Teaching Our Children

Preventing gun deaths in children.

21/6/2018

As practicing pediatricians who have lost patients to gun violence, we join our colleagues in mourning the 20 children and their teachers who were killed in Newtown, Connecticut, on December 14, 2012. Our sadness is deepened by our knowledge that the deaths, terror, and post-traumatic stress of the relatives and friends left behind could have been prevented.

Prevention is the core of pediatric work. We aim to protect children from all things that can harm them. Injuries are the biggest threat to U.S. children over 1 year of age. In 2010, gun-related injuries accounted for 6570 deaths of children and young people (1 to 24 years of age). That includes 7 deaths per day among people 1 to 19 years of age. Gun injuries cause twice as many deaths as cancer, 5 times as many as heart disease, and 15 times as many as infections (see graph).1
How can we prevent gun injuries? We know the behaviors that place children and adolescents at high risk. Little children explore their worlds without understanding danger, and in one unsupervised moment, an encounter with a gun can end in fatality. School-age children often enter the worlds created by television shows, movies, and video games. Because of their developmental age, school-age children don't necessarily understand that people who are really shot may really die. A firearm in their hands can transform fantasy into tragedy. Even in our own lives, this risk has been manifest: to this day, one of us is haunted by the childhood memory of aiming a loaded rifle at a babysitter.
Teenagers get into fights over girlfriends or sneakers, get furious or scared. Alcohol and drugs may impair their judgment. A fistfight may cause transient injuries, but a gunfight can kill rivals, friends, or innocent bystanders. Depressed young people may attempt suicide. Less than 5% of such attempts involving drugs are lethal, but 90% of those involving guns are.2 Our niece might be alive today if she hadn't had easy access to a handgun at 18. Finally, permitting guns to reach the hands of severely deranged persons can have monstrous results. The American Academy of Pediatrics (AAP), recognizing all these vulnerabilities, declared in a policy statement on firearms in October 2012 that “the absence of guns from homes and communities is the most effective measure to prevent suicide, homicide, and unintentional injuries to children and adolescents.”2
In the early 1990s, there was a surge of violence and firearm-related deaths. The death rate was so high (nearly 28 of every 100,000 people 15 to 19 years of age)2 that pediatricians joined with other professionals (police officers, clergy, and educators) to find ways to combat the epidemic. Pediatricians began to address the protection of children from gun-related causes alongside the prevention of other types of injuries, poisonings, child abuse, lead toxicity, and infectious diseases.
Screening tools and basic interventions became routine practice through nationally accepted programs such as Connected Kids and Bright Futures. AAP guidelines recommend that when families report the presence of firearms in the house, pediatricians should counsel about gun removal and safety measures (gun locks and safe storage). One mother responded to routine screening questions asked by one of our colleagues, “Why, yes, I have a loaded gun in the drawer of my bedside table.” Until that moment, she had apparently never considered the risk to her child.
Although such screening and counseling are important in general, it is particularly important that children's health care providers have the opportunity (and time) to discuss the issue of guns with the families of children and young people who have developmental, behavioral, or mental health problems. In the United States, far too little attention is paid to the seriousness of our children's mental health problems. Families are often left unsupported as they try to protect their children who may be depressed, impulsive, or combative.
Since 1994, the AAP has conducted periodic member surveys to ascertain physicians' attitudes about gun safety and to see whether doctors are performing recommended screening and counseling. In both 2000 and 2008, approximately 70% of physicians reported that they “always or sometimes” asked whether there were guns in the home and recommended unloading and locking guns. In 2008, 50% of the doctors surveyed reported “always or sometimes recommending the removal of the guns from the house.”3 A recent AAP research analysis of these data show that doctors who live in states with high levels of gun ownership are just as likely as those in states with low levels to ask about guns in the home but are likely to counsel families about safe gun storage rather than removal.
In a randomized, controlled, cluster-design study by the Pediatric Research in Office Settings network, the intervention group that received specific gun-safety counseling from their doctors reported significantly higher rates of handgun removal or safe storage than did the control group. This study showed that families do follow through on pediatricians' recommendations about gun safety.4
Despite this evidence, in 2011, Florida passed legislation, the Firearms Owners' Privacy Act, making it illegal for a doctor to conduct preventive screening by asking families about guns in the home — essentially “gagging” health care providers. Under the aegis of the Second Amendment, the First Amendment rights and the Hippocratic responsibilities of physicians were challenged. In response, the AAP's Florida chapter brought suit, and in June 2012, Miami-based U.S. District Judge Marcia Cooke issued a permanent injunction banning the state from enforcing the law. Governor Rick Scott has appealed the ruling, and similar bills have been introduced in three additional states.
At the federal level, problematic language was introduced into the Affordable Care Act. Section 2717(c) sets restrictions on the collection and aggregation of data on guns in the home. Furthermore, Congress has restricted the research activities of the Centers for Disease Control and Prevention (CDC) by stipulating that no funds that are made available for injury prevention and control at the CDC “may be used to advocate or promote gun control.”5 Strictures like these often have a chilling effect on the gathering of important public health data.
The Newtown tragedy is galvanizing a national understanding of the pervasive threats that guns pose and the toll they take. The picture of wailing children leaving Sandy Hook Elementary School is seared into our collective consciousness like the image of the Kent State students or the smoking Twin Towers. The country's heart goes out to the families.
It is time to act for these families and for those who continue to lose children to gun violence. Newtown concentrated the horror in one place for one hour, but the same outrage occurs daily in U.S. cities, suburbs, and rural areas.
As a nation, we have it in our power to protect our children from gun injuries, as other countries have done. Doctors, teachers, city and state officials, gun owners, families, and young people must come together with a creative and meaningful commitment to improving our society.
We believe that, at a minimum, several specific measures should be taken. First, the ban on assault weapons should be reinstituted. Magazine and ammunition capacity and the tissue-destruction capability of ammunition should be limited. Rather than increasing the number of guns in public places, as was recently suggested by the National Rifle Association, we need to set a goal of reducing the number of guns in our homes and communities. This reduction can be accomplished through tighter consumer-safety regulations, as well as licensure and certification of gun owners. Federal restrictions on the collection of public health data about gun-related injuries should be reversed.5 Continued emphasis should be placed on limiting children's viewing of violent material on TV and through video games. Finally, we must dedicate more state and local funding to effective treatment of young people who are identified by parents, schools, and law-enforcement or mental health professionals as being at high risk for committing interpersonal violent acts.
If we take these steps, we will honor our children who have died needlessly. Our nation can prevent the loss of precious lives.

PRESIDENT BARACK OBAMAThe Making of a True American Hero.

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PRESIDENT BARACK OBAMA
The Making of a True American Hero.

John M. Rinaldi
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