researched argument draft essay

The Role of Health and Mental Health Care Providers in Gun Violence Prevention

Ariel A. Williamson and Nancy G. Guerra

University of Delaware

W. Douglas Tynan Nemours Health and Prevention Services, Newark,

Delaware and Jefferson Medical College

Firearm-related homicides, suicides, and unintentional injuries continue to undermine the wellbeing and safety of children and adolescents. According to 2010 statistics, homicide and suicide are the second and third leading causes of death, respectively, among youth ages 10 to 19 years. Firearms are involved in a substantial proportion of youth homicides and suicides. Despite the protective benefits of storing guns and ammunition safely, few gun-owning families do so. Health and mental health care providers in pediatric settings can play an important role in educating families about gun safety and in preventing youth involvement in gun violence. This article reviews developmental risk factors for involvement in youth gun violence, as well as evidence- based community programs to prevent gun violence. We then discuss ways in which health and mental health care providers can prevent youth gun violence and promote safety.

Keywords: adolescents, children, firearm safety, gun counseling, primary care

Despite some recent declines in the rates of firearm-related homicides and suicides within the United States, firearm-related deaths and injuries continue to undermine the wellbeing and safety of children and adolescents. In 2010, there were 2,711 firearm-related deaths among infants, children, and adolescents (Centers for Disease Control and Prevention, National Cen- ter for Injury Prevention and Control, 2013). Among children and adolescents ages 10 to 19 years, homicide and suicide remain the second and third leading causes of death, respectively, with 1,982 homicides and 1,926 suicides for this age group in 2010 (Centers for Disease Control and Prevention, National Center for In- jury Prevention and Control, 2013). For chil- dren between ages 1 and 9 years, homicide was

the fourth leading cause of death in 2010, im- pacting 514 children (Centers for Disease Con- trol and Prevention, National Center for Injury Prevention and Control, 2013). In 2010, 83.8% of homicide victims between the ages of 10 and 19 years were killed with a firearm, and 38.8% of youth in this age group used a firearm to commit suicide (Centers for Disease Control and Prevention, National Center for Injury Pre- vention and Control, 2013).1

The prevention of homicide-and suicide- related gun violence among youth is a salient concern in home, school, and community set- tings. For example, research has shown that rates of suicide, homicide, and unintentional firearm injury are higher among 5- to 14-year- olds who live in states or regions with more prevalent gun ownership (Miller, Azrael, & He- menway, 2002). Keeping guns in one’s home is not a direct cause of firearm-related deaths, but failure to lock or otherwise safely store guns and ammunition in the home is a known risk for youth suicide and unintentional firearm injuries and deaths (Barkin et al., 2008; Grossman et al.,

1 The 2010 data shown here are available at http://www .cdc.gov/injury/wisqars/fatal_injury_reports.html

This article was published Online First February 10, 2014.

Ariel A. Williamson and Nancy G. Guerra, Department of Psychology, University of Delaware; and W. Douglas Tynan, Nemours Health and Prevention Services, Newark, Delaware and Jefferson Medical College.

Correspondence concerning this article should be ad- dressed to Ariel A. Williamson, Department of Psychology, 108 Wolf Hall, University of Delaware, Newark, DE 19716. E-mail: [email protected]

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Clinical Practice in Pediatric Psychology © 2014 American Psychological Association 2014, Vol. 2, No. 1, 88 –98 2169-4826/14/$12.00 DOI: 10.1037/cpp0000055

88

2005; Okoro et al., 2005). In one study of fire- arm injuries and deaths among 0- to 14-year-old children, Wintemute and colleagues (1987) found that the majority of these cases occurred using guns that children had found at home. Studies have also shown that youth who commit suicide using a firearm often do so with their parents’ guns (Johnson, Barber, Azrael, Clark, & Hemenway, 2010). Unfortunately, in a recent study of 3,745 children ages 2 to 11 years, DuRant et al. (2007) found that only one third of gun-owning families reported safe firearm storage.

Although widely publicized instances of ho- micide at school and mass school shootings represent less than 1–2% of homicides against youth (Borum, Cornell, Modzeleski, & Jimerson, 2010; Centers for Disease Control and Prevention, National Center for Injury Pre- vention and Control, 2013), a number of stu- dents have reported weapon-carrying behaviors and suicidality at school. For instance, the 2011 National Youth Risk Behavior Surveillance System survey found that 5.1% of high school students in Grades 9 through 12 reported carry- ing a gun at least once in the 30 days prior to the survey (Eaton et al., 2012). This same survey showed that in the 12 months prior to the sur- vey, 15.8% of students surveyed had seriously considered attempting suicide, 12.8% of stu- dents had made a plan to attempt suicide, and 7.8% of students had attempted suicide one or more times (Eaton et al., 2012). In other com- munity settings, particularly high-violence and low-income neighborhood contexts, studies have shown that youth weapon-carrying is as- sociated with decreased perceptions of neigh- borhood safety, increased exposure to violence, and easy access to guns (e.g., Molnar, Miller, Azrael, & Buka, 2004; Spano, Pridemore, & Bolland, 2012). Youth exposed to community violence and peer victimization have also re- ported increased suicidal behavior (e.g., Mazza & Reynolds, 1999; Nickerson & Slater, 2009).

Gun violence can have a substantial impact on the mental health of children, adolescents, and their families. Complicated grief, posttrau- matic stress disorder, depression, substance use, and externalizing problems, among other con- cerns, can emerge following the loss of a loved one due to suicide or homicide, or through repeated exposure to community gun violence (Buka, Stichick, Birdthistle, & Earls, 2001;

Burke, Neimeyer, & McDevitt-Murphy, 2010; Garbarino, Bradshaw, & Vorrasi, 2002). Pedi- atric psychologists and other health and mental health care providers can play an important role in the coordinated prevention of youth gun vi- olence and its effects across multiple settings. Indeed, the American Academy of Pediatrics (AAP, 2012) has taken a supportive position on educating physicians and other health care pro- fessionals about the effects of firearm-related violence, and has urged pediatricians to counsel parents who own guns about safe storage. Health and mental health care providers are uniquely positioned to prevent gun violence by assessing for risk in youths’ homes, schools, and communities. Following a review of infor- mation about risk factors for youth gun violence and evidence-based gun violence prevention programs, we discuss the ways in which health and mental health care providers can participate in efforts to prevent gun violence and promote youth safety.2

Developmental Risk Factors for Youth Gun Violence

Only a small number of youth who are at-risk during childhood and adolescence continue to commit serious acts of violence toward them- selves or others during adulthood (Moffitt, 1993). However, knowledge of risk factors for involvement in gun violence across youth de- velopment can help health and mental health care providers identify children who may espe- cially benefit from gun violence prevention. Similar to developmental models of youth vio- lence and aggression (e.g., Brennan, Hall, Bor, Najman, & Williams, 2003; Dishion, Véron- neau, & Myers, 2010; Dodge & Pettit, 2003), no single risk factor can adequately predict youth involvement in gun-related homicide or suicide. Risk for youth involvement in firearm-related injuries and death likely stems from the accu- mulation of multiple factors in individual, fam- ily, peer, school, community, and other socio- cultural contexts.

2 Review information and recommendations for practice are drawn from our recent work on the American Psycho- logical Association’s Panel of Experts Report, Gun Vio- lence: Prediction, Prevention, and Policy (American Psy- chological Association, 2013).

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In considering developmental risk factors for youth gun violence, it is important to acknowl- edge that homicide and suicide disproportion- ately affect different youth populations. For ex- ample, whereas gun-related homicide is the leading cause of death for African American boys, gun-related suicide rates are highest among non-Latino White males (Centers for Disease Control and Prevention, National Cen- ter for Injury Prevention and Control, 2013). Variation in homicide and suicide rates by eth- nic background is likely due to differences in the sociocultural factors that contribute to gun violence, such as variation in youths’ experi- ence of poverty and other environmental adver- sities (Borum & Verhaagen, 2006). In addition, there are different risk factors for gun-related homicide and suicide. Below, we focus first on developmental factors that contribute to risk for serious antisocial behavior, which includes gun- related homicide and intentional injury. We then summarize risk factors for suicidal behav- ior, and for suicide using a firearm. Risk factors for involvement in youth gun-related homicide and suicide appear in Table 1.

Early onset aggression is a significant risk factor for subsequent youth antisocial behavior. Moffitt’s (1993) taxonomy of life-course persis- tent versus adolescent-limited youth has dem- onstrated that children who are highly aggres- sive during both childhood and adolescence are more likely to engage in criminal offending into adulthood than children who are aggressive

only during adolescence and desist by adult- hood. Individual, biological risks as well as environmental factors during prenatal develop- ment, infancy, and early childhood have been linked to early onset aggression and the life- course persistent developmental pathway (Brennan et al., 2003; Dodge & Pettit, 2003; Moffitt, 2005). For example, maternal substance use during pregnancy, low birth weight, serious birth complications, malnutrition, genetic vul- nerabilities, exposure to environmental toxins, poor behavioral control, an irritable tempera- ment, and high levels of maternal stress are all risk factors that may interact with one another to predict early aggressive behavior problems (Brennan et al., 2003; Dodge & Pettit, 2003; Moffitt, 1993, 2005).

The family context is an important influence on the development and continuation of early child aggressive behavior, as well as on risk for gun violence. High levels of family stress and poor parent– child interactions can exacerbate preexisting child aggression and increase risk for continued antisocial behavior over time and across settings (Patterson, Forgatch, & De- Garmo, 2010). Within the parent– child rela- tionship, poor or disrupted attachment relation- ships, low affect coordination (synchrony), harsh and/or inconsistent parenting, and the emergence of coercive parent– child dynamics have been found to contribute to the develop- ment of aggressive behavior and poor behav- ioral control (Dodge & Pettit, 2003; Patterson et

Table 1 Cumulative Risk Factors for Involvement in Youth Gun-Related Homicide and Suicide

Gun-related homicide Gun-related suicide

• Unsupervised access to firearms and ammunition • Unsupervised access to firearms and ammunition • Early-onset of aggressive behavior • Previous suicide attempts • High levels of early environmental and family stress • Male gender • Poor parent–child relationships, including harsh or

inconsistent discipline and coercive interactions • Positive individual or family-level normative beliefs about

aggression, violence, and firearm usage as methods for problem-solving

• Affiliations with deviant and antisocial peers • Academic disengagement and school failure or dropout • Neighborhood disadvantage and exposure to community

violence • Exposure to violent media

• Non-Latino White ethnic background • Psychological disorders and comorbidities, such as

depression and substance use • Other psychological vulnerabilities, such as

impulsivity, hopelessness, feelings of burdensomeness, and a failed sense of belonging

Note. There is no one risk factor that can account for youth involvement in gun-related homicide or suicide. Risk factors accumulate and interact over time to predict subsequent violent behavior. Even in the context of multiple risk factors throughout development, few youth go on to commit serious acts of violence toward themselves or others.

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al., 2010). The family setting is also a context for socialization and the development of norma- tive beliefs, or perceptions about socially appro- priate behaviors (Huesmann & Guerra, 1997). Family characteristics may promote beliefs about violence and perhaps gun usage as adap- tive or normative methods for social problem solving. For instance, family criminal behavior and family attitudes that support violence have been associated with later adolescent gang membership and delinquency (Farrington, Jol- liffe, Loeber, Stouthamer-Loeber, & Kalb, 2001; Hill, Howell, Jawkins, & Battin-Pearson, 1999). Youth who live in homes where firearms and ammunition are not safely stored are more likely to be involved in gun violence, particu- larly suicide or unintentional injury (Grossman et al., 2005; Johnson et al., 2010). Unsupervised access to guns at home, coupled with provio- lence attitudes of family members, normative child beliefs about aggressive behavior, and low child behavioral control may put children at increased risk for involvement in gun violence.

Outside of the family setting, involvement with deviant, antisocial peers and low school engagement are additional contextual risks that have been associated with the development of aggressive and antisocial behavior. These influ- ences are also risk factors for involvement in gun violence. Children with high levels of early aggression and problematic family relations may have difficulty adjusting to school and get- ting along with peers and teachers (Dodge & Pettit, 2003). Academic failure, disengagement from school, truancy, and dropout are correlated with increasing involvement in problem behav- iors like drug use and trafficking, gang affilia- tion, risky sexual behavior, and youth violence (e.g., Guerra & Bradshaw, 2008). Friendships with similarly aggressive and antisocial peers have also been found to increase positive atti- tudes toward and engagement in deviant behav- iors during adolescence, through a process re- ferred to as peer deviancy training (Dishion et al., 2010). Related to gun violence, research has shown that youth who are involved in school- based physical fights, substance use, and drug trafficking are more likely to carry weapons to school (Furlong, Bates, & Smith, 2001). In ad- dition, gang membership in adolescence and having peers who own guns have been found to predict youth gun carrying in adolescence and

young adulthood (Lizotte, Krohn, Howell, To- bin, & Howard, 2000).

Sociocultural influences such as youths’ neighborhood context and exposure to violent media have also been associated with the devel- opment of antisocial behavior and can be ex- tended to risk for gun violence. Living in dis- advantaged neighborhoods with few prosocial opportunities can contribute to poor behavioral functioning and to the development and conti- nuity of violent behaviors (Borum & Verhaa- gen, 2006). In addition, some neighborhood characteristics have been associated specifically with youth gun carrying. For example, research has shown that youth are more likely to carry firearms in neighborhoods that they perceive to be unsafe, as well as in neighborhoods with high levels of social and physical disorder, such as public substance use, street fighting, prosti- tution, graffiti, gang signs, and litter (Molnar et al., 2004). Community violence exposure is an- other salient predictor of increased youth weapon carrying (e.g., Spano et al., 2012). Al- though it is a more distal sociocultural influ- ence, exposure to violent media through video games, TV, and movies has additionally been associated with increased aggressive behaviors, thoughts, and feelings, especially for children who identify with other aggressive individuals (Anderson et al., 2003; Huesmann, Moise- Titus, Podolski, & Eron, 2003). As with other risk factors, the association between exposure to violence in one’s community or in the media and gun violence must be considered along with the accumulation of risk factors in other do- mains.

Compared to research on developmental models of aggression and violence, less longi- tudinal work is available on youth suicidal be- havior, although there are many well-estab- lished risk factors for suicide. As Harrison (2013) has suggested, an understanding of such risk factors is important for the prevention of suicide among youth by health care providers in primary care settings. Previous suicide at- tempts, male gender, non-Latino White ethnic background, and a single or comorbid psychi- atric disorder, such as substance use or a mood disorder, are all associated with greater risk for suicide attempts (Fowler, 2012). Other psycho- logical vulnerabilities, such as depressive symp- toms, impulsivity, and hopelessness, have been linked to risk for suicide attempts (Fowler,

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2012). In particular, feelings of burdensome- ness and a failed sense of belonging have addi- tionally been associated with suicide (Joiner & Van Orden, 2008). Mazza and Reynolds (1999) have also found that suicidal ideation among adolescents exposed to community violence was mediated by the development of posttrau- matic stress disorder. With regard to gun-related suicide, research suggests that access to guns and ammunition at home is a significant risk for adolescent suicide by firearm (Grossman et al., 2005; Johnson et al., 2010) underscoring the importance of family-based suicide prevention.

Evidence-Based Gun Violence Prevention Programs

Just as risk factors for gun-related homicide and suicide span individual, family, peer, school, community, and other sociocultural contexts, a comprehensive approach across multiple settings is necessary to prevent gun violence among youth. Comprehensive pro- gramming is difficult to coordinate and imple- ment across these settings, given the multifac- eted nature and complexity of the risks for youth gun violence, and given the number of individuals involved in youths’ daily lives. De- spite these challenges, several community- based programs and policing strategies have demonstrated some positive effects on gun vio- lence in youth populations.

In their comprehensive report on gun vio- lence research, the National Research Council of the National Academy of Sciences (Wellford, Pepper, & Petrie, 2004) noted that problem- oriented policing is a promising community- based approach for gun violence prevention. This type of prevention program targets com- munity “hot spots,” or neighborhood areas with increased crime and gun violence (Wellford, Pepper, & Petrie, 2004). One example of a successful problem-oriented program is the Boston Gun Project, also called Operation Ceasefire (Braga, Kennedy, Piehl, & Waring, 2001; Kennedy, Braga, & Piehl, 2001). The Boston Gun Project involved a coordinated ap- proach among law enforcement officers, proba- tion and parole officers, and other youth and community workers to deter the firearm vio- lence and trafficking that was occurring among gang members in high-violence neighborhoods (Braga et al., 2001; Kennedy et al., 2001). De-

terrence strategies included meetings between gang members and police and probation offi- cers, meetings with inmates in detention facili- ties, and outreach by other community mem- bers, such as by members of the religious community (Kennedy et al., 2001; Wellford et al., 2004). The program also targeted illegal firearm trafficking through increased investiga- tions and prosecutions (Wellford et al., 2004). Program evaluations showed reductions in the Boston youth homicide rate following program implementation (Braga et al., 2001), although effects were modest and coincided with nation- wide reductions in rates of youth violence (Wellford et al., 2004).

Similar programs have been implemented with some success in other cities. For instance, a program called Safe Streets, which was adapted from the Chicago CeaseFire program, was recently evaluated in Baltimore, Maryland and showed some positive effects in certain neighborhoods on youth gun-related homicides (Webster, Whitehill, Vernick, & Curriero, 2013). Consistent with the Boston Gun Vio- lence project and the Chicago CeaseFire pro- gram, Safe Streets directed intervention efforts toward high-violence communities and used outreach workers to build relationships with youth who were gang-involved or otherwise at high risk for gun violence. Controlling for pre- existing police activity and gun-related vio- lence, Webster et al. (2013) found that rates of homicide and nonfatal shootings declined in some, but not all, neighborhood intervention sites, as well as in neighborhoods bordering some of the intervention sites.

Another community effort that has had some effects on gun violence is Project Safe Neigh- borhoods, which aims to reduce firearm-related death and injury through law enforcement, de- terrence, and prevention strategies (McGarrell et al., 2009). Similar to the programs described above, this effort used a problem-solving frame- work and a multicomponent approach to gun violence reduction, which involved multiple stakeholders in law enforcement agencies and in high-violence communities. The program worked to establish partnerships between stake- holders, to reduce the supply of guns through increased federal investigation and prosecution of illegal gun usage and possession, and to promote community outreach for at-risk youth (McGarrell et al., 2009). Research indicates that

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this program has had modest effects on gun- related homicide rates, among other outcomes, in various communities (McGarrell et al., 2009).

Gun violence prevention efforts have also been adopted in K–12 schools and university settings, in light of the mass school shootings that have occurred over the past two decades. Rather than use simple characteristic-based checklists to identify individuals at-risk for in- volvement in mass shootings, the U.S. Secret Service (Vossekuil, Fein, Reddy, Borum, & Modzelski, 2002) has recommended the use of the behavioral threat assessment model. This model was developed by the U.S. Secret Service and involves a multidisciplinary threat assess- ment team that examines individuals who have engaged in preparatory behaviors related to or have made direct threats about future violence. The threat assessment team then makes evi- dence-based individual-level recommendations for managing and treating these individuals (Vossekuil et al., 2002). Adapted for primary school students, the Virginia Student Threat As- sessment Guidelines (Cornell, 2010) have been found to improve the resolution of school-based student threats and reduce the rate of school suspensions (e.g., Cornell, Allen, & Fan, 2012; Cornell, Gregory, & Fan, 2011). This approach offers a systematic method for school profes- sionals to respond to gun violence in school settings.

Another promising approach for youth gun violence prevention involves the integration of law enforcement and mental health services, through the Crisis Intervention Team (CIT) model. The CIT model trains a group of officers within each law enforcement agency to effec- tively respond to individuals who are engaged in violence or threats of violence and also have mental health concerns (Steadman, Deane, Bo- rum, & Morrissey, 2000; Teller, Munetz, Gil, & Ritter, 2006). Studies have indicated that this type of specialized responding is useful in de- escalating risk situations and diverting at-risk individuals to treatment rather than to jail, by reducing the rates of arrest associated with men- tal health disturbance calls when possible (e.g., Steadman et al., 2000; Teller et al., 2006). Al- though this approach has not been specifically applied to gun violence, CIT training was re- cently supported by the National Alliance on Mental Illness and has implications for the pre-

vention of youth gun violence. Training law enforcement officers to respond in a sensitive manner to youth who are involved in gun- related homicide or suicide attempts may facil- itate treatment for these youth and prevent sub- sequent acts of community-based violence.

The Role of Health Care Providers in Gun Violence Prevention

Given their prevalence in pediatric settings and their frequent contact with youth and fam- ilies, health and mental health care providers are poised to actively participate in the prevention of gun violence among youth. As described above, prevention activities are important in multiple settings, including community-based agencies such as primary care settings and out- patient mental health treatment centers. Across settings, health and mental health care providers can prevent youth gun violence by assessing for youth risk factors and by providing basic coun- seling and education about gun safety to chil- dren, youth, and their families (AAP, 2012; Barkin et al., 2008; Grossman et al., 2005). Assessment for salient gun violence risks can include screening for youth depression, anger control concerns, impulsivity, homicidality and suicidality, weapon carrying, gang involvement, exposure to violence, and access to and storage of firearms in home, school, and other commu- nity settings (Johnson, Fein, Campbell, & Gins- burg, 1999). Practitioners can then provide in- formation about gun safety, which research has shown is associated with reductions in the risk for involvement in youth gun violence (AAP, 2012).

For instance, Johnson et al. (1999) evaluated a one-time violence prevention program that was implemented by pediatric residents in an inner-city hospital and satellite site. This pro- gram trained pediatric residents to discuss vio- lence and safety issues in families’ homes with patients during routine well-child visits. John- son et al. (1999) surveyed patients before, im- mediately after, and 6 months after program implementation and found that counseling about guns or violence improved from 9.7% of visits before program implementation to 19.1% following program implementation, which was sustained at 6-month follow-up. Residents also reported that they felt more knowledgeable about violence prevention and indicated that

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they would use the violence prevention coun- seling skills in future visits (Johnson et al., 1999).

Although this program did not directly assess family practices following violence prevention counseling, other studies have shown positive effects of counseling on family behavior. For example, Barkin and colleagues (2008) found that primary care practitioner counseling about gun violence prevention could impact family behavior and promote youth safety. In a cluster- randomized controlled trial, 137 pediatric of- fices were randomly assigned to either a control condition (an educational brochure about liter- acy promotion) or a violence prevention pro- gram. Program components included both as- sessment and intervention procedures to address violence-related concerns. Families in the pro- gram completed previsit screening checklists to identify concerns about problematic media ex- posure, parental discipline strategies, and chil- dren’s exposure to firearms (Barkin et al., 2008). Primary care practitioners then reviewed this checklist and counseled families on rele- vant concerns, using motivational interviewing techniques as needed. Practitioners also distrib- uted tangible intervention tools based on pre- senting family concerns, including timers for consistent discipline (time-out) procedures and cable locks for safe firearm storage (Barkin et al., 2008). Families were also given referrals to other community agencies for mental health treatment if childhood aggression was a present- ing problem. Results of this study showed that caregivers in the intervention condition reported increased safe firearm storage and increased limitations on child media usage compared to the control condition (Barkin et al., 2008). In light of the known risk that unlocked firearms confer for youth gun violence, this intervention is a good example of how health and mental health practitioners can impact family practices and promote youth safety.

Safe storage of firearms is useful for the prevention of youth homicide, unintentional in- jury, and suicide. Apart from counseling by practitioners on safe gun storage, Wintersteen and Diamond (2013) have also described a screening and intervention protocol for youth suicide risk in primary care and other pediatric settings. The Youth Suicide Prevention in Pri- mary Care model is a multicomponent program that involves screening, intervention, and refer-

ral activities conducted by primary care practi- tioners. Providers are trained in assessment, in- tervention, crisis planning, and documentation and are provided with additional resources for implementation, including a suicide prevention toolkit and a validated screening tool for pri- mary care settings (the Behavioral Health Screen—Primary Care). Referral sources for community-based treatment are also identified for suicidal youth. An evaluation of this pro- gram showed that program implementation was associated with reductions in referrals to emer- gency department evaluations in the year after intervention, compared to preintervention emer- gency referral rates (Wintersteen & Diamond, 2013). Although not specific to gun violence, this systematic and universal screening method has important implications for the role of health and mental health providers in gun violence prevention. Questions about suicidal youths’ ac- cess to lethal means, such as firearms, caregiver safety counseling about firearms, and appropri- ate referrals for continuity of care and preven- tion of future violence could easily be integrated into this program as a method for gun-related suicide prevention.

Despite the benefits of these activities for families and youth, health and mental health care professionals have identified many barriers to gun safety counseling in pediatric settings. Although primary care practitioners have indi- cated that addressing gun safety with families is important, practitioners have reported barriers such as a lack of time for and comfort with such activities, and low feasibility and implementa- tion of gun safety counseling and other types of in-office violence prevention strategies (Borowsky & Ireland, 1999; Johnson et al., 1999). Indeed, in the Johnson et al. (1999) res- ident training intervention program described above, even though the vast majority of partic- ipating practitioners reported that they felt com- fortable with the training and would use the skills they learned again, the majority of subse- quent visits with families (over 80%) did not include violence prevention training. In addi- tion, recent legal and legislative changes have threatened practitioners’ ability to counsel fam- ilies on firearm safety in some states. The 2011 Florida Firearm Owners’ Privacy Act, for in- stance, prevented physicians from providing counseling on gun safety and threatened finan- cial penalty and loss of licensure if practitioners

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violated this agreement. Although this law was blocked by a U.S. district court, several other states (Alabama, Minnesota, North Carolina, Oklahoma, Tennessee, and West Virginia) have introduced similar policies.

There is a growing awareness that gun safety counseling by health and mental health practi- tioners is an integral part of youth gun violence prevention (AAP, 2012). Gun safety counseling can be easily integrated into routine well-child visits, just as safety counseling about car seats, bicycle helmets, healthy eating habits, and other health-related issues are (Johnson et al., 1999). Although gun violence prevention activities are

difficult for practitioners to implement indepen- dently and may be challenged by gun-related legislation in some states, it is critical that prac- titioners seek training on this topic and imple- ment preventive gun counseling to promote youth gun safety. Simple questions and educa- tion about keeping guns locked and unloaded and storing and locking ammunition in a sepa- rate location can promote youth safety and deter gun-related youth suicide and homicide (Gross- man et al., 2005). The use of universal risk screening protocols, coordinated care, and com- munication across health and mental health pro- fessionals and pediatric settings and education

Table 2 Practice Recommendations, Guidelines, and Resources for Gun Violence Prevention

Practice recommendations and guidelines Relevant resources

• Integrate questions about gun ownership and safe gun and ammunition storage into routine well-child visits, psychological intakes, and psychological evaluations for all children, youth, and families.

• AAP Bright Futures Practice Guidelines: http://brightfutures.aap.org/

ΠIs there a gun in your home? Where is it kept? Is it loaded? Is it locked up?

ΠWhere is ammunition stored? Is ammunition locked up and stored separately from guns?

• AAP Patient Education Online Firearm Safety and Suicide Prevention Patient Handouts: http://patiented.aap.org/• Integrate questions about youth aggressive behavior or

violence, gun carrying, homicidality, and suicidality into routine pediatric and psychological visits for older children and adolescents. Œ When you get angry, do you do violent things? • AAP Patient Education Online Framingham

Safety Survey: http://patiented.aap.org/ΠHave you ever carried a gun in your community or to school?

ΠHave you ever seriously thought about wanting to kill yourself or someone else? Have you ever made a plan or an attempt to kill yourself or someone else?

• Use evidence-based screening tools for suicide and related risk behaviors.

• Pennsylvania Youth Suicide Prevention Initiative Website: www.payspi.org

Œ The Behavioral Health Screen—Primary Care • Provide basic counseling about gun safety to gun-owning

families. ΠIf you must keep a gun in your home, ensure that guns

are stored unloaded, in a locked location, and separately from ammunition.

• Johnson et al. (1999) article: Violence Prevention in the Primary Care Setting

ΠUse gun safes, trigger guards, cable locks, or other safe storage devices.

ΠKeep keys to guns and ammunition in a place where children cannot access.

• Provide families and youth with educational handouts about gun safety and the prevention of gun-related youth homicide, unintentional injury, and suicide.

• Harrison (2013) article: Managing Suicidal Crises in Primary Care

• Provide families and youth with appropriate psychological or psychiatric referrals for treatment given risk for aggression, violence, homicidality, and suicidality.

• Seek training opportunities to learn more about gun safety counseling and other prevention practices.

• Wintersteen & Diamond (2013) article: Youth Suicide Prevention in Primary Care

Note. AAP � American Academy of Pediatrics.

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about gun safety can have an important impact on the wellbeing of children, youth, and fami- lies. We encourage health and mental health providers to take preventive steps toward the normalization of gun safety discussions and practices among all families and youth who visit pediatric settings, not just among families or youth who appear to be at-risk. The AAP’s Bright Futures practice guidelines for pediatri- cians (http://brightfutures.aap.org/) contains sample questions and guidance for providers related to gun safety. Table 2 summarizes these guidelines and recommendations about gun vi- olence counseling strategies, and includes a list- ing of resources for health and mental health providers. We also urge the professionals who oversee the policies and procedures in pediatric settings to familiarize themselves with and im- plement evidence-based strategies in these set- tings to support health and mental health care providers in preventing youth gun violence.

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Received December 13, 2013 Revision received January 3, 2014

Accepted January 6, 2014 �

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