Children in the United States often have access to unlocked firearms in their homes.^1,2 Surveys show that among households with children, one-third have at least one firearm in the home, and among firearm-owning households with children, only three in ten households safely store firearms (i.e., both unloaded and locked).² Firearm injury is a leading cause of death among children aged from birth to 19 in the United States.^3–5 In-home gun access, in particular, poses significant risk of firearm injuries among children. For instance, more than 80% of firearm suicides for children aged 10-17 happened in a house or apartment,⁶ and more than 70% of suicides and suicide attempts used the victim’s parent’s gun.⁷ Firearm suicide risk is also over-represented among children diagnosed with mental health problems.⁶

For decades, public health and healthcare practitioners have advocated access reduction approaches such as safe storage or firearm removal practices,^8–10 lethal means restriction,^11,12 and violence or suicide intervention programs in hospitals,^13,14 to reduce firearm-related violence, suicide, and injury for children. State-level child access prevention laws that impose criminal liability for negligently stored firearms are also associated with reductions in pediatric firearm injuries.^15,16 In most of those existing interventions, parents play a crucial role in preventing firearm injuries to their children, in particular those struggling with mental health or behavioral problems. While existing literature has focused on identifying intervenable approaches to encourage firearm-owning parents to address child firearm access, few studies have examined how parents exercise control over child firearm access in response to their children’s mental and behavioral problems.

Existing studies show mixed evidence of a relationship between in-home firearm storage practice and children’s mental illness.^17–21 A major limitation of the existing studies is that the associations assessed are cross-sectional and prone to confounding by various demographic and socioeconomic factors underlying the link between mental or behavioral disorders and firearm access in childhood. A clear chronological order between mental health disorder symptomology onset and subsequent firearm access is necessary to evaluate how they relate. In addition, past studies suffer from data quality issues (e.g., low response rate²⁰, small selected sample with low generalizability¹⁷, lack of accurate measurement of mental health disorders^18,22). To our knowledge, no existing study has prospectively followed children with a cohort design that enables the observation of changes in both behavioral and mental health disorder symptoms and firearm access, along with related factors.

This study addresses this gap by conducting a secondary analysis of data from the prospective, community-representative Great Smoky Mountain Study (GSMS), a study on children living in predominantly non-urban, American Indian or White households that are known to have a high rate of in-home firearm possession.²³ GSMS collected repeated annual observations on children and their families during middle childhood and adolescence and measured both access to unlocked guns and childhood mental health symptoms. This design allows us to employ a lagged analysis to test whether increases in different types of childhood mental health symptoms affected subsequent child access to unlocked guns. This study will consider two conditions: 1) homes in which children did not have access to unlocked guns at baseline and 2) homes in which children already had access to unlocked guns. In addition, we tested the potential differences in the association of mental health symptoms and gun access by developmental period (age<13 or ≥13), sex, and race (American Indian vs. White).

In this community-representative, predominantly rural sample, most children had either access to unlocked guns or self ownership reported at least once from age 9 to 16. Changes in in-home access to unlocked guns during childhood were common (27.0%). Such changes in gun access were associated with changes in childhood mental health symptoms, but the results were asymmetric. Children who had access to unlocked guns tended to have their access limited after increases in mental health symptoms like deceitfulness, violation of rules, oppositionality and depression. Increases in symptoms were often associated with a significant reduction in the odds of the child having gun access at follow-up in adolescence, among males, and among Whites. In contrast, changes in youth mental health symptoms did not increase or decrease the likelihood of parents granting gun access to children in the first place.

Parents are often in the best position to evaluate their children’s emotional and behavioral functioning, and it is reasonable for them to consider such information when deciding whether to keep a gun in the home and providing the child access to unlocked guns. Each of the symptoms identified here is associated with adverse outcomes. For example, oppositional defiant disorder and conduct disorder are considered part of a continuum of disruptive and antisocial behaviors, with the former considered milder and a potential precursor to the onset of more severe behavioral or mental health problems or criminality.^33,34 While this study was not designed to establish a direct association between suicidality and gun access, depression has long been recognized as a potent risk factor for suicidal ideation or attempts. (e.g., ³⁵) Among children with worsening depression, reducing access to unlocked guns can significantly decrease both suicide attempts and death by suicide rates.⁷

Changes in gun access may reflect parental concerns about behavioral disorders or depressive symptoms in children. Parents might restrict firearm access as a precautionary measure in response to increasing behavioral issues or mental health challenges, aiming to ensure safety rather than using it as a form of discipline. Past studies have not linked childhood mental health symptoms with reduced gun access because they have all relied upon a cross-sectional design. The current study followed families over time and suggests that parents whose children have access to unlocked guns may limit that access based on symptom levels.

Among children with access to unlocked guns at the baseline, how changes in mental health symptoms influenced children’s gun access varied by developmental stage, where parents were more responsive to increased symptoms during adolescence (age 13- 16) compared to age below 13. As children enter adolescence, parents may become more attuned to the risks associated with access to unlocked guns due to the known correlation between adolescent mental health problems and increased risk for violent behaviors and suicide.^37,38 For younger children (below 13), mental health changes might not be deemed severe enough to warrant restrictions or may not correlate strongly with gun access decisions, as firearms might be seen as off-limits regardless. Moreover, increased symptoms in conduct disorder (in particular deceitfulness/theft) were more predictive of reduced gun access among male than female participants, whereas symptom changes in oppositional defiant disorder were about equally predictive of access to unlocked guns for both male and female participants. The association between increased depressive symptoms and reduced access to unlocked guns was more pronounced among female participants, suggesting that parents may be more responsive to what they perceive as gender-typical patterns of mental health issues. Conduct problems are generally more common in male participants, while depressive symptoms are typically more prevalent in female participants.^39,40 In addition, symptom changes in deceitfulness/theft, oppositional defiant disorders, and depression were predictive of reduced access to unlocked guns only among Whites but not among American Indians, though the interactions between racial groups and changes in symptom scores were all insignificant. This may be related to the relatively small number of American Indian participants, but could also reflect the complex interplay of factors such as cultural attitudes toward firearms within some Native American communities, ⁴¹ historical inequalities (e.g., historical trauma, distrust of external authorities), ^42,43 and disparities in access to health resources (e.g., mental health services, counseling, and interventions).^44,45 We note that few studies include an adequate subsample of Native American youth, and urge future researchers to ensure representation of Native American populations to allow further investigation of these relationships. Additionally, our results also suggested parental response to mental health symptoms differed between children who already had access to unlocked gun and those who were initially granted access. For the latter, some positive symptom-access associations were observed among male participants. Besides differentiated gender norms, children who already have access to unlocked gun at baseline may be part of families where firearms are normalized and integrated into the household routine, and these families may be more sensitive to changes in the child’s mental health because they are aware of the potential risks posed by guns in the home.⁴⁶

These findings have implications for healthcare providers and other practitioners working with families. First, gun access can be fluid over time. Even in an area of the country where gun culture is strong,⁴¹ parents appear to be aware of, and potentially responsive to, the risks posed by access to unlocked guns when their children exhibit emotional or behavioral issues. Healthcare practitioners may have the potential to influence parents’ decisions on how and when to limit their children’s gun access. This aligns with the approach suggesting that healthcare providers play a pivotal role in firearm safety counseling, especially in pediatric and family health settings (e.g., ^47,48). The effectiveness of such interventions can be enhanced through culturally competent approaches that consider the context of families living in regions with strong gun traditions.⁴⁹ Second, this study suggests that even families that do not currently allow their children access to guns may still benefit from education on risks for firearm injury. In households that did not give their children access to firearms at baseline, no association was found between children’s mental health symptoms and gun access; in some cases, increases in symptoms were paradoxically linked to greater access at follow-up. Our findings therefore support the idea that routine firearm counseling should be a standard part of pediatric and family healthcare, regardless of firearm access at baseline, much like interventions on safe sex, smoking, and alcohol use.^48,50 Providing firearm safety education, even in the absence of confirmed gun access, may help families make informed decisions about gun safety in their homes.

This study leveraged a distinctive community-representative sample followed repeatedly over time and assessed rigorously for mental health symptoms and gun access. However, the following caveats should be considered when evaluating our findings. First, although the lagged analysis used here inherits the logic of the “difference-in-difference” model⁵¹ which is often used to estimate a causal effect, it likely does not completely eliminate confounding in a cohort design. Changes in mental health symptoms can possibly be either a cause or consequence of another causal agent that affects gun access. As such, the interpretation of our results should still be considered associational. Our analysis, stratified by the gun access of children at time t, is unconditional on either the gun access or symptom score changes at previous times. The underlying assumption here is that given observations at time t, the outcome of gun access is independent of observations before time t. Second, our effect estimates are based on a single-point change in symptoms. While these estimates show good sensitivity in the potential responses of parents to children’s mental health conditions, the unit of effect might not be clinically relevant. Third, the measurement of gun access in our study is based on parental reports, which may not fully capture children’s actual access to firearms. Prior research has demonstrated that caregiver perceptions and child-reported access can be discordant,^52,53 and this reliance on parental perception introduces the potential for reporting bias. As such, our findings may only reflect how parents perceive and report their children’s access to firearms, which may not align with actual access. Fourth, the GSMS collected data from 11 rural counties in the Southeast since the early 1990s and was designed to be representative of rural areas in the Southeast United States and Appalachia. Results may or may not generalize to other periods and broader regions. Fifth, our results are limited by potential recall bias and ambiguity in self-reported firearm storage, as our instrument lacks specificity in defining ‘locked’ firearms. Reporting may also be influenced by the child’s mental health status, potentially affecting associations. The fluctuations in firearm access over time may reflect genuine changes in household ownership or storage practices, though recall bias remains a possibility. Future research is needed to better understand the stability of household firearm ownership and the factors that drive changes over time.

Given the 30-year difference between the study data and the present day, it is important to acknowledge that societal, cultural, political, and policy factors, such as the development of social media, the increased frequencies of school shootings, changing views on firearm ownership may influence the relevance of our findings. Notably, the period of study predates the 1999 Columbine High School shooting, an event that fundamentally changed public discourse on youth access to firearms and prompted a wave of policies and parental vigilance ⁵⁴ Subsequent incidents, including the shootings at Sandy Hook Elementary (2012), Marjory Stoneman Douglas High School (2018), and Robb Elementary School in Uvalde (2022), have amplified concerns and awareness about the link between children’s mental health and gun access. The high-profile conviction of the parents of the Michigan shooter Ethan Crumbley in 2021 (Oxford High School) further underscores growing societal and legal expectations for parental responsibility. While it is possible that heightened awareness has led to greater restrictions on firearm access in response to children’s mental health concerns, it remains unclear how these shifts have affected household firearm practices over time. We hope this analysis will inform future research to capture contemporary parental attitudes and behaviors surrounding firearm access and youth mental health.

In conclusion, in-home gun access among children is common in the United States and is a major risk factor for firearm injuries among children, including suicide, homicide, and accidents. We present a high-risk demographic group of predominantly White, rural residents in the American Southeast, where the prevalence of in-home firearm access among children is high,^21,23 and the willingness to curb firearm access or practice safe storage is low.¹⁷ Nevertheless, our findings suggest that parents in such a high-risk demographic group may reduce gun access for children when they observe increased symptoms of certain mental and behavioral problems. Increasing parents’ exposure to knowledge on mental and behavioral health risk factors for firearm injuries through education can be a viable means of informing parents’ decision-making over children’s gun access.