In 2022, injury from a firearm was the leading cause of death for children 1 through 19 years of age in the US.1,2 Pediatric primary care providers (PCPs) are tasked with assessing gun violence risk and providing firearm safety counseling to patients and families at every encounter.

Several pediatric professional organizations have put forth guidance on gun violence in recent years. The National Association of Pediatric Nurse Practitioners (NAPNAP) released a position statement in 2023 on firearm violence and injury prevention in children.3 The organization acknowledged firearm violence as a critical health issue affecting children of all ages and backgrounds. The American Academy of Pediatrics (AAP) released a policy statement in 2022 discussing injury prevention and harm reduction.4 Following these frameworks released by pediatric care authorities, this article discusses strategies for effectively discussing and incorporating firearm safety into all pediatric patient visits.

Implications and challenges in primary care

PCPs can be strong advocates for the recommendations put forth by NAPNAP and the AAP. Firearm anticipatory guidance, lethal means counseling, mental health screenings, and safe gun storage education are recommended as part of routine primary care visits.4,5 Pediatric PCPs are afforded the opportunity to promote safety discussions with parents and children/adolescents during the same visit. Screening questions for parents regarding firearms in the home can be incorporated into each appointment to identify the need for further discussion regarding safe gun storage. Screening children and adolescents for exposure to violence is equally important, as witnessing community violence has been shown to increase the likelihood of gun carrying, substance use, and suicidality.6

Unfortunately, only a small number of PCPs report counseling around firearm injury prevention.7 Previous research has noted that many PCPs never provide firearm safety counseling and noted that pediatric medical residents looked for “specific language to use when talking to families.”8 A cross-sectional analysis of online survey data collected in 2019 of over 4,000 US adults residing in a household with firearms showed that 76% to 89% felt that the PCP should sometimes or always discuss firearm safety within certain contexts. Only about 7% of US adults report recalling ever discussing firearm safety with a healthcare provider.9 Personal, political, and societal influences all play a role in a provider's willingness to engage in discussions about firearm safety. Pediatric PCPs may be hesitant to initiate firearm safety discussions with patients and their family members, as they may be unsure whether families will be open to the discussion.8 Framing discussions around firearms in the context of safety has been shown to be the most well-received course of action.10

Identifying teenagers with depression or anxiety and/or who are at risk for self-harm is important for appropriate patient and family intervention. Use of validated tools in primary care such as the Patient Health Questionnaire-9 (PHQ-9): Modified for Teens and General Anxiety Disorder-7 (GAD-7) can help to identify youth at risk for depression and anxiety. The Youth Risk Behavior Survey showed a notable increase between 2011 and 2021 in the percentage of high school students experiencing persistent feelings of sadness or hopelessness. In 2021, 42% of high school students reported feeling this way every day in the preceding 2 weeks.11 Regarding suicidality, in 2021, 22% reported seriously considering attempting suicide during the past year, and 10% attempted suicide one or more times during the past year.11 Due to the substantial lethality of firearms and the impulsive nature often linked to suicidal thoughts, it is imperative to either remove firearms from the home or securely store them. This practice, known as lethal means restriction, holds particular significance for youth vulnerable to suicide.4

Safety counseling is an integral part of every visit, and patients anticipate and appreciate time during each visit to discuss ways to keep their families safe. The AAP suggests that a home without a firearm is safest for children and teenagers.4 For adults that have firearms in a home with children and teenagers, the AAP advocates for keeping the firearms unloaded and locked away, with the ammunition stored separately from the firearm and locked.4 Knowing why a family might have a firearm in their home is the first step in knowing how to start the conversation around safety. By incorporating motivational interviewing techniques, the PCP may be able to help initiate small changes. Simply asking questions such as the following can help garner useful information to propel the conversation: “Tell me about your firearms: How do you store them? Why do you choose to store them that way?”12 Families often have firearms for protection or self-defense. In this case, they might not be ready or willing to hear that they should be storing them unloaded and locked away, but they may be willing to listen to suggestions around “quick access” safes as an option.13 Assessing for behavior modification and helping to motivate and encourage healthy behaviors are core components of primary care.

Examples of firearm anticipatory guidance in practice

As PCPs, being knowledgeable about firearms and about related safety behaviors for families is crucial for breaking down barriers in the firearm safety discussion. As one study noted, using an approach that motivates adults living with children and adolescents to change their behavior and store guns locked away can result in prevention of up to 32% of youth firearm deaths in the US.14 The 5 As of counseling (Ask, Advise, Assess, Assist, and Arrange) have been used to address complex health behaviors, including those around obesity and smoking.15 Hoops and colleagues found that by providing the 5 As counseling framework as a “patient-centered, non-judgmental, [and] risk-based” model for clinicians to approach firearm safety counseling and specific questions to ask in navigating difficult conversations around firearm safety, 60% of clinicians noted that their comfort in engaging in such counseling was “much improved.” Those who are more comfortable engaging in these conversations and providing education may be more likely to do so on a regular basis.15

Setting the stage by discussing safety helps to transition seamlessly to screening for exposure to firearms. Starting this discussion while stepping away from the computer or minimizing documentation might help to show the provider's seriousness and commitment to the discussion. Using the 5 As of counseling, PCPs can start with a statement such as: “Firearms are now the leading cause of death for children and teenagers under 18 years of age in the US. Knowing this, I want to assess the risk for you and your family. Is it ok if we discuss ways your child could be exposed to firearms?” If the family is not willing to discuss the issue at this visit, you can provide general firearm safety information and note that you would like to try to discuss it again at the next visit. If you note that an exposure risk exists, next advise and assess: “The AAP recommends that all firearms be kept unloaded and locked separately from ammunition. Is this possible in your home?” Assist the family in creating a firearm safety plan to which they can adhere; for example, the PCP can offer the following: “We have trigger locks available today in the office if you would use one. If not, can we discuss solutions to find a gun safe for your home?” Finally, arrange follow up by checking at the next visit whether the family was able to find a way to safely store the firearm and, if not, by providing further assistance.

The authors of this article currently practice in Philadelphia, the 6th most populous city in the US, which has the highest poverty rate in the nation among large cities at 22.8%.16 In 2023, there were 1,293 victims of nonfatal gun violence and 373 fatal shooting victims within the city of Philadelphia.17 Of all victims, 10% were younger than 18 years of age.17 An Adolescent Health Questionnaire formulated by the Children's Hospital of Philadelphia Possibilities Project to be completed by teenagers starting at age 13 years at well visits has been integrated into the health system's clinical practices.18 The questionnaire includes typical teenager health assessment items and also includes screens for depression, trauma, exposure to violence, and access to firearms. To assess access to firearms, the teenager is asked, “If you wanted, could you obtain a gun within a day?” This question assists the PCP in tailoring counseling regarding firearm access. Data collected from May 2023 to November 2023 via this question showed that an average of 3.5% of teenagers reported being able to access a firearm.18 These results can help PCPs to identify interventions needed at a broader community level and provide support for advocacy efforts.

Advocacy for firearm safety

Pediatric PCPs can also promote firearm safety beyond the exam room. Current national advocacy efforts focus on the importance of injury prevention measures and responsible gun ownership. These efforts can decrease the impact of gun-related injuries and fatalities by raising awareness of and participation in forums that address the impact of gun violence on children's health. Additionally, providers can join or support organizations that focus on gun safety and advocate for evidence-based policies.

The advocacy recommendations set forth by the AAP and NAPNAP include increasing community awareness regarding firearm safety and working alongside community organizations and schools to support youth resiliency and trauma-informed care programs.3,4 Collaboration with community partners to develop evidence-based programs aiming to reduce firearm violence is also recommended. Advocacy to help to secure funding for these programs and those that provide mental health screening and suicide prevention is critical in helping to reduce firearm violence.

The AAP and NAPNAP encourage PCPs and lawmakers to work together to advocate for child access prevention laws.3,4 These laws enforce safe storage of firearms to prevent access by children and adolescents. They can also hold adults accountable for keeping guns secure to reduce the risk of unintentional injuries or incidents involving children. Additionally, these organizations advocate for mandates on safe storage practices, including the use of secure locks and storage devices, to prevent unauthorized access to firearms. Finally, advocating for restriction of illegal firearm sales to minors through age-appropriate regulations is critical to prevent access by underage individuals. These legislative advocacy efforts are aimed at creating safer environments by addressing specific aspects of firearm access and storage.

Conclusion

Pediatric firearm injuries and deaths are a preventable public health crisis in the US. Pediatric PCPs provide a wide range of education and counseling in visits promoting optimal health, growth and development, and safe environments in a patient's life. Firearm risk assessment and counseling should be included in every visit to reduce firearm-related injuries and deaths. Primary care visits and continued advocacy efforts for firearm safety play a vital role in protecting children and communities.

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