Where do we go from here?

[michigangirl]

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A devastating tragedy that instantly took 20 of the lives that we have devoted our careers as pediatricians to-- where do we go from here? How should the AAP tackle the call of gun control in this seemingly new era? How can we help?

So many questions-- so few answers-- so much grief.

 

[oldbearprofessor]

A devastating tragedy that instantly took 20 of the lives that we have devoted our careers as pediatricians to-- where do we go from here? How should the AAP tackle the call of gun control in this seemingly new era? How can we help?

So many questions-- so few answers-- so much grief.

http://www.healthychildren.org/Engl...t-to-Preventing-Gun-Injuries-in-Children.aspx

The AAP has had, for many years, a very strong position on this topic. I'm not sure how much more strongly they can advocate on this issue than they currently do.

 

[justdoit31]

This tragedy is more of a mental health issue than one of gun control. For all we know every child killed lived in a gun-free home. The people who commit these acts will get guns even if they don't pass screening (this young man took his mothers).

I personally grew up in a family that had many guns and was taught gun safety and shooting skills from a young age. Yes my parents kept them in a gun safe but I knew better to play with them.

As a pediatrician our job is to educate families about safety and work to screen children and adolescents for psych conditions. No matter what we do however we can't prevent all of these incidents.

 

[Stitch]

As a pediatrician our job is to educate families about safety and work to screen children and adolescents for psych conditions. No matter what we do however we can't prevent all of these incidents.

I find it unacceptable to just say 'well, we can't prevent them all.' Perhaps we can't, but can we reduce the body count? Extended clips, assault rifles, sniper rifles all make it much easier and more efficient to kill larger numbers. It's unrealistic to think that America will completely ban guns (nor would it really be possible). But given the number of shootings in the past 15 years we need to have a discussion of how to protect ourselves and children.

I get really tired of hearing terms like unAmerican and tyranny without context. People are way too interested in speaking in absolutes than in having a real discussion.

 

[jkurtz02]

.

 

[michigangirl]

The obsession with guns in this country is beyond my comprehension. Just come take a look at the top thread currently on the anesthesia boards, what the thread was focused on before Friday's events.

I, like many, am trying to figure out what I can do. Yes, we've had many wake-up calls as a country. But unfortunately it takes some personal connection to an event to get folks in action. My six year old reading a Highlights magazine next to me on the couch is that current connection. 20 sets of parents can't do that right now. In addition, my immediate family was personally affected by mass gun violence last year. I'm sick with sadness for our society who sees the right to bear arms paramount to our children's safety. Show me numbers on how many civilians lives have been saved with a gun, and how many have been taken-- not how much enjoyment is had at a shooting range or hunting. Perhaps then I'll understand.

I was never exposed to guns growing up so I know my life experience shapes my opinions. I just. don't. get it.

 

[diagonal]

An armed populace is less likely to be ruled by tyranny - those are the origins. Also an armed citizen has the resources to defend his home and family from those that wish harm upon him. If that is not a fundamental right, what in the hell is? Guns have already been invented, there's no way to erase that reality. Any efforts to outlaw guns, by definition, will only affect law-abiding citizens. There will always be a black market for guns, because, well, guns exist. And they are a very handy tool for criminals and the depraved. Criminals will ALWAYS have guns. But the last thing I want is said criminal coming into my home and standing face to face with my wife or child, while I sit in the corner castrated by idealists that look at life through a latte-colored lens.

What don't you get about that?

 

[physicsnerd42]

Japan has basically solved this problem. It's interesting to think about whether their approach would work in the US. Whether that approach is viable or not, I agree that something needs to be tried to eliminate these terrible incidents.

 

[diagonal]

Japan has basically solved this problem. It's interesting to think about whether their approach would work in the US. Whether that approach is viable or not, I agree that something needs to be tried to eliminate these terrible incidents.

From your very article:

"The Japanese and American ways of thinking about crime, privacy, and police powers are so different -- and Japan is such a generally peaceful country -- that it's functionally impossible to fully isolate and compare the two gun control regiments"

It also never states why Japanese organized crime has chosen to forgo the use of firearms. I can assure you, should they have chosen to use firearms, they could.

Oh, BTW, if guns didn't exist and I had a hankering for mass killing, I'd use an explosive. Care to ban gasoline? You guys are approaching the problem of violence and mental illness from a ridiculous angle.

 

[physicsnerd42]

From your very article:

"The Japanese and American ways of thinking about crime, privacy, and police powers are so different -- and Japan is such a generally peaceful country -- that it's functionally impossible to fully isolate and compare the two gun control regiments"

Oh, BTW, if guns didn't exist and I had a hankering for mass killing, I'd use an explosive. Care to ban gasoline? You guys are approaching the problem of violence and mental illness from a ridiculous angle.

I don't disagree that the Japanese system wouldn't work in it's entirety here. I do, however, think it's reasonable that every gun be registered, that background checks be performed, that everyone who purchases a gun be required to take a firearms safety class (with periodic recertification), that certain psych diseases and being a felon should make you ineligible to purchase a gun, that the kinds of guns that can be purchased be limited, that the purchase of ammunition be limited, etc..

I also agree with your second point, that people can find a way to kill others if determined, as evidenced by the stabbings of over 20 kids at a school in China yesterday (fortunately they all lived). At the same time, however, I think we should make it as difficult as possible for one person to kill many. Limiting who can own weapons and what kinds of weapons they can legally own is reasonable.

 

[diagonal]

I don't disagree that the Japanese system wouldn't work in it's entirety here. I do, however, think it's reasonable that every gun be registered, that background checks be performed, that everyone who purchases a gun be required to take a firearms safety class (with periodic recertification), that certain psych diseases and being a felon should make you ineligible to purchase a gun, that the kinds of guns that can be purchased be limited, that the purchase of ammunition be limited, etc..

I also agree with your second point, that people can find a way to kill others if determined, as evidenced by the stabbings of over 20 kids at a school in China yesterday (fortunately they all lived). At the same time, however, I think we should make it as difficult as possible for one person to kill many. Limiting who can own weapons and what kinds of weapons they can legally own is reasonable.

You've just listed a thousand ways that law-abiding citizens will be tangled up with respect to firearm purchase, yet have no answer as to how those determined to kill will.

 

[Socrates25]

People who plot mass murder and are determined are going to find a way. However, many school shootings are not organized plots as much as they are sudden flashes of rage that are made easier to carry into fruition by easy access to firearms. Could this guy have gotten all of these arms by illegal means if guns were banned? Probably. But it would take some time, and there is some risk that he would be thwarted somehow or run into issues that he wouldnt have otherwise. Lets remember this guy was Aspergers and apparently not very willing/able to engage with others. Somebody socially isolated like that and not used to dealing with people would have a MUCH harder time navigating illegal channels to procure firearms compared to having easy/open access at home 24/7.

The mother of this shooter deserves some responsibility for what happened. I think from all accounts it is fairly obvious that the shooter had some kind of social isolation issues, whether its Aspergers or whatever. Regardless, a responsible parent should KNOW BETTER than to have weapons in easy reach of a child at home, ESPECIALLY a child with "issues" like this shooter apparently had.

 

[diagonal]

People who plot mass murder and are determined are going to find a way. However, many school shootings are not organized plots as much as they are sudden flashes of rage that are made easier to carry into fruition by easy access to firearms. Could this guy have gotten all of these arms by illegal means if guns were banned? Probably. But it would take some time, and there is some risk that he would be thwarted somehow or run into issues that he wouldnt have otherwise. Lets remember this guy was Aspergers and apparently not very willing/able to engage with others. Somebody socially isolated like that and not used to dealing with people would have a MUCH harder time navigating illegal channels to procure firearms compared to having easy/open access at home 24/7.

The mother of this shooter deserves some responsibility for what happened. I think from all accounts it is fairly obvious that the shooter had some kind of social isolation issues, whether its Aspergers or whatever. Regardless, a responsible parent should KNOW BETTER than to have weapons in easy reach of a child at home, ESPECIALLY a child with "issues" like this shooter apparently had.

He took the gun from his mom, or so I've gathered. So all your "screening for gun purchases" arguments are now moot. And sorry, you can't legislate a mother hiding her gun from her crazy kid.

 

[Socrates25]

This tragedy is more of a mental health issue than one of gun control. For all we know every child killed lived in a gun-free home. The people who commit these acts will get guns even if they don't pass screening (this young man took his mothers).

I personally grew up in a family that had many guns and was taught gun safety and shooting skills from a young age. Yes my parents kept them in a gun safe but I knew better to play with them.

As a pediatrician our job is to educate families about safety and work to screen children and adolescents for psych conditions. No matter what we do however we can't prevent all of these incidents.

You are assuming that all children/adolescents who are given good firearms training are "rational actors" which is an unreasonable assumption.

No matter how much firearms safety and "respect" for guns that are given by parents to children, teenagers remain very impulsive actors and wont behave rationally in many circumstances, therefore throwing at least some of their "good training" out of the window.

News sources are reporting that the shooter's mom trained her sons in firearms and took them out for target shooting on a regular basis. My bet is that she preached firearm safety too, but in the shooter's case it didnt seem to matter.

Having a gun at home is dangerous, ESPECIALLY when there are children or those with mental issues at home. They behave unpredictably, regardless of what kind of training they get.

 

[Socrates25]

I, like many, am trying to figure out what I can do. Yes, we've had many wake-up calls as a country. But unfortunately it takes some personal connection to an event to get folks in action. My six year old reading a Highlights magazine next to me on the couch is that current connection. 20 sets of parents can't do that right now.

Good place to start is to ASSUME your own children will have contact with guns and teach them how to handle that accordingly. Seem farfetched? I thought so too until I found out that a good physician friend of mine (who lives down the street, where my 8 year old plays with their son several times a week) has a shotgun and handgun in the house. I've known this guy for 15 years and he never bothered to mention that to me until about a month ago.

 

[diagonal]

Good place to start is to ASSUME your own children will have contact with guns and teach them how to handle that accordingly. Seem farfetched? I thought so too until I found out that a good physician friend of mine (who lives down the street, where my 8 year old plays with their son several times a week) has a shotgun and handgun in the house. I've known this guy for 15 years and he never bothered to mention that to me until about a month ago.

Last I checked, this incident had nothing to do with how to properly handle a gun. He seemed to have that box checked.

 

[Enkidu]

An armed populace is less likely to be ruled by tyranny - those are the origins. Also an armed citizen has the resources to defend his home and family from those that wish harm upon him. If that is not a fundamental right, what in the hell is? Guns have already been invented, there's no way to erase that reality. Any efforts to outlaw guns, by definition, will only affect law-abiding citizens. There will always be a black market for guns, because, well, guns exist. And they are a very handy tool for criminals and the depraved. Criminals will ALWAYS have guns. But the last thing I want is said criminal coming into my home and standing face to face with my wife or child, while I sit in the corner castrated by idealists that look at life through a latte-colored lens.

What don't you get about that?

This is the lamest argument that simply won't die. That situation in which a criminal breaks into your house and you shoot him with your gun is every right-wing loony's wet dream. But it's not reality.

The incidence of children being injured or killed by guns around the house is massively higher than the incidence of them being "protected" in that way. Everybody knows this.

As for the whole tyranny business - it's beyond ridiculous. What will these patriotic gun-owners do? Overthrow the government? Commit acts of domestic terrorism?

Guns kill kids, period.

 

[diagonal]

This is the lamest argument that simply won't die. That situation in which a criminal breaks into your house and you shoot him with your gun is every right-wing loony's wet dream. But it's not reality.

The incidence of children being injured or killed by guns around the house is massively higher than the incidence of them being "protected" in that way. Everybody knows this.

As for the whole tyranny business - it's beyond ridiculous. What will these patriotic gun-owners do? Overthrow the government? Commit acts of domestic terrorism?

Guns kill kids, period.

Guns kills kids. Ha! Good one. You should get a bumper sticker with that on your Prius.

Oh wait, cars also kill kids. A lot more kids than guns. Sell your car and buy a horse.

 

[Enkidu]

Guns kills kids. Ha! Good one. You should get a bumper sticker with that on your Prius.

Oh wait, cars also kill kids. A lot more kids than guns. Sell your car and buy a horse.

That's a straw man. Guns are designed to kill people - shoot burglars and overthrow tyranny, just like you said. It's not analogous to a car.

But I am well-versed with guns. I've been in the army since 2002. While you have been pretending to "overthrow tyranny" by keeping guns around the house, we actually were overthrowing tyranny abroad.

Frankly, I find American gun culture to be pathetic. It's dreams of glory - one day being able to shoot a bad guy who really deserves it. How Awesome! That urge is even stronger than your common sense. Adam Lanza wasn't going to kill 20 kids with a car, he wasn't even going to do it with a knife. He needed guns, and thanks to our ridiculous laws, he had them.

 

[diagonal]

That's a straw man. Guns are designed to kill people - shoot burglars and overthrow tyranny, just like you said. It's not analogous to a car.

But I am well-versed with guns. I've been in the army since 2002. While you have been pretending to "overthrow tyranny" by keeping guns around the house, we actually were overthrowing tyranny abroad.

Frankly, I find American gun culture to be pathetic. It's dreams of glory - one day being able to shoot a bad guy who really deserves it. How Awesome! That urge is even stronger than your common sense. Adam Lanza wasn't going to kill 20 kids with a car, he wasn't even going to do it with a knife. He needed guns, and thanks to our ridiculous laws, he had them.

Actually, he stole the gun. And don't pretend to know my history.

 

[oldbearprofessor]

Back and forth increasingly hostile debates about the details of the events in CT are not best carried out on the pediatric forum. Please go to SP or similar places on SDN or elsewhere for that. The purpose of this thread on the pediatric forum is to discuss the role of pediatricians in advocating for, or not advocating for, changes in regulation of firearms. Keep it to that or we'll need to close this thread.

Thanks

OBP

 

[Enkidu]

OBP - Thanks for getting this back on track. Sorry to all if my tone seemed hostile. Like everyone here I've been upset by the shootings. As you mentioned earlier, the AAP probably can't take a stronger position than it already has - but other voices seem to be louder in influencing our national policy.

 

[michigangirl]

Sorry obp, as you know the way this thread has gone was totally not my intention.

Socrates25, I Do agree with you about assuming your kids will be in close proximity to guns- I similarly recently found out about a neighbor whose house my kids frequented having a gun in the home during a random conversation. I was shocked. What are parents to do? Ask each parent of the kids who invite your kids over for a playmate/slumber party if they have a gun in the home? Seems irrational- but is it? The number of children who are doa or come to PICUs due to accidents while playing with guns is just unacceptable.

 

[Stitch]

Some data relevant to children from Up To Date.

Compared with other industrialized countries, the United States has the highest rate of firearm-related deaths among children younger than 15 years of age. Children ages 5 to 14 in America are 13 times as likely to be murdered with guns as children in other industrialized countries. In 2007, 2251 children younger than 19 years of age were killed by firearms, and in 2009, 9981 were injured. Most pediatric firearm-related deaths occur before or within 24 hours of hospital arrival. Nearly all unintentional firearm fatalities in children occur in or around the home; 50 percent occur in the home of the victim, while nearly 40 percent occur in the home of a friend or relative.

Adolescents who carry guns to school report that they do so because they are afraid or because of peer pressure.

Can we all at least agree that we need to address these statistics in some manner?

It seems odd to me that we have more legislation and regulation involving getting a driver's license than we do obtaining a firearm.

So what should we do? I didn't find much evidence that legislation helps, but it's so hard to objectively measure. Maybe the wrong laws are in effect. What steps should we take that are agreeable to both sides here? Should we put police officers and metal detectors in all schools while locking all the doors? This NY Times article has some ideas and describes what other countries have done to tighten regulations.

 

[Perrotfish]

Back and forth increasingly hostile debates about the details of the events in CT are not best carried out on the pediatric forum. Please go to SP or similar places on SDN or elsewhere for that. The purpose of this thread on the pediatric forum is to discuss the role of pediatricians in advocating for, or not advocating for, changes in regulation of firearms. Keep it to that or we'll need to close this thread.

I think what we as physicians can do is to try to steer the conversation away from changes in the regulation of firearms and towards advocacy for mental health. When I've discharged patients from the ward/ED that I considered to be 'at risk' for violence, for example schizophrenics or manic bipolars, my main regret isn't our permissive gun culture as the fact that I have no practical option to help them. Psych hospitals are getting rare, group homes even rarer, and the kind of community intervention team that we rely on to keep people on their meds are so rare they barely exist at all. Where I went to med school even the completely florid schizophrenics, the ones who were catatonic or raving, could expect to spend days or even weeks strapped to a bed in the ER overflow psych trailer waiting for a spot to open up at a mental hospital. If they were lucky enough to catch an ambulance before they got sent to jail, that is.

This is a conversation we could have that doesn't raise any questions about our culture, our freedoms, or our constitution and it seems, at least to me, to be a solution that would have been much more likely to prevent this kind of tragedy than any gun control law I could imagine passing.

 

[olemissbabydoc]

Another twist on this issue - how do we deal with the mental anguish left behind on these children (and all those victims of gun violence)? The survivors are in as much danger as the deceased due to their age it would seem. How many parents will seek direct psychologic/psychiatric help for their children, and how much of this will fall on the general pediatrician?

I feel like I need a good lesson in learning to convince parents of the benefit of strong mental health and its influence in helping these kids be able to lead "normal" lives, as I see an influx of kids that will be seeking psychiatric help/meds from the pediatrician.

 

[Stitch]

Did anyone see this story written by a mom of a 13 year old kid with a mental disorder? Basically he's threatened her, pulled a knife on her and she and her kids live in fear of him. But there's no help for him in 'the system' and she doesn't just want him sent to jail. How many times have we seen someone like here come into the ED at their wits end, and we are unable to help?

 

[olemissbabydoc]

Did anyone see this story written by a mom of a 13 year old kid with a mental disorder? Basically he's threatened her, pulled a knife on her and she and her kids live in fear of him. But there's no help for him in 'the system' and she doesn't just want him sent to jail. How many times have we seen someone like here come into the ED at their wits end, and we are unable to help?

Breaks my heart when these kids come in. We've got a pretty small peds psych unit and they're always at capacity - we can't even attempt to admit 12yr+. There's another nearby facility that will take some overflow and the teenagers, but even then... we're often left with no answers for parents and truly no help.

And I, for one (even almost completing a master's in clinical psychology before med school), feel extremely incompetant in taking care of these kiddos. I'll be doing a month or so in inpatient child psych if the programs will allow the crossover. I really feel it should be an almost required (or at least highly encouraged) "elective" month for peds.

 

[KidDr]

Did anyone see this story written by a mom of a 13 year old kid with a mental disorder? Basically he's threatened her, pulled a knife on her and she and her kids live in fear of him. But there's no help for him in 'the system' and she doesn't just want him sent to jail. How many times have we seen someone like here come into the ED at their wits end, and we are unable to help?

It happens all. the. time. in the ER I work at (tertiary referral center, dedicated children's hospital). Psych patients in the ER are inherently risky (from a liability standpoint) and, in general, I feel like these patient encounters are very dissatisfying for the provider, patient, and family. Yes, we can hold your child down and give them IM meds if they're really out of control, and we can admit your child somewhere if we determine they are a threat to themselves or others (though more often than not, we end up admitting to the general pediatric ward because there are no psych beds available). But I rarely feel like I did anything for the families we send back out into the world to navigate the outpatient psych system (and I feel like we only did a tiny bit more for the kids we end up admitting). Our ER social workers, as a whole, are a good group. But the system is broken.

 

[Stitch]

It happens all. the. time. in the ER I work at (tertiary referral center, dedicated children's hospital). Psych patients in the ER are inherently risky (from a liability standpoint) and, in general, I feel like these patient encounters are very dissatisfying for the provider, patient, and family. Yes, we can hold your child down and give them IM meds if they're really out of control, and we can admit your child somewhere if we determine they are a threat to themselves or others (though more often than not, we end up admitting to the general pediatric ward because there are no psych beds available). But I rarely feel like I did anything for the families we send back out into the world to navigate the outpatient psych system (and I feel like we only did a tiny bit more for the kids we end up admitting). Our ER social workers, as a whole, are a good group. But the system is broken.

So what is the solution? Does it take funding to build facilities? How do we make incentives for people to go into child or adolescent psych?

 

[henge]

So what is the solution? Does it take funding to build facilities? How do we make incentives for people to go into child or adolescent psych?

There are a lot of very good reasons to improve child psych treatment and access, but such improvement might have little or no effect on the frequency of mass killings. Today's NYT had an article entitled "In Gun Debate, a Misguided Focus on Mental Illness:"

'According to Dr. Michael Stone, professor of clinical psychiatry at Columbia and an expert on mass murderers, “Most of these killers are young men who are not floridly psychotic. They tend to be paranoid loners who hold a grudge and are full of rage.”

Even though we know from large-scale epidemiologic studies like the E.C.A. study that a young psychotic male who is intoxicated with alcohol and has a history of involuntary commitment is at a high risk of violence, most individuals who fit this profile are harmless.

Jeffery Swanson, a professor of psychiatry at Duke University and a leading expert in the epidemiology of violence, said in an e-mail, “Can we reliably predict violence? ‘No’ is the short answer. Psychiatrists, using clinical judgment, are not much better than chance at predicting which individual patients will do something violent and which will not.”

http://www.nytimes.com/2012/12/18/h...ss-in-gun-control-debate.html?ref=todayspaper

 

[KidDr]

To answer the 2nd question--I have no idea...

As for the 1st question, I would love it if my hospital had an emergency child psych clinic that offered "asap" follow up appointments for kids who don't meet the criteria for hospitalization (or for partial hospitalization programs). The goal would be for high-risk kids to be able to see a psychiatrist (and hopefully a psychologist and social worker) within a few days, without having to hospitalize them. Sometime we put kids in the hospital (or, more commonly, in partial hospitalization programs) because it's the only way for them to see a child psychiatrist within 24 hours (otherwise, most of them are looking at 1-2+ month waits...during which time many of them end up back in the ER). We need to be able to give families better options that fall between the 2 extremes of hospitalization/partial hospitalization (which guarantees seeing a psychiatrist within 24 hours) and a 2+ month wait to see a psychiatrist.

 

[oldbearprofessor]

AAP statement with links

 

[olemissbabydoc]

Thanks OBP

 

[vistaril]

what gun control people don't seem to get is that NONE of the new laws ever proposed do a darn thing to prevent any of these tragedies.

This new obsession with magazine clips is absurd. It takes all of 3-4 seconds for someone to replace a clip in many handguns, and they are portable enough that someone could bring enough to get off a hundred rounds easy.

The background check thing is stupid as well. A lot of criminals aren't going to go through proper channels anyways to obtain guns. Or like lanza they just take their mom's gun. And a lot of them with no criminal history(which many of them dont have) and no psych committments(which most don't have) aren't going to be flagged any ways.

When the gun control crowd is presented with these obvious facts(that there solutions wouldnt do anything), they get defensive or present a strawman argument.

We already have way too many silly gun laws on the books.

What the gun control really wants is england-like gun culture. They realize they have a better chance vacationing on Saturn than this happening here(for a lot of reasons), so they go down these other paths(magazine clips, background checks) that are of no value whatsoever.

 

[henge]

Given our limited ability to understand the consequences of laws, I hope you'll understand if everyone does not share your view that "NONE" of the gun laws has ever presented "any" tragedy.

I am curious, though, as to the perceived harm. Assume for the moment, that the Constitutional right to bear arms is not completely unlimited and does not give anyone the right to possess WMD, artillery, shoulder launched surface to air missiles, etc., nor are terrorists and felons Constitutionally entitled to own weapons, so we're really just talking about here line drawing. In keeping with the principle that we should do no harm: What harm would it do to restrict clip size? What harm would it do to increase background checks?

 

[oldbearprofessor]

The purpose of this thread was to discuss the response of pediatricians to this topic. This has been done and general discussion of this topic should be done on the innumerable other SDN threads about gun control.

Therefore...

closed.