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We read with interest the article by Himle et al,1 which evaluated 2 training methods to prevent gun play among children. Their study joins a series of other studies, several of which were cited in their article, that have demonstrated that gun-safety education among young children does not prevent children's subsequent handling of guns in naturalistic settings. Although their study findings seem clear, we are puzzled by the authors' conclusions, which seem inconsistent with their data.
Unintentional firearm injuries are an extremely important cause of preventable death and disability. In 2001, >350 American children <10 years old received emergency treatment for unintentional firearm injuries, and at least 33 died.2
The first line of protection must be the safest, meaning, in this case, the physical separation of the gun from the child. Eliminating or reducing the hazard in the environment has been applied successfully to a variety of childhood injury types including pool drowning,3 childhood poisoning,4 and tap water burns.5
Could teaching children to not handle a gun and to tell an adult when they find one introduce greater risk? A concerning finding in the most recent study by Hardy6 was a borderline increase in gun handling by children who received the intervention (60%) versus the control group (47%). Additionally, as stated by Himle et al, any education program that gives parents a sense of complacency without altering the child's behavior might do more harm than good. Even more concerning is the possibility that a program directed solely at childhood behavior could provide a greater sense of comfort for adults who want a gun in the home that is readily accessible. Pitting gun accessibility against child safety introduces a gamble with odds that clearly are not in a child's favor.
It would be helpful if child-based training skills served as another layer in firearm injury prevention, but as clinicians, we need to advise families that no such effect has ever been demonstrated. Current information, including this study, support the American Academy of Pediatrics policy7 that counsels separation of the gun from the child by removal or safe storage. Those actions rest squarely on the shoulders of adults.
REFERENCES
In Reply.—
We appreciate the thoughtful response to our article1 by Dowd et al,2 representing the American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention. They make an extremely important point when they suggest that "the first line of protection must be the safest, meaning, in this case, the physical separation of the gun from the child." We agree fully with this point. We stated in our article that we believe "parents are the first line of defense for children," that safety-skills training programs for children "should not replace parent-based strategies for preventing firearm injuries in children," and that "programs that are designed to increase parents' safe storage of firearms are a must." There is no argument here; we must do everything possible to eliminate children's access to firearms.
In their letter, Dowd et al raised a number of important questions about the value of teaching skills to children to prevent gun play. First they asked: "Could teaching children to not handle a gun and to tell an adult when they find one introduce greater risk?" This is a good question, but we are not aware of any evidence to support this concern. Second, Dowd et al suggested that the results of Hardy3 demonstrated a "borderline increase" in gun play after an intervention. It should be noted, however, that this increase was not statistically significant, and as such, it cannot be concluded that the intervention used by Hardy resulted in a paradoxical increase in gun-play behavior. Third, Dowd et al question whether child-based approaches will decrease the safety behavior of gun-owning parents (ie, make parents complacent about storing their firearms safely). Although Christoffel4 raised this issue some years ago, we are not aware of any empirical research to support the proposition. The questions raised by Dowd et al emphasize the need for continued critical evaluation of programs designed to teach skills to children to prevent gun play.
We are steadfast in our contention that a multifaceted approach to safety is best. First and foremost, efforts to keep guns out of the hands of children should continue. These efforts must include parent education and legislation that makes parents criminally liable if their gun is accessed by a child who injures or kills another individual with it. There is evidence that such legislation can work.5 However, unless such efforts are shown to be 100% effective (which, unfortunately, they are not), children will continue to find firearms and be at risk for injury. Therefore, it is our contention that successfully teaching safety skills to children to prevent gun play will minimize the risk of injury further. As such, we believe that there is considerable work to be done in modifying the safety behavior of both adults and children.
Although the results of Himle et al showed that the children did not use the safety skills when tested in a naturalistic setting, other research has shown that young children can learn important safety skills (ie, abduction-prevention skills, fire-safety skills) and use the skills when tested in naturalistic situations.6,7 Furthermore, in another recent study, Himle et al8 demonstrated that more intensive behavioral-skills training procedures were effective for teaching young children skills to prevent gun play and that the children used the skills when finding a gun in a naturalistic situation. We believe that continued research in this area is necessary so that effective and efficient programs can be developed for teaching these important skills. A child is best protected when the hazard has been reduced or eliminated and the child has learned skills to deal safely with the hazard should it ever be encountered.
REFERENCES
This article has been cited by other articles:
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  M. D. Dowd, R. Sege, G. A. Smith, J. L. Wright, and R. G. Miltenberger Firearm Injury Prevention: Failure of Gun-Safety Education Pediatrics, June 1, 2004; 113(6): 1847 - 1848. [Full Text] [PDF]
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