Advice for Suicide Prevention and Firearm Safety

ORLANDO, Fla. — Pediatricians and other healthcare providers have a valuable role to play in screening parents for firearm ownership and offering counseling on safe storage practices, according to researchers who presented their findings on September 28 at the American Academy of Pediatrics (AAP) 2024 National Conference.

An estimated 4.6 million US homes with children have firearms that are loaded and unlocked, a risk factor for youth suicide, yet only about half of parents of suicidal children had been screened for gun ownership in the hospital even as most would be receptive to both firearm screening and counseling, found one study in Texas. In another study in Colorado, nearly all firearm owners believed that securely storing guns reduces the risk for firearm injury or death, but owners were less likely than non-owners to believe suicide is preventable or that removing a gun from the home reduces the risk for injury or death.

“Previous studies have shown that when pediatricians discuss the importance of armed safe storage guidance with families, families are actually more likely to go home and store firearms safely — storing them locked, unloaded, and separate from the ammunition,” said study author Taylor Rosenbaum, MD, a former pediatric fellow at Baylor College of Medicine/Texas Children’s Hospital in Houston and now an assistant professor at Children’s Hospital University of Miami, Miami. “However, previous studies have also shown that pediatricians really are not discussing firearm safe storage with our patients and their families, and we see this both in the outpatient setting, but especially in the inpatient setting for youth suicides, which have risen since 2020 and now are the second leading cause of death for those who are 10-24 years old in the United States.”

Firearm Safety Is a Necessary Conversation

The leading cause of death among children and teens aged 1-19 years is actually firearms, which are also the most fatal method for suicide. While only 4% of all suicide attempts in youth are fatal, 90% of those attempted with a firearm are fatal, Rosenbaum said. In addition, she said, 80% of the guns used in attempted suicide by children and teens belonged to a family member, and an estimated 70% of firearm-related suicides in youth can be prevented with safe storage of guns.

“This really gives us, as pediatricians, something actionable to do during these hospitalizations” for suicidal ideation or attempts, Rosenbaum said. “We know that when pediatricians discuss the importance of firearm safe storage guidance with families, they’re more likely to store their firearm safely,” Rosenbaum said. “We also know that families are not being screened for firearm ownership, that caregivers of youth who are in the hospital for suicidal thoughts or actions want their healthcare team to be screening for firearms, to be giving them information on how to safely secure their firearms, and to be providing free firearm blocks.”

Nathan Boonstra, MD, a general pediatrician at Blank Children’s Hospital, Des Moines, Iowa, said these findings are encouraging in terms of the opportunity pediatricians have.

“There is so much politicization around even basic firearm safety that pediatricians might shy away from the topic, but this research is reassuring that parents are receptive to our advice on safe gun storage,” said Boonstra, who was not involved in any of this presented research. “It’s especially important for pediatricians to address home firearms when their patient has a history of suicidal ideation or an attempt.”

Reducing the Risk

The Colorado findings similarly reinforce the opportunity physicians have to help caregivers reduce suicide risk, according to author Maya Haasz, MD, an associate professor of pediatrics and emergency medicine at the University of Colorado Anschutz Medical Campus, Aurora, Colorado.

“Only 60% of firearm owners believed that removing firearms from the home in times of mental health crisis can decrease the risk of suicide,” she said. “These findings are really concerning, but what we found on the flip side was that 93% of firearm owners actually believe that secure storage can overall decrease the risk for firearm injury and death. So overall, we are underestimating the risk for suicide in our community, and we’re also underestimating our ability to prevent it.”

That presents an opportunity, Haasz said, “to educate families both about the preventability of suicide but also to have specific strategies, like secure storage and temporary removable requirements from the home, that can prevent suicide.”

Boonstra found it “disheartening that so many children live in a house with an unlocked and even loaded firearm when the evidence is so clear that this is a significant risk factor for youth suicide,” he said. “It’s also disheartening, though not too surprising, that families with a firearm are less likely to think that youth suicide can be prevented.”

Survey Results

Rosenbaum’s team conducted the survey in Houston with caregivers whose children were 8-21 years old and hospitalized for suicidal ideation or attempts at a large children’s hospital and two nearby community hospitals between June 2023 and May 2024. The respondents were 46% White and 23% Black, and 47% of the population were Hispanic, all but three of whom were not gun owners.

Among 244 potential participants, only 150 were eligible and approached, and 100 of these completed the surveys, including 26% firearm owners and 68% non-owners. Most of the youth (74%) were aged 14-17 years, and about three in four respondents were their mothers. Only half of the respondents (51%) said the healthcare provider had asked them whether they owned a gun.

One of the key findings Rosenbaum highlighted was the receptiveness of firearm-owning caregivers to advice from healthcare providers about ownership. If the healthcare team advised parents not to have any guns in the home for the safety of their child with self-arm, 58% of the firearm owners would follow the advice and 27% would consider it, with none saying they would be offended by it.

Among the firearm owners, 81% said their guns were safely secured where they did not believe their child could access it, which meant one in five youth had unsecured access to firearms. Most of the gun owners (77%), like the non-owners (70%), were “not at all worried” about their child getting ahold of a gun in the home, though 11.5% of the firearm owners were “very worried” about it. Interestingly, more gun owners (19%) were very worried about their children accessing a gun outside their home, a concern shared by 37% of non-owners. Nearly twice as many gun owners (46%) as non-owners (25%) were not at all worried about their child getting a gun outside the home.

The vast majority of respondents — 88% of gun owners and 91% of non-owners — felt it was “very important for the healthcare team to ask parents of children with suicidal ideation/attempts about firearms in the home.” Similarly, high proportions believed it was important for the healthcare team to counsel those parents on safe gun storage. Although only 69% of firearm owners believed it was important to distribute firearm locks in the hospital, 81% would be interested in receiving a free one. Significantly more of the non-owners (80%; P=.02) believed free lock distribution was important, and 72% of non-owners would also be interested in one.

About half the respondents (55%) preferred to hear firearm counseling one-on-one from a provider, whereas 31% would like written information and 27% would be interested in a video. In terms of what information parents preferred to receive, a little over half of owners (54%) and non-owners (56%) were interested in how or when (50% and 40%, respectively) to discuss the topic with their child. Only about a third (35% owners and 37% non-owners) wanted information on how to discuss the topic with the parents of their child’s friends.

The survey’s biggest limitations after its small size were the selection bias of those willing to complete the survey and potential response bias from the self-reported data.

The study of Colorado caregivers, just published in Pediatrics, surveyed 512 Colorado caregivers in April-May 2023 to learn about their beliefs and perceptions regarding firearms, firearm storage and risk, and youth suicide. Just over half the respondents (52%) had grown up in a household with firearms, and 44% currently lived in a household with a gun. The sample was 43% men and 88% White, predominantly non-Hispanic (75%), with 11% living in rural areas and 19% who currently or previously served in the military. Most (79%) had a child age 12 or younger in the home.

Only about one in four caregivers (24%) correctly answered that suicide is the leading cause of firearm death in Colorado, with similar rates of correct responses among both firearm owners and non-firearm owners. Both groups were also similarly likely (64% overall) to be concerned about youth suicide in their community, though those from homes with firearms were less likely to be concerned about youth suicide in their own family (28%) than those from homes without firearms (39%; P=.013).

In addition, caregivers from homes with vs without firearms were considerably less likely to believe suicide can be prevented (48% vs 69%) and were less likely to believe that temporarily removing a firearm from the home reduces the risk for gun injury or death (60% vs 78%; P <.001 for both comparisons).

Firearm owners were also much less likely than non-owners to believe keeping a gun in the home makes it more dangerous (7% vs 29%) and over twice as likely to think keeping a firearm makes their home safer (52% vs 22%; P <.001). The vast majority of respondents (89%) believed secure storage of guns reduces the risk for injury or death, though the response was higher for firearm owners (93%) than for non-owners (86%; P <.001).

“Our finding that most firearm owners believe that secure firearm storage is protective against firearm injury is a promising messaging strategy,” the authors wrote. “It presents a preventive education opportunity for adults living with children who have mental health concerns, who may benefit most from secure in-home storage and/or temporary and voluntary storage of firearms away from home.”

Firearm Injuries

A separate study at the AAP conference underscored the devastating impact of firearm injuries even among those who survive, whether self-inflicted or not, and the potential for reducing healthcare treatment and costs from effective prevention efforts. A national analysis of pediatric inpatient data from 2017 to 2020 calculated how much greater the burden of healthcare treatment and costs is for firearm injuries of any kind compared with penetrating traumas and blunt traumas.

“As a surgical resident, I have seen these patients who make it into the trauma bed that we are then faced to care for,” Colleen Nofi, DO, PhD, MBA, a general surgery resident at Cohen Children’s Medical Center at Northwell Health in New York, said. “Anecdotally, we understand that the devastation and injury caused by bullets far outweighs the injuries caused by other trauma mechanisms,” but the actual calculation of the burden hasn’t been studied.

Among 6615 firearm injuries, 9787 penetrating traumas and 66,003 blunt traumas examined from the National Inpatient Sample Healthcare Cost and Utilization Project Database, 11% of firearm traumas required a transfusion of red blood cells, compared with 1.4% of penetrating traumas and 3% of blunt traumas (P <.001). Patients with firearm injuries also had a longer length of stay — 10.8 days compared with 8.3 for patients with penetrating trauma and 9.8 for those with blunt trauma — and significantly higher rates of CPR, pericardiotomy, chest tube, exploratory laparotomy and/or thoracotomy, colorectal surgery, small bowel surgery, ostomy formation, splenectomy, hepatic resection, tracheostomy, and feeding tube placement.

Pulmonary complications were higher for firearm injuries (4.9%) than for penetrating trauma (0.6%) or blunt trauma (2.9%), and septicemia rates were also higher (1.7% vs 0.2% and 1%, respectively). Cardiac, neurologic, and urinary complications were also significantly and substantially higher for firearm injuries, 6.9% of which resulted in death compared with 0.2% of penetrating traumas and 1.2% of blunt traumas.

The costs from firearm injuries were also significantly higher than the costs from other traumas; “firearm injury remained independently predictive of greater hospital costs, even when controlling for injury severity as well as age, sex, race, insurance, region, hospital type, and household income.

“These findings underscore the urgent need for targeted prevention, supportive measures, and resource allocation to mitigate the devastating impact of firearm injuries on children and healthcare systems alike,” Nofi said.

The Colorado study was funded by the Colorado Department of Public Health and Environment and a National Institutes of Health grant to Haasz. The Texas study and the one from Northwell Health did not note any external funding. Haasz, Rosenbaum, Boonstra, and Nofi had no disclosures.

Tara Haelle is a health/science journalist based in Dallas. Follow her at @tarahaelle.