Extreme Risk Protection Orders for Firearm-Related Harm Prevention in Pediatrics: Results from a Survey of New York State Pediatricians?

Nina Agrawal, MD
Pallavi Arora, MPH, MA
Christopher Knoepke
Gale Burstein
Lucy Leid Simon
Alison Mitzner
Carine Hedari

Firearm-related harm towards self and others is a significant adolescent health problem. Extreme risk protection orders (ERPOs), also known as “Red Flag Laws”, offer an evidence-informed prevention approach. Through a non-criminalizing process, ERPOs remove legal access to firearms from individuals at risk of causing harm. Despite passage of ERPO laws in numerous states and expansion to authorize clinicians to independently file for such orders in some states, including New York, ERPOs remain underutilized. While federal funds are available to promote uptake, there has been a lack of attention to youth-serving clinicians. This study aimed to assess New York State (NYS) pediatricians’ familiarity with and willingness to use ERPOs, understand barriers and facilitators to ERPO use, and offer strategies to improve uptake in pediatric settings.

An anonymous online survey was distributed to New York State American Academy of Pediatrics members from October to December 2023. The survey included 24 items covering awareness, attitudes, and barriers/facilitators to utilizing ERPOs, as well as participant demographics. Responses were descriptively analyzed, with thematic analysis used to characterize open-response data.

Of the 180 participants included in the analysis, most were pediatricians (97%, n=175), were practicing primary care (69%, n=119) for >20 years (56%, n=100) in urban areas (60%, n=107). Slightly more reported encountering, a few times a year, patients “in contact” with a person at risk of harm (e.g. parents, 61%) compared to patients at risk of harming themselves or others (54%). Less than half (42%, n=77) were familiar with ERPOs; while 63% (n=113) reported being likely to file an ERPO, none had ever done so. Most common barriers were lack of knowledge about the ERPO filing process (82%, n=148) and filing criteria (68%, n=123), followed by conducting risk assessments (53%, n=95). Additional barriers described in open-response data included perceived inapplicability to their practice (e.g. neonatology), gun rights infringement, belief in centering mental health support, and retaliation risk from patients/families. Commonly identified facilitators were access to ERPO training (72%, n=130), legal consultation (67%, n=120), filing coordinators (64%, n=115), patient supports (52%, n=94), clinician anonymity (51%, n=103), and liability protections (50%, n=90).

This study is the first to characterize pediatricians’ views regarding use of ERPOs for firearm-related harm prevention in pediatrics. Our findings highlight policy-practice gaps, including lack of knowledge about filing procedures and conducting risk assessments. Our study underscores the importance of allocation of ERPO resources for clinician and patient supports (e.g. education, filing coordinators, crisis response teams, legal protections), particularly within pediatric settings that demand greater sensitivity and caution.

1. Enhance awareness of ERPOs as a tool for firearm injury prevention by clinicians.
2. Understand barriers and facilitators to clinician initiated ERPOs and identify factors specific to pediatricians.
3. Bring attention to unique considerations for ERPO implementation in the pediatric population.