Efficacy of Technology-Augmented Behavioral Counseling for Risky Firearm Behaviors: A Randomized Clinical Trial.

Importance: Firearm violence is a leading cause of morbidity and mortality for US adolescents and emerging adults (A/EAs). Health care visits are an important opportunity to provide preventive counseling addressing risky firearm behaviors (RFBs), which increase fatal and nonfatal firearm injury risk, as well as associated negative health and social outcomes. Objective: To determine the efficacy of a technology-augmented behavioral counseling intervention addressing RFBs among A/EAs seeking emergency department (ED) treatment. Design, Setting, and Participants: This prospective, 2-arm randomized clinical trial was conducted at 2 US trauma center EDs in Michigan. A/EAs aged 16 to 30 years reporting past 3-month firearm carriage and smartphone ownership were enrolled from January 24, 2022, through October 25, 2024, and randomized to either IntERact or enhanced usual care (EUC). Follow-up surveys were conducted through April 2025, with data analysis conducted from May 2025 to November 2025. Intervention: IntERact included (1) 3 sessions of trauma-informed behavioral counseling delivered by a telehealth health coach and integrating motivational interviewing and strengths-based care management; and (2) a smartphone application delivering additional tailored therapeutic content between counseling sessions. Both were delivered during the 30 days after an ED visit. EUC participants received an assessment-only application for 30 days. Participants in both groups received a resource brochure and gunlock(s). Main Outcomes and Measures: The primary outcome was self-reported RFBs evaluated at 3 and 6 months. Secondary outcomes included experiencing physical violence and nonfirearm physical aggression. Exploratory outcomes included violent injuries, violence consequences, criminal justice outcomes, substance use and consequences, mental health symptoms, and any firearm violence. Results: A total of 373 patients were randomized to IntERact (n = 186) or EUC (n = 187). Mean (SD) age was 25.0 (3.7) years, 195 patients (52.3%) were female, and 278 of 371 patients (74.9%) reported past 3-month RFBs at baseline. Compared to EUC, IntERact participants demonstrated significantly greater reductions in RFBs at 6 months (IntERact: -57.4%; EUC: -25.4%; rate ratio [RR] = 0.51; 95% CI, 0.33-0.79). IntERact participants also demonstrated significantly greater reductions in experiencing physical violence at 3 months (RR = 0.46; 95% CI, 0.26-0.81) compared to EUC. Among exploratory outcomes, between-group comparisons demonstrated that compared to EUC, patients in the IntERact group showed greater reductions in violent injuries at 3 and 6 months, as well as violence consequences, substance use, anxiety, and depression outcomes at 6 months. Patients in the IntERact group also showed greater reductions in delinquency, violent offending, and any firearm violence at both 3 and 6 months. Conclusions and Relevance: In this randomized clinical trial among A/EAs reporting firearm carriage, technology-augmented behavioral counseling showed promise reducing RFBs, as well as violence, criminal justice, substance use, and mental health outcomes. Trial Registration: ClinicalTrials.gov Identifier: NCT05109325.