Ep. 103: Kids & Guns: A Conversation on Firearm Safety

In September 2024, the Johns Hopkins Center for Gun Violence Solutions released its annual report analyzing 2022 Centers for Disease Control (CDC) data on firearm deaths in the U.S. The report highlights a 106% increase in firearm deaths among children ages 1 to 17 since 2013. Since 2020, firearms have been the leading cause of death for children and teens nationwide.

On this episode of Well Beyond Medicine, we explore firearm safety with two of the nation’s leading researchers on the topic.

Guests:
Lisa M. Costello, MD, MPH, FAAP, Assistant Professor, West Virginia University
Lois K. Lee, MD, MPH, Senior Faculty Advisor, Office and Health Equity & Inclusion; Senior Associate in Pediatrics, Division of Emergency Medicine, Boston Children’s Hospital

Host/Producer: Carol Vassar

Views expressed by guests do not necessarily reflect the views of the host or management.

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Transcript

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Carol Vassar, podcast host/producer:

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Carol Vassar, podcast host/producer:

In September 2024, the Johns Hopkins Center for Gun Violence Solutions released its annual report examining CDC data from 2022, the last year available, related to firearms deaths in the US. Its focus? Firearms deaths among children ages one to 17, which have increased an alarming 106% since 2013. And since 2020, firearms deaths are the leading cause of death among children and teens here in the US.

Firearm safety is our topic on this episode with two of the nation's leading researchers on the issue. Dr. Lisa Costello is an Assistant Professor of Pediatrics at West Virginia University, and Dr. Lois Lee is an attending physician in the Division of Emergency Medicine at Boston Children's Hospital. They stopped by to talk with us while attending the 2024 American Academy of Pediatrics Experience National Conference in Orlando. We began our conversation with a primer on the difference between intentional injuries and unintentional injuries. A key distinction for our discussion, which begins with Dr. Lois Lee.

Dr. Lois Lee, Boston Children's Hospital:

It's important to make that distinction because if you say accidents, people think, well, this is something that's just going to happen. We can't prevent it. But if you distinguish between unintentional versus intentional injuries, then that implies, oh, these are things that actually can be predicted. We can determine risk factors and protective factors and then actually think about what are the harm reduction and injury prevention principles, not just for firearm-related injuries and deaths, but really any type of injury.

Carol Vassar, podcast host/producer:

So, let's talk about unintentional firearm injuries and deaths involving children. What's the scope of the issue? What is the data telling you?

Dr. Lois Lee, Boston Children's Hospital:

So we know that firearms are now the number one killer of children, youth, and young adults in the United States, surpassing motor vehicle crashes and surpassing things that most people think might be the leading cause. So, far surpassing cancer, infections, congenital heart disease or other types of diseases or even other injuries. The vast majority, however, of injuries and deaths are from intentional injuries. So, generally, homicide, but can also be suicide. And then when we talk about unintentional firearm injuries, that's a much smaller amount, usually less than 5% of firearm injuries and certainly less than 5% of deaths. It's a larger percentage of the injuries of children who survive. But that's when maybe somebody's trying to look at a gun or just playing around with it and unintentionally fires and shoots somebody that they were not planning to shoot.

Carol Vassar, podcast host/producer:

And are these unintentional and intentional injuries prominent amongst children? How prominent are they, I guess, is the question?

Dr. Lois Lee, Boston Children's Hospital:

So, really, the intentional injuries make up most of the firearm injuries and deaths. And again, it's the number one killer of our children. And even for those who survive, it is an important mechanism of injury among the non-fatal. Unintentional, much smaller, but still a very important population to talk about because that's really a place where we can think about injury prevention principles, some of the things we're going to talk about today.

Dr. Lisa Costello, West Virginia University:

Yeah. And I would just add in that I think it is now we are seeing these in such high numbers that most people that you interact with they know someone or someone in their family has been impacted by whether it was intentional or an unintentional firearm injury, unfortunately. And that's why I think it's so important, as Dr. Lee kicked us off here, in talking about prevention, and I look forward to diving more into that.

As a parent of a toddler myself, it's an important discussion to have whether I'm in the parent role to have with other families. If my daughter's going to be going to play at someone's house. Or as a pediatrician myself, talking to families, both anticipatory guidance, but then also if there's a situation, I work in the hospital and say someone comes in and they had a suicide attempt not with a firearm, that's a time that I make sure that I'm doing that counseling to make sure that, what are we doing to prevent additional injuries? And we want to obviously get the child the help that they need, but we need them to be doing that counseling, like are you removing firearms from the home? Assessing if there's firearms in the home to help prevent injuries from happening, both intentional and unintentional, and in some situations.

Carol Vassar, podcast host/producer:

What are some common misconceptions that parents might have about kids and firearms?

Dr. Lisa Costello, West Virginia University:

So I think many times, and being a parent myself, sometimes individuals are like, "Well, my child's not going to touch that," or, "They are too young to discharge a firearm." And, unfortunately, we know that very young children, two to 3-year-old children. They have the strength to potentially discharge a firearm. And so really it's important to have education. And we know that kids are curious, so they're going to explore their surroundings. And if there is a firearm on a table, they very much are curious, and they're going to go look, even if they've potentially been told you're not supposed to touch that. That's why it's so important, particularly for younger children, that we know the safest home is one that does not have a firearm. However, if you are having a firearm in the home, to make sure that it's not loaded, that it's locked, and that the ammunition is stored separately and locked separately to really try to prevent that access for younger children.

So I think a misconception is that, "Oh, my child's too young. They would not fire a firearm." Or "My child would never point a firearm at someone." Unfortunately, we see those injuries happen that are, again, in that time unintentional, and it happens so quickly. And what I hear from families is, "I never thought this would happen to me. We never thought that this would happen." And so I think, for me, that's one of the big misconceptions that I see. And Dr. Lee, I'm sure you know more working in emergency medicine and hearing those stories as well.

Dr. Lois Lee, Boston Children's Hospital:

Yeah. I think parents of teenagers think, well, my teenagers know better. But when we're thinking about suicide prevention, for example, we know, especially in teenagers but also in older individuals, that suicide can be very impulsive. And there's data that shows that the majority of individuals who are thinking about killing themselves will actually try to initiate action towards that, be it finding a gun, looking for pills, within 30 minutes to an hour. So, this prevention of access to lethal means is very important. And then to Lisa's point, oftentimes parents will say, "Listen, I've talked about firearm safety with my school-aged child. I know they won't touch a gun."

We actually have a study where they put groups of boys in threes into a room that had cabinets that were locked and closed, and some were unlocked cabinets, and one of them had a loaded firearm. However, it was rigged in a way so, obviously, that if they pulled the trigger, there was no bullet that was discharged. However, they could tell that the child pulled the trigger. So they hid away the firearm in a drawer, they put other toys in the room, and then, behind a one-way mirror, they watched groups of three boys go into the room to just see what they did. And more than 50% of the boys, when they found the gun, touched it, and another 30% actually pulled the trigger.

Carol Vassar, podcast host/producer:

That is sobering. I want to ask, when it comes to talking to children about firearms, firearms in the home, maybe firearms not in the home, when and what should parents be telling the children, Dr. Costello?

Dr. Lisa Costello, West Virginia University:

So it's important that we're talking to the children and the parents together. Because I think, as Lois just pointed out, even sometimes when children are told not to do something, I can tell you as a mother of a two-and-a-half-year-old, even if you tell them not to do something, many of the times they still may do that. And that's part of the education, and so you certainly should continue that. However, when it comes to firearms or because the injury itself has the potential to be lethal or very devastating, we really want to try to prevent and do whatever we can to prevent their access to the firearms. So I hail from the great state of West Virginia, more than half of the homes in my state have some type of firearm. So a lot of the education is on how you are going to store that firearm safely.

And so making sure that the device is unloaded, locked with ammunition locked, and stored separately. And having those discussions also when they go to friend's houses. Because you may know what happens in your home, but if you send your child over to a play date, you may not know if they have firearms or how they're stored. And so asking the question and having that and saying, "I just want to keep my child safe." We should be doing the same thing. Do you have a pool? What water toys do you have? Do you have pools? Again, be promoting safety.

Firearms are a discussion that should happen as well so that you can talk with the family that you're sending your child to and then also talk to your child. And as your child grows, obviously you need to continue to have those questions. As Lois just said, many times people think, oh, my teenager knows better. However, in that impulsive moment, that's not the main thinking anymore. So I think it's important to be having those conversations across the lifespan and to change our education and our counseling just like we do with other injury prevention and poison prevention that we try to do in pediatrics to keep children and families safe.

Carol Vassar, podcast host/producer:

It's probably important to raise the issue whether or not there is a gun in the child's home. Talk about how parents who probably don't have guns in the home can help and talk to their children about the importance of staying away from a gun. Because it might not be a conversation because they don't have guns in the home that they're having with the child.

Dr. Lois Lee, Boston Children's Hospital:

So it is important to know our children, we want them to go to their friend's house, we want them to go to their relative's house. So it is important for every family to have this conversation and make it developmentally appropriate. So with the school age child or teenage child, you would want to say, "Listen, when you go to your friend's house, please make sure you're in a booster seat or you're in a seatbelt." If you're talking to an older child. "And please make sure that if there are any firearms that you know that it's not a toy, it's very dangerous, please don't play with it. And please either call me, text me." As the parent or call or text the parent of that home. Same thing for going to grandparent's house or to a relative's house. So I think just having this awareness, other people might have firearms, this is how you need to behave. And making sure that you as the caregiver or parent are the safe place is a really important thing.

Carol Vassar, podcast host/producer:

How can parents have these discussions without alarming their children, without raising fear?

Dr. Lisa Costello, West Virginia University:

Obviously parents, we have tough discussions all the time, and I think it's really a matter of just like I'm trying to keep my child safe if there's something too hot, like her food's too hot, and I'm like, "We need to let that cool down." We really have to talk about this in a way that we know that there are firearms in households. Like I said, in my state where I live, it's very common to have some type of firearm.

And I think we need to just be having those discussions of that you will see these throughout. I mean, many of times now, if even individuals are watching television or they'll ask, obviously there's toys that can look very similar to firearms. So it's a matter of having that discussion. And, as Lois just said, developmentally appropriate, at what age, know your child and know to see, and what's a good time to have those discussions and say, "We're going to have a discussion about something important to keep you safe." And make sure that you're doing it more than just one time. Because I think that repeated message is really important.

Dr. Lois Lee, Boston Children's Hospital:

And unfortunately in the news, we are seeing more and more news stories about shootings, mass shootings or school shootings or whatever type of shooting. So use that as a teachable moment for your child to say, A, make sure that they're not having fear or if they are, addressing that mental health issue separately. But then also talking about if you're in a situation, how do you keep yourself safe?

Carol Vassar, podcast host/producer:

I'm glad you brought up the mental health side of the equation here. Because in a home, if firearms are present, and you brought up the fact, Dr. Lee, that this is a very impulsive kind of move for somebody who is perhaps in a state of mental health that is not as healthy as it could be. How should parents who may be gun owners address gun safety if the child is struggling with mental health issues?

Dr. Lois Lee, Boston Children's Hospital:

So, I first want to make it clear that individuals who have mental health disorders are much more likely to be victims and not perpetrators of firearm violence. I think we need to make that clear because that really gets muddied in the general media. If you do know that your child is at risk, either because they have depression or have had previous suicidal ideation or substance use disorders, really need to think hard about the risks and benefits of having the firearm in the home. Depending on where you live, there are other places where you can temporarily store your firearms. It might be at the shooting range, it might be at the gun store, or maybe it's at a relative's house or a friend's house. So that is something that you really have to think about.

But what we also know for teenagers many times suicide is impulsive. Maybe they broke up with a partner, had a fight with the parent, made a bad grade, didn't make the team. So, you can't always predict if your child is going to have any suicidal thoughts. So really, again, that risk-benefit of having that firearm in the home and how you're going to secure it if you're going to keep it in your home, how do you make sure that your teenage child or even younger age child does not have access and the ability to pull the trigger?

Carol Vassar, podcast host/producer:

We talked a little bit earlier about gun cabinets, locked gun cabinets. Are there any technologies or tools that are coming along like smart guns or higher end gun saves that can help parents ensure that firearms are more securely stored and less accessible to the children in the home?

Dr. Lisa Costello, West Virginia University:

I think that the education piece is really important, and I think that as we continue to see advances in technology, that will be ongoing. I will just say I have guns in the home. I've never personally owned a firearm. My husband's family, they are really big into hunting. And the first thing I said, even before we had our daughter, I was like, "When are you going to get the gun safe?" And I was like, "We need to make sure." And I said, "Before there's any gun brought into our home, it will be stored in a gun safe with all the proper precautions to prevent it because there's going to be firearms in our home."

So I do think there's been more technology. We've seen more digital technology where you can use obviously a fingerprint to be able to get in that, it can be done very quickly because I think sometimes people are like, "Oh, well I want to have quick access to my firearm." And I think it's important that some of these technologies are going to be able to keep it locked so that we know that that's going to be what's needed to be safe to prevent access for that child, particularly younger children. But then still the adult would still be able to access it. So that's one. And I think maybe Dr. Lee would know more about some of the other smart technology that might be being developed than me. But I think that it's going to be something that we continue to see advance as just technology advances in general.

Carol Vassar, podcast host/producer:

Dr. Lee?

Dr. Lois Lee, Boston Children's Hospital:

So, these types of firearms are referred to as personalized smart guns. And if you Google that, there's actually a couple of companies now in the United States that are starting to sell them on the US consumer market. But the idea is that, generally, it will read your fingerprint. So, like an old-styled iPhone, now the iPhone can read your face. And I imagine that would be maybe the next iteration. The firearm recognizes your face or the other adults, but not the children in the home who could be the authorized user.

Some of them also use RFID or radio frequency ID technology. So you're wearing a ring or a bracelet, and then the firearm recognizes you as the authorized user. That is for the firearm specifically. For storage, there are things like biometric gun lock boxes. Generally, it will read your handprint and, within seconds, will release and open the gun lock box so that, presumably, this would be if you had a loaded firearm for self-protection. So there are things: they do tend to be more expensive, but this is what we would recommend as some ways to try to prevent unauthorized access to the firearm.

Carol Vassar, podcast host/producer:

You are both pediatricians as you are here at AAP and we talk with and you talk with pediatricians from across the nation. I'm wondering what role they play in of firearm injury prevention?

Dr. Lisa Costello, West Virginia University:

Pediatricians, like so many aspects of child health, play a pivotal role in talking about firearm injury prevention. Both in that individual at that visit, whether it's a well-child check or when you're even seeing them and having interface. And then also in the community because this is, as we said at the onset, the leading cause of death in children. And so we have to be talking about it in regards to how we can better prevent these injuries from happening. And so having that discussion and giving tools like we've talked here today on what parents and those who care for children do. Whether it's in your own home or when you're visiting somebody else's home, how are you able to then keep your child safe? Just like as pediatricians, we talk about car seats, just like we talk about water safety.

These are parts of a person's life. And particularly a child when they're young and curious and then as they grow older and have more of that impulsive nature, it's pivotal that pediatricians are having these conversations because we know in a variety of areas that people listen to their pediatricians, pediatricians are credible, they're trustworthy, they have a relationship with their families and really the communities that they care for. And so pediatricians play a pivotal role in providing this education that's needed and to create awareness as well as additional ways to even, we know many pediatricians who will give gun locks away as part of their clinic and other boxes and other safety mechanisms. Again, with the goal of trying to prevent injury. And I think that that's really what this is focusing on the area. Sometimes, people are like, "Oh, it's a tough area to talk about." It's like I talk about water safety, I talk about safe sleep, I talk about what we can do to keep a child safe in a car. It should be the same when we're talking about how to prevent firearm injury as well.

Carol Vassar, podcast host/producer:

What steps can parents take if they find that their child has been maybe playing with a gun in the home or maybe playing with a gun in somebody else's home? What's the best course of action for parents?

Dr. Lois Lee, Boston Children's Hospital:

I think having an honest conversation and even just starting with, "Well, how was that? What were you curious about? What did you find out about it?" And then having an honest conversation about the potential harms and then what are the harm reduction strategies about being safe and making sure that they know that there is a risk that they unintentionally could shoot somebody. And then also making it important that that is a two-way conversation between the caregiver parent and the child and say, "Please, every time you get into that situation, I would like to know about it because we're here because we care about you and we want to keep you safe and these are the best practices."

I think everybody needs to realize this is an everybody issue. It's not a me issue. It is not a you issue. And whether or not you are a pediatric practitioner, a parent, a community member, we know that this is now impacting everybody daily. And everybody has a role in advocacy, either at just a personal level, talking to another family member or family friend one-on-one about safety. But we are in an election season, I'm going to let Dr. Costello talk a little bit more, but really just having everybody vote to make sure that child health and child safety is a priority for everybody.

Dr. Lisa Costello, West Virginia University:

And that's what I would add on and say is that this is an issue that is part of, I feel, our job as pediatricians, that we're providing education to families about all the potential risks that they could have, particularly the ones that are the highest risks. And just having that awareness. And as Dr. Lee said, there are a lot of policy issues that impact firearms. And so it's important now that we're in an election season, one, for individuals to vote and also to know the issues. So, know where individuals stand on particular policies to try to keep it safer.

Because at the end of the day, pediatricians, when you talk to us and caregivers share this, we want to keep kids safe. We want to allow children to grow, to thrive wherever they live, play, go to school. And we know that there's many different factors that impact that, and firearms are one of them. And so we have to be mindful of policies that are getting made, and knowing individuals' stances on different policies and electing individuals who share in that goal of trying to keep our children safe is an important thing to consider when you go to the ballot to cast your vote. So, being registered to vote and then getting out the vote and knowing the issues. And certainly, as a parent of a toddler myself, those are issues that I'm looking at for the individuals that I'm looking at up and down the ballot.

Carol Vassar, podcast host/producer:

Dr. Lisa Costello is an Assistant Professor of Pediatrics at West Virginia University. We also heard from Dr. Lois Lee, an Attending Physician in the Division of Emergency Medicine at Boston Children's Hospital.

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Carol Vassar, podcast host/producer:

Thanks to both Dr. Costello and Dr. Lee for stopping by the Nemours Podcast Booth at the 2024 American Academy of Pediatrics Experience National Conference in Orlando. And thanks, as always, to you for listening. More of our interviews with healthcare leaders from AAP coming your way in the next few weeks. We'll be talking about issues such as obesity and medication use for children, bullying, and the effects of dark design on our children and teens. Don't miss an episode. Visit nemourswellbeyond.org to subscribe to the podcast and leave a review. That's nemourswellbeyond.org.

Our production team for this episode includes Cheryl Munn, Susan Masucci, and Lauren Teta. I'm Carol Vassar. Until next time, remember, we can change children's health for good, well beyond medicine.

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