When a firearm injury happens, our systems know exactly what to do with the person who was shot.
Stabilize.
Operate.
Admit.
Discharge.
What they are far less prepared to do is notice the children who go home afterward — the ones whose sense of safety has been quietly, sometimes permanently, disrupted.
A new open-access study in the New England Journal of Medicine asks us to pay attention to those children. In “Mental Health Outcomes in Children after Parental Firearm Injury,” co-authored by Peter Masiakos, MD, and colleagues, put careful data behind what many of us in schools have suspected: when a parent is injured by a gun, children are affected, deeply, measurably, and often invisibly.
This is not speculation. It is evidence.
The Harm Extends Beyond the Hospital
The researchers followed children whose parents survived a firearm injury and compared them with closely matched peers who had not been exposed to parental firearm injury. In the year following the injury, children in the exposed group experienced clear increases in psychiatric diagnoses and mental health visits, driven primarily by trauma- and stress-related disorders, including PTSD.
Two patterns are especially important.
First, injury severity matters. Children whose parents sustained more severe firearm injuries — particularly those requiring intensive care — experienced larger increases in mental health diagnoses. ICU admission functions as an observable marker of severity, but it also creates a point of contact: longer hospitalizations, greater involvement of clinicians and social services, and more opportunity for identification and support.
At the same time, the study makes clear that mental health consequences are not limited to children of severely injured parents. Children whose parents sustained less severe injuries also showed increased mental health needs, yet they are less likely to be identified or engaged by support systems once the injured parent is discharged. In practice, this means that the children who are easiest to miss may also be the ones receiving the least support.
Second, the study found larger mental health effects among female children. This finding matters because girls’ experiences of firearm violence are often underrecognized, even as boys and men account for most firearm deaths. The authors appropriately note that sex differences in diagnosis rates, help-seeking behavior, and clinician bias may shape these findings, including the possibility that mental health needs among boys are underdiagnosed. Still, the signal is clear: the effects of parental firearm injury extend across genders, with particularly pronounced impacts for girls.
Taken together, these findings make something unmistakable: parental firearm injury belongs in the category of adverse childhood experiences. This is a child’s direct exposure to violence, which is not abstract, not theoretical, and not benign. Like other ACEs, it can be severe, ongoing, and compounded by fear, instability, and loss of safety, with lasting effects on brain development and lifelong health. Naming parental firearm injury as an ACE is not about language. It is about whether we notice these children early, respond with intention, and build systems that support them instead of leaving them to carry the consequences alone.
What Doesn’t Show Up Still Matters
The study did not find an increase in substance use disorder diagnoses among children in the year following parental firearm injury. That finding should not reassure us. The children in this cohort were young, and substance use disorders often emerge later, develop gradually, and may never come to medical attention — especially within a limited observation period.
More broadly, this research underscores a familiar limitation: insurance claims only capture what is diagnosed, documented, and billable. They miss the sleepless nights, the hypervigilance, the stomachaches that appear every morning before school. They miss the counseling that happens in school health offices and quiet conversations — care that never generates a claim but often keeps a child functioning.
What this study captures is not the full impact. It is the portion our systems are structured to count.
A Family Wound, Not an Individual One
One of the most important contributions of this article is how clearly it shows that firearm injury is not an isolated clinical event. It is a family-level trauma, with ripple effects that extend well beyond the injured parent.
The mental health impact on children whose parents were injured rivaled — and in some cases exceeded — the impact seen when children are injured themselves. This finding aligns with earlier research showing that parental trauma can be profoundly destabilizing for children, particularly when it undermines their sense of safety and trust in the world.
Fear of further violence.
Changes in caregiving roles.
Financial instability.
Strained family dynamics.
These experiences fit squarely within what we understand as adverse childhood experiences — exposures known to affect brain development, stress regulation, and long-term physical and mental health.
How This Shows Up in Schools — Even When No One Tells Us
For school nurses, none of this is theoretical.
Children do not arrive at school carrying diagnostic codes. They arrive with headaches that don’t resolve, stomach pain that shows up every morning, irritability, withdrawal, exhaustion, and sudden difficulty concentrating.
And often, we do not know what happened at home.
Parents are not required to disclose a firearm injury. Schools are rarely notified. There is no automatic handoff from trauma centers to school health services. So school nurses are frequently asked to respond to the effects of violence without ever being told the cause, to support children whose lives have been upended by an event we are piecing together through symptoms alone.
Sometimes the story comes out.
Often, it doesn’t.
This study reinforces the need for intentional coordination between the teams caring for injured adults and the professionals caring for their children. Hospital-based violence intervention programs can help bridge that gap, as can communication — with permission, between adult care teams and pediatric providers.
Schools are already part of this network, whether or not systems formally acknowledge it.
What School Nurses Can Do — Starting Now
Assume impact, even without confirmation.
When a child shows sudden, unexplained changes after a family crisis, consider trauma — even if no one has told you a parent was injured.
Recognize trauma without waiting for disclosure.
Recurrent somatic complaints, sleep problems, behavioral changes, and difficulty concentrating are often the earliest signs.
Strengthen referral pathways before a crisis.
Know your school-based and community mental health partners and how to quickly access them.
Document patterns, not just visits.
Patterns tell the story that single encounters cannot — and they matter for advocacy and care coordination.
Use the evidence.
This study further supports that firearm injury prevention and trauma-informed care are essential components of school health.
A Policy Responsibility — Not a Side Conversation
This evidence demands action across systems.
Health care teams must look beyond the injured adult and proactively consider the mental health needs of children after parental firearm injury, including supporting communication and coordination with pediatric and school-based providers when families consent.
Schools must be funded and staffed to deliver trauma-informed mental health supports, recognizing that many affected children will never be formally identified or referred through medical systems.
Policymakers must acknowledge firearm injury as a child and family health issue and invest in prevention, coordinated care models, and school-based mental health services accordingly.
This is not about ideology.
It is about what the evidence requires.
Seeing the Wounds That Don’t Bleed
When a parent is injured by a gun, the wound does not stop with the person who was shot. It follows children home. It walks with them into school, often without explanation. It shapes how safe the world feels.
School nurses are trained to notice what others miss — and to act, even when information is incomplete. This research gives us another reason, and another responsibility, to do exactly that.
Because survival is not the same as healing.
And children deserve both.
NEJM Special Article- Mental Health Outcomes in Children after Parental Firearm Injury
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