Highlight
Impact on Pediatric Mental Health
Children whose parents sustain firearm injuries experience a statistically significant increase in psychiatric diagnoses, with an additional 8.4 cases per 1000 youths annually compared to matched controls.
Rise in Trauma-Related Disorders
The most pronounced increase was observed in trauma-related disorders, including Post-Traumatic Stress Disorder (PTSD), which rose by 8.5 diagnoses per 1000 youths following the parental injury.
Increased Healthcare Utilization
Parental firearm injury is associated with a substantial rise in mental health visits—23.1 additional visits per 1000 youths—indicating a high demand for psychological support in the aftermath of such events.
Background: The Unseen Victims of Firearm Violence
Firearm violence in the United States is a public health crisis with far-reaching consequences that extend well beyond the primary victim. While the physical toll on those injured or killed is documented, the secondary effects on family members—particularly children—have remained historically understudied. Current estimates suggest that approximately 20,000 children lose a parent to firearm injury every year in the U.S. However, this figure does not account for the thousands more who witness a parent survive a nonfatal firearm injury or who live with the chronic psychological and physical aftermath of such an event.
Clinicians and health policy experts have long suspected that parental firearm injury acts as a significant adverse childhood experience (ACE). Such events can disrupt the home environment, impair parental caregiving capacity, and induce acute or chronic stress. Despite these concerns, there has been a lack of large-scale, longitudinal data quantifying the specific mental health outcomes and healthcare utilization patterns of children following a parent’s firearm-related injury. The study by Karandinos et al., published in the New England Journal of Medicine, addresses this gap by analyzing over a decade of insurance claims data to illuminate the psychological burden carried by these youths.
Study Design and Methodology
To evaluate the impact of parental firearm injury on children, researchers conducted a retrospective cohort study using U.S. commercial health insurance claims data spanning from 2007 to 2022. The study cohort consisted of youths aged 1 to 19 years whose parents received medical treatment for a firearm injury (the exposure group).
To ensure a robust comparison, each exposed youth was matched with up to five control youths. Matching criteria included the year and month of the event, youth sex, geographical location (metropolitan statistical area and state), insurance plan type, and prescription drug coverage. To further refine the comparison, the researchers balanced the groups based on the youths’ age and a risk score that predicts future healthcare utilization, serving as a proxy for baseline health status.
The primary outcome measured was the diagnosis of a psychiatric disorder. This was assessed as a rate—the number of youths with at least one related insurance claim per month divided by the total number of youths in the group. Secondary outcomes included substance use disorder diagnoses, general healthcare utilization (such as emergency department visits or hospitalizations), and total medical spending. The researchers utilized a difference-in-differences (DID) approach, comparing the change in outcomes from 12 months before the injury to 12 months after the injury between the exposure and control groups. This model adjusted for age and risk scores to isolate the effect of the firearm injury itself.
Key Findings: Quantifying the Psychological Toll
The study examined 3,790 exposed youths and 18,535 matched controls. The mean age of the participants was 10.7 years, with a nearly even distribution of sex (51.5% male). The results provide clear evidence of a significant psychological impact on children following a parental firearm injury.
Psychiatric Diagnoses and Trauma
The most striking finding was the increase in psychiatric diagnoses among children in the exposure group. Compared to the control group, parental firearm injury was associated with an additional 8.4 psychiatric diagnoses per 1000 youths per month, averaged over the first year following the injury (95% CI, 4.8 to 12.0). When looking specifically at trauma-related disorders, including PTSD, the increase was even more pronounced, with an additional 8.5 diagnoses per 1000 youths (95% CI, 6.0 to 10.9). This suggests that the mental health burden is heavily weighted toward acute stress and trauma responses.
Mental Health Service Utilization
The increase in diagnoses was reflected in healthcare utilization patterns. The exposure group saw an additional 23.1 mental health visits per 1000 youths (95% CI, 8.2 to 38.1) over the year following the parental injury. This indicates that families are seeking professional help, though it also underscores the increased pressure on the pediatric mental health infrastructure.
Stability in Other Medical Domains
Interestingly, the study did not find significant changes in other areas of healthcare. There were no apparent relative increases in substance use disorder diagnoses, general medical encounters, surgical procedures, or overall medical spending. This suggests that the health impact of parental firearm injury is highly specific to the psychiatric and psychological domains, rather than manifesting as general physical illness or increased use of acute medical services for non-psychiatric reasons.
Expert Commentary and Clinical Implications
The findings of this study reinforce the conceptualization of firearm violence as a multi-generational trauma. For pediatricians and family medicine practitioners, these data emphasize the necessity of screening for parental health events and domestic trauma during routine well-child visits. When a parent sustains a firearm injury, the child effectively becomes a secondary patient who requires monitoring for signs of PTSD, anxiety, and other trauma-related conditions.
Trauma-Informed Care
Clinicians should adopt a trauma-informed approach when treating children in these circumstances. This includes recognizing that behavioral changes, academic decline, or somatic complaints may be rooted in the psychological stress of the parental injury. Early intervention through counseling or family therapy may mitigate long-term psychiatric morbidity.
Study Limitations
While the study is comprehensive, it has limitations. The use of commercial insurance claims data means the findings may not be fully generalizable to uninsured populations or those on Medicaid, who may face different barriers to accessing mental health services. Furthermore, claims data only capture conditions that are formally diagnosed and treated; the actual psychological burden may be higher if many children suffer in silence without seeking professional care. The study also does not distinguish between intentional (assault/self-harm) and unintentional firearm injuries, which might carry different psychological nuances for the child.
Conclusion: A Call for Comprehensive Support
The research by Karandinos et al. provides empirical evidence that parental firearm injuries are associated with a significant and measurable increase in psychiatric disorders and mental health service use among children. These findings highlight a critical window for intervention. As the medical community continues to grapple with the epidemic of firearm violence, it is essential to look beyond the immediate victim and provide comprehensive, trauma-informed support for the families—and especially the children—left in the wake of these events.
Future research should focus on the long-term developmental trajectories of these children and evaluate the effectiveness of specific interventions designed to support families after firearm-related trauma. For now, the data serve as a stark reminder that the bullets fired in firearm incidents leave scars on more than just their primary targets.
Funding and References
This study was funded by the National Institute for Health Care Management and the National Institute of Mental Health.
Reference: Karandinos G, Giuriato M, Zubizarreta JR, Koh KA, Masiakos PT, Song Z, Sacks CA. Mental Health Outcomes in Children after Parental Firearm Injury. N Engl J Med. 2026 Jan 29;394(5):475-485. doi: 10.1056/NEJMsa2502702. PMID: 41604640.
