Ending the Silence on Gun Violence   Leave a comment


Summarized from an article by Brent et al. published online 25 January 2013 in

the Journal of the Am. Acad. of Child & Adolescent Psychiatry

The massacre this past December in Newtown, Connecticut of 20 elementary school children and six school personnel is the most recent but not the final destructive episode involving assault weapons. I am opposed to the gun lobby’s opposition to any infringement on the right to own and bear arms. But I first want to balance a perspective on mass shootings vs. guns in general. Mass shootings, defined as those involving the deaths of at least four individuals through firearm homicide, represent a very small proportion of all firearm deaths in the United States. Since 2005, there have been an average of 55 individuals per year who have died in mass shootings. Mass shootings account for only one in more than 500 of the firearm homicides and suicides that occur in the United States every year. Mass shootings and other firearm homicides do have one thing in common—both are much more common in the United States than in any other high-income country in the world. Fifteen of the most recent 25 mass shootings recorded worldwide occurred in this country.

Firearm deaths also occur in the home and give cause for concern. For every self-defense homicide in the home, there were nearly five times as many domestic criminal homicides and 37 suicides.

After a firearm massacre in Australia in 1996 in which 35 people died, the Australian government passed legislation to remove semiautomatic and pump-action shotguns and rifles from civilian possession, bought back nearly 650,000 of these weapons, and required that firearm sales occur only through licensed arms dealers, with police approval. In the 18 years before this legislation, there were 13 mass shootings in Australia and none in the 10.5 years thereafter. There was already evidence of a decrease in firearm homicides and suicides, but the rate of decrease doubled after the legislation, with no evidence of method substitution. Although researchers with funding from gun-ownership advocates have challenged these findings, subsequent analyses have generally supported the initial conclusions about the effects of the legislation.8 Consistent with these findings, multiple studies in the United States and in other countries have shown that decreases in firearm ownership and accessibility, whether occurring naturally or after to legislation, are associated with parallel changes in firearm suicide and homicide rates.

The manner in which guns in the home are stored has great protective significance. One study found that the risk of firearm suicide or unintended firearm death among youth was four- to sixfold lower if guns and ammunition were inaccessible. Suicide in younger adolescents tends to be an impulsive act, and having a loaded gun in the home may be a factor in successful adolescent suicide. Medical practice guidelines in primary care recommend assessing for the presence and method of storage of firearms, and at least three intervention studies have demonstrated that a 1-minute intervention as part of well-child care, along with an offer of free trigger locks, can substantially improve the safety of firearm storage. More than three fourths of parents were positive toward physicians providing gun safety counseling, even though relatively few (17%) were willing to actually remove guns from their homes.

Nevertheless, the gun lobby has made multiple legislative initiatives designed to inhibit physician inquiry about gun ownership and storage, including five provisions in the Affordable Care Act (Obamacare). These sections prohibit requiring disclosure or collection of information about the presence or storage of a lawfully possessed firearm, effectively inhibiting physician firearm safety counseling. Further unconscionably, the gun lobby has severely limited the Centers for Disease Control in its ability to fund firearm research for the past 15 years, despite the well-established connection between firearm availability and child and adolescent mortality.

A common profile of perpetrators of school shootings includes a recent threat of violence, suicidal ideation or behavior, and having been bullied by a peer. Such hindsight, however, does not equate to increased foresight. To put the issue of prediction in statistical perspective, around 25% of individuals in the United States have a mental disorder, whereas 15 mass shootings have occurred in the United States since 1982! Predicting precisely who will commit these types of violent rampages, let alone when, is simply not an achievable goal. The prediction of imminent violence, given the frequency of these indicators and the rarity of school shootings, is impossible

Although I support the need for rapid access to mental health care for those thought to be at risk for imminent violence, it is unrealistic to place complete emphasis on mental health treatment, both because of the difficulty in assessing imminent risk for violence and because the United States leads all high-income countries in mass shootings despite having a similar rate of mental disorders.

The main factor that differentiates the United States from other high-income countries is having a much higher rate of per capita gun ownership, correlating with a much higher firearm homicide rate and homicide rate overall. Simply put, we ignore this huge disparity in gun availability and firearm death between the United States and other high-income countries at our collective peril.

Psychiatric disorder is also associated with risk for homicides that occur outside the context of mass shootings, which constitute the vast majority of homicides in the United States. Nevertheless, the proportion of psychiatrically disordered individuals who perpetrate homicide is small. Therefore, although access to good-quality treatment in high-risk individuals may lower the rate of homicide, our ability to precisely identify which individuals are at imminent risk is limited. It is unrealistic to place complete emphasis on mental health care without also attending to the strong association between the very high availability of firearms in the United States and the similarly high American homicide rates.

Adolescent suicide serves as another example of the relative contribution of mental disorder and firearm availability to risk for mortality in youth. Mental disorder is a critical risk factor for youth suicide, but firearms in the home is one of the only characteristics that differentiate suicide victims from psychiatrically ill, living, suicide attempters. Furthermore, many early adolescent suicide victims do not show clear evidence of a mental disorder, and one of the only risk factors for these young suicides is the presence of a loaded gun in the home.

Other factors that have been discussed as contributing to mass shootings and to firearm violence in general have been the effects of exposure to violence by the media, games and entertainment, and neighborhood violence. Media exposure at most may have very modest effects on homicide, and although exposure to violence in entertainment may increase aggressive behavior, its link to actual criminal behavior has not been demonstrated. Exposure to neighborhood violence is associated with an increased likelihood of weapon-carrying and violent behavior, but the effects of violence exposure are difficult to disentangle from those of overall social disadvantage.

We summarize our recommendations as follows:

  1. Effective legislation that will bring our country’s firearm death toll more in line with the rest of the developed world, such as universal background checks for all firearm purchases and a ban on the sale of assault weapons and other firearms with high-capacity magazines. Such programs have been shown to dramatically decrease the incidence of mass shootings and appear to accelerate an overall downward trend in firearms deaths. The United States leads all high-income countries in rates of firearm availability and in firearm deaths.
  2. Promote physician screening and counseling for firearm safety and remove legislative barriers to counseling and recording firearm safety information in health records.  Firearm deaths and injuries are less likely to occur if guns and ammunition are stored locked. Physician counseling can increase safe storage of firearms in the homes of patients
  3. Investment in better mental health care. Prediction of particular violent incidents is nearly impossible, given the high rate of mental disorders and low rate of homicidal acts. However, a substantial proportion of the precursors of homicidal behavior can respond to preventive interventions early with at-risk youth.
  4. Congress to lift the ongoing restrictions constraining research on one of the most common causes of morbidity and mortality in childhood, including research on gun safety and storage to shield children from the lethal acts of mayhem.

Do not be silent about gun violence. Speak for those who have been silenced.


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