Firearm injury is a leading cause of death and injury for children and adolescents, able to cause disability and interfere with normal development. Child developmental stages, variance of behavior, and mental health may all put children at risk for firearm injury or lead to increased morbidity after experiencing firearm violence. Family, community, and contextual factors can accentuate the risk of violence. Adults and social structures have the responsibility to protect children and adolescents from firearm violence.
Key points
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Firearm violence can disrupt normal child development.
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In combination with normal child developmental stages, firearms pose significant risk of death, injury, and psychosocial trauma.
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Speaking to children is not enough to prevent firearm violence.
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Prevention of firearm violence requires adult responsibility, including methods to reduce child/adolescent access to firearms.
Introduction
Death is the ultimate interference with child development. Firearm violence has the potential to disrupt child development completely, by causing premature child death, or to hinder normal health via the loss of family members, guilt from having pulled the trigger (unintentional or otherwise), stress of chronic community violence, the ominous threat of mass shootings, or even accumulated adverse responses to media violence. Unintentional injury is the leading cause of death in children and adults aged 1 to 44 years and the fourth most common cause of death in the overall population. Gun trauma may cause physical, emotional, and mental health disruption to injured victims as well as to those who were not directly in a bullet’s trajectory.
Firearm injury prevention research has been insufficiently funded for decades. Children have been among the victims of mass shootings and have experienced the consequences of interpersonal, family, and community violence that occurs in homes and streets on a daily basis. Studies have enumerated pediatric firearm death and injury; additional research catalogues the consequences of violent trauma to children and adolescents, including physical and behavioral disruptions, assault recidivism, perpetration of violence, and negative socioeconomic outcomes. Research-based guidance about how to prevent firearm violence caused by or inflicted on children and adolescents provides insight, but no clear map toward elimination. More questions remain than answers. There is still more to discover about the interplay between normal child and adolescent growth, mental health, learning, attention and firearm access, ownership, handling, play, shooting, and violence. In addition, risk and outcome variances that might be caused by differences posed by conditions of mental illness, chronic disease, learning or attention disorders, and social determinants either in children or their household members and how these affect firearm injury risk or should inform policy have not been completely described.
Despite seemingly daily headlines, the consequences of gun injury on children’s lives and development and, relatedly, how child growth and development influence gun events are incompletely understood. However, where associations are strong, such as accumulated research indicating a direct relationship between firearm availability and risk of homicide, suicide, and unintentional gun injury, there is less science on how to meaningfully reduce that availability, at least in the United States. This omission is of great concern, because firearm injury accounts for nearly 18% of all deaths in the United States; almost as many deaths as those caused by car crashes. Unlike motor vehicle deaths, the number of firearm deaths has not decreased over the past half-decade, but instead its slight increase has been driven largely by suicides.
Introduction
Death is the ultimate interference with child development. Firearm violence has the potential to disrupt child development completely, by causing premature child death, or to hinder normal health via the loss of family members, guilt from having pulled the trigger (unintentional or otherwise), stress of chronic community violence, the ominous threat of mass shootings, or even accumulated adverse responses to media violence. Unintentional injury is the leading cause of death in children and adults aged 1 to 44 years and the fourth most common cause of death in the overall population. Gun trauma may cause physical, emotional, and mental health disruption to injured victims as well as to those who were not directly in a bullet’s trajectory.
Firearm injury prevention research has been insufficiently funded for decades. Children have been among the victims of mass shootings and have experienced the consequences of interpersonal, family, and community violence that occurs in homes and streets on a daily basis. Studies have enumerated pediatric firearm death and injury; additional research catalogues the consequences of violent trauma to children and adolescents, including physical and behavioral disruptions, assault recidivism, perpetration of violence, and negative socioeconomic outcomes. Research-based guidance about how to prevent firearm violence caused by or inflicted on children and adolescents provides insight, but no clear map toward elimination. More questions remain than answers. There is still more to discover about the interplay between normal child and adolescent growth, mental health, learning, attention and firearm access, ownership, handling, play, shooting, and violence. In addition, risk and outcome variances that might be caused by differences posed by conditions of mental illness, chronic disease, learning or attention disorders, and social determinants either in children or their household members and how these affect firearm injury risk or should inform policy have not been completely described.
Despite seemingly daily headlines, the consequences of gun injury on children’s lives and development and, relatedly, how child growth and development influence gun events are incompletely understood. However, where associations are strong, such as accumulated research indicating a direct relationship between firearm availability and risk of homicide, suicide, and unintentional gun injury, there is less science on how to meaningfully reduce that availability, at least in the United States. This omission is of great concern, because firearm injury accounts for nearly 18% of all deaths in the United States; almost as many deaths as those caused by car crashes. Unlike motor vehicle deaths, the number of firearm deaths has not decreased over the past half-decade, but instead its slight increase has been driven largely by suicides.
Gun injuries
Gun injuries are a leading cause of death for children and adolescents. The United States outpaces all other high-income countries in overall firearm death, firearm homicide, firearm suicide, and unintentional firearm deaths by several-fold. Most homicides and suicides in the United States are firearm homicides and suicides. The more guns there are, the higher the burden of violence: for every 1% increase in household gun ownership, youth firearm homicide increases 2.4%.
Firearm suicide accounts for approximately two-thirds of all US firearm deaths, although firearm homicide outnumbers firearm suicides among the young. Unintentional deaths are harder to accurately enumerate, because such incidents, particularly among children, may be coded as homicides or suicides in vital statistics data.
However, even when such data are used, unintentional firearm death disproportionately affects youth. In 2014, 106 children died of unintentional firearm-related injuries. Unintentional firearm injuries are among the top 10 leading causes of injury-related deaths for children aged 7 to 16 years. These shootings occur most often when children gain access to an unsecured firearm in a home.
Pediatric firearm homicide may also occur close to home. When the source of the gun is known, it often did not come further than friends and family. Most school shooters obtained their guns from home or a relative. The origin of guns used by youth in crimes is more storied. A national sample of incarcerated youth who committed crimes as juveniles reported that 47% of their guns came from the street or black market, whereas 38% were obtained from a friend or family member.
Normal child development and risk of firearm injury
Pediatrics is concerned with optimal child growth, development, and health. Pediatricians follow patients from birth into adulthood and ensure their continued development, often assessing progress against recognizable milestones. As children journey through development, they interact with their environment. Their growth stage poses challenges and even risks that differ based on physical, emotional, and cognitive abilities. In every developmental phase, child and adolescent curiosity, which propels those reaching for maturity to explore, puts them in contact with new objects, situations, and contexts, often in ways their prior developmental stage did not prepare them to encounter. A child’s ever-increasing independence and changing developmental tasks require that they learn, and potentially confront risk, in new ways, within varying contexts. As children progress, parents may not always understand a child’s full developmental capacities or the limits of those capacities, which operate within normal ranges rather than fixed points, and fluctuate over time even within the same child.
Early Childhood/Preschool
Thus, once fully dependent newborns surprise parents when they roll off a bed or first learn to scoot and fall down a step. The physical capacity and evolving independence of toddlers surely contributes to the unexpected shootings by this age group. Toddlers are developmentally able to find firearms left in purses, drawers, on shelves, or under bedding. The combination of new physical skills and strengths, the need to interact with the environment, but also an inability to recognize or even cognitively conceive of an object’s potential lethality places very young children in harm’s way when there is access to loaded firearms. For the very young, the world is to be experienced without fear of harm. Toddlers are supposed to touch and pick up everything they find, and even put such things in their mouths. Slightly older children still see such objects as toys or other irresistible items of curiosity, and this is normal. Even if an adult speaks with a child of such an age, imploring the child to restrain from a certain behavior, impulse control has not developed in preschoolers. Thus, it is predictable that children 2, 3, and even 4 years of age will shoot themselves or someone else when they find a loaded firearm in a bedroom, car, or another unsecured location.
School Age
Parents speak with their older, school-aged children about concepts such as danger causing pain, and what not to touch, but, developmentally, school-aged children should not be depended on to never touch things that might be dangerous, or to always follow a parent’s instructions, especially when the parent is not present. Developmental gains are incomplete and lapses occur regularly. Conceptualization of finality, which is required to fully understand death, does not usually begin until approximately age 7 years. Understanding causality begins in early childhood, but continues to develop through adolescence. Grasping the concept of the action of handling a gun and the lethal consequence of injury or death is still abstract for many children, particularly when they see so many images of guns in the media, often displayed with little to no consequence for their heroes. For school-aged children, firearm injury, by all intents, ranks as the fourth leading cause of injury death. By age 11 years, firearm injury is the second leading cause of injury death. Children in this age group increasingly seek independence, but are also subject to peer pressure, which may encourage them to investigate firearm mechanisms, power, and potential, even when that contradicts parental advice.
Early Adolescence
Advancing elementary and middle school youth are often anxious to imitate older teens and adults, but may also rebel as they realize parents are not perfect. Although they understand right from wrong, it is normal at this stage for young adolescents to test rules and push limits, and to question authority. Their expressive skills are not yet fully developed and so they may put feelings into action rather than words, sometimes leading to physical conflict or self-harm.
Adolescents’ emotional growth is not necessarily linear; they may revert to more immature behaviors, particularly under stress. Under such conditions, access to weapons presents risk. A study of more than 6000 fifth to seventh graders in the nonmetropolitan southeast, reported that 46% themselves owned guns (including BB/pellet guns). Nearly a quarter reported owning firearms (rifles, shotguns, pistols, or handguns). These firearms were in addition to family guns, reported by more than 70% of the students. Of concern, but predictable and consistent with young adolescent development, 11.3% of the adolescent gun owners reported using the gun to frighten someone and 5.5% had brought it to school at least once.
Advancing Adolescence
Even older adolescence presents developmental challenges. Cognitively, much growth has occurred, but emotional regulation is incomplete. The executive functions, required for impulse control, are among the last to mature, and do not do so at the same rate among all youth. However, there are too many examples in every community of adolescents who hastily claimed their own lives, who acted recklessly and harmed another, who were not intending any harm but were nonetheless playing with a gun that went off. Sometimes teens really were in the wrong place at the wrong time; in other cases, they made an impulsive decision or a regrettable safety omission because they were behaving as teenagers. In every case, both the tissue damage and the emotional trauma are serious. Adolescence is a time to be protected from gun violence, not to be experimenting with it.
Weapon carrying may occur with less frequency among urban teens than rural teens, who are more accustomed to the hunting and sporting culture. Nonetheless, youth firearm carrying occurs throughout the United States. Per the Youth Risk Behavior Surveillance Survey, in 2013, 5.5% of high schoolers carried guns in the 30 days before the survey.
An adolescent propensity for violence, at least on the part of some teens, though most often temporary, should not be ignored. Violence victimization and perpetration, both in general and specifically with firearms, increases during adolescence into the early adult years. Adolescents are more likely to be victims of bullying, assault, and violent crime than other age cohorts. Being a victim of violence puts people at risk for violence perpetration. A compelling study regarding the cycle of violence found that exposure to firearm violence doubled the probability that an adolescent would perpetrate serious violence within 2 years. The good news is that, for the greatest proportion of teens, the adolescent spike in experienced violence decreases. The decrease in aggression and assault perpetration coincides with adolescent maturation, particularly developmental gains in impulsiveness and self-control. The adolescent/young adult period is a time of particular developmental risk regarding firearm violence. Protecting adolescents from firearm violence, both as victims and perpetrators, while their own development matures may be key to individual and community health.
Firearm injury, violence, behavior, and mental health
The lifetime prevalence of mental illness approaches half the overall population. The most common of these conditions, anxiety, mood, and behavioral disorders, begin during childhood and adolescence. Substance use also often has its origins during adolescence. Prevalence of such disorders during childhood and adolescence approximates 22%.
Per the Youth Risk Behavior Surveillance Survey, 29.9% of high school students nationwide had felt so sad or hopeless almost every day for 2 or more consecutive weeks that they stopped doing some usual activities, 13.6% of students had made a plan to attempt suicide, and 8% had attempted suicide during the past 12 months. According to the National Health and Nutrition Examination Survey, 7.8% of children 3 to 17 years old had learning disorders; 7.9% had attention-deficit/hyperactivity disorder; and 5.9% had autism, intellectual delays, or other developmental delays. Many of these conditions place affected youth at higher risk of self-inflicted and impulsive firearm injury. An accessible firearm is one of the most concerning risk factors for suicidal patients.
The risk of violent acts committed against others is nominally higher among those with severe mental illness than among the general population. Although mental illness is often thought to contribute significantly to assault violence, only 3% to 5% of such violence in the United States might be so attributed. Signs that someone may commit violence are the same among the severely mentally ill as in the population overall. More than mental illness per se, low self-control, which corresponds with higher impulsivity, has been found to be among the strongest correlates of crime, delinquency, violence, and other problem behaviors.
Mental health consequences of victimization
Further research defining the relationships between pediatric firearm violence, behavior, and mental health is still much needed. Injury and violence generally can increase the risk of morbidities such as posttraumatic stress disorder, mood disorders, and substance abuse. These same conditions may predate violence and potentially increase a person’s risk of disturbance after a violent event. However, how such factors interact with each other; individual, family, and community contexts; and what tools can meaningfully predict or prevent further assault victimization, self-harm, or perpetration of violence against others is less clear.
Child shooters
In the case of unintentional firearm shooting by a child, the traumatic consequences of survivor’s guilt may be significant. As a 10-year-old child, Sean Smith found his father’s unlocked and loaded gun when he was looking for video games. Pulling the trigger, he mistakenly shot his 8-year-old sister when she ran by. She died in his lap while Sean called 911. Now a recovering adult, Sean attributes his drug use, school dropout, and other behavioral problems as a teen and younger adult to the pain that followed him after the shooting. There is little research on child shooter survivors, their outcomes, or how to treat them. The best means to prevent their trauma seems to be empirically obvious: to reduce or eliminate child and adolescent access to firearms and ammunition.
Community violence
High exposure to community violence tends to occur in communities with low social capital, high levels of poverty, and high crime. Families in these communities experience multiple sources of stress, which may include unstable housing, reduced opportunities for youth, high levels of school dropout, unemployment, incarceration, and other factors known to put children at risk.
Children 7 to 12 years old exposed to high rates of community violence tended to show more externalizing behaviors, showed impaired social and behavioral functioning, and were more likely to come from families with high levels of conflict and low cohesiveness. Early studies of children exposed to high levels of chronic community violence revealed similar findings, and association with high-risk behaviors, including fighting and gun and knife carrying. Exposure to community violence seems to increase aggressive behaviors, not only in the near term but also long term, through changes in social cognition. Community violence exposure was related to increases in aggressive behavior and depression among fifth and seventh graders, which persists a year later, and was observed even after controlling for prior affective issues, family functioning, and parenting style.
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