoid introducing them into the conversation and alienating the patient. Families endorse feeling judged or “criminalized” if they feel their physician is making assumptions about their firearm ownership,7Hinnant A. Boman C.D. Hu S. Ashley R.R. Lee S. Dodd S. et al.The third rail of pediatric communication: discussing firearm risk and safety in well-child exams.Health Commun. 2021; 36: 508-520Crossref PubMed Scopus (3) Google Scholar which can lead to decreased acceptance of safety messaging.14Wojtowicz A. French M. Alper J. Health systems interventions to prevent firearm injuries and death. Proceedings of a workshop. National Academies Press, US, Washington (DC)2019Google ScholarListening to the caregiver's perspective allows the HCP to counsel the family about safe firearm storage and provide guidance based on their values and beliefs.20Fernández-Ballesteros R. Sánchez-Izquierdo M. Olmos R. Huici C. Ribera Casado J.M. Cruz Jentoft A. Paternalism vs. autonomy: are they alternative types of formal care?.Front Psychol. 2019; 10: 1460Crossref PubMed Scopus (21) Google Scholar,21Erickson S.J. Gerstle M. Feldstein S.W. Brief interventions and motivational interviewing with children, adolescents, and their parents in pediatric health care settings: a review.Arch Pediatr Adolesc Med. 2005; 159: 1173-1180Crossref PubMed Scopus (201) Google Scholar For injury prevention and anticipatory guidance, this may mean employing a harm reduction approach by tailoring interventions to the individual (eg, use of locking devices) rather than encouraging complete elimination of risk (eg, removing firearms from home permanently).One example of this in adolescent health care is guidance about adolescent sexual activity and counsel around prevention of sexually transmitted infections and unwanted pregnancy, rather than encouraging (or assuming) abstinence.23Marcell A.V. Burstein G.R. Committee on AdolescenceSexual and reproductive health care services in the pediatric setting.Pediatrics. 2017; 140: e20172858Crossref PubMed Scopus (80) Google Scholar A similar approach may be more acceptable in firearm safety discussions. Families may own a gun for protection and therefore want rapid access. In that setting, the gold standard “Triple-Safe” storage (firearms locked, unloaded, and with ammunition locked separately) endorsed by the American Academy of Pediatrics and National Shooting Sport Foundation24Bulger E.M. Kuhls D.A. Campbell B.T. Bonne S. Cunningham R.M. Betz M. et al.Proceedings from the Medical Summit on Firearm Injury Prevention: a Public Health Approach to Reduce Death and Disability in the US.J Am Coll Surg. 2019; 229: 415-430.e12Crossref PubMed Scopus (57) Google Scholar,25National Shooting Sports FoundationProject Childsafe Newton, CT2021.www.nssf.org/safety/project-childsafe/Date: April 23, 2021Date accessed: June 16, 2022Google Scholar is not practical for their circumstances. Nonjudgmental communication and considering a patient's values requires working together to identify an acceptable strategy, such as storing a loaded firearm in a quick-access safe (instead of in an unlocked bedside table).26Beidas R.S. Rivara F. Rowhani-Rahbar A. Safe firearm storage: a call for research informed by firearm stakeholders.Pediatrics. 2020; 146: e20200716Crossref PubMed Scopus (6) Google ScholarThe strategy of eliciting patient's beliefs and values before counseling is also a central component of motivational interviewing.27Rubak S. Sandbaek A. Lauritzen T. Christensen B. Motivational interviewing: a systematic review and meta-analysis.Br J Gen Pract. 2005; 55: 305-312PubMed Google Scholar This approach requires identifying the patient's barriers to change and the associated costs and benefits of their choice, with motivation to change then coming from the patient rather than being imposed by the provider.27Rubak S. Sandbaek A. Lauritzen T. Christensen B. Motivational interviewing: a systematic review and meta-analysis.Br J Gen Pract. 2005; 55: 305-312PubMed Google Scholar Motivational interviewing has been effective in changing risk behaviors in the health care setting in general27Rubak S. Sandbaek A. Lauritzen T. Christensen B. Motivational interviewing: a systematic review and meta-analysis.Br J Gen Pract. 2005; 55: 305-312PubMed Google Scholar and firearm storage in the pediatric primary care setting specifically,10Barkin S.L. Finch S.A. Ip E.H. Scheindlin B. Craig J.A. Steffes J. et al.Is office-based counseling about media use, timeouts, and firearm storage effective? Results from a cluster-randomized, controlled trial.Pediatrics. 2008; 122: e15-e25Crossref PubMed Scopus (147) Google Scholar and is well-aligned with patient-centered care recommendations.Another important element of patient-centered care is developing a partnership with families. Placing the conversation in context of safety rather than being about the firearm16Pallin R. Siry B. Azrael D. Knoepke C.E. Matlock D.D. Clement A. et al.“Hey, let me hold your guns for a while”: a qualitative study of messaging for firearm suicide prevention.Behav Sci Law. 2019; 37: 259-269Crossref PubMed Scopus (24) Google Scholar creates a partnership centered on the common goal of protecting their child. Assessing the caregiver's response and working together to identify the most acceptable means of limiting access is most likely to achieve maximal harm reduction. Finally, given that caregivers tend to underestimate their child's access,18Salhi C. Azrael D. Miller M. Parent and adolescent reports of adolescent access to household firearms in the United States.JAMA Netw Open. 2021; 4: e210989Crossref PubMed Scopus (12) Google Scholar HCP should develop partnerships with the youth as well, asking adolescents directly about their access to on and off-property firearms.Universal Delivery of Firearm Safety MessagingRather than asking screening questions (“do you have a firearm in the home?”) before counseling, HCPs could consider universal firearm safety messaging—ie, delivering the same message to all families, whether or not there are firearms in the home—a strategy that is viewed favorably by both caregivers and providers.5Knoepke C.E. Allen A. Ranney M.L. Wintemute G.J. Matlock D.D. Betz M.E. Loaded questions: internet commenters' opinions on physician-patient firearm safety conversations.West J Emerg Med. 2017; 18: 903-912Crossref PubMed Scopus (23) Google Scholar,7Hinnant A. Boman C.D. Hu S. Ashley R.R. Lee S. Dodd S. et al.The third rail of pediatric communication: discussing firearm risk and safety in well-child exams.Health Commun. 2021; 36: 508-520Crossref PubMed Scopus (3) Google Scholar,15Wolk C.B. Van Pelt A.E. Jager-Hyman S. Ahmedani B.K. Zeber J.E. Fein J.A. et al.Stakeholder perspectives on implementing a firearm safety intervention in pediatric primary care as a universal suicide prevention strategy: a qualitative study.JAMA Netw Open. 2018; 1: e185309Crossref PubMed Scopus (17) Google Scholar,28Hudak L. Schwimmer H. Warnock W. Kilborn S. Moran T. Ackerman J. et al.Patient characteristics and perspectives of firearm safety discussions in the emergency department.West J Emerg Med. 2021; 22: 478-487Crossref PubMed Scopus (2) Google Scholar One of the benefits to this approach is that it addresses some patient concerns of privacy infringement,17Betz M.E. Knoepke C.E. Siry B. Clement A. Azrael D. Ernestus S. et al.‘Lock to Live': development of a firearm storage decision aid to enhance lethal means counselling and prevent suicide.Inj Prev. 2019; 25: i18-i24Crossref PubMed Scopus (22) Google Scholar particularly in communities that place greater value on privacy issues in general.7Hinnant A. Boman C.D. Hu S. Ashley R.R. Lee S. Dodd S. et al.The third rail of pediatric communication: discussing firearm risk and safety in well-child exams.Health Commun. 2021; 36: 508-520Crossref PubMed Scopus (3) Google Scholar Individuals have expressed concern about firearm ownership being documented in the medical record, with concerns that it might lead to a federal registry of firearms.5Knoepke C.E. Allen A. Ranney M.L. Wintemute G.J. Matlock D.D. Betz M.E. Loaded questions: internet commenters' opinions on physician-patient firearm safety conversations.West J Emerg Med. 2017; 18: 903-912Crossref PubMed Scopus (23) Google Scholar,7Hinnant A. Boman C.D. Hu S. Ashley R.R. Lee S. Dodd S. et al.The third rail of pediatric communication: discussing firearm risk and safety in well-child exams.Health Commun. 2021; 36: 508-520Crossref PubMed Scopus (3) Google ScholarWe also know that patients may not disclose information to their providers if they are embarrassed or feel they might be judged or lectured on their behavior.29Levy A.G. Scherer A.M. Zikmund-Fisher B.J. Larkin K. Barnes G.D. Fagerlin A. Prevalence of and factors associated with patient nondisclosure of medically relevant information to clinicians.JAMA Network Open. 2018; 1: e185293Crossref PubMed Scopus (66) Google Scholar Because this is a concern among firearm owners, providers risk missing families who do not disclose firearm ownership if they do not discuss safe firearm storage with everyone. Providing the same message to everyone can be inclusive of nonfirearm owners by providing advice on asking others about safe storage in any place where their children may encounter a firearm, such as at a friend or family's house. By providing all patients with similar information, providers will capture more firearm owners in their safety conversations. In addition, they will be able to more broadly distribute educational materials, safe storage messaging, and locking devices to communities. This approach is also more acceptable to firearm owners.5Knoepke C.E. Allen A. Ranney M.L. Wintemute G.J. Matlock D.D. Betz M.E. Loaded questions: internet commenters' opinions on physician-patient firearm safety conversations.West J Emerg Med. 2017; 18: 903-912Crossref PubMed Scopus (23) Google Scholar,7Hinnant A. Boman C.D. Hu S. Ashley R.R. Lee S. Dodd S. et al.The third rail of pediatric communication: discussing firearm risk and safety in well-child exams.Health Commun. 2021; 36: 508-520Crossref PubMed Scopus (3) Google Scholar,28Hudak L. Schwimmer H. Warnock W. Kilborn S. Moran T. Ackerman J. et al.Patient characteristics and perspectives of firearm safety discussions in the emergency department.West J Emerg Med. 2021; 22: 478-487Crossref PubMed Scopus (2) Google Scholar This does not mean that providers should not address specific risk factors—after explaining that firearms are discussed “across the board,”7Hinnant A. Boman C.D. Hu S. Ashley R.R. Lee S. Dodd S. et al.The third rail of pediatric communication: discussing firearm risk and safety in well-child exams.Health Commun. 2021; 36: 508-520Crossref PubMed Scopus (3) Google Scholar describing the specific risks knowing the child's age and circumstance is appropriate. For example, The HCP can discuss the risk of accidental injury for an 8-year-old child, or temporary removal of firearms from the home if an adolescent is contemplating suicide.Tailoring the Discussion to the Patient's Age and Risk FactorsThe HCP should place firearm safety counseling into the context of general anticipatory guidance relevant to the child's age and circumstance.15Wolk C.B. Van Pelt A.E. Jager-Hyman S. Ahmedani B.K. Zeber J.E. Fein J.A. et al.Stakeholder perspectives on implementing a firearm safety intervention in pediatric primary care as a universal suicide prevention strategy: a qualitative study.JAMA Netw Open. 2018; 1: e185309Crossref PubMed Scopus (17) Google Scholar If the patient is a toddler, the HCP can discuss car seats and bicycle helmet use; for an adolescent, the provider can review seatbelts and driving.10Barkin S.L. Finch S.A. Ip E.H. Scheindlin B. Craig J.A. Steffes J. et al.Is office-based counseling about media use, timeouts, and firearm storage effective? Results from a cluster-randomized, controlled trial.Pediatrics. 2008; 122: e15-e25Crossref PubMed Scopus (147) Google Scholar Then, after initiating the conversation with a normative statement23Marcell A.V. Burstein G.R. Committee on AdolescenceSexual and reproductive health care services in the pediatric setting.Pediatrics. 2017; 140: e20172858Crossref PubMed Scopus (80) Google Scholar (eg, “many families keep a firearm in or near their home”), the HCP should move along to an age-appropriate discussion of firearm safety.Unintentional firearm injuries are more common among younger children (aged 1-9 years) than older children and adolescents.30Cunningham R.M. Walton M.A. Carter P.M. The major causes of death in children and adolescents in the United States.N Engl J Med. 2018; 379: 2468-2475Crossref PubMed Scopus (282) Google Scholar Among children who die from an unintentional firearm injury, the most common circumstances are playing with the gun, unintentionally pulling the trigger, not knowing that the gun was loaded, and showing the gun to others.31Fowler K.A. Dahlberg L.L. Haileyesus T. Gutierrez C. Bacon S. Childhood firearm injuries in the United States.Pediatrics. 2017; 140: e20163486Crossref PubMed Scopus (165) Google Scholar Caregivers may assume that their child can—or will—not access a home firearm, but previous studies have shown that parents underestimate their child's knowledge about whether they have a firearm, whether they have handled it, and its location in the home.18Salhi C. Azrael D. Miller M. Parent and adolescent reports of adolescent access to household firearms in the United States.JAMA Netw Open. 2021; 4: e210989Crossref PubMed Scopus (12) Google Scholar,32Simonetti J.A. Theis M.K. Rowhani-Rahbar A. Ludman E.J. Grossman D.C. Firearm storage practices in households of adolescents with and without mental illness.J Adolesc Health. 2017; 61: 583-590Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar,33Doh K.F. Morris C.R. Akbar T. Chaudhary S. Lazarus S.G. Figueroa J. et al.The relationship between parents' reported storage of firearms and their children's perceived access to firearms: a safety disconnect.Clin Pediatr (Phila). 2021; 60: 42-49Crossref PubMed Scopus (3) Google Scholar These concerns can be relayed to caregivers after initiating a conversation and prior to development of a patient-centered firearm storage plan.In contrast, in adolescence (10-19 years old), nearly 97% of fatal firearm injuries are intentional homicide or suicide.30Cunningham R.M. Walton M.A. Carter P.M. The major causes of death in children and adolescents in the United States.N Engl J Med. 2018; 379: 2468-2475Crossref PubMed Scopus (282) Google Scholar Discussions of safe firearm storage with youth and their caregivers in this demographic should be presented as a preventive approach for self-harm and assault. The approach to engaging patients and their families, however, varies depending on the reason for firearm ownership and the child's age and risk factors.Discussing the increased risk of suicide death with a home firearm that is not stored safely (locked, unloaded, and with ammunition stored separately)34Grossman D.C. Mueller B.A. Riedy C. Dowd M.D. Villaveces A. Prodzinski J. et al.Gun storage practices and risk of youth suicide and unintentional firearm injuries.JAMA. 2005; 293: 707-714Crossref PubMed Scopus (354) Google Scholar is particularly important in youth with existing mental health disorders, as they are at greater risk for self-harm than their peers.35Nock M.K. Hwang I. Sampson N. Kessler R.C. Angermeyer M. Beautrais A. et al.Cross-national analysis of the associations among mental disorders and suicidal behavior: findings from the WHO World Mental Health Surveys.PLoS Med. 2009; 6: e1000123Crossref PubMed Scopus (534) Google Scholar Despite this increased risk, and the evidence supporting lethal means safety as an effective suicide prevention strategy,36Suicide Prevention Strategic Plan FY 2020-2022: Centers for Disease Control and Prevention; 2020.https://www.cdc.gov/suicide/pdf/SuicidePrevention_StrategicPlan-508.pdfDate: March 13, 2021Google Scholar, 37Zalsman G. Hawton K. Wasserman D. van Heeringen K. Arensman E. Sarchiapone M. et al.Suicide preventio