Prevent youth assault by assaulting firearm violence.

Abstract

For decades, firearm injuries have been a leading cause of death, acquired disability, emotional anguish, and fear for our children and their families. Counting is easy: >32 000 deaths and 84 000 nonfatal shootings occurred in the United States in 2013.1 Among the average of 320 shootings per day were 48 children aged <19 years or 130 youth aged <25 years. What is harder to enumerate is the impact on affected siblings, cousins, neighbors, and classmates, as well as the classmates—children who may have witnessed the event or experience it in the retelling. Too many feel scared and alone. A portion will arm themselves, for “protection.” Thus, our children will be terribly harmed or will do terrible harm, or both, largely as a result of easy access to firearms.In a 2-year longitudinal study reported in this issue of Pediatrics, Carter et al2 examined the risk of subsequent gun violence among 2 groups of young drug-using subjects who presented to an urban emergency department. Although the authors found that those presenting initially with assault injury were at higher risk of gun violence compared with nonassault-injured youth, the most striking finding was that all of these youth had a very high risk. Even nonassault-injured patients reported >40% incidence of gun violence during follow-up. Other important risk factors for gun violence were identified, such as an earlier diagnosis of posttraumatic stress disorder and negative retaliatory attitudes, but arguably none of those is as surprising as the sheer magnitude of the risk itself.The authors2 suggest that the first assault injury provides a teachable moment to intervene, with secondary prevention initiatives targeting the youth identified. Instead, we believe that the high risk demonstrated for all these patients alerts us to begin earlier and further upstream, aiming for the adults responsible for access to firearms and the social norms that contribute to violence.The United States ranks first internationally in personal firearm supply.3 Gun availability has been associated with increased rates of pediatric gun carrying, weapon use, and serious injury rates.4–6 Our children are not inherently more violent than youth from other countries,7 but the high prevalence of gun carriage8 and ownership by our youth is associated with an increased risk of violent gun deaths.9Carter et al2 have illuminated the problem in Flint, Michigan. Although the authors acknowledge that their population is singularly urban and uniquely located, firearm possession, carriage, usage, and injury are problems that affect youth across the country, including rural youth10–14; almost all pediatricians, therefore, must deal with gun violence in some form. Youth such as those in the Flint study state that it is easy to obtain a gun,12,15 but there is evidence that young people wish guns were less prevalent or even “impossible to get.”16 Children cannot make that happen alone.We believe physicians can help to address the proliferation, nonchalant carriage, and excessive injurious use of guns in our communities.17 When a child is shot or shoots, we need to ask, “Where did the gun come from?” This question may require us to move beyond our usual important concerns about how to limit child access to firearms in patients’ homes to confront realities such as gun trafficking,18 guns-for-drugs trading, and negligent sales. Although advocates for child health should continue to urge removal of guns or safe storage of guns in homes where they are kept, they can also support legislative efforts (eg, universal background checks) to help decrease access to illegal guns.19Many states now allow a “stand your ground” legal defense for some who commit violent acts, even lethal ones, with guns. This defense seems to be dictating a new social norm, much akin to what dueling once was. Fortunately, social norms can be changed.20 A healthier approach might be “share our ground.” Adults can teach and model for our children prosocial conflict resolution that values all lives. Pediatricians can lead the way to encourage healthier, life-sustaining social norms, in our encounters with children and parents as always, but also outside of our offices and hospitals, speaking up in favor of limiting access to weapons, tightening restrictions on weapon carrying, and freeing our children from the far-too-common threat of gun violence.