A sobering look at children and gun violence in the United States


Steven Selbst, MD, comments on a new study showing the devastation of gun violence in low-income communities.

Gun violence is an ongoing epidemic in the United States. Firearms-related deaths are the second leading cause of death among children and young adults, with nearly a quarter of all deaths among people aged 15 to 24 years resulting from firearms.1-4 Ninety-one percent of firearm deaths around the world in children aged 0 to 14 years occur in the United States.5 The risk of death linked to unintentional injury is higher in counties with a higher level of poverty. An investigation examines whether living in a county with a higher poverty concentration was linked to a child or teenager’s risk of death related to a firearm.6

The investigators ran a cross-section study that analyzed US firearm fatalities among children and young adults aged 5 to 24 years from January 2007 to December 2016. They used data from the Compressed Mortality File from the Centers for Disease Control and Prevention as well as annual intercensal population data from the US Census Bureau. Firearm-related deaths included homicides, suicides, unintentional deaths, and deaths that had undetermined intent. Poverty concentration was defined as population that was living below the federal poverty level, which was #21,027 in 2007 and $24,339 in 2016 for a family of 4, and divided into 5 groups: 0% to 4.9%, 5% to 9.9%, 10% to 14.9%, 15% to 19.9%, and ≥20%).

There were 67,905 firearm-related deaths from 2007 to 2016 included in the cohort, which was mainly comprised of 60,164 males. Among these deaths, 42,512 were homicides; 23,034 were suicides; and 1627 were considered unintentional. The investigators found that there was a stepwise increase in firearm-related mortality risk due tied to increasing county poverty concentration. When compared with counties that had the lowest poverty concentration, those with the highest poverty concentration saw an increased rate of total deaths related to firearms (adjusted incidence rate ratio [IRR], 2.29; 95% CI, 1.96-2.67), homicides (adjusted IRR, 3.55; 95% CI, 2.80-4.51), suicides (adjusted IRR, 1.45; 95% CI, 1.20-1.75), and unintentional deaths (adjusted IRR, 9.32; 95% CI, 2.32-37.4). The population-attributable fraction was .51 (95% CI, 0.43-0.57) for all firearm-related deaths, 0.66 (95% CI, 0.57-0.73) for homicides, 0.30 (95% CI, 0.17-0.42) for suicides, and 0.86 (95% CI, 0.46-0.97) for unintentional deaths. This means that 34,292 deaths from firearms would not have occurred if all counties had the same level of risk as the ones with the lowest concentration of poverty. Overall, a total of 3,833,105 years of potential life were lost.

Investigators did note that there were limitations to their study. The first was that they could only report association and not causations. The demographic variables as well as causes of death noted in the Compressed Mortality File may have been misclassified. The heterogenous nature of counties, where neighborhoods may have varying levels of poverty, along with the inability to determined income data for the teenagers and young adults themselves meant the investigators were not able to determine the implications of individual-level poverty versus county-level poverty. Additionally, the investigators were not able to account for illicit firearm ownership.

The investigators concluded that counties with a higher level of poverty concentration were linked to increased rates of total firearm deaths, homicides, suicides, and unintentional deaths. Particularly troubling was the fact that over 50% of the fire-arm related deaths as well as over two-thirds of all homicides tied to firearms in the age group could be linked to living in a county with a higher poverty concentration. With the trend of increasing income inequality, this data could indicate the potential likelihood for increasing risk of firearm-related death because of county-level poverty.

Commentary from Steven Selbst, MD:

This important article shows the dramatic impact of poverty on firearm-related deaths in the United States.It is no surprise that deaths from gun violence are related to poverty, but the numbers reported here and the strong association with higher county poverty concentration is staggering.

It is well known that school shootings have increased in the United States in recent years, and these tragic events understandably capture national attention. This article makes us look closely at the more subtle epidemic of gun-related deaths that occur daily on the streets of our country.

The authors briefly describe the impact of children living in high poverty concentration neighborhoods.Children in these communities often have inadequate housing, limited access to high quality schools, and increased toxic stress.It is no surprise they also have a disproportionate number of firearm-related deaths. The New York Times reported that Chicago had 101 gun-related homicides in residents under age 20 in 2021, up for 76 in 2019.In my own city of Philadelphia, 2021 brought a new record for homicides (562) and the large majority of these deaths was by firearms.More than 200 teens were caught in the cross fire with the rising gun violence in Philadelphia and at least 36 were killed in 2021. The large majority of these shootings also occurred in sections of the city with increased concentration of poverty.

In 2016 the American Academy of Pediatrics (AAP) noted that almost half of children in the United States live in poverty or near poverty. They issued a Policy Statement indicating the AAP is “committed to reducing and ultimately eliminating poverty in the United States”.This is a daunting task, as is ending the crisis of gun violence in our country.The authors of this study in JAMA Pediatrics mention some helpful interventions such as the Child Tax Credit, Head Start, the Special Supplementation Nutrition Program for Women, Infants and Children.They also note the importance of firearm regulation legislation.Our country seems to be a long way off from this.

We need data to make any progress in reducing gun-related violence.This study provides very valuable data that will at least help us target our efforts


1. Centers for Disease Control and Prevention. Wide-ranging Online Data for Epidemiologic Research (WONDER). Accessed March 31, 2021. https://wonder.cdc.gov/

2. LeeLK, MannixR.Increasing fatality rates from preventable deaths in teenagers and young adults. JAMA. 2018;320(6):543-544. doi:10.1001/jama.2018.6566

ArticlePubMedGoogle ScholarCrossref

3. Centers for Disease Control and Prevention. WISQARS (Web-Based Injury Statistics Query and Reporting System). Choice Reviews. 2011;48(08):48-4227.

4. Centers for Disease Control and Prevention. Leading causes of injury death highlighting violence. WISQARS. Accessed March 31, 2021. https://webappa.cdc.gov/sasweb/ncipc/mortrate.html

5. GrinshteynE, HemenwayD. Chapter 6: Firearm violence in the pediatric population: an international perspective. In: LeeLK, FleeglerEW, eds.Pediatric Firearm Injuries and Fatalities: The Clinician’s Guide to Policies and Approaches to Firearm Harm Prevention. Springer International Publishing; 2021:75-85. doi:10.1007/978-3-030-62245-9_6

6. Barrett J, Lee L, Monuteaux M, Farrell C, Hoffmann J, Fleegler E. Association of county-level poverty and inequities with firearm-related mortality in US youth. JAMA Pediatr. Epub ahed of print. November 22, 2021. doi:10.1001/jamapediatrics.2021.4822

NAPNAP urges the government to address gun violence

The day after the November 30, 2021 shooting in Oxford Township, Michigan, the National Association of Pediatric Nurse Practitioners released a statement1 calling for the leaders of state and federal government to immediately start addressing the gun violence issue facing the United States. The organization advocated for several congressional reforms including:

Increasing funding to programs that research and track gun violence

Institute 72-hour waiting periods to allow for thorough background checks

Set the federal minimum age for firearm purchase to 21 years, with exemptions for people in the military or law enforcement

Support access to mental health services

Bolster background check and remove loopholes that prevent background checks from occurring

Constrain the sale and import of high-capacity magazines


1. NAPNAP urges government to address gun violence. NAPNAP.org. December 1, 2021. Accessed January 10, 2022. https://www.napnap.org/napnap-urges-government-to-address-gun-violence/

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