PEDIATRICS Vol. 107 No. 2 February 2001, pp. 408-410

COMMENTARY:
Serious Firearm Injury Prevention Does Make Sense

The policy statement "Firearm Injuries Affecting the Pediatric Population" that appeared in the April 2000 issue of this journal reaffirmed the position of the American Academy of Pediatrics (AAP) that firearm injuries and deaths in children represent a public health problem.¹ Most importantly, the statement outlined 2 effective measures to achieve absence of guns in the home.

• A ban on handguns and semiautomatic weapons; and
• Anticipatory guidance by pediatricians, including asking questions about guns when obtaining patient histories and urging parents who possess guns, especially handguns, to remove them from the home.

The support of these 2 measures was placed in the context of other violence prevention activities, support for safety and design regulations that would treat guns as other consumer products, engineering efforts to decrease the chances that a child could fire a gun, and support for a national surveillance data system on morbidity and mortality associated with firearms.

The recent publication of Healthy People 2010 clearly cites the prevention of violence and injury as 1 of 5 health system indicators.² The Surgeon General's Report on Youth Violence Prevention to be released later this year underscores the importance of violence prevention.³ For the first time, AAP recommendations for preventive pediatric health care list violence prevention anticipatory guidance in the periodicity table, extending from the prenatal period through adolescence.⁴ There can be no question that violence and its prevention are seen as part of the domain of physicians. Understandingly, however, the AAP policy statement on firearm injuries has raised many questions on the practicality of the proposed interventions.

DOES THE POLICY STATEMENT MAKE SENSE?

The data provided by the policy statement clearly define the firearm injury problem as one of the leading causes of death and injury for children; a problem requiring a comprehensive approach to its prevention. The public health model is such an approach. Viewing gun violence as a public health problem requires problem definition, identification of risks, and suggestions for interventions and evaluations. The public health approach to other injury problems, such as automobile crashes, has taught pediatricians that to impact the death rates, it is important to shift the debate from one that targets only the individual to one which includes broader community and legislative interventions.⁵ The difficulty of changing individual behavior can be contrasted with the effectiveness of passive, one-time measures that remove the hazard. Towards that end, handguns, which are responsible for at least 70% of deaths in all categories (homicide, suicide, and unintentional) are specifically targeted in the recommendations. Despite the need for more research, there are current, sound studies that indicate that the presence of a gun in the home increases the risk of homicide, suicide, and injury to family and friends.^6-9

Pediatricians are poised to play a key role in providing counsel to families regarding firearm safety in the home. In 1994, data from a national random AAP survey of 982 pediatricians involved in direct patient care found that 1 in 5 pediatricians had treated a gun injury in the past 12 months and 92.5% supported restricting the sale and possession of handguns.¹⁰ Seventy-six percent supported banning the sale and possession of handguns. Most respondents (82%) believed that anticipatory guidance on firearm safety could reduce the numbers of injuries and deaths; 95% supported asking parents to unload and lock firearms, and 66% supported encouraging parents to remove handguns from the home. Other studies have pointed to the effectiveness of anticipatory guidance for injury prevention.¹¹ The need for such anticipatory guidance has been supported by numerous studies showing that gun owners often do not store guns properly and that people who do not own guns often do not know how guns belonging to other family members are stored in their homes.^12,13 Often parents do not realize the risks that guns pose to their children, do not recognize the inability to trust them with a loaded gun, and may overestimate the ability of their child to differentiate a toy gun from a real gun.^14,15

HOW CAN THE RECOMMENDATIONS BE IMPLEMENTED, AND WILL THEY BE EFFECTIVE?

Asking pediatricians to address the issue of firearm injuries to children in their clinical practice is not a simple matter of following a few straightforward anticipatory guidance protocols. This is a complex issue that is greatly influenced by standards and behaviors that vary greatly from community to community. In many communities, gun ownership is commonplace. Involving children in hunting and teaching them how to shoot may be routine. In many communities, gun ownership for the purpose of self-protection is also common, and the belief in the individual right of people to own and keep guns is strong. We recognize and respect the importance of pediatricians incorporating community values into their clinical practice and recognize that these issues can complicate the context for discussing the risks of guns in the environment. However, it is also the role of pediatricians to analyze data, share those data with families, and counsel families on strategies that have proven to be most effective in preventing harm to children. This is one of the reasons that the policy statement focused so extensively on certain types of guns (particularly handguns and semiautomatic weapons), about which scientific and epidemiologic data tell us that major problems exist. It is the presence of these types of guns that specifically elevates the risk of intentional and unintentional injury. Although recreational guns must be stored safely because they represent a danger to children, it is handguns and semiautomatic weapons that pose the greater risk, because they are far more often stored unsafely and are more often involved in serious injuries and deaths of children.

Pediatricians have an important role to play in promoting the safety of children in all communities. Repetitive anticipatory guidance by pediatricians is effective and powerful. What the periodic survey of 1994 and other studies have revealed, however, is that there is a gap between attitudes and practice.¹⁶ Pediatricians often lack the tools to effectively counsel families to remove guns from the home or at least to store them unloaded and locked. Pediatricians have expressed concern that some parents may object to being asked about guns and that this advice may not be practical if the parent is, for example, a police officer.

However, some surveys of parents have shown their acceptance of firearm safety information from their pediatrician,¹⁷ but others have revealed that parents do not see their primary care provider as a credible source of information on firearms.¹⁸ This is not surprising, given that this is a new area of attention for physicians, and they must therefore increase their knowledge of the circumstances under which injuries occur, the guns involved, and the effectiveness of proposed strategies.¹⁹ The more comfortable physicians become in this area, the more parents will seek their advice. Pediatricians regularly address difficult or controversial areas, such as immunizations, human immunodeficiency virus infection counseling, domestic violence, and child abuse. Risk of firearm injuries is no less urgent and no more difficult to address.

From the beginning of the state legislative session in 1999, close to 1000 pieces of firearm legislation were considered by legislators (M. Glasstetter, written communication, September 2000). In the past 2 years several states (California, Illinois, Maryland, New Hampshire, New York, and Rhode Island) have enacted legislation aimed at preventing firearm violence. Current gun control laws fall into the categories of registration, safety training, regulation of sales, safe storage and accessibility, owner licensing, litigation, and preemption. Two states (California and Connecticut) have bans on assault weapons, and 2 states (Hawaii and Maryland) have bans on assault pistols. Seven states (Massachusetts, Hawaii, California, Maryland, Illinois, South Carolina, and Minnesota) have bans on "junk guns."²⁰ The flurry of legislative efforts in the past years is testimony to the belief that there is a critical role that legislation can play in reducing firearm-related deaths and injuries.

In addition to state legislation, there have been significant efforts to enact federal legislation to reduce firearm death and injury. Some of these efforts have been successfulresulting in the "Brady Law," requiring background checks before gun purchases from licensed dealers, and the assault weapons ban (which expires in 2003). But other common-sense measures were rejected by Congress, including a background check requirement for weapons purchased at gun shows (such as those used in the Columbine shootings). Because individual state laws restricting access to firearms can be undermined by less restrictive laws in neighboring states, federal regulation of firearms is especially important (J. Guerney, written communication, November 2000).

Supporting legislation is not new to pediatricians. We have backed seat belt and car safety seat legislation for years. Mandated reporting of child abuse in all 50 states is the result of advocacy work fueled by hard medical data supporting the diagnosis of the battered child syndrome. The risk that guns pose to adolescents and children is one that is worthy of the support for strong national legislation. The support for such measures exists even among gun owners.²¹

The effects of such legislation are already being noticed. After implementation of a Maryland law banning "Saturday night special" handguns, a gun banned under this law was more than twice as likely to be the subject of a crime gun trace request in 15 other cities combined than in Baltimore.²² Among homicide guns, a comparable difference was observed. Contrary to the claims of opponents of gun control laws, regulation of the lawful market for firearms also affected criminals.

HOW CAN PEDIATRICIANS BECOME INFORMED AND INVOLVED?

The essential elements of advocacy defined by Knitzer²³ in 1976 are fact-finding, assessing the political situation, development of strategy, and follow-through. Others have applied similar conceptual frameworks in suggesting practical ways that the model can be applied to prevent injuries, including firearm injuries.^24,25 One such organization that concentrates its efforts on strategy is the Handgun Epidemic Lowering Plan Network (also known as HELP), an international coalition of more than 120 medical and allied organizations and individuals working to reduce handgun deaths and injuries. The AAP chapters may become members and obtain periodic, up-to-date listings of relevant literature, legislative efforts and bills passed, summaries of local and national events, and networking opportunities.

The reaction of numerous groups has also begun to shape the firearm debate. This has never been clearer than at the Million Mom March in Washington, DC in May 2000. This movement reflects a parent-led grassroots response to the firearm problem calling for common sense gun laws. Pediatricians have supported and should continue to join parents and take a leadership role in preventing tragedies related to gun deaths and injuries.

In August 2000, the Academy joined the Asking Saves Kids (ASK) campaign. The ASK campaign is run by PAX, a nonprofit organization devoted to reducing gun violence. This campaign urges parents to ask their neighbors and family if there is a gun in the home before sending their child to play there. The campaign suggests that the safest choice is not to send the child to play in a home where there is a gun. The ASK brochure can be given to families to begin to facilitate this important discussion. Brochures may be obtained from PAX by calling (212) 983-8705 ext. 228.

We should continue to monitor our progress. A repeat AAP survey on experience and opinions regarding firearm safety will be administered this year. The AAP Department of Federal Affairs and Division of State Government Affairs will continue to monitor gun legislation, and the Academy will continue to support legislation deemed to be in the best interest of children.

At both the state and federal levels, individual pediatricians can play a critical role in educating their elected officials about the devastation caused by firearms in their own communities, and about the applicability and effectiveness of a public health approachincluding legislationto the reduction of firearm death and injury. Pediatricians can join the AAP Federal Advocacy Action Network to receive information and alerts about the need to contact members of Congress or the administration on specific legislation. At the state level, pediatricians can work on this issue in coordination with their state chapters.

There is still much to be done. Despite some successes, the recent Open Society Institute Report on Gun Control in the United States²⁰ shows that, of a maximum possible score of 100, 46 states scored <50% on gun control measures. The 7 highest ranking states were Massachusetts (76%), Hawaii (71%), California (53%), Connecticut (50%), Maryland (43%), New Jersey (35%), and Illinois (35%). Seven states have no legal minimum age for a child buying rifles or shotguns from an unlicensed seller. Eighteen states have no minimum age for possession of these guns. Six states have no legal minimum age for a child to possess handguns, and 5 states set the minimum age below 18 years. In 43 states, no license or registration is required for assault weapons, such as AK-47s. Only 4 states (California, Connecticut, Hawaii, and Massachusetts) have safe storage laws. Recent successes against the tobacco manufacturers are great examples of the possibilities of public health strategies and legislation in reducing product-related deaths and disabilities.

The AAP policy statement on firearm injuries to children and adolescents is timely. The policy statement sets a course for pediatricians along many avenues. Each of us, within the contexts of our regions, communities, and practices, can be effective in some measure to reduce the numbers of injuries and deaths of children and those who love them.

Danielle Laraque, MD
Mount Sinai School of Medicine
One Gustave L. Levy Place
New York, NY 10029-6574

Howard Spivak, MD
Tufts University School of Medicine
Boston, MA 02111

Marilyn Bull, MD
Department of Pediatrics
James Whitcomb Riley Hospital for Children
Indianapolis, IN 46202

FOOTNOTES

Received for publication Nov 13, 2000; accepted Nov 13, 2000.

Reprint requests to (D.L.) Mount Sinai School of Medicine, One Gustave L. Levy Pl, Box 1198, New York, NY 10029-6574.

ABBREVIATIONS

AAP, American Academy of Pediatrics; ASK, Asking Saves Kids (campaign).

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