Perspectives: Youth and Physician Attitudes Towards Firearm Injury Prevention

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Just as adults are not a monolith, neither are teenagers or doctors. To effectively engage our young patients in conversations about firearm injury, we must first understand their widely varied experiences and attitudes while empowering them to join the fight against this growing danger. In 2018, we reached a grim mile marker in the United States: firearm injury surpassed motor vehicle accidents and became the leading cause of death in people ages 1-24 years old.¹The same threshold has since been crossed for children 1-17 years old.² Teenagers from 15-19 years old, especially boys, bear the brunt of this burden, accounting for over 80% of gun-related deaths in 2021.³ Clearly, prevention efforts must be concentrated towards this age group. Here we will explore some of the barriers faced by physicians, the beliefs held by our field vs those held by adolescents, and the varied approaches we can take to engage the next generation.

Physician Perspectives

Even broaching the topic of firearms can be daunting for physicians. Surveys of primary care providers and resident physicians have demonstrated a desire for more training on how to talk to families about firearm injury prevention; barriers include time, lack of resources, and discomfort.⁴ With firearms being one of the most common methods of suicide in children and young adults, it is reasonable to specifically address firearm access within these age groups.¹

Furthermore, physicians bring their own experiences with firearms to their practice. A survey of 1901 emergency physicians from across the country showed significant differences in attitudes and confidence regarding counseling on firearm safety. For example, the majority of the respondents that owned a firearm reported that their knowledge and training was adequate to educate patients about firearm injury prevention. Over 70% of respondents who strongly agreed that they wanted more training in identifying at-risk patients and counseling them were not firearm owners. Only a quarter of respondents overall agreed or strongly agreed that counseling was likely to result in people changing how they stored their firearms.⁵

A survey of 149 pediatricians in Ohio (excluding residents and subspecialists) indicated that the majority of those surveyed agreed or strongly agreed that physicians are responsible for talking about firearm safety. Approximately 61.5% of respondents indicated that they screened for firearms in less than half of well-child visits, and 80% screened or counseled at less than half of well-child visits for teenagers 14 and older. Some of the more frequently reported barriers to screening and counseling included lack of time, lack of resources, and concern that families and patients would respond negatively.⁴

Given that firearm access and related legislation can be contentious areas of public discourse, concern about negative reactions or lack of receptivity to counseling about firearm survey seems intuitive. However, there is some promising data on patients’ attitudes towards such counseling. A survey of 200 parents whose children were presenting to a pediatric emergency department or being admitted to the floor or pediatric ICU, found 14% reported having a firearm in the home. Of those that had a firearm, 75% said that they did not mind answering questions about firearms, and 75% also indicated that they had never had a medical provider discuss firearm safety with them.⁶ In a survey of 625 patients over 18 who presented to 1 of 3 emergency departments in the South, approximately half of participants reported access to firearms. Most respondents generally agreed that firearms should be regarded similarly to other public health topics. Most respondents, with and without firearm access, agreed that asking about firearms is appropriate.⁷

Finally, a survey of family physicians found over 90% of respondents identified firearm safety as a public health issue, and that family medicine physicians have a right to talk to their patients about firearm safety. Still, almost 70% reported that they did not have the knowledge to discuss devices designed for safer storage, and only a quarter of respondents felt comfortable discussing firearm removal. Unsurprisingly, formal training on how to counsel patients about firearm safety was correlated with higher levels of comfort providing such counseling.⁸

Adolescent Perspectives

Suicide accounts for most firearm-related deaths overall, but for adolescents, homicides account for a higher proportion of gun deaths than suicide.⁹

Mass public shootings, while far less common than suicide or targeted homicide, tend to capture more public attention and give rise to emergency drills, zero-tolerance policies, and lockdowns in school, which in turn have their own detrimental impact on American youth.

Elizabeth, a senior in high school, shares her experience of a school lockdown during 10th grade:

One average afternoon at school, the principal announced we were having a lockdown. At first, we all thought it was a drill, something not that uncommon. But that was when rumors started flying. “There’s a shooter in the school,” I heard someone say. “A kid brought a gun and was showing off at lunch,” said another. One of my teachers was holding the fire extinguisher saying that they would “whack anyone if they tried to get into our [heavily barricaded] room.” We were all looking at our phones, and there was a picture of a policeman armed with what appeared to be an AK-47 outside the school building that was being sent around. My classmates were texting their parents that they loved them and my heart began to pound loudly in my chest. What if someone came through that door? What if this is my last day? My mother was furiously sending me texts to see how I was and if we knew any more information. This was the moment we had all feared¾a real shooter in the school. Luckily it turned out that nobody actually had a firearm, but that moment left a lasting imprint on all of us. Gun violence is a cruel reality for my age group. Talking to my parents and other adults, their childhoods seem like an entirely different world. A world where they did not have to worry about not coming home from school or whether they could safely shop at a certain mall. I still have infrequent nightmares from that day and occasionally, when I walk into school, my mind will drift back to that afternoon and a shiver shoots down my spine.

Far from unique, her experience mirrors that of many students. Lockdowns due to threats of violence have been associated with increased symptoms of anxiety and somatic disorders, with a higher risk of lasting impact on those with preexisting attention-deficit/hyperactivity disorder or clinically significant stress issues.¹⁰ Pediatricians and child psychiatrists frequently manage these diagnoses and symptoms. Understanding what children have been exposed to surrounding firearms can provide valuable context, even in a case like Elizabeth’s that did not pose real danger. On the other hand, lockdown drills yield more mixed results. They can result in increased levels of anxiety, but also a sense of preparedness.

While firearm injury and death pose a national public health problem, differences in the mechanism of firearm injury and death among ethnic groups and geographic location are evident.For example, firearm homicides and assaults occur at a higher rate in urban areas, and suicides by gunshot disproportionally occur in rural areas.¹¹ Prior studies have confirmed that exposure to gun violence is associated with long term poor health outcomes as well as significant increases in the likelihood that they will be a perpetrator of violent crime as an adolescent.¹²

A lot of American teens have been exposed directly or indirectly to gun violence and/or suicide and its effects, regardless of where they are located, and thus have their own opinions on the subject. Focus groups and a survey of 2 single-sex high schools in the Bronx indicated that across genders, a majority of the students believed that there should be stricter background checks. When asked about whether having a gun in the home would or did make them feel safer, the majority were either unsure or disagreed. Some of the teens expressed concern about firearm carriage and violence being glorified in the media.¹³ While this is only 1 study, and included only students at private, parochial schools, the mixed methodology of focus groups and surveys provides unique insights.

Comparatively, rural adolescents and those receiving training through 4H and similar programs are more likely to have access to a firearm compared with their urban counterparts.

Regardless, rural adolescents’ overall attitudes are similar to that of urban adolescents on the topic of firearms and firearm injury prevention. In a mixed methods study similar to the one done in urban New York, 93 adolescents enrolled in 4H clubs in rural areas or reservations were surveyed and participated in interviews. They primarily agreed that it is acceptable for adults, not adolescents, to carry handguns for personal protection and recreational purposes. The majority also responded that it was highly unlikely that carrying a handgun would make them seem cool to peers.¹⁴

As far as prevention, urban teens in the mixed method study referenced previously reasoned that education on firearm injury prevention is crucial in lessening firearm related injury and that adolescents would be receptive and willing to discuss prevention with trusted adults¾particularly physicians.¹³ Information about gun violence and firearm injury prevention should be widely available and patients should be screened for risk-factors relating to gun violence at well-child visits.¹⁵ Moreover, urban adolescents mentioned there should be training on how to handle certain gun violence situations, including how to manage firearm related injury while no formal medical intervention is available.¹³

To their point, studies show that bystander emergency intervention programs like Stop the Bleed training can be helpful in a pragmatic sense, including an increase in middle and high school students’ confidence, sense of self-efficacy, and reported willingness to help someone with a bleeding injury.^16,17 Further research is needed to determine if this effect translates to a lasting positive impact psychologically.

Concluding Thoughts

Firearm related injury and death has become a public health crisis that must be addressed¾our youth are paying the price as firearm injury has become a leading cause of adolescent death. Both adolescents and their healthcare providers recognize the problem and are looking for avenues to address the issue. There is agreement across the board on the importance of firearm safety education, but also clear evidence that many physicians either feel uncomfortable or poorly trained in providing that education.

Exposure to firearm violence is also not an uncommon occurrence for adolescents and can have lifelong consequences. Today’s generation of preteens and adolescents have expressed a desire for more first aid training in this area, and the literature reviewed suggests efficacy of such training for students at least as early as middle school. Adolescents also seem to favor more legislation and/or enforcement of existing legislation as a means of reducing firearm related injuries or death. If the reaction of the students who survived the Parkland shooting is any indication, we will likely hear more from the coming generation about these issues. While a discussion of different types of existing and proposed legislation is beyond the scope of this article, intergenerational and interdisciplinary collaboration is essential.

We must be prepared as physicians to partner with adolescents and young adults in preventing injury and death within the current landscape and adapt to changes as they come. Based on current evidence, physicians and other health care professionals can take the following steps: attending physicians can educate themselves about ways to teens about firearm access and safety; we should consider making discussions about firearm safety part of the standard curriculum for medical students and residents; we should advocate for increased access to Stop the Bleed and similar training. Future directions for research might include longitudinal observation of physicians’ firearm safety counseling habits pre and post training, and larger scale studies of youth perceptions and attitudes, and a direct comparison of urban and rural youth within the same study.

Dr Soliman is an assistant professor of psychiatry at the Wake Forest School of Medicine and is affiliated with Advocate Health. Ms Rachal is a 12th grade student at Ardrey Kell High School.

References
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16. Canseco L, Johnson A, Mathews J, et al. Efficacy of healthcare student-led stop the bleed training for middle school students. Disaster Medicine and Public Health Preparedness. 2025;19:e71.

17. Goolsby C, Rojas LE, Rodzik RH, et al. High-school students can stop the bleed: a randomized, controlled educational trial. Acad Pediatr. 2021;21(2):321-328.