Abstract
Firearm suicides among adolescents have increased in the US and rates vary across racial and ethnic groups. In this study, we examined contextual information around adolescent firearm suicides and analyzed how incident characteristics vary across racial and ethnic groups. We analyzed firearm suicides among adolescents (ages 10–18 years) from 2004 to 2020 using data from the National Fatality Review-Case Reporting System (NFR-CRS). There were 4,153 firearm suicides during that period. Suicides often involved males, older adolescents (15–18 years), and handguns. Most firearms belonged to the primary caregiver and incidents frequently occurred at home. However, we found that characteristics varied substantially across racial and ethnic groups. Overall, we provide new information on firearm suicides among adolescents in the US using a larger dataset than previous studies and found significant differences in characteristics and demographics across racial and ethnic groups. This finding suggests the need for tailored prevention strategies.
Introduction
Firearm injuries are the leading cause of death among children and adolescents in the United States (US), with suicides representing a third of those deaths (Centers for Disease Control and Prevention, 2024; Goldstick et al., 2022). Following decreasing rates of adolescent (10–18 years) suicides from 2004 to 2007, adolescent suicide rates have increased 81% from 2007 to 2020 (Centers for Disease Control and Prevention, 2024). In 2020, firearms were the method used in 45% of adolescent suicides in the US (Centers for Disease Control and Prevention, 2024). Firearms remain the most lethal means of suicide, with fatality rates of roughly 90% (Conner et al., 2019), meaning that adolescents who attempt suicide with a firearm are unlikely to survive.
Evidence suggests that suicide risk for adolescents is three to four times higher if they live in a household with a firearm (Swanson et al., 2021). Although households with children are more likely than households without children to have their firearms stored unloaded and locked, a protective factor against firearm suicide (Azrael et al., 2000; Crifasi et al., 2018), roughly 4.6 million children (<18 years) in the US live in a household with at least one firearm that is stored loaded and unlocked (Azrael et al., 2018; Miller & Azrael, 2022). Moreover, more than one third of adolescents living households with firearms report being able to access their parents’ firearm in less than 5 min, a proportion that falls to nearly one quarter if all firearms are locked (Salhi et al., 2021). A recent analysis of National Violent Death Reporting System (NVDRS) data from five states (reflecting n = 123 youth suicides) indicated that 79% of the firearms used in youth suicides belonged to a parent (59%) or extended family member (20%), highlighting the critical role of household locked and unloaded firearm storage as a suicide prevention strategy (Barber et al., 2022).
There are concerning disparities in suicide mortality by race and ethnicity. These disparities are likely perpetuated by inequities such as historical trauma (Willmon-Haque & BigFoot, 2008), racism (Williams et al., 2019), and systemic barriers to accessing care (Price et al., 2022). American Indian and Alaska Native adolescents have long had the highest rates of suicide relative to any other racial and ethnic group in the US (Centers for Disease Control and Prevention, 2024). However, from 2016 to 2020, rates of suicide among Black non-Hispanic and Hispanic adolescents increased 46% and 30% respectively (Centers for Disease Control and Prevention). Focusing specifically on recent changes in firearm suicides, there are also substantial racial and ethnic disparities. Data from the Centers for Disease Control and Prevention (CDC) indicates that from 2017 to 2020 (a period with available annual data across all racial and ethnic categories), rates of firearm suicides increased 45% among American Indian/Alaska Native non-Hispanic, 31% among Asian/Pacific Islander non-Hispanic, 22% among Black non-Hispanic, and 18% among Hispanic adolescents (Centers for Disease Control and Prevention, 2024). During the same period, firearm suicide rates for White non-Hispanic adolescents declined by 8% (Centers for Disease Control and Prevention, 2024). These data suggest growing disparities among certain US racial and ethnic subgroups.
Previous descriptive epidemiological studies of youth firearm suicides have focused either on data sources with limited contextual data (e.g., CDC WONDER) or have provided more in-depth contextual data on geographically restricted samples (Barber et al., 2022). Given substantial increases in overall adolescent suicide mortality, increases in the use of firearms in adolescent suicides, and growing disparities by race and ethnicity, enhanced descriptive epidemiology of adolescent firearm suicides using a broader, more heterogenous dataset (e.g., greater geographic breadth) is an important prerequisite to effective prevention efforts. Our objective was to describe adolescent firearm suicides across a large dataset representing 40 states.
We first focus on describing sociodemographic factors that have been found to be associated with suicides, particularly firearm suicides (sex, age, and urbanicity). In this regard, previous studies have reported that men and rural areas present higher rates of firearm suicide (Goldstick et al., 2021; Nestadt et al., 2017) and other studies have reported differences in rates and circumstances around suicide between younger (10–14 years) and older (15–17 years) adolescents (De Silva & Diduk-Smith, 2021). We further describe contextual factors (e.g., weapon type, weapon ownership, firearm storage behaviors) associated with firearm suicides (Barber et al., 2022; Shenassa et al., 2004).
While previous studies have explored racial and ethnic differences in adolescent firearm homicides and overall firearm mortality (Mariño Ramírez et al., 2022), limited studies have focused specifically on firearm suicides. This study makes a unique contribution by using a large national data set of adolescent firearm suicides evaluating differences in sociodemographic and contextual variables across racial and ethnic groups. Understanding similarities and differences across groups is key to allocating prevention resources to groups with elevated risk profiles and to designing culturally tailored interventions and outreach strategies with the goal of reducing rates in firearm suicides across all communities.
Methods
We examined de-identified data reported in the National Fatality Review-Case Reporting System (NFR-CRS), a system that encompasses and standardizes information discussed during child death review (CDR) meetings (Covington, 2011). Multidisciplinary CDR teams discuss child and adolescent deaths to identify contributing factors for the fatality, beyond forensic information. CDR teams often include representatives from law enforcement, child protective services, prosecutor/district attorney offices, coroner and medical examiner agencies, pediatricians or other health care providers, public health agencies, schools, and emergency medical services. In addition to demographic information (e.g., age, sex, race, ethnicity, and urbanicity), NFR-CRS data includes information on the circumstances of death, for example where the incident occurred, or the type of weapon involved. For deaths involving firearms, the dataset contains information on the type of firearm, firearm ownership (i.e., who the firearm belonged to), as well as storage variables, such as whether the firearm was kept unlocked and/or loaded. The origins and structure of NFR-CRS and CDR, and their strengths and limitations, have been documented elsewhere (Covington, 2011).
We obtained information on firearm-related suicides occurring among adolescents 10 to 18 years (including 18-year-olds) and occurring from 2004 to 2020, a period based on data availability. Data included in this study came from 40 states. Missing information from 10 states may be due to sharing restrictions, states not utilizing the NFR-CRS, or because states did not report deaths in the NFR-CRS consistent with the inclusion criteria of the study.
We included deaths where we could determine race and ethnicity of the adolescent, removing observations where we could not make such determination (n = 91). We further removed a small number of observations where sex was not specified or determined (n = 14). We categorized deaths into six racial and ethnic groups. These were (in alphabetical order): American Indian/Alaska Native non-Hispanic (AI/AN non-Hispanic), Asian/Pacific Islander/Native Hawaiian non-Hispanic (API/NH non-Hispanic), Black non-Hispanic, Hispanic (of all races), Multiracial non-Hispanic, and White non-Hispanic.
Descriptive statistics were used to describe sociodemographic and incident characteristics overall and across the six racial and ethnic groups. These variables included sex, age (10–14 and 15–18 years), urbanicity (frontier, rural, suburban, or urban), type of firearm (handgun, rifle, or shotgun), firearm storage (stored loaded, stored unlocked, stored loaded, and unlocked), if the firearm belonged to the adolescent’s primary caregiver, and location of incident (home, other, or undetermined locations). Within urbanicity, those incidents reported as having occurred in a frontier area (n = 21) were categorized as rural. We treated undetermined (where responses were unknown or missing) as a separate category, except for location of the incident. We used chi-square analyses to examine differences in these factors across racial and ethnic groups. For each chi-square analysis, we removed observations where information was not specified or determined.
Results
The analytic dataset included 4,153 adolescent firearm suicides reported in the NFR-CRS that occurred from 2004 to 2020. These deaths represent 34% of adolescent firearm suicides reported by the CDC during the same period (n = 12,040). A description of these incidents, stratified by race and ethnicity, are presented in Table 1. Among adolescents who died by firearm suicide, 2% were AI/AN non-Hispanic (n = 94), 2% were API/NH non-Hispanic (n = 85), 8% were Black non-Hispanic (n = 353), 12% were Hispanic (n = 483), 1% were Multiracial non-Hispanic (n = 61), and 74% were White non-Hispanic (n = 3,077).
Distribution of Adolescent Firearm Suicides Among Racial and Ethnic Groups, by Sociodemographic and Firearm-Related Characteristics, 2004–2020.
Most adolescents were male (85%) and the proportion of firearm suicides involving a male adolescent was higher across all racial and ethnic groups (>74%). However, there were significant differences in the male/female ratio across racial and ethnic groups (χ2 = 11.65, df = 5, p ≤ .05). The proportion of females was highest among API/NH non-Hispanic (25%) and was lowest among Black non-Hispanic (11%) adolescents. Similarly, most adolescent firearm suicides occurred in adolescents aged 15 to 18 years (75%) but there were statistical differences in this proportion across racial and ethnic groups (χ2 = 28.41, df = 5, p ≤ .01). AI/AN non-Hispanic adolescents had the highest proportion (83%) of adolescents aged 15 to 18 years, while API/NH non-Hispanic adolescents had the lowest proportion (65%).
More firearm suicides occurred in rural (33%), as well as suburban areas (32%), relative to urban areas (23%). There were significant differences across racial and ethnic groups across incident urbanicities: urban (χ2 = 272.42, df = 5, p ≤ .01), rural (χ2 = 257.61, df = 5, p ≤ .01), or suburban areas (χ2 = 31.60, df = 5, p ≤ .01). A higher proportion of deaths among Black non-Hispanic, Multiracial non-Hispanic, and Hispanic adolescents occurred in urban areas (>35%), while a higher proportion of deaths among API/NH occurred in suburban areas (53%) and a higher proportion of firearm suicides among AI/AN non-Hispanic and White non-Hispanic adolescents were in rural areas (>38%).
Handguns accounted for the majority (62%) of adolescent firearm suicides, but this proportion differed significantly across racial and ethnic groups (χ2 = 161.01, df = 5, p ≤ .01). The percentage of firearm suicides involving handguns was higher among Black non-Hispanic, Hispanic, and Multiracial non-Hispanic adolescents (>75%). Roughly 28% of adolescent firearm suicides involved long guns (i.e., shotguns or rifles), thought this percentage increases to 39% in rural areas. Similar to handguns, across racial and ethnic groups, there were significant differences in the proportion of adolescent firearm suicides involving long guns, both shotguns (χ2 = 69.40, df = 5, p ≤ .01), and rifles (χ2 = 100.49, df = 5, p ≤ .01). The percentage of firearm suicides involving shotguns was higher among White non-Hispanic adolescents (18%), while the percentage of suicides involving rifles was higher among AI/AN non-Hispanic adolescents (37%).
In the 1,143 deaths where household firearm storage could be determined (i.e., loaded and locked status), 52% of firearms were kept loaded and unlocked (i.e., least secure storage). This proportion varied significantly across racial and ethnic groups (χ2 = 31.07, df = 5, p ≤ .01). Among deaths where storage status could be determined, Black non-Hispanic and Hispanic adolescents had the highest percentage of firearms kept loaded and unlocked (>62%).
Firearms used in these suicide deaths mainly belonged to the primary caregiver (48%) and most incidents occurred at the adolescent’s home (75%). However, the percentage of firearms belonging to the primary caregiver significantly varied by race and ethnicity (χ2 = 47.14, df = 5, p ≤ .01). While 72% of firearms used in suicides among API/NH non-Hispanic adolescents belonged to the primary caregiver, this percentage was 33% for Black non-Hispanic adolescents. There were also differences when examining incident location, specifically the proportion of firearm suicides occurring at home was lower among Black non-Hispanic, Hispanic, and AI/AN non-Hispanic adolescents (<70%).
Discussion
We examined child death review (CDR) reports from 4,153 firearm suicides of adolescents aged 10 to 18 years that occurred across 40 states from 2004 to 2020. These suicides represent over one third of adolescent firearm suicides reported by the CDC during the same period (Centers for Disease Control and Prevention, 2024) and encompasses a greater breadth than prior analyses (Barber et al., 2022). In this regard, while a previous study reported on the contextual aspects of a small sample of adolescent firearm suicides across only five states (Barber et al., 2022), our study explored contextual aspects from a significantly larger and more diverse number of suicide decedents and examined differences in sociodemographic and incident characteristics across racial and ethnic groups, with the goal of informing tailored prevention and outreach strategies and reducing disparities in suicide.
Males represent a large majority of suicide deaths in this dataset, underscoring sex as a well-known risk factor for suicide (Goldstick et al., 2021). Prior studies have reported that suicide deaths are increasing among adolescent females (Ruch et al., 2019), and our study indicates that the male/female ratio is not homogeneous across racial and ethnic groups. There was a higher percentage of female suicide decedents among API/NH non-Hispanic adolescents. Similarly, consistent with national data, older adolescents (15–18 years) represented three quarters of deaths, yet important racial and ethnic differences in terms of the age distribution of firearm suicides were identified in our analysis. Proportionally, Hispanic and AI/AN non-Hispanic adolescents who died by suicide were older (i.e., high school age) while API/NH non-Hispanic adolescents represented a higher proportion of younger adolescents (ages 10–14 years). More research is needed to understand elevations in risk occurring among school age and early adolescent youth in racial and ethnic subgroups. A key implication of these data is the need to offer prevention programing that meets the unique needs of children and adolescents in different racial and ethnic groups, as well as screening for suicide risk at younger ages. Additionally, individuals who have frequent contact with adolescents and teenagers (e.g., school employees and church/religious youth group leaders) should receive training to recognize signs of depression and risk factors for suicide and may also be key partners in offering safe firearm storage education
Previous studies have suggested that firearm suicide rates in rural communities are increasing at an alarming rate (Goldstick et al., 2021). Isolation in rural areas, limited access to behavioral health care (Hirsch & Cukrowicz, 2014), and increased access to firearms contribute to disparities in poor mental health and suicidality among rural populations. Within our dataset, firearm suicides occurred in every type of community, with about one third occurring in rural areas. In this study, firearm suicides among Black non-Hispanic, Hispanic, and Multiracial non-Hispanic adolescents occurred more frequently in urban areas, while suicides among AI/AN non-Hispanic and White non-Hispanic adolescents more frequently occurred in rural areas. Reasons for firearm ownership likely differ across these communities and may impact storage practices; regardless of rural, urban, or suburban residence. Prevention efforts should be tailored to meet the needs of the community.
Although handguns accounted for most of the adolescent suicides in these data, 3 in 10 firearm suicides used a long gun (i.e., rifles or shot gun). This pattern varied by racial and ethnic groups, with important information gleaned regarding the use of long gun types among AI/AN non-Hispanic and White non-Hispanic adolescents. Black non-Hispanic, Hispanic, and Multiracial non-Hispanic adolescents were significantly more likely to use a handgun, whereas AI/AN non-Hispanic adolescents are significantly more likely to use a rifle, compared to White non-Hispanic adolescents, where long guns are used in one third of firearm suicides. A key implication of these findings is the need to assess for long gun storage and access among adolescents at risk for suicide who may reside in areas where hunting and sport shooting is a common practice. Prevention implications include training firearm/hunter’s safety instructors to identify youth at risk for suicide, as well as education for rural families about the need for secure storage of long guns even in homes where parents may feel confident in their teen’s training in safely handle firearms.
Storing firearms unloaded and locked is protective against firearm suicides. Previous studies analyzing adolescent firearm deaths have reported that over one third involved an unlocked firearm, and that among those adolescents at higher risk of suicide, firearms were less likely to be locked (Schnitzer et al., 2019). Among deaths in the current study where household firearm storage could be determined, nearly half of the firearms used were stored unlocked and nearly one in seven were stored both unlocked and loaded. This is a critical reminder of the lifesaving implications of secure household firearm storage. Moreover, a large majority of decedents in this study died at home, with nearly half using a firearm that belonged to their primary caregiver. Given the current youth mental health crisis (American Academy of Pediatrics, 2023) and findings that 85% of youth who died on their first suicide attempt used a firearm (McKean et al., 2018), reducing access to firearms in an adolescent’s home environment is a critical prevention strategy.
Our findings suggest possible differences in firearm access and storage patterns across groups, with firearms more likely to have been reported as loaded and/or unlocked in firearm suicide incidents involving Black non-Hispanic and Hispanic adolescents. Our results also indicate that Black non-Hispanic, Hispanic, and AI/AN non-Hispanic adolescents are more likely to use firearms that do not belong to their primary caregiver and more frequently died in a location other than a family home. Although results around firearm storage and access should be interpreted with caution, as data around these variables were missing in a large portion of adolescent suicides, findings have several implications. There is a need to study factors that influence firearm ownership and family storage decisions in different communities. As levels of new firearm ownership have increased among API/NH non-Hispanic, Black non-Hispanic, and Hispanic populations (Miller et al., 2022; Wu et al., 2022) conducting these studies is important. These data suggest that prevention strategies that encourage families to inquire about secure firearm storage in friend and relative homes where their children spend time may be particularly beneficial in certain communities. Using community engaged strategies such as trusted and credible messengers to impart information about the importance of secure firearm storage may be beneficial (Ewell Foster et al., 2024).
Limitations
Here we note limitations to our study. First, certain data elements had high proportions of missing data—particularly those on firearm storage, highlighting the need for more comprehensive death scene investigation and standardized reporting of firearm storage in surveillance systems, such as the NFR-CRS. Despite this missing data, our results make a key contribution to the field given the lack of similar large datasets with important contextual information on the circumstance such as firearm ownership, and incident location type. In this regard, CDR is an important data source by which communities can learn about the contributing factors that lead to the death of an adolescent. Second, while we examined six racial and ethnic groups, we acknowledge that there is heterogeneity within these groups that is not captured within the examined dataset. We have long known that risk for suicide is not equitably distributed, and this study makes an important contribution to enhance understanding of these disparities in suicide risk among racial and ethnic adolescent populations. Future studies could complement our work by conducting comparative analyses to explore within group variation in adolescent firearm suicides. For example, studies could focus on subgroup differences within the Hispanic population or explore differences by country of origin among first generation Hispanics or API/NH non-Hispanics.
As a descriptive study, we are unable to examine or consider potential temporal factors such as circumstances that preceded the deaths which would provide other important predictive information. In addition, research shows that the COVID-19 pandemic may have impacted suicide dynamics (Yan et al., 2023), yet, given that data in this sample was largely obtained prior to the COVID pandemic’s onset, we were not able to examine any impact of the pandemic on our research questions.
Conclusion
Overall, our results align with previous studies focusing on adolescent firearm suicides yet highlight significant differences across racial and ethnic groups. We found racial/ethnic differences in sex, age groups, urbanicity, types of firearms used, access to loaded and unlocked firearms, who owned the firearm, and incident location. These differences emphasize the need for culturally tailored approaches to reduce adolescent firearm suicides across all racial and ethnic groups. These actions should include the use of credible messengers within each community, as well as factors that may differ across communities such as reasons for firearm ownership, the impact of systemic racism and other inequities such as barriers to accessing resources like mental and behavioral health care that may influence risk for adolescent firearm suicide.
Footnotes
Data Availability Statement
The data for this study are available from the National Center for Fatality Review and Prevention, but restrictions apply to the availability of these data. The data are, however, available from the authors upon reasonable request and with the permission of the National Center for Fatality Review and Prevention.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Dr. Weigend Vargas’ work on this manuscript was funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health under award number T32HD108054. The National Center for Fatality Review and Prevention is funded in part by Cooperative Agreement (UG7MC28482) from the U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA), and Maternal and Child Health Bureau (MCHB). The ideas in this article are those of the authors and do not necessarily represent the official position of the funding agencies. No honoraria, grants, or other form of payment were received for producing this manuscript. The content is solely the responsibility of the authors and does not necessarily represent the official views of the above agencies.
