Firearms Access among Pediatric Patients at Risk for Suicide

Abstract

Background:

Approximately 2,900 youth who die by suicide each year in the United States use a firearm. To inform lethal means safety counseling efforts, this study aimed to describe firearm access among youth deemed at risk for suicide in pediatric medical settings.

Methods:

Youth who presented to one of four urban pediatric medical centers were screened for suicide risk and access to firearms. Suicide risk was determined by a positive screen on the Ask Suicide-Screening Questions (ASQ) tool. Firearm access was assessed via a structured questionnaire.

Results:

This secondary analysis analyzed data from 1065 youth aged 10 to 17 years. Overall, 110 (10.3%) participants screened positive for suicide risk. Among those at risk, 28% (31/110) reported guns kept in or around their home, 8% (9/110) had access to a firearm, and 5% (6/110) reported that bullets were not stored separately from the guns.

Conclusions:

Over a quarter of youth at risk for suicide reported a firearm stored in or around their home. To ensure the safety of young people at risk for suicide, clinicians should assess whether youth have access to firearms and conduct lethal means safety counseling with youths, as developmentally appropriate, and their parent/caregivers.

In 2019, approximately 2,900 youth aged 10 to 24 years in the United States (U.S.) died by an intentional, self-inflicted gunshot wound, accounting for nearly half of all suicide deaths in this age group (Centers for Disease Control and Prevention, 2022). Notably, firearms are highly lethal; over 85% of the youth who use firearms to attempt suicide die during the index attempt (McKean et al., 2018). Firearm ownership is also related to increased risk of death by suicide (Kivisto et al., 2021; Anglemyer et al., 2014) and significantly correlated with the U.S. youth suicide rate (Knopov et al., 2019). Of concern, one nationally representative study found that a third of U.S. youth who live in households with firearms could access a loaded firearm within five minutes (Salhi et al., 2021). For these reasons, asking at risk youth about access to lethal means, such as firearms, has been identified as a critical suicide prevention strategy (Office of the Surgeon General, 2012; Barber et al., 2014).

Studies show that youth are at lower risk of death by suicide when firearms are stored unloaded and locked (Grossman et al., 2005). In a 2016, study of U.S. gun owners in urban settings, 46% of respondents indicated they used safe storage practices for their firearms (Crifasi, Merrill-Francis, et al., 2018). Furthermore, research shows a discordance between parent perceptions about their children’s access to guns and their children’s self-reports (Salhi et al., 2021; Baxley & Miller, 2006), emphasizing the importance of asking at-risk youth explicitly about access to firearms. Additionally, providing lethal means safety counseling to parents/caregivers of youth with access to a firearm has been identified as a best practice in suicide prevention (Chu et al., 2015; Bryan et al., 2011). Examples of lethal means counseling include recommendations to store a gun unloaded, locked, in a secure location (e.g., a gun safe), and separate from its ammunition (Bryan et al., 2011).

Firearm safety among children is a challenge that pediatric providers face, regardless of suicide risk. This concern is further intensified when a patient is identified as having suicidal ideation or behaviors. Given that 80% of youth who die by suicide visited a medical setting in the months prior to their death (Ahmedani et al., 2015; Rhodes et al., 2013), healthcare providers are well-positioned to detect suicide risk through screening. These medical visits also afford the opportunity to ask about access to firearms and provide lethal means safety counseling for both the patient and their family. The present study aims to describe the prevalence of self-reported access to firearms in the home among youth who screen positive for suicide risk in medical settings. These data can further inform the importance of lethal means safety counseling efforts with youth, as developmentally appropriate, and parents/caregivers to prevent intentional injury among youth.

Methods

Sample and Setting

This study is a secondary analysis of cross-sectional data collected from several multisite studies that developed and validated the Ask Suicide-Screening Questions (ASQ) instrument (Horowitz et al., 2012). Participants were youth ages 10 to 17 years, inclusive, who presented to either the emergency department (ED), inpatient medical/surgical units, or outpatient specialty and primary care clinics of one of four urban pediatric medical centers (Children’s National Hospital, Washington, DC; Nationwide Children’s Hospital, Columbus, OH; Boston Children’s Hospital, Boston, MA; and Children’s Mercy Hospital Kansas City, Kansas City, MO). Data collection for these studies was conducted between 2008 and 2019. These instrument validation studies were approved by National Institutes of Health Institutional Review Board (IRB) and the IRBs at all participating institutions. Assent was obtained from all patients per local guidelines, and written informed consent was obtained from the parent/guardian. Further methodologies of these studies have been described elsewhere (Horowitz et al., 2012; Horowitz, Wharff, et al., 2020; Aguinaldo et al., 2021).

Measures

Ask Suicide-Screening Questions (ASQ).

The ASQ is a 4-item suicide risk screening instrument that was developed for youth in medical settings (Horowitz et al., 2012). The ASQ identifies youth who have clinically significant suicidal ideation/past suicidal behavior and require further mental health evaluation. Respondents are presented with four Yes/No questions (Figure 1); a response of “Yes” to any one of the items indicates a positive screen. The ASQ was first developed and validated in the pediatric ED, with a sensitivity of 96.9% and specificity of 87.6% for detecting suicide risk (Horowitz et al., 2012). The ASQ has since been validated for use in pediatric inpatient medical/surgical units and outpatient specialty and primary care settings, as well as among adult medical patients, with equally strong psychometric properties (Horowitz et al., 2012; Horowitz, Wharff, et al., 2020; Aguinaldo et al., 2021; Horowitz, Snyder, et al., 2020).

Figure 1:

Ask Suicide-Screening Questions (ASQ) Tool

Firearm access.

All participants were asked a question about firearms in the home (“Are any guns kept in or around your home?”). Each participant was given a forced choice response option of “Yes,” “No,” or “No Response.” If the participant answered “Yes,” follow-up questions with the same response set assessed knowledge of gun storage (“Do you know how to access these guns?”) and storage of bullets (“Are the bullets kept in or around your home locked and separate from the guns?”). Firearm access questions were read aloud verbatim to the participant by a study staff member.

Data Analytic Strategy

A positive screen on the ASQ was considered at risk for suicide. Not all patients who participated answered items about firearm access, resulting in missing data. Patients who did not answer the first firearm access question (“Are any guns kept in or around your home?”) were excluded for the purposes of this analysis. Descriptive statistics, univariate analysis (chi-square), and multivariate regression (logistic regression) were utilized to describe and compare youth firearm access by suicide risk status. Significance was defined as a p<0.05.

Results

After removing 1 patient due to missing data, a total of 1065 patients were included in this analysis [53.4% female; 55.8% White; mean age 14.2±2.0] (Table 1). Of these patients, 23% were ED patients, 40% medical inpatients, and 37% outpatient specialty and primary care patients. When asked about access to firearms, 25.1% (267/1065) of patients reported guns kept in or around their home, 6.9% (73/1065) had access to a gun in their home, and 4.3% (46/1065) reported that bullets were not stored separately from the firearm.

Table 1:

Demographic Data by Suicide Risk

Characteristic	Entire Sample (N = 1065)	ASQ Positive (N = 110)	ASQ Negative (N = 955)	P Value
Gender				<0.001
Male	485 (45.5%)	30 (27.3%)	455 (47.6%)
Female	569 (53.4%)	77 (70%)	492 (51.5%)
Unknown	11 (1.1%)	3 (2.7%)	8 (0.9%)
Race/Ethnicity				0.58
White	594 (55.8%)	63 (57.3%)	531 (55.6%)
Black	213 (20%)	19 (17.3%)	194 (20.3%)
Hispanic/Latino	95 (8.9%)	14 (12.7%)	81 (8.5%)
Asian/Pacific Islander	21 (2%)	3 (2.7%)	18 (1.9%)
Mixed	83 (7.8%)	6 (5.5%)	77 (8.1%)
Other/Unknown	59 (5.5%)	5 (4.5%)	54 (5.6%)
Mean age	14.2 (SD = 2.0)	14.9 (SD = 1.7)	14.1 (SD = 2.0)	<0.001
Medical Setting				.05
Outpatient	391 (36.7%)	52 (47.3%)	339 (35.5%)
Inpatient	429 (40.3%)	38 (34.5%)	391 (40.9%)
Emergency Department	245 (23%)	20 (18.2%)	225 (23.6%)

Abbreviation: ASQ, Ask Suicide-Screening Questions. Significance defined at the p < 0.05 level.

Among the 1065 patients, 110 youth (10.3%, 110/1065) screened positive on the ASQ and were considered “at risk for suicide” [70% female; 57.3% White; mean age 14.9±1.7] (Table 1). Among these 110 youth, 28.2% (31/110) reported guns kept in or around their home; 8.2% (9/110) knew how to access a gun in their home and 4.5% (6/110) reported that the bullets were not stored separately from the firearm (Table 2). In multivariate analysis, comparing youth positive and negative on the ASQ and controlling for age, sex, and race/ethnicity, there were no significant differences for firearms stored in the house, firearm access, or safe storage of bullets. Table 3 reports adjusted odds ratios and confidence intervals.

Table 2:

Firearm Access Data by Suicide Risk

Firearm Access Item	Entire Sample (N = 1065)	ASQ Positive (N = 110)	ASQ Negative (N = 955)
Firearm stored in house	25.1% (267/1065)	28.2% (31/110)	24.7% (236/955)
Has access to a firearm	6.9% (73/1065)	8.2% (9/110)	6.7% (64/955)
Bullets not locked and separate from firearm	4.3% (46/1065)	4.5% (6/110)	4.2% (40/955)

Note: frequencies presented are for a “yes” response to firearm access items. Abbreviation: ASQ, Ask Suicide-Screening Questions.

Table 3:

Logistic Regression Models for Association Between Firearm Access Items and Suicide Risk

	Adjusted OR (95% CI)
	Firearm stored in house	Has access to a firearm	Bullets locked and separate from firearm
ASQ Outcome
Positive (N = 110)	1.3 (0.8-2.2)	1.2 (0.5-2.7)	1.0 (0.4-3.1)
Negative (N = 955)	Reference	Reference	Reference

Abbreviation: ASQ, Ask Suicide-Screening Questions. Significance defined at the p < 0.05 level. All regression models adjusted for age, sex, and race/ethnicity.

Discussion

Among a large sample of youth who presented to pediatric medical centers throughout the U.S., over a quarter of patients at risk for suicide reported that guns were kept in or around their homes. Moreover, 8% of youth knew how to access a gun in their home and 4.5% reported that the bullets were not stored separate from the firearm. This study found no significant differences in firearm access between youth with and without risk for suicide, which is consistent with previous research showing that firearm access is not associated with suicidal ideation (Mann & Michel, 2016). Furthermore, these findings directly support a prior study that showed youth with mental health risk factors are just as likely to live in homes with firearm access as low risk youth (Scott et al., 2018). Of note, reported access to firearms among this sample of patients at risk for suicide is lower than that reported in recent national samples of youth (Salhi et al., 2021). This may be due to recent surges in U.S. firearm ownership (FBI, 2022).

The current findings suggest that a considerable proportion of youth at risk for suicide have access to a firearm stored in their home, representing a major safety concern. Notably, previous research has found that 82% youth who end their life with a firearm are not in mental health treatment at the time of their death (Fowler et al., 2017), emphasizing the need to better identify at risk youth and limit their access to firearms. Pediatric medical settings represent an important venue for detecting at risk youth and ensuring that their homes are kept safe (Horowitz et al., 2014; Larkin & Beautrais, 2010; King et al., 2009). If a patient screens positive for suicide risk, clinicians are optimally positioned to provide lethal means safety counseling to youth and their families (Betz et al., 2010, 2013). Asking youth and their families about the presence of a firearm in or around their home while promoting safe firearm storage is a potential first step towards preventing suicide and unintentional injury.

Increased efforts are needed to ensure that clinicians are adequately trained in not only screening and managing suicide risk, but also how to talk to youth and their families about safely storing lethal means (Schmitz et al., 2012). An important topic for clinicians to discuss when providing lethal means safety counseling is the safe storage of bullets. Notably, 21% of youth at risk in this study who reported firearms kept in or around their homes also reported that the bullets were not stored separately from the guns, which is contrary to recommendations (Grossman et al., 2005). Several studies suggest that speaking with youth and families about safe storage, clinicians should counsel families on the importance of storing bullets separately from guns and ensuring that youth do not have access to either (Miller et al., 2020; Chu et al., 2015).

Greater efforts are also needed to ensure patients and their families adhere to clinical advice to limit access to firearms during at risk periods for safety purposes. Given that most parents reportedly agree that a pediatrician should ask about firearms (Garbutt et al., 2016), more studies are needed to determine how to most effectively counsel families about risks of guns in the home and attendant suicide risk. Importantly, the way firearm lethal means safety counseling is communicated may impact patient adherence to recommendations (Stanley et al., 2017, 2020). While clinicians may not be viewed by parents/caregivers as “experts” in lethal means storage, they are experts on brain development and the negative effects of impulsivity (Crifasi, Doucette, et al., 2018). Future research on how to best deliver safety recommendations is critical.

Limitations

This study has several limitations. First, data used in this analysis was collected between 2008 and 2019. This likely resulted in an underestimate of self-reported youth firearm access, as recent trends indicate a surge in U.S. firearm ownership between 2019 and 2020 (FBI, 2022). Second, the primary study from which these data were obtained was not designed to systematically assess firearm ownership and access. Thus, nuanced information about firearm ownership (e.g., quantity, type, and storage practices) and collateral information from parents/caregivers was not collected, limiting findings to youth perceptions of firearm ownership and access. Additionally, this study used the term “bullets” when assessing participant knowledge of ammunition storage, which may have resulted in inaccurate reporting of safe storage practices. Third, small cell sizes prevented us from examining differences in firearm access by demographics. Lastly, data were collected from a convenience sample of patients presenting to one of four pediatric medical centers, limiting the generalizability of results. No outcome or follow-up data were available.

Conclusions

Regardless of suicide risk, 1 in 4 youth in this study reported a firearm kept in or around their home. Concerningly, 8% of youth at risk for suicide indicated they had access to a firearm. To ensure the safety of all young people, pediatric medical settings are well positioned to inquire about firearm access and conduct lethal means safety counseling, as developmentally appropriate, with patients and their parent/caregivers.

Highlights:

• Roughly 28% of pediatric patients deemed “at risk” for suicide in this study reported a firearm kept in or around their home.

• Among youth at risk for suicide, 8% reported having access to the gun.

• These results add further evidence that it is important for clinicians to conduct lethal means safety counseling with patients and their families.

Biographies

Nathan J. Lowry, BA is an Intramural Research Training Award (IRTA) research fellow at the National Institute of Mental Health (NIMH), where he studies youth suicide prevention research. At the NIMH, he manages several international multi-site suicide risk screening research studies to validate the Ask Suicide-Screening Questions (ASQ) tool among pediatric medical patients. He also engages in public health outreach by disseminating research findings through manuscript writing. He received his bachelor’s degree in Psychology from Iona College in 2020 where he served as a research assistant in a self-injury/suicide prevention lab.

Ian H. Stanley, PhD is a research fellow in the National Center for PTSD at VA Boston Healthcare System and the Department of Psychiatry at Boston University School of Medicine. He received his PhD in clinical psychology from Florida State University. His research focuses on suicide prevention, with specific interests in improving suicide risk assessment, examining the interplay between PTSD and suicide risk, and developing clinical and public health strategies to reduce the risk of firearm suicide. Dr. Stanley has published over 100 peer-reviewed publications and has presented at local, national, and international venues. His work has been supported by the American Foundation for Suicide Prevention, National Institute of Mental Health, and US Department of Defense.

Annabelle M. Mournet, BA is a Clinical Psychology doctoral student at Rutgers University where she studies the use of ecological momentary assessment to understand suicidal thoughts and behaviors among high-risk populations, including adults with autism spectrum disorders. Previously, she was an Intramural Research Training Award (IRTA) research fellow at the National Institute of Mental Health, where she managed several multi-site suicide risk screening research studies and engaged in public health outreach by utilizing the data from these research studies to disseminate results through manuscript writing. She received her bachelor’s degree in Public Health from the University of Rochester in 2019.

Elizabeth A. Wharff, PhD, M.S.W. is a clinician/researcher at Boston Children’s Hospital where she directed Emergency Psychiatry for almost 20 years. Her research focuses on prevention of suicide through the development and testing of screening and intervention tools designed to reduce suicide risk in child/adolescent populations. Dr. Wharff developed the Family Based Crisis Intervention (FBCI) for suicidal adolescents which has been shown to reduce suicidality and prevent psychiatric hospitalization. It is validated in the Emergency Department and currently is being tested in Primary Care settings. Dr. Wharff has a particular interest in the use of technology in mental health treatment, and her research team has also developed a smartphone application (app), CrisisCare, with complementary modalities for the child/adolescent and the parent, that is designed to provide rapid access to a personalized set of therapeutic skills for the potentially suicidal adolescent. Dr. Wharff’s team has worked with other sites nationally to develop suicide screening tools, like the ASQ (Ask Suicide Screening Questions), a 4-item questionnaire which screens both medical and psychiatric patients in a variety of settings. Dr. Wharff is dedicated to improving mental health service delivery and consults nationally on the development of systems of emergency psychiatric care for youth.

Shayla A. Sullivant, MD completed undergraduate training at Creighton University and medical school at the University of Kansas, where she also completed a residency in adult psychiatry and fellowship in child and adolescent psychiatry. Since 2010 she has been on staff at Children's Mercy Kansas City where she currently serves as an associate professor. Dr. Sullivant co-leads the suicide prevention research group at Children’s Mercy and is completing research on suicide screening in conjunction with the NIMH. Her current work focuses on providing education for parents on ways to reduce suicide risk for adolescents, including safe storage.

Stephen J. Teach, MD, MPH is the associate dean for Pediatric Faculty Affairs and chair of the department of Pediatrics at George Washington University School of Medicine and Health Sciences; and director and principal investigator of IMPACT DC (Improving Pediatric Asthma Care in the District of Columbia), a care, research, and advocacy program focused on under-resourced and largely minority children with asthma. Dr. Teach also serves as the Washington, D.C., site principal investigator for the NIH/NIAID-funded Inner City Asthma Consortium. Dr. Teach’s primary academic focus is on the disparities evident in the care of inner-city children with asthma, including their over-reliance on urban emergency departments for episodic asthma care.

Maryland Pao, MD is the Clinical Director and Deputy Scientific Director of the National Institute of Mental Health Intramural Research Program at the National Institutes of Health. She is board certified in Pediatrics, General Psychiatry, Child and Adolescent Psychiatry and Consultation Liaison Psychiatry. Her core research interests are in the complex interactions between medical and psychiatric symptoms in pediatric disorders and on the impact of these diseases on a person’s development. She studies distress and its correlates including suicidal thoughts and behaviors in medically ill children. She is on the Clinical Faculty at Georgetown University, George Washington University and at Johns Hopkins University Schools of Medicine.

Lisa M. Horowitz, PhD, MPH is a Staff Scientist/Pediatric Psychologist in the National Institute of Mental Health Intramural Research Program at the National Institutes of Health. She is lead PI on six NIMH suicide prevention protocols that involve validating and implementing the Ask Suicide-Screening Questions (ASQ) in the ED, inpatient medical/surgical, outpatient primary care settings. Dr. Horowitz is collaborating with hospitals, outpatient pediatric clinics, and school settings around the country, assisting with implementation of suicide risk screening and management of patients who screen positive using the ASQ Toolkit and Youth Suicide Risk Screening Clinical Pathways.

Jeffrey A. Bridge, PhD is an epidemiologist and director of the Center for Suicide Prevention and Research in the Abigail Wexner Research Institute at Nationwide Children’s Hospital and Professor of Pediatrics, Psychiatry and Behavioral Health at The Ohio State University College of Medicine. His research focuses on the epidemiology of suicide and suicidal behavior in young people, neurocognitive vulnerability to suicidal behavior, screening for suicide risk in medical and school settings, and on improving the quality of care for suicidal youth.

Data availability statement:

Due to the nature of this research, participants of this study did not agree for their data to be shared publicly, so supporting data is not available.