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© The Children's Mercy Hospital, 2017 Why we need to talk about guns as a child health risk problem M. Denise Dowd, MD, MPH Professor of Pediatrics

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Page 1: Why we need to talk about guns as a child health risk problem · 2018-10-08 · Why we need to talk about guns as a child health risk problem M. Denise Dowd, MD, MPH Professor of

© The Children's Mercy Hospital, 2017

Why we need to talk

about guns as a child

health risk problemM. Denise Dowd, MD, MPH

Professor of Pediatrics

Page 2: Why we need to talk about guns as a child health risk problem · 2018-10-08 · Why we need to talk about guns as a child health risk problem M. Denise Dowd, MD, MPH Professor of

Disclosures

In the past 12 months, We have not had a significant financial

interest or other relationship with the manufacturer(s) of the

product(s) or provider(s) of the service(s) that will be discussed in my

presentation.

This presentation will not include discussion of pharmaceuticals or

devices that have not been approved by the FDA or if you will be

discussing unapproved or “off-label” uses of pharmaceuticals or

devices.

I was one of the primary authors of the AAP’s policy statement on

firearm injury prevention, October 2012

Page 3: Why we need to talk about guns as a child health risk problem · 2018-10-08 · Why we need to talk about guns as a child health risk problem M. Denise Dowd, MD, MPH Professor of

Objectives

Describe the magnitude of current child firearm injury

morbidity and mortality

Understand the importance of child development in

considering prevention interventions.

Give examples of what we, in health care, can do in their

practices and communities to help diminish firearm injury

among children.

Discuss firearm injury prevention with a public health

framework.

Page 4: Why we need to talk about guns as a child health risk problem · 2018-10-08 · Why we need to talk about guns as a child health risk problem M. Denise Dowd, MD, MPH Professor of
Page 5: Why we need to talk about guns as a child health risk problem · 2018-10-08 · Why we need to talk about guns as a child health risk problem M. Denise Dowd, MD, MPH Professor of

5-year-old boy died after he reportedly shot himself inside and apartment in

the 9600 block of Lydia Avenue in south Kansas City – Aug. 6, 2017.

10-year-old boy was hospitalized after shooting himself in the leg when he

found a gun left in a house near 23rd Street and Poplar Avenue in Kansas

City – July 21, 2017.

8-year-old girl was critically wounded when she was shot in the head by a

juvenile on a playground at 20th Street and Park Tower Road in Kansas City-

June 25, 2017.Read more here: http://www.kansascity.com/news/local/article174703051.html#storylink=cpy

Young child hurt in accidental shooting in KC, expected to

survive – Sept. 21, 2017

1-year-old girl killed in accidental shooting in Lawrence, police

say – Sept. 22, 2017

Page 6: Why we need to talk about guns as a child health risk problem · 2018-10-08 · Why we need to talk about guns as a child health risk problem M. Denise Dowd, MD, MPH Professor of

US Gun Deaths

Total in one year: 33,599 (92 per day)

Suicide 63%

Homicide 33%

Unintentional 2%

Fatal Injury Reports, 2014, CDC

NB: Total MV Traffic Deaths in

2014 = 33,736

Page 7: Why we need to talk about guns as a child health risk problem · 2018-10-08 · Why we need to talk about guns as a child health risk problem M. Denise Dowd, MD, MPH Professor of

31,672

Deaths1

41,363

Hospitalized

Injuries2

42,656

Treated & Released

from EDs2

Firearm Injury Pyramid

1 Centers for Disease Control National Vital Statistics, 20102 Estimates from the CDC Firearm Injury Surveillance Survey

Page 8: Why we need to talk about guns as a child health risk problem · 2018-10-08 · Why we need to talk about guns as a child health risk problem M. Denise Dowd, MD, MPH Professor of

US Gun Deaths

Children and Teens (<18y)

Total in one year: 1297

493 were Suicide (38%)

693 were Homicide (53%)

82 were Unintentional (6%)

Fowler, et al Pediatrics July 2017

Page 9: Why we need to talk about guns as a child health risk problem · 2018-10-08 · Why we need to talk about guns as a child health risk problem M. Denise Dowd, MD, MPH Professor of

Firearm death rates by age and intent

0

5

10

15

20

25

30

1 7 13 19 25 31 37 43 49 55 61 67 73 79 85+

Age

De

ath

s p

er

10

0,0

00

po

pu

lati

on

Unintentional

Suicide

Homicide

All firearm

Source: NCHS, National Vital Statistics System

Page 10: Why we need to talk about guns as a child health risk problem · 2018-10-08 · Why we need to talk about guns as a child health risk problem M. Denise Dowd, MD, MPH Professor of

Causes of Death among Persons 1 to 24 Years of Age in the United States, 2010.

Palfrey JS, Palfrey S. N Engl J Med 2013;368:401-403.

Page 11: Why we need to talk about guns as a child health risk problem · 2018-10-08 · Why we need to talk about guns as a child health risk problem M. Denise Dowd, MD, MPH Professor of

Fatal firearm injury rates by intent and year, children aged 0 to 17

years, United States, 2002–2014.

Katherine A. Fowler et al. Pediatrics 2017;140:e20163486

©2017 by American Academy of Pediatrics

Page 12: Why we need to talk about guns as a child health risk problem · 2018-10-08 · Why we need to talk about guns as a child health risk problem M. Denise Dowd, MD, MPH Professor of

Katherine A. Fowler et al. Pediatrics 2017;140:e20163486

©2017 by American Academy of Pediatrics

Page 13: Why we need to talk about guns as a child health risk problem · 2018-10-08 · Why we need to talk about guns as a child health risk problem M. Denise Dowd, MD, MPH Professor of
Page 14: Why we need to talk about guns as a child health risk problem · 2018-10-08 · Why we need to talk about guns as a child health risk problem M. Denise Dowd, MD, MPH Professor of
Page 15: Why we need to talk about guns as a child health risk problem · 2018-10-08 · Why we need to talk about guns as a child health risk problem M. Denise Dowd, MD, MPH Professor of

What don’t we know:

the numbers

Basic surveillance is lacking

Intent based counting is problematic

No national system like CODES or FARS

(NVDRS hopeful but needs expansion)

Source of the firearms used in injurious

episodes

Page 16: Why we need to talk about guns as a child health risk problem · 2018-10-08 · Why we need to talk about guns as a child health risk problem M. Denise Dowd, MD, MPH Professor of

Compared to other countries, American

Children (younger than 15) are:

12 times more likely to be killed by a gun

17 times more likely to be a gun homicide victim

10 times more likely to die of a gun suicide

9 times more likely to die of an unintentional gun

injury.

Richardson, Hemenway. J Trauma

2011;70(1):238-243.

Page 17: Why we need to talk about guns as a child health risk problem · 2018-10-08 · Why we need to talk about guns as a child health risk problem M. Denise Dowd, MD, MPH Professor of

How We Study Injury and Disease

Epidemiologic Triangle

HOST

AGENT ENVIRONMENT

Person Injured

Thing That Injures Where Host and Agent Are Found

VECTOR

Page 18: Why we need to talk about guns as a child health risk problem · 2018-10-08 · Why we need to talk about guns as a child health risk problem M. Denise Dowd, MD, MPH Professor of

Epidemiologic Triangle

Host (Human)

– Infant asleep in car seat,

– distracted mom driving

Agent (Vehicle)

– Convertible Mini-Cooper

Environment

– Busy roadway with no shoulder

Page 19: Why we need to talk about guns as a child health risk problem · 2018-10-08 · Why we need to talk about guns as a child health risk problem M. Denise Dowd, MD, MPH Professor of

What We Know

Children commonly live in environments containing

unsecured firearms. (Johnson RM,, et al. Arch Pediatr Adolsec Med 2006;160(8):788-)

Children have the ability to fire guns. (Naureckas SM Arch Pediatr Adolesc

Med. 1995 Dec;149(12):1318-22.)

Little children are curious; Big children are impulsive.

Guns are lethal.

Safe storage work to prevent unintentional and self-

inflected GSW deaths (Grossman et al. JAMA 2005 Feb 9;293(6):707-14).

http://webappa.cdc.gov/cgi-bin/broker.exe
Page 20: Why we need to talk about guns as a child health risk problem · 2018-10-08 · Why we need to talk about guns as a child health risk problem M. Denise Dowd, MD, MPH Professor of

Risk Factors - Gun Storage

Of gun-owning parents:

Keep firearm unlocked and loaded 9%

Keep firearm unlocked, unloaded, stored with ammunition 4%

At least one gun unlocked 43%

Keep firearm locked, unloaded, and separate from ammunition 39%Source Schuster April 2000

Page 21: Why we need to talk about guns as a child health risk problem · 2018-10-08 · Why we need to talk about guns as a child health risk problem M. Denise Dowd, MD, MPH Professor of

© The Children's Mercy Hospital, 2017

Who Is Strong Enough

to Fire a Gun?

25% of 3 to 4 year olds

70% of 5 to 6 year olds

90% of 7 to 8 year oldsSource: Naureckas et al, 1995

Page 22: Why we need to talk about guns as a child health risk problem · 2018-10-08 · Why we need to talk about guns as a child health risk problem M. Denise Dowd, MD, MPH Professor of

Where do the guns come from?

Among suicide completers and attempters:

75% of the guns came from the residence of

the victim, friend or relative

Grossman, et al. Arch Pediatr Adolesc Med. 1999;153:875-878.

Page 23: Why we need to talk about guns as a child health risk problem · 2018-10-08 · Why we need to talk about guns as a child health risk problem M. Denise Dowd, MD, MPH Professor of

Child-focused Education

Does it Work?Gun Safety Programs

Ineffective for injury reduction among adults

No effect on safe storage

No effect on youth accessing for self harm

Gun Avoidance Programs

Examples: Eddie Eagle (NRA), STOP (AAP)

A single, small evaluation demonstrates no effect on pre-schoolers

No effect on youth accessing for self harm.

Hardy. J Dev Behav Pediatr. 2002;23(2):71-76

Jackman, et al. Pediatrics. 2001;107(6):1247-50

Himle, et al. Pediatrics 2004;113(1 pt1):70-77.

Page 24: Why we need to talk about guns as a child health risk problem · 2018-10-08 · Why we need to talk about guns as a child health risk problem M. Denise Dowd, MD, MPH Professor of

Grossman et al, JAMA, February 9, 2005.

Storage Practices and Suicide Risk, 5-19 year olds

No. (%)

Firearm Storage Practice Cases

(N=106)

Controls

(N=480)

Adjusted Odds

Ratio (95% CI)

Gun unloaded 66% 91% 0.30 (0.16-0.56)

Gun locked 32% 58% 0.27 (0.17-0.45)

Ammunition locked 24% 48% 0.39 (0.23-0.66)

Safe Storage Works

Page 25: Why we need to talk about guns as a child health risk problem · 2018-10-08 · Why we need to talk about guns as a child health risk problem M. Denise Dowd, MD, MPH Professor of

Types of Gun Locks

Cable Locks

Trigger Locks

Biometric Locks

Lock Boxes

Gun Safes 25

Page 26: Why we need to talk about guns as a child health risk problem · 2018-10-08 · Why we need to talk about guns as a child health risk problem M. Denise Dowd, MD, MPH Professor of

Handgun Cable Locks

Revolver Semi-Automatic

26

Page 27: Why we need to talk about guns as a child health risk problem · 2018-10-08 · Why we need to talk about guns as a child health risk problem M. Denise Dowd, MD, MPH Professor of

Long Gun Cable Locks

Rifle Cable Lock Rifle Cable Lock

27

Page 28: Why we need to talk about guns as a child health risk problem · 2018-10-08 · Why we need to talk about guns as a child health risk problem M. Denise Dowd, MD, MPH Professor of

Trigger Locks

Semi-Automatic

Trigger Locks

Various Trigger

Locks

28

Page 29: Why we need to talk about guns as a child health risk problem · 2018-10-08 · Why we need to talk about guns as a child health risk problem M. Denise Dowd, MD, MPH Professor of

Biometric Locks

Biometric Trigger Lock Biometric Gun Box

29

Page 30: Why we need to talk about guns as a child health risk problem · 2018-10-08 · Why we need to talk about guns as a child health risk problem M. Denise Dowd, MD, MPH Professor of

Gun Box & Gun Safe

Gun Box/Lock Box Gun Safe

30

Page 31: Why we need to talk about guns as a child health risk problem · 2018-10-08 · Why we need to talk about guns as a child health risk problem M. Denise Dowd, MD, MPH Professor of

What Else We Know

Parents are receptive of discussion of risk of guns

during pediatric visits (Webster DW,. Pediatrics 1992;89:908-14)

Receptivity to discussion on firearm safety may

differ between owners and non-owners (Garbutt, et al Jpediatr

2016;179:166-71)

Anticipatory guidance on safe storage of firearms is

likely to result in more guns being safely stored (Barkin

SL.et al. Pediatrics 2008;122:e15-e25. McGee KS, Coyne-Beasley T, et al.. Inj Prev 2003:9:108-11; Grossman DC, et al. Am J Public

Health. 2012;102(suppl 2): S291-S297)

Page 32: Why we need to talk about guns as a child health risk problem · 2018-10-08 · Why we need to talk about guns as a child health risk problem M. Denise Dowd, MD, MPH Professor of

A Perfect Epidemiologic Triangle Storm

Curious

Child*

Unsecured

gunSupervision

Lapse

* or depressed/impulsive teen

Page 33: Why we need to talk about guns as a child health risk problem · 2018-10-08 · Why we need to talk about guns as a child health risk problem M. Denise Dowd, MD, MPH Professor of

American Academy of Pediatrics Firearm Injury Prevention Policy 2012

Pediatricians, as part of their anticipatory guidance

with families should inquire about guns in the home

and offer most effective child protection strategies

Best: Guns kept out of the environment of children

Good: Guns in the home should be stored safely:

guns separate from ammo., both locked.

Page 34: Why we need to talk about guns as a child health risk problem · 2018-10-08 · Why we need to talk about guns as a child health risk problem M. Denise Dowd, MD, MPH Professor of

American Academy of Pediatrics Firearm Injury Prevention Policy 2012

Regulations of firearms

Child access prevention laws

Regulation of manufacture, sales. Waiting periods,

closure of gun show loophole, background checks

Restoration of assault weapons ban

Research in firearm injuries , including public health

surveillance

Continued physician education

Page 35: Why we need to talk about guns as a child health risk problem · 2018-10-08 · Why we need to talk about guns as a child health risk problem M. Denise Dowd, MD, MPH Professor of

What Can You Do?

• ASK your families and advise to : keep guns in the home safety

secured: unloaded, locked, ammo locked separately; no access to

key by kids

• Encourage families to talk to their family, friends, neighbors about

the danger of unsecured guns.

• For children with behavioral or mental health issues of concern:

advise removal guns from home. This is SAFETY planning !

Page 36: Why we need to talk about guns as a child health risk problem · 2018-10-08 · Why we need to talk about guns as a child health risk problem M. Denise Dowd, MD, MPH Professor of

How To Ask About Guns

• “OK, you might think I’m a bit nervous, but I do worry about

the safety of my children when I’m not around. So, I’ve got to

ask you… Do you have any guns in the house?”

• “Before my child visits, I need you to know he is really curious

and can be mischievous. He gets into to everything! So, I’ve

got to ask you… Do you have any guns in the house?

• “These cases of kids getting killed or badly injured when they

find a gun in the home makes me really worry”

Page 37: Why we need to talk about guns as a child health risk problem · 2018-10-08 · Why we need to talk about guns as a child health risk problem M. Denise Dowd, MD, MPH Professor of

Child Injury Prevention = Layers of Protection

Pool

DrowningGun Death

Pool fencing Gun Lock

Supervision Supervision

Teach child Teach child

Page 38: Why we need to talk about guns as a child health risk problem · 2018-10-08 · Why we need to talk about guns as a child health risk problem M. Denise Dowd, MD, MPH Professor of
Page 39: Why we need to talk about guns as a child health risk problem · 2018-10-08 · Why we need to talk about guns as a child health risk problem M. Denise Dowd, MD, MPH Professor of

Unaddressed Child Specific

Questions When should children be allowed to handle guns?

What are the influences on gun ownership? Does the presence of

children influence gun ownership?

How do families balance risk of gun in the home with perceived benefit

of gun availability? Does this change with the presence of children?

Should we screen for guns in the home OR provide universal prevention

messages?

Page 40: Why we need to talk about guns as a child health risk problem · 2018-10-08 · Why we need to talk about guns as a child health risk problem M. Denise Dowd, MD, MPH Professor of

After Newtown, Sales Boom for Kids' Body

Armor

—By Tim Murphy

| Tue Dec. 18, 2012 9:24 AM PST

192

http://www.motherjones.com/authors/tim-murphy
Page 41: Why we need to talk about guns as a child health risk problem · 2018-10-08 · Why we need to talk about guns as a child health risk problem M. Denise Dowd, MD, MPH Professor of
Page 42: Why we need to talk about guns as a child health risk problem · 2018-10-08 · Why we need to talk about guns as a child health risk problem M. Denise Dowd, MD, MPH Professor of

“In this age of space,” President Johnson

remarked, “we are getting plenty of information

about how to send men into space and how to bring

them home. Yet we don’t know for certain whether

more auto collisions are caused by faulty brakes, or

by soft shoulders, or by drunk drivers, or even by

the deer crossing a highway.”

Page 43: Why we need to talk about guns as a child health risk problem · 2018-10-08 · Why we need to talk about guns as a child health risk problem M. Denise Dowd, MD, MPH Professor of

Role of Health Care

Consider universal education within anticipatory

guidance

Speak to your expertise

Understand the epidemiologic approach to prevention

(the kid AND the gun AND the environment) and

advocate for better understanding

Prioritize: risks that are prevalent, lethal and

preventable

Page 44: Why we need to talk about guns as a child health risk problem · 2018-10-08 · Why we need to talk about guns as a child health risk problem M. Denise Dowd, MD, MPH Professor of

Every parent knows.....

It just takes a minute.


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