Firearm Storage Practices in Households of Adolescents With and Without Mental Illness

Mental Health Comorbidities, Household Firearm Ownership, and Firearm Access Among Children

OBJECTIVES

To examine how youth and their caregivers' mental health risk factors for suicide are associated with youth firearm access inside and outside the home.

METHODS

This study examines a cross-section of the Adolescent Brain and Cognitive Development Social Development study data collected from 2016 to 2021. The sample included 2277 children aged 10 to 15 years from 5 study sites across the United States. We estimated multilevel generalized linear models of household firearm ownership and the child's reported firearm access (hard access or easy access). The primary exposures were the child's and their caregivers' mental health risk factors for suicide.

RESULTS

In the Adolescent Brain and Cognitive Development Social Development study sample, approximately 20% of children lived in a firearm-owning household and 5% of all children reported easy firearm access. In non-firearm-owning households, children with diagnosed lifetime suicidality were 2.48 times more likely (95% confidence interval [CI], 1.50-4.10) than their counterparts to report easy firearm access. In firearm-owning households, children of caregivers who self-reported any mental health history or externalizing problems were 1.67 times (95% CI, 1.10-2.54) and 2.28 times (95% CI, 1.55-3.37) more likely than their counterparts to report easy firearm access.

CONCLUSIONS

Youths with mental health risk factors for suicide may be just as likely or more likely to report firearm access as those without such risk factors. Youth suicide prevention efforts should address youths' firearm access outside the home and caregiver mental health.

Firearms Availability Among High-School Age Youth With Recent Depression or Suicidality

BACKGROUND AND OBJECTIVES

Limiting firearm access is essential to decreasing teen suicide. Previous efforts have focused on household firearms; however, less is known about firearm access and possession among teens at increased suicide risk. Our objective was to estimate prevalence of firearm possession and access among high school-aged teens with recent depression and/or lifetime history of suicidality (DLHS).

METHODS

We conducted a probability-based, cross-sectional Web survey of 1914 parent-teen dyads between June 24, 2020, and July 22, 2020, with data weighted to generate a nationally representative sample of US teenagers (aged 14-18). Logistic regression analyses examined the difference between teens with and without DLHS for: (1) personal firearm possession, (2) perceived firearm access, and (3) method of firearm attainment.

RESULTS

Among high school-aged teens, 22.6% (95% confidence interval [CI], 19.4-25.8) reported DLHS, 11.5% (95% CI, 8.7-14.3) reported personal firearm possession, and 44.2% (95% CI, 40.2-48.2) endorsed firearm access. Teens experiencing DLHS had increased perceived access (adjusted odds ratio, 1.56; 95% CI, 1.07-2.28) compared with non-DLHS peers. There was no association between DLHS and personal firearm possession (adjusted odds ratio, 0.97; 95% CI, 0.47-2.00). Among teens reporting firearm possession, those with DLHS were more likely to have acquired it by buying/trading for it (odds ratio, 5.66; 95% CI, 1.17-27.37) and less likely receiving it as a gift (odds ratio, 0.06; 95% CI, 0.01-0.36).

CONCLUSIONS

High school-aged teens experiencing DLHS have higher perceived firearm access compared with lower-risk peers. Providers should speak directly to high school-aged teens at increased suicide risk about firearm access, in addition to counseling parents.

Population-Based Assessment of Urban Versus Rural Child Fatalities From Firearms in a Midwestern State

INTRODUCTION

Several studies have evaluated differences in firearm injury patterns among children based on regionalization. However, many of these studies exclude patients who die before arriving at a trauma center. We therefore hypothesize that important population-based differences in pediatric firearm injuries may be uncovered with the inclusion of both prehospital firearm mortalities and patients treated at a tertiary children's hospital.

METHODS

Patients less than 15 y of age who sustained a firearms-related injury/death between the years 2012 and 2018 were identified in: (1) death certificates from the Office of Vital Statistics State of Indiana and (2) Riley Hospital for Children at Indiana University Health Trauma Registry. Counties of injury were classified as either urban, midsized, or rural based on the National Center for Health Statistic's population data. Significant variables in univariate analysis were then assessed using multivariate logistic regression models.

RESULTS

A total of 222 patients were identified. Median age of firearm injury survivors was 13 (interquartile range 7-14), while the median age of nonsurvivors was 14 (interquartile range 11-15), P = 0.040. The proportion of suicide was significantly higher in rural counties (P < 0.001). When controlling for shooter intent, patients from a rural or midsized county had statistically significant higher odds of dying before reaching a hospital than their urban counterpart (rural odds ratio [OR] 5.67 [95% confidence interval {CI} 2.23, 14.38]; midsized OR 6.53 [95% CI 2.43, 17.46]; P < 0.001).

CONCLUSIONS

Important differences exist between pediatric firearm injuries based on where they occur. Public health initiatives aimed at reducing pediatric firearm injury and death should not exclude rural pediatrics patients.

Type of household firearm ownership and firearm suicide among adolescents, 1976-2018

After declining steadily for almost two decades, the rate of firearm suicide among adolescents (aged 15-19 years) has increased nearly every year since 2007. At the same time, overall levels of household firearm ownership have been declining. In this paper, we examined whether and how types of firearms in the homes of adolescents have changed over time, and the extent to which such changes are associated with trends in firearm suicides among adolescents. Our analyses focused on understanding these trends among Black and White male and female adolescents to better understand longstanding race-gender differences in firearm ownership and firearm suicide. With combined data from the General Social Survey (GSS) and the National Center for Health Statistics (NCHS), the findings show that handgun ownership in Black and White households increased over the last four decades, while overall levels of firearm ownership declined. Increases in handgun ownership were predictive of increased firearm suicide rates among White adolescents, especially among males. We found no significant relationship between firearm suicide among Black adolescents and firearm ownership among Black households, regardless of gun type, which is potentially unsurprising given that firearm ownership is substantially lower in Black households compared to White households. Possibly reflecting race and gender differences in household gun ownership, our findings also show that rates of firearm suicide were lower for Black and female adolescents and highest for White male adolescents. Taken together, these findings provide new evidence on the relationship between trends in firearm ownership and adolescent firearm suicide and address important questions about the influence of race and gender for understanding firearm suicide among adolescents.

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.

Impact of a Firearm Safety Device Distribution Intervention on Storage Practices After an Emergent Mental Health Visit

OBJECTIVE

To determine if providing firearm storage devices with training during clinical care improves safe storage practices in household members of children who present to a pediatric hospital with an emergent mental health complaint.

METHODS

Prospective, pre-post study. Enrollment occurred in the emergency department or the inpatient psychiatric unit. Participants in the observation phase received usual care. Participants in the intervention phase were randomized to be offered a firearm storage device at either no or low ($5) cost and trained in its use. We surveyed participants at enrollment, 7, & 30 days post visit. Our primary outcome was triple-safe storage (TSS) - storing firearms unloaded, locked, and with ammunition stored and locked separately.

RESULTS

About 256 participants enrolled. In the observation phase TSS increased from 21% (95% confidence interval [CI] 14%-30%) at baseline to 31% (95% CI 21%-42%) at 7 and 31% (95% CI 21%-43%) at 30 days. In the intervention phase, TSS increased from 32% (95% CI 25%-39%) at baseline to 56% (95% CI 48%-64%) at 7 and 56% (95% CI 47%-64%) at 30 days. Among those not practicing TSS at baseline, 7-day TSS was higher in the intervention (38%) versus the observation phase (14%, P = .001).

CONCLUSIONS

Distribution and training in the use of firearm storage devices increased TSS in the study population, improves pediatric safety and should be part of the routine care of these high-risk patients.

Rural Communities and Violence

Among US geographic regions classified as rural, death rates are significantly higher for children and teens as compared with their urban peers; the disparity is even greater for Alaskan Native/American Indian and non-Hispanic black youth. Violence-related injuries and death contribute significantly to this finding. This article describes the epidemiology of violence-related injuries, with a limited discussion on child abuse and neglect and an in-depth analysis of self-inflicted injuries including unintentional firearm injuries and adolescent suicide. Potential interventions are also addressed, including strategies for injury prevention, such as firearm safe storage practices.

Patterns of gun owner beliefs about firearm risk in relation to firearm storage: a latent class analysis using the 2019 National Firearms Survey

BACKGROUND

Research on gun owners' risk-related beliefs has focused on how gun owners answer discrete questions about firearm risk. The current study is the first to use latent class analysis (LCA) to: (A) identify groups of gun owners who share patterns of beliefs about firearm-related risk and (B) examine whether class membership predicts household firearm storage.

METHODS

We conducted LCA using the 2019 National Firearms Survey, a nationally representative survey of US adult gun-owners (n=2950). The LCA assigned gun owners to classes based on responses to four questions about firearm-related risk. Identified classes were included in logistic regression models predicting firearm storage, along with characteristics linked to storage in past research.

RESULTS

Three classes emerged: (1) owners who believe that guns unconditionally make the home safer and should generally be readily accessible (47%); (2) owners who believe that whether guns make homes safer or less safe depends on context (34%); (3) owners who believe that guns do not pose a risk if stored safely (19%). In adjusted models, compared with owners in class 1, those in classes 2 and 3 were less likely to store guns loaded and unlocked (class 2: OR 0.30, 95% CI 0.23 to 0.39; class 3: OR 0.23, 95% CI 0.16 to 0.32).

CONCLUSION

Our LCA is a first step towards better understanding variation in patterns of beliefs among gun owners regarding the risks and benefits of firearms. Our results suggest that messaging aimed at promoting safer firearms storage might benefit from the empirically derived typologies we identify.

Firearm Storage Practices and Risk Perceptions Among a Nationally Representative Sample of U.S. Veterans With and Without Self-Harm Risk Factors

Despite the disproportionate use of firearms in Veteran suicides and the well-established link between firearm access and suicide, little is known about how Veterans store their firearms or what they think about the relationship between firearm access and suicide risk. Using data from 2015 nationally representative online survey (response rate 60.9%), we compare characteristics of Veteran firearm owners with and without self-harm risk factors with respect to how they store their firearms and their beliefs about suicide risk related to firearms. Overall, one in three U.S. Veteran firearm owners store household firearms loaded and unlocked, one in twenty believe that a firearm increases household suicide risk, and one in four consider their loaded and unlocked firearm to be inaccessible to suicidal household members. Storage practices and risk perceptions are similar among those with and without self-reported suicide risk factors. Affecting risk perceptions may be a critical aspect of interventions addressing lethal means safety among U.S. Veterans.

Psychiatric Disorders and Gun Carrying among Adolescents in the United States

OBJECTIVES

To estimate associations between psychiatric disorders and gun carrying among adolescents and to estimate the total number of adolescents in the US who have psychiatric disorders and report carrying guns.

STUDY DESIGN

We used cross-sectional data from the National Comorbidity Survey - Adolescent Supplement, a nationally representative sample of adolescents age 13-18 years (N = 10 123; response rate = 75.6%). Psychiatric disorders were assessed using the Composite International Diagnostic Interview. Gun carrying in the 30 days prior to the interview was assessed by self-report. We used multivariable Poisson regression to test for associations.

RESULTS

The analytic sample included 10 112 adolescents, 2.4% of whom reported carrying a gun in the prior 30 days. The prevalence of gun carrying was greater among adolescents with conduct disorder (adjusted prevalence ratio [APR] = 1.88, 95% CI 1.38, 2.57), drug use disorders (APR = 1.91, 95% CI 1.05, 3.45), and specific phobias (APR = 1.54, 95% CI 1.07, 2.22) compared with adolescents without these disorders. We estimated that 1.1% (95% CI 0.77, 1.48) of adolescents with a disorder associated with self- or other-directed violence also carry guns. Nationally, that is approximately 272 000 adolescents with both risk factors.

CONCLUSIONS

Specific psychiatric disorders are associated with an increased risk of gun carrying among adolescents, but the vast majority of adolescents with psychiatric disorders did not report gun carrying. Targeted efforts to assess access to and use of firearms in mental healthcare and other clinical settings are important, as are efforts to identify population approaches to prevention.

Firearm Storage and Adult Alcohol Misuse Among Washington State Households With Children

IMPORTANCE

Firearm injuries and fatalities among children are an important public health problem. Children living with an adult misusing alcohol may be at a heightened risk for self-harm or unintentional injury, highlighting the need to investigate the association between household firearm storage and adult alcohol misuse.

OBJECTIVES

To characterize household firearm presence among children by various sociodemographic characteristics, and to assess the association between children living in a home with an unsafely stored firearm and an adult reporting alcohol misuse.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional investigation uses data from the 2013 and 2016 Behavioral Risk Factor Surveillance System in the state of Washington, a program that administers a telephone survey statewide to randomly selected noninstitutionalized adults at least 18 years of age about their health-related risk behaviors, chronic health conditions, and use of preventive services. The 2013 and 2016 data included 5241 responses to the firearm ownership and storage module and the Random Child Selection module (intended for a randomly selected child younger than age 18 years and reported by an adult living in the same household). Data for this study were collected from January 1 through December 31, 2013, and January 1 through December 31, 2016. Data were analyzed from March through May 2018.

MAIN OUTCOMES AND MEASURES

The primary outcomes were a child's residence in a firearm-owning home, the manner in which household firearms were stored, and the adult respondent's alcohol consumption.

RESULTS

Among the 3443 children living in a non-firearm-owning household, 50.7% were male (all values given as a percentage only are weighted); among those reporting specific age, the weighted mean age was 9.3 years (unweighted mean [SD], 10.1 [5.2] years). In the 1756 children living in a firearm-owning household, 52.5% were male; among those reporting specific age, the weighted mean age was 9.1 years (unweighted mean [SD], 9.8 [5.4] years). An estimated 470 000 children (29.4%; 95% CI, 27.3%-31.7%) in the state resided in a firearm-owning household. Among them, 258 000 children (54.6%; 95% CI, 51.5%-57.6%) lived with at least 1 firearm that was not stored safely (ie, not locked and unloaded). Firearms were more likely to be stored unsafely in homes in which an adult reported alcohol misuse (prevalence ratio: 1.20; 95% CI, 1.07-1.35).

CONCLUSIONS AND RELEVANCE

Children living in a household with an adult who misuses alcohol may be more likely to live with an unsafely stored firearm, which is concerning given the association between adult alcohol misuse and children's risk for sustaining injury.

Firearm Ownership, Storage Practices, and Suicide Risk Factors in Washington State, 2013-2016

OBJECTIVES

To characterize firearm ownership and storage practices in Washington State and assess their relationship with suicide risk factors.

METHODS

Using Washington State Behavioral Risk Factor Surveillance System data for 2013 to 2016, we conducted survey-weighted multivariable Poisson regression models to obtain prevalence ratios (PRs) and confidence intervals (CIs).

RESULTS

Of 34 884 adult respondents, 34.3% (95% CI = 33.7%, 35.0%) reported a firearm in their household, among whom 36.6% (95% CI = 35.4%, 37.7%) stored their firearm locked and unloaded. There were no differences in mental health indicators by firearm ownership or storage practice status. Binge and chronic alcohol use were somewhat more prevalent among adults from firearm-owning households (PR = 1.2; 95% CI = 1.1, 1.3; PR = 1.2; 95% CI = 1.1, 1.4, respectively) and among those living in households not practicing safe storage (PR = 1.4; 95% CI = 1.2, 1.7; PR = 1.9; 1.5, 2.3, respectively).

CONCLUSIONS

Variability in mental health does not explain the substantial increased suicide risk among individuals in firearm-owning households. Greater prevalence of alcohol misuse among adults in firearm-owning households not practicing safe storage highlights the need for suicide prevention interventions.

Firearm Storage in Homes With Children With Self-Harm Risk Factors

OBJECTIVES

To describe firearm storage practices in homes with children who have versus do not have self-harm risk factors.

METHODS

A cross-sectional analysis of a nationally representative probability-based online survey of US adults conducted in 2015 (n = 3949; response rate 55%). Respondents self-reported whether they lived with children and were a caretaker/health care decision-maker for a child. Household firearm ownership was ascertained for all respondents; how firearms were stored in homes with guns was asked of gun owning respondents only; all respondents were asked whether their child had a history of the following self-harm risk factors: depression, mental health conditions other than depression, or attention-deficit/hyperactivity disorder.

RESULTS

Household firearms were present in 43.5% (95% confidence interval [CI]: 34.4-64.7) of homes with children who had a history of self-harm risk factors (n = 52), compared with 42.3% (95% CI: 35.2-49.7) of homes in which no child had self-harm risk factors (n = 411). Among parents or caretakers with firearms, 34.9% (95 % CI: 20.2-53.2) stored all guns locked and unloaded when they had a child with a history self-harm risk factors, compared with 31.8% (95% CI: 25.9-38.3) when none of their children had such a history.

CONCLUSIONS

Millions of US children live in homes in which firearms are left loaded or unlocked or both. A child's history of depression, mental health conditions other than depression, or attention-deficit/hyperactivity disorder does not appear to appreciably influence caretaker decisions about whether to (1) have firearms in the home, or (2) store all household firearms in accordance with American Academy of Pediatrics recommendations (ie, locked and unloaded).