Extreme Risk Protection Orders Research Articles

Extreme Risk Protection Orders: Legislative Intent and Clinician Guidance.

In this second column of a 2-part series exploring extreme risk protections orders, we utilize recent events in Colorado, including legislative efforts to expand the list of eligible petitioners to include clinicians, as an opportunity to explore questions and challenges faced by mental health and medical professionals serving in this capacity. Clinicians are in need of more clear guidance, given an emerging role that comes without clear evidence or practice standards to inform individualized clinical decision-making, and which potentially pits public safety interests against patient care needs, especially those pertaining to therapeutic relationships. In the interim, clinicians will best serve their patients by continuing to practice in a fashion that is analogous to decision-making around other interventions with serious implications for patient autonomy such as involuntary hospitalization. Ongoing collaboration with legislators is needed to arrive at laws that are informed by the limitations inherent in clinical risk assessment and that can be translated into clinical practices that simultaneously support patient needs and community safety.

(182) Held Hostage: The Case of a Difficult Patient, Hospital Discharge and an Extreme Risk Protection Order

(182) Held Hostage: The Case of a Difficult Patient, Hospital Discharge and an Extreme Risk Protection Order

Law Enforcement Officer Knowledge of, Attitudes Toward, and Willingness to Use Extreme Risk Protection Orders

Understanding knowledge of, attitudes toward, and willingness to use extreme risk protection order (ERPO) laws among law enforcement officers (LEOs) can inform efforts to improve implementation of this underused firearm violence prevention strategy. To characterize LEOs' knowledge of, attitudes toward, and willingness to use ERPOs across a range of scenarios. A cross-sectional online survey, fielded from April 5 to August 30, 2021, was conducted in all 19 states and the District of Columbia with an ERPO law in 2021. A nonprobability sample of active-duty LEOs was used. Being a LEO in a state with an ERPO law. Survey participants answered questions about their familiarity with and opinions on ERPO laws, as well as whether they would agree with using an ERPO in a variety of specific case scenarios. The analysis included an exploration of whether within-scenario differences, such as ERPO respondent race or gender, affected agreement by randomly assigning survey participants to 1 of 2 versions of each scenario. A total of 600 eligible individuals started the survey, and 283 survey participants were included in the analysis. The analytic sample consisted mostly of cisgender men (85.2%) and non-Hispanic White (71.4%) LEOs. Participants represented 14 states and the District of Columbia, with 53.7% living in California. Most participants (81.3%) were very or somewhat familiar with ERPO laws and 56.2% had received ERPO training. Opinions about ERPO laws were generally favorable but varied by self-identified political ideology. Across all scenarios, most participants supported using an ERPO; however, support was highest in cases involving intimate partner violence (71.4%-78.6%) and lowest in cases involving suicidality (54.2%-73.3%). Across all scenarios, LEOs with ERPO training or experience were substantially more likely to agree with using ERPOs than those without. None of the randomly assigned within-scenario differences were associated with differences in ERPO support. In this survey study of LEOs in states with ERPO laws, many officers had not received training on their use. Additionally, while conservative political ideology was associated with less favorable views of ERPOs, training and experience with ERPOs was associated with greater support for their use across a range of scenarios. These findings suggest that LEO training on ERPOs may promote their uptake and improve implementation.

Extreme Risk Protection Orders in Older Adults in Six U.S. States: A Descriptive Study

ABSTRACT Objectives Extreme Risk Protection Orders (ERPOs) allow a court to restrict firearm access for individuals (“respondents”) at imminent risk of harm to self/others. Little is known about ERPOs use for older adults, a population with higher rates of suicide and dementia. Methods We abstracted ERPO cases through June 30, 2020, from California, Colorado, Connecticut, Florida, Maryland, and Washington. We restricted our analysis to petitions for older (≥65 years) respondents, stratified by documented cognitive impairment. Results Among 6,699 ERPO petitions, 672 (10.0%) were for older adults; 13.7% (n = 92) of these noted cognitive impairment. Most were white (75.7%) men (90.2%). Cognitively impaired (vs. non-impaired) respondents were older (mean age 78.2 vs 72.7 years) and more likely to have documented irrational/erratic behavior (30.4% vs 15.7%), but less likely to have documented suicidality (33.7% vs 55.0%). At the time of the petition, 56.2% of older adult respondents had documented firearm access (median accessible firearms = 3, range 1–160). Conclusions Approximately 14% of ERPO petitions for older adults involved cognitive impairment; one-third of these noted suicide risk. Studies examining ERPO implementation across states may inform usage and awareness. Clinical Implications ERPOs may reduce firearm access among older adults with cognitive impairment, suicidality, or risk of violence.

The origins of California’s gun violence restraining order law: a case study using Kingdon’s multiple streams framework

BackgroundFirearm violence is a major public health problem in the United States, yet most states lack a mechanism to temporarily remove firearms from individuals who are at high and imminent risk of harming themselves or others and are not otherwise prohibited. Extreme risk protection order (ERPO) laws are intended to close this gap. The current study examines the passage of California’s gun violence restraining order (GVRO) bill using Kingdon’s multiple streams framework.MethodsThis study was based on an analysis of interview data from six key informants involved in the passage of the GVRO legislation.ResultsFindings indicate policy entrepreneurs framed the problem and designed the policy to target individuals at behavioral risk of imminent firearm violence. Policy entrepreneurs comprised an integrated policy network that engaged in a lengthy period of collaboration and bargained with interest groups to yield a bill that satisfied diverse concerns.ConclusionsThis case study may inform efforts in other states to pass ERPO policies and other firearm safety laws.

The association between permit-to-purchase laws and shootings by police

BackgroundFatal and nonfatal shootings by police are a public health issue that warrants additional research. Prior research has documented associations between fatal shootings by police and gun ownership, legislative strength scores, and lax concealed carry weapons laws. Despite research on other firearm-related outcomes, little is known about the impact of permit-to-purchase (PTP) laws on shootings by police. We generated counts of fatal and nonfatal OIS from the Gun Violence Archive from 2015 to 2020. We conducted cross-sectional regression modeling with a Poisson distribution and robust standard errors. In addition to PTP, we included several state-level policies that may be associated with shootings by police: comprehensive background check only (CBC-only) laws, concealed carry licensing laws, stand your ground laws, violent misdemeanor prohibitions, and extreme risk protection orders (ERPO). We controlled for state-level demographic characteristics and included a population offset to generate incidence rate ratios (IRR).FindingsPTP laws were associated with a 28% lower rate in shootings by police [IRR = 0.72, 95% confidence interval (CI) 0.64–0.81]. Shall Issue (IRR = 1.34, 95% CI 1.17–1.53) and Permitless (IRR = 1.61, 95% CI 1.35–1.91) concealed carry laws and CBC-only laws (IRR = 1.12, 95% CI 1.01–1.25) were associated with higher rates of shootings by police. Stand your ground, violent misdemeanor prohibitions, and ERPO laws were not associated with shootings by police.ConclusionsOur study found that PTP laws were associated with significantly lower rates of shootings by police. Removing restrictions on civilian concealed carry was associated with significantly higher rates. State-level firearm policies may be a lever to address shootings by police.

Extreme Risk Protection Orders in Washington State: Understanding the Role of Health Professionals.

Extreme Risk Protection Orders (ERPO) allow a petitioner to file a civil order to temporarily restrict access to firearms among individuals ("respondents") deemed to be at extreme risk of harming themselves, others, or both. Although unable to file ERPOs for their clients in most states, health professionals may play a pivotal role in the ERPO process by recommending an eligible petitioner initiate the process. We describe the process of filing an ERPO when a healthcare, mental health, or social service professional contacted an ERPO petitioner. Court documents of ERPOs involving health professionals in Washington State between December 8th, 2016 and May 10th, 2019 were qualitatively analyzed (n=24). We constructed pen portraits from the documents and analyzed them using an inductive qualitative thematic approach. Themes included factors influencing the process by which each professional evaluated respondent behaviors, factors considered during assessment, factors influencing interpretation of respondent behaviors and subsequent provider response during a crisis. These influenced the outcome of the crisis event that led to ERPO filing. Each professional group differed in their approach to risk assessment of respondent behaviors. Strategies to better coordinate and align approaches may improve the ERPO process.

Gun Violence and Risk to Children and Youth in the United States.

As we write this editorial on March 14, 2023, the Gun Violence Archive (2023) reports 110 mass shootings, 48 children aged 0 to 11 killed (114 injured), and 284 teens aged 12 to 17 killed (710 injured) from gun violence so far in 2023 in the United States. Tragically, school shootings are no longer uncommon. Some politicians, lobbyists, national organizations, and gun advocates strongly oppose any type of gun control legislation including universal background checks and closing gaps in background checks before being allowed to purchase a gun, red flag laws, raising the age to 21 to be able to purchase a gun, and bans on sale to the public of assault-type weapons such as semiautomatic military-style weapons and high-capacity magazines often used in mass shootings. Gun violence is the leading cause of death among children and youth aged 0 to 24 in the United States, surpassing deaths from motor vehicle injuries in 2017 (Lee et al., 2022a). Most homicides (~80%) and suicides (~55%) in the United States involve firearms (Kegler et al., 2022). There has been a significant increase in gun violence during the COVID-19 pandemic (Iantorno et al., 2022; Kegler et al., 2022). Not all injuries from guns result in death. Exponentially more children and youth suffer long-term physical and psychological harm from gun violence. In December 2022, the American Academy of Pediatrics published a policy statement on firearm-related injuries and deaths in children and youth and offered strategies for injury prevention and harm reduction (Lee et al., 2022b). Pediatric nurses have many interactions with children, youth, and their families. Pediatric nurses can encourage gun safety among parents who have guns at home including making sure they are unloaded, storing bullets and guns in separate locations, and maintaining guns in a locked gun safe. Parents should be urged to ask other parents and relatives about the state of gun safety when their children are invited to their home. Children and youth should be educated about firearms including what to do if they come across an unsecured weapon. Nurses can be strong advocates for gun control legislation on the local, state, and national level. Despite the heavily funded misinformation campaign that the wide access to guns is not related to the continued increase in firearm violence, injuries, and death, there are ample data to support the link, and evidence-based strategies to promote gun safety and minimize risk of harm from guns (Lee et al., 2022b). The editors of MCN, The American Journal of Maternal Child Nursing strongly support gun control legislation to increase the legal age to purchase a gun to 21, a ban on the sale of assault-type weapons, and universal background checks. Nurses are well positioned to influence change to keep America's children and youth safe from gun violence.

Social Workers' Perspectives on Extreme Risk Protection Orders.

Extreme risk protection orders (ERPOs), which allow for the temporary restriction of firearm access for individuals at substantial risk of harming themselves and/or others, are a promising policy tool to address increasing rates of firearm-related suicide, homicide, and mass shootings. Social workers frequently assess clients at risk of firearm-related harm, positioning social workers to play a key role in ERPO implementation. This study sought to understand social workers' perspectives on ERPOs. Authors invited 6,910 licensed social workers in Washington state to participate in a survey in May and June of 2021 about facilitators and barriers to their willingness to counsel clients' family members, contact law enforcement, or independently file ERPOs for clients at risk of harm to self (HTS) or others (HTO). Of the 1,381 survey participants, most were willing to counsel (96 percent for HTS; 96 percent HTO), contact law enforcement (84 percent for HTS; 87 percent for HTO), or independently file an ERPO (78 percent for HTS; 79 percent for HTO). Common barriers associated with willingness were lack of understanding about the ERPO process and concerns with involving the legal system/law enforcement. Key facilitators included training social workers about ERPOs and availability of legal experts for consultations. Social workers are willing to incorporate ERPOs into their practice for clients, but remaining barriers need to be addressed to support the practice.

Gun owners’ assessment of gun safety policy: their underlying principles and detailed opinions

BackgroundWhile gun owners are frequently surveyed, we are not aware of any study that has examined principles held by gun owners that underlie their gun policy opinions, or their opinions about specific provisions of each policy. To find the common ground between gun owners and non-gun owners, this paper aims to answer the following: (1) What underlying principles affects gun owner support for gun policies; (2) how do gun owners’ attitudes change depending on the specific provisions within these policies?MethodsIn May 2022, a survey was administered by NORC at the University of Chicago and completed by adult gun owners (n = 1078) online or by phone. Statistical analyses were performed using STATA. The survey used a 5-point Likert scale to evaluate gun owners’ principles and attitudes toward firearm regulation, such as red flag laws, and possible provisions to these policies. Focus groups and interviews were conducted with 96 adult gun owners and non-gun owners to further clarify points in the survey for the former and to ascertain support for the same policies and their potential provisions for the latter.ResultsThe principle that gun owners identified with the most concerned keeping guns out of the hands of those with an increased risk for violence. There was significant overlap among gun owners and non-gun owners on policy support, especially with this central theme that those with a history of violence should be prevented from accessing a firearm. The degree of support for policies was different depending on what provisions were said to be included in the policy. For example, the degree of support for universal background checks ranged from 19.9 to 78.4% depending on the details of the legislation.ConclusionThis research demonstrates common ground between gun owners and non-gun owners: It informs the gun safety policy community about gun owners’ views and principles on gun safety policy and which policy provisions impact their support for a given law. This paper suggests that an effective, mutually agreed upon gun safety policy is possible.

Proceedings from the Second Medical Summit on Firearm Injury Prevention, 2022: Creating a Sustainable Healthcare Coalition to Advance a Multidisciplinary Public Health Approach.

Proceedings from the Second Medical Summit on Firearm Injury Prevention, 2022: Creating a Sustainable Healthcare Coalition to Advance a Multidisciplinary Public Health Approach.

Session on Firearm Violence to Stress Nonpartisanship

Back to table of contents Previous article Next article Annual MeetingFull AccessSession on Firearm Violence to Stress NonpartisanshipTerri D'ArrigoTerri D'ArrigoSearch for more papers by this authorPublished Online:26 Feb 2023https://doi.org/10.1176/appi.pn.2023.03.3.24AbstractUnderstanding the epidemiology of gun violence will equip psychiatrists for public health advocacy.In 2018, the National Rifle Association posted a tweet that began with “Someone should tell self-important anti-gun doctors to stay in their lane.” Many in the medical community considered that to be a gauntlet thrown, and since then health professionals have demonstrated the myriad ways they have seen firearm violence harm and kill their patients. At APA’s 2023 Annual Meeting, a session titled “I Am in My Lane: A Public Health Approach to the Role of Health Care Providers in Firearm Violence” will offer strategies on how health professionals can convey the message that preventing firearm violence is a matter of public health, not politics or partisanship.Psychiatrists who wish to address firearms violence should focus on public health, says Aradhana Bela Sood, M.D., M.S.H.A.“Firearm violence is a polarizing topic, where any discussion of it is often equated with gun control,” session chair Aradhana Bela Sood, M.D., M.S.H.A., told Psychiatric News. She is a senior professor for child and mental health policy at Children’s Hospital of Richmond at Virginia Commonwealth University. “As medical providers who deal with the aftermath of firearm-related morbidity and mortality, we would be well served to shift rhetoric that appears to infringe on individual rights to a focus on gun safety and preventive practices.”The session will cover the epidemiology of firearm violence and provide a historical perspective of the polarization surrounding the causality of firearm violence that will better enable attendees to frame the issue in terms of public health.Attendees will come away from the session with an understanding of regional firearm laws, including Extreme Risk Protection Orders (“red flag” laws) that allow family members or law enforcement to petition a judge to remove a firearm from the environment of a person considered to be at risk of harming themselves or others. The session will explore the challenges and barriers to implementing these laws and delve into how these laws have reduced morbidity and mortality from firearm violence, thus equipping attendees to be more effective as advocates for public health strategies to address the issue.Finally, attendees will learn how to get involved at the hospital, city, and state levels to advocate for policies and legislation that support safe firearm practices. ■ ISSUES NewArchived

Firearm Injury: An Escalating Health Crisis.

Firearm Injury: An Escalating Health Crisis.

The Impact of Extreme Risk Protection Orders on Homicide and Suicide: Are there Any Red Flags?

The Impact of Extreme Risk Protection Orders on Homicide and Suicide: Are there Any Red Flags?

Firearm Mortality Among Pre-school Age Children, 2010-2020.

Firearms are a substantial cause of death for pre-school children (ages 0-5 years). The purpose of this study was to characterize fatal firearm violence in this age group. The Web-Based Injury Statistics Query and Reporting System (WISQARS) data from the Centers for Disease Control and Prevention (CDC) were analyzed for the years 2010-2020. There were 1,220 firearm deaths during the study period with a 75% increase in the rate of deaths per 100,000 population. Most deaths (two-thirds) were among males. Non-Hispanic Blacks comprised 56.4% of all deaths in 2020, a 172% increase from 2010 and the rate for non-Hispanic Whites increased by 15.4% from 2010 to 2020. The majority of the deaths occurred in the South. Almost two-thirds (65.9%) of all firearm deaths were homicides, 30% were unintentional, and 4.1% were undetermined. Homicides were also the majority of deaths for non-Hispanic Blacks (64.9%), non-Hispanic Whites (60.8%), and Hispanics (81.3%). The years of potential life lost before 80 years of age were 94,105, with a plurality (43.3%) of losses occurring among non-Hispanic Black children. Sustained awareness campaigns should be implemented to make parents and guardians aware of the profound dangers of unlocked and loaded or unsafely stored firearms in the home. Child healthcare providers should counsel parents and guardians on firearm safety in households. Public health professionals should advocate for laws that can help protect children from firearm violence (e.g., Domestic Violence Restraining Orders, Child Access Prevention laws, and Extreme Risk Protection Order laws).

Firearm-Related Injuries and Deaths in Children and Youth.

Firearms are the leading cause of death in children and youth 0 to 24 years of age in the United States. In 2020, firearms resulted in 10,197 deaths (fatality rate 9.91/100,000 youth 0-24 years old). Firearms are the leading mechanism of death in pediatric suicides and homicides. Increased access to firearms is associated with increased rates of firearm deaths. Substantial disparities in firearm injuries and deaths exist by age, gender, race, ethnicity, and sexual orientation and gender identity and for deaths related to legal intervention. Barriers to firearm access can decrease the risk to youth for firearm suicide, homicide, or unintentional shooting injury and death. Given the high lethality of firearms and the impulsivity associated with suicidal ideation, removing firearms from the home or securely storing them-referred to as lethal means restriction of firearms-is critical, especially for youth at risk for suicide. Primary care-, emergency department-, mental health-, hospital-, and community-based intervention programs can effectively screen and intervene for individuals at risk for harming themselves or others. The delivery of anticipatory guidance coupled with safety equipment provision improves firearm safer storage. Strong state-level firearm legislation is associated with decreased rates of firearm injuries and death. This includes legislation focused on comprehensive firearm licensing strategies and extreme risk protection order laws. A firm commitment to confront this public health crisis with a multipronged approach engaging all stakeholders, including individuals, families, clinicians, health systems, communities, public health advocates, firearm owners and nonowners, and policy makers, is essential to address the worsening firearm crisis facing US youth today.

Extreme risk protection orders in response to threats of multiple victim/mass shooting in six U.S. states: A descriptive study

Extreme risk protection orders (ERPOs), also known as red flag laws, are a potential tool to prevent firearm violence, including mass shootings, but little is currently known about the extent of their use in cases of mass shooting threats or about the threats themselves. We collected and abstracted information from ERPO cases from six states (California, Colorado, Connecticut, Florida, Maryland, and Washington). Ten percent (N = 662) of all ERPO cases (N = 6787) were in response to a threat of killing at least 3 people. Using these cases, we created a typology of multiple victim/mass shooting threats, the most common of which was the maximum casualty threat. The most common target for a multiple victim/mass shooting threat was a K-12 school, followed by businesses, then intimate partners and their children and families. Judges granted 93% of petitions that involved these threats at the temporary ERPO stage and, of those cases in which a final hearing was held, judges granted 84% of final ERPOs. While we cannot know how many of the 662 ERPO cases precipitated by a threat would have resulted in a multiple victim/mass shooting event had ERPO laws not been used to prohibit the purchase and possession of firearms, the study provides evidence at least that ERPOs are being used in six states in a substantial number of these kinds of cases that could have ended in tragedy.

Voluntary Firearm Divestment and Suicide Risk: Real-World Importance in the Absence of Causal Identification.

Voluntary Firearm Divestment and Suicide Risk: Real-World Importance in the Absence of Causal Identification.

Physicians' perspectives on Extreme Risk Protection Orders (ERPOs) in the clinical setting: Challenges and opportunities for gun violence prevention.

BackgroundFirearm-related injuries remain a heavy public health and clinical burden in the United States. Extreme Risk Protection Order (ERPO) laws, which create a path through a civil court process to temporarily remove firearms from individuals deemed to be at risk of harming themselves or others and are one strategy designed to reduce firearm violence. Maryland was the first state to authorize clinicians as ERPO petitioners.ObjectiveWe aim to document a sample of Maryland physicians’ perspectives about the utility of, any barriers to, and other thoughts on clinicians as ERPO petitioners.DesignA series of semi-structured interviews with Maryland physicians identified through a combination of purposive and snowball sampling. We coded the transcribed interviews and analyzed the coded transcripts for themes using deductive content analysis.Setting/Participants13 Maryland-based physicians interviewed over Zoom in and around Baltimore City, Maryland.ResultsThe interviewees had overall positive feedback about ERPO as a gun violence prevention tool in the clinical setting. They identified several barriers to effective implementation such as time spent on paperwork and in court, a lack of awareness among clinicians about ERPO, threats to therapeutic alliance, and a sense of futility in a culture where firearms are easy to obtain. Solutions such as providing clinician education about ERPO laws, allowing for virtual court testimony, and creating a consult service with ERPO specialists to manage ERPO petitions were discussed.LimitationsThis study includes a small sample of Maryland-based physicians.ConclusionsThe physicians we interviewed expressed interest in knowing more about ERPO laws and emphasized education as an important tool for improving implementation. Addressing physicians’ concerns about ERPO implementation will improve their ability to be effective and efficient petitioners.

School shootings: Advocacy and education as prevention

Perhaps the school shooting in Uvalde, Texas in May of 2022 will lead to lasting change with the signing of the bipartisan gun bill on June 26 by President Biden. Though not as far reaching as some hoped it would be — it does extend requirements for background checks for prospective buyers under the age of 21, funds increases in mental health and drug courts to carry out red flag laws and confiscate guns, funds increases in school safety, toughens laws against trafficking of guns, and includes recent partners in the ban on domestic abusers purchasing firearms. These are positive steps.