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There are no words.

There are no words.

On 14 December 2012, Adam Lanza shot and killed his mother before driving from his home to Sandy Hook Elementary School and opening fire on students and staff. Twenty children and six adults were murdered before the gunman committed suicide. Many Oxford University Press authors felt compelled to share their expertise to offer comfort, explanations, and understanding. Here’s a round-up of their recent articles on the tragedy.

UCLA Professor Emeritus Rochelle Caplan on the significant reduction in public mental health care in the United States.

Pediatric psychologist Brenda Bursch offers helpful approaches for parents to explain the tragedy to their children.

Clinical Professor of Psychiatry J. Reid Meloy on warning behaviors that precede mass violence.

Professor of Criminology Kathleen M. Heide on the parricide element of Adam Lanza’s actions.

Associate Professor of Government Elvin Lim on the different political perspectives on the massacre, essential to understanding across party lines and taking non-partisan action on the issue of gun control.

School psychologist Eric Rossen advocates for stronger mental health services in schools.

Professor of Psychiatry Donald W. Black on the diagnosis, treatment, and prevention of antisocial behavior.

School psychologist Robert Hull offers some advice and resources to help traumatized children.

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By Robert Hull

As parents, children, and communities struggle to come to terms with the events in Newtown last week, it is important for educators and parents to be aware of just how deeply children can be affected by violence.

Community violence is very different from other sources of trauma that children witness or experience. Most trauma impacts individual students or small groups, whereas the violence that was experienced in Newtown affected the local community and the entire nation. The lack of warning and the unexpected nature of these kinds of events, combined with the seemingly random nature of the attack, contribute to a change in individuals’ personal views of the world, and their ideas about how safe they and their loved ones actually are. The world comes to seem more dangerous, people less trustworthy.

Exposure to trauma can impact several areas of children’s functioning. Teachers may notice that students who have experienced trauma appear to be shut down, bored, and/or hyperactive and impulsive. Interpersonal skills might be impacted, which can lead to social withdrawal, isolation, or overly aggressive behavior. Students might appear confused or easily frustrated. In addition they might have difficulty understanding and following directions, making decisions, and generating ideas or solving problems.

Family members and educators are often at a loss in how to support students following an event such as what happened in Newtown. The following are guidelines on helping students exposed to community violence:

• Teachers and family members should attempt to maintain the routines and high expectations of students. This directly communicates to children that they can succeed in the face of traumatic events.
• Reinforcing safety is essential following unpredictable violence. Remind children that the school is a safe place and that adults are available to provide assistance.
• Do not force children to talk. This can lead to withdrawal and downplaying the impact. A neutral conversation opening can be stated in this way: “You haven’t seemed yourself today. Would you like to share how you are feeling?”
• Teachers can model coping mechanisms such as deep breathing, relaxation and demonstrating empathy.
• Being flexible is a must following traumatic events. Teachers should allow students to turn in work late or to postpone testing.
• Educators should increase communication with parents in order to provide support that recognizes a specific child’s vulnerabilities.

There are several websites that can provide additional information on supporting students who have been exposed to violence. These include:

• The National Child Traumatic Stress Network
• The National Association of School Psychologists
• The National Center for Children Exposed to Violence

Robert Hull is an award-winning school psychologist with over 25 years of experience working in some of the most challenging of educational settings, and was for many years the facilitator of school psychology for the Maryland State Department of Education. Currently he teaches at the University of Missouri. He is the co-editor, with Eric Rossen, of Supporting and Educating Traumatized Students: A Guide for School-Based Professionals.

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By Donald W. Black

For many years I have pondered the mental state and motivations of mass shooters. The tragic events in Newtown, CT this past week have brought this to the fore. Mass shootings have become everyday occurrences in the United States, and for that reason tend not to attract much attention unless the circumstances are especially heinous, such as this instance in which the victims were young children. We are all left wondering what can be done. While the attention span of the general public and the media is usually a matter of nanoseconds, this mass shooting seems different, and I hope will lead to positive policy changes. This tragedy presents an opportunity for our leaders to step up to the plate and lead and, one hopes, implement rational gun control legislation most of us agree is necessary.

But back to the shooters. As a psychiatrist with an intense interest in bad behavior, I expect that discussions will center on mental health issues which many believe motivate the shooters. I am intensely interested in these “issues” because, to me, the main issue that keeps coming up is that of psychiatric diagnosis. Everyone seems interested in the possibility of a psychiatric diagnosis, because it suggests that we might “understand” the shooter, and this may lead to better identification of future shooters, and both improved treatment and prevention.

But will the presence of a psychiatric diagnosis improve our understanding? Probably not, because — at least in the cases we know about — the apparent psychiatric diagnosis runs the gamut. Some shooters appear to have schizophrenia, others a depressive disorder, and still others a personality disorder, as has been alleged in the case of Adam Lanza. While we seem able to understand that a “crazy” person out of touch with reality might carry out an otherwise senseless act, the thought that someone who is not psychotic carrying out such an act is very unsettling. How could a person who is not psychotic behave this way? For example, depressed persons are by and large not psychotic, yet some will — in the context of being hopeless and suicidal — want to take others with them: spouses, children, etc. More typically, while planning to harm themselves, most depressed persons have no desire to hurt anyone else.

What about the non-psychotic people with a personality disorder? The Diagnostic and Statistical Manual of Mental Disorders — a compendium of psychiatry’s officially recognized disorders (about to come out in its 5th edition) — lists ten personality disorders; the most relevant to our discussion is antisocial personality disorder. This disorder is quite common (up to 4.5% of the population) and causes all manner of problems because the antisocial person always seems to be in trouble with the law, their spouses and families, or their employers.

The term antisocial is almost always misunderstood and is often construed to mean ”shy” or “inhibited,” yet in a psychiatric sense the term suggests rebellion against society. My profession has done a poor job in educating the general public about the disorder and for that reason it remains under the radar screen. (An older term that seems more entrenched is sociopathy.) In the DSM, the diagnosis rests on the person having three or more of seven symptoms (such as deceitfulness, impulsivity, irritability and aggressiveness, etc). Perhaps the most important is “lack of remorse,” which occurs in about half of those diagnosed antisocial. This is what allows the antisocial person to hurt, to mistreat, or even to kill others. These are the “psychopaths” we read about and fear. (Psychopathy is at the extreme end of the antisocial spectrum of behavior.) Few antisocials are killers, but many of today’s mass shooters would fit the description of antisocial personality disorder. I don’t know if Adam Lanza would, but as we peel back the layers of his personal history, we might find that he does.

We don’t know what causes antisocial personality disorder, but like many disorders it probably results from a combination of genetic and environmental factors. I have argued for many years that the federal government needs to direct more funds to investigating its causes and developing effective treatments. Despite its high prevalence and the fact that it contributes to so much of society’s ills, the government has shown little interest in funding research on the disorder. The National Institutes of Health RePORTER website lists only two projects in which the term “antisocial” appears in the title and only five in which the terms “psychopathy” or “psychopathy” are used. Considering that NIH funds literally thousands of projects, this can only be considered hopelessly inadequate. Overcoming this resistance to research on antisocial personality disorder and related conditions must be a priority.

We need wide-ranging projects to explore the origins of antisocial behavior and search for methods to change its course. Geneticists should investigate the mechanisms underlying antisocial behavior, locating genes that might predispose individuals to antisocial behavior and determining how these genes function. Neuroscientists should pinpoint brain regions or networks linked to antisocial behavior and identify biochemical and physiological pathways that influence its expression. A range of treatments — both drugs and therapy — need to be developed, tested, and refined.

Will these steps help us understand the conundrum of the mass shooter? Will they allow us to treat antisocial persons and prevent youth with antisocial tendencies from developing a full-blown disorder? We can certainly hope.

Donald W. Black, MD is a professor of psychiatry at the University of Iowa Roy J. and Lucille A. Carver College of Medicine in Iowa City. He is the author of Bad Boys, Bad Men: Confronting Antisocial Personality Disorder (Sociopathy), Revised and Updated (Oxford University Press, 2013).

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By Kathleen M. Heide, Ph.D.

The mass shooting in Newtown, Connecticut is a tragic event that is particularly painful as it comes at a time when people across the world are trying to focus on the upcoming holidays as the season of peace bringing good tidings of great joy.

Three factors about the Newtown school shooting are noteworthy. First, it was a mass murder. Second, it appears to have been precipitated by the killing of a parent (parricide). Third, it was committed by a 20-year old man. All of these factors are relevant in making sense of what appears to be inexplicable violence.

What drives a person to take an assault rifle into an elementary school and open fire on very young children and the teachers, some of whom died protecting them? Individuals in these cases are typically suicidally depressed, alienated, and isolated. They have often suffered a series of losses and are filled with a sense of rage. All too frequently they see themselves as having been wronged and want to play out their pain on a stage. The fact that mass shootings are routinely covered in depth by the media is not lost on them. They are typically aware that their name will go down in history for their destructive acts. Their murderous rampage is an act of power by an individual who feels powerless. Unable to make an impact on society in a positive way, the killer knows that he can impact the world through an act of death and destruction.

The fact that the first victim was reportedly the victim’s mother is significant. The first victims in other adolescent school shootings have also involved parents in some cases. My research and clinical practice has indicated that there are four types of parricide offenders.

• The first type is the severely abused parricide offender who kills out of desperation or terror; his or her motive is to stop the abuse. These individuals are often diagnosed as suffering from post-traumatic stress disorder or depression.
• The second type is the severely mentally ill parricide offender who kills because of an underlying serious mental illness. These individuals typically have a longstanding history of severe mental illness, often along the schizophrenia spectrum disorder or might be diagnosed as having depression or bi-polar disorder with psychotic features.
• The third type is the dangerously antisocial parricide offender who kills his or her parent to serve a selfish, instrumental reason. Reasons include killing to get their parents’ money, to date the boy or girl of their choice, and freedom to do what they want. These individuals are often diagnosed as having conduct disorder if under age 18 and antisocial personality disorder if over age 18. Some meet the diagnostic criteria of psychopathy. Psychopaths have interpersonal and affective deficits in additional to antisocial and other behavioral problems. They lack a connection to others and do not feel empathy. They do not feel guilty for their wrongdoing because they do not have a conscience.
• The fourth type is a parricide offender who appears to have a great deal of suppressed anger. If the anger erupts to a boiling point, the offspring may kill in an explosive rage often fueled by alcohol and/or drugs.

Interestingly, most parents are slain by their offspring in single victim-single offender incidents. Multiple victims incidents are rare. In an analysis of FBI data on thousands of parricide cases reported over a 32 year period, I found that on the average there were only 12 cases per year when a mother was killed along with other victims by a biological child. In more than 85% of these cases, the matricide offender was a son.

The actual number of victims involved in multiple victim parricide situations was small, usually two or three. Murders of the magnitude as seen in Newtown, CT that involved a parent as a first victim are exceedingly rare.

Assessment of the dynamics involved in the killing of parents is also important in terms of prognosis and risk assessment. The first victims of some serial murderers were family members, including parents. Serial murderers are defined as individuals who kill three or more victims in separate incidents with a cooling off period between them. If the parricide offender intended to kill his parent and derived satisfaction from doing so, he represents a great risk to society. (This type of killer is known as the Nihilistic Killer.)

The gunman’s age (in Newtown’s case, he was 20 years old) is also an important factor in understanding how an individual could engage in such horrific violence. Research has established that the brain is not fully developed until an individual reaches the age of 23 to 25 years old. The last area of the brain to develop is the pre-frontal cortex. This area of the brain is associated with thinking, judgment, and decision making. A 20-year-old man filled with rage would have great difficulty stopping, thinking, deliberating, and altering his course of action during his violent rampage. He is likely to be operating from the limbic system, the part of the brain associated with feelings. Adam Lanza was likely driven by raw feeling and out of control when he sprayed little children with rounds of gunfire. Simply put, it would be very difficult for him to put the brakes on and desist from his violent behavior.

Events like the shooting in Newtown leave society once again asking what can be done to stop the tide of senseless violence. Clearly Adam Lanza and other mass killers have been able to kill dozens of people in a matter of a few moments because of high powered weaponry. It is time to ask whether our nation can continue to allow assault weapons appropriate for our military to be easily available to citizens in our society. It is time for us to ask what can be done to increase access to mental health services to those who desperately need them. My prediction is, when the facts are more clearly known, risk factors will be identified in the case of Adam Lanza and missed opportunities to intervene to help Adam will be uncovered, contributing to the profound sadness that we are experiencing in the United States and across the world.

Kathleen M. Heide, Ph.D., is Professor of Criminology at the University of South Florida. Her lastest book, Understanding Parricide: When Sons and Daughters Kill Parents, was published in December 2012 by Oxford University Press.

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By J. Reid Meloy, Ph.D.

As the debate concerning public and social policy surrounding gun control intensifies, I would like to offer some comments on the identification of individuals who concern us as potential perpetrators of planned killing(s). These thoughts are from the trenches of threat assessment, and don’t address or offer opinions concerning the larger policy issues we face as a country regarding firearms and public mental health care — one of which is emotionally charged and the other sorely neglected.

The usual demographic characteristics such as a young male, loner, psychiatrically impaired, bullied, and angry don’t work as markers of risk, simply because there are hundreds of thousands of individuals in the USA, and the world, who match these demographics and pose no risk at all. The disturbing fact is that targeted violent events, such as the mass murder in Newtown, cannot be predicted because they are too rare. If we attempt to do this, we err on the side of labeling thousands of individuals as potential perpetrators when they are not a risk at all. So where do we turn?

For the past several years we have been working on identifying warning behaviors (acute and dynamic patterns of risk), which may signal an impending act of targeted violence, including mass murder. These patterns create concern in observers, and warrant a reasonable response to mitigate such risk, whether that involves increased community and educational attention, mental health intervention, or law enforcement interdiction. Anyone can evidence these warning behaviors:

1. Pathway warning behavior: any behavior that is part of research, planning, preparation, or implementation of an attack.
2. Fixation warning behavior: any behavior that indicates an increasingly pathological preoccupation with a person or a cause. There is a noticeable increase in perseveration; strident opinion; negative statements about the target(s); increasing anxiety and/or fear in the target; and an angry emotional undertone. It is accompanied by social or occupational deterioration.
3. Identification warning behavior: any behavior that indicates a psychological desire to be a “pseudocommando” or have a “warrior mentality”, closely associate with weapons or other military paraphernalia, identify with previous attackers or assassins, or identify oneself as an agent to advance a particular cause or belief system.
4. Novel aggression warning behavior: an act of violence which appears unrelated to any pathway warning behavior which is committed for the first time, often to test the ability of the individual to actually do a violent act.
5. Energy burst warning behavior: an increase in the frequency or variety of any noted activities related to the target, even if the activities themselves are relatively innocuous, often in the hours or days before the attack.
6. Leakage warning behavior: the communication to a third party of an intent to do harm to a target through an attack.
7. Last resort warning behavior: increasing desperation or distress through declaration in word of deed; there is no other choice but violence, and the consequences are justified.
8. Directly communicated threat warning behavior: the communication of a direct threat to the target or law enforcement beforehand.

If we observe these warning behaviors in others, we should be concerned. If we see something, we should say something. We don’t know if these warning behaviors predict targeted violence, yet these accelerating patterns have been found in a number of small samples of subjects in Germany and the US that have committed school shootings, mass murders, attacks and assassinations of public figures, and acts of terrorism. We are getting some tantalizing results: in comparing a small sample of school shooters and school threateners in Germany, our research group (with Dr. Jens Hoffmann) found that the school shooters were much more likely to exhibit pathway, fixation, identification, novel aggression, and last resort warning behaviors when compared to the school threateners who had no intention to attack. Although the samples were small, the effect sizes were large in a statistical sense.

The paradox in all this work — targeted violence threat assessment — is that we will never know which of the individuals of concern would have carried out an act of violence if there had been no intervention.

J. Reid Meloy, Ph.D. is Clinical Professor of Psychiatry at the University of California, San Diego, and President of Forensis, Inc., a nonprofit dedicated to forensic psychiatric and psychological research. He co-edited Stalking, Threatening, and Attacking Public Figures (OUP, 2008) with Lorraine Sheridan and Jens Hoffmann, and is currently co-editing another volume entitled International Handbook of Threat Assessment, which is scheduled to publish in 2013. Learn about his latest news by following Forensis on Twitter at @ForensisInc. The scientific basis of this blog article is available in Behavioral Sciences and the Law, 30:256-279, 2012.

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By Brenda Bursch

Children look to their parents to help them understand the inexplicable. They look to their parents to assuage worries and fears. They depend on their parents to protect them. What can parents do to help their children cope with mass tragedy, such as occurred this week with the shooting at Sandy Hook Elementary School in Newtown, Connecticut?

The first thing that parents can do is to calm themselves. Remember that your children will react to your fear and distress. It will be reassuring to them to see that you are calm and not afraid to discuss the event with them.

Next, parents can consider limiting their children’s exposure to media coverage and to adult discussions of the shooting. Young children may have particular difficulty understanding what they see on news stories and what they overhear from adult discussions. They may also have difficulty assessing their own level of safety.

It can be helpful for parents to check in with their children in order to learn about their thoughts and emotional reactions to the shooting. After carefully listening to their children, parents can then determine if it is necessary to correct distressing misunderstandings, answer questions, validate feelings of anger or sadness, and remind their children about how their family members and others, including police officers, help to keep them safe.

Most children will not be traumatized by their media exposure to the shooting, but they may have questions or concerns. Some children will be fearful about returning to school or have other signs of distress, but will adjust with the support and reassurances provided by parents and others. Children who are especially sensitive, those who have a tendency to worry, those with little emotional support, and those who have been previously traumatized, may be more vulnerable.

Trauma symptoms among children vary, but include talking about the event, distress when reminded of the trauma, nightmares, new separation anxiety or clinginess, new fears, sleep disturbance, physical symptoms (such as stomachaches), and more irritability or tantrums. Children may regress, that is, soothe or express themselves in ways they did when they were younger. For example, they might want to sleep with parents or they may wet the bed. Parents might notice an increase in behavioral problems or a decrease in school functioning. If these symptoms don’t improve in the coming weeks, such children may benefit from professional assistance.

Children are reassured by calm and supportive adults, by their normal routines, and by age-appropriate information when they have questions or misconceptions. For those children with ongoing signs of trauma, effective treatments are available. For additional information, parents can access information from the National Child Traumatic Stress Network website.

Brenda Bursch, PhD is a pediatric psychologist and Professor of Psychiatry & Biobehavioral Science, and Pediatrics at the David Geffen School of Medicine at UCLA. She is co-author of “How Many More Questions?” : Techniques for Clinical Interviews of Young Medically Ill Children.

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By Rochelle Caplan, MD

Surely the time has finally come to put our heads together and focus on three seldom connected variables regarding mass murders in the United States: the lack of comprehensive psychiatric care for individuals with mental illness, poor public recognition of the red flags that an individual might harm others, and easy access to firearms.

How should we address the first problem? The fiscal problems this country has faced during the past decade, combined with skewed budget priorities, have lead to a significant reduction in public health care, in particular for mental illness. Insurance companies have limited the time providers have for mental health assessments, the duration and frequency of treatment, and the types of intervention they cover. These cutbacks have forced psychiatrists to do abbreviated and superficial psychiatric evaluations and to prescribe medications as stopgap treatment in lieu of more effective evidence-based therapies. Furthermore, the number of individuals without mental health coverage who also face unemployment, homelessness, or insufficient money to feed and clothe their families — all significant mental health stressors — is steadily rising.

How then can mental health professionals conduct the comprehensive, time consuming evaluations needed to determine if an individual might be dangerous towards others? Self-report questionnaires, another quick method professionals use to conduct psychiatric evaluations, are clearly not the answer. Few people with homicidal or suicidal thoughts acknowledge these “socially unacceptable” intentions or plans on paper. Expert clinical acumen is needed to carefully and sensitively help patients talk about these “taboo” topics and their triggers. A five-to-ten minute psychiatric appointment clearly doesn’t do the job!

The lack of comprehensive mental health care is most sorely evident for such conditions as schizophrenia, as well as psychosis associated with substance abuse, depression, bipolar disorder, neurological disorders, or medical illnesses. In these conditions individuals can be plagued by and act in response to hallucinations that include voices commanding them to kill or visions that incite their aggressive response. Delusions (rigid, pervasive, and unreasonable thoughts) that people threaten them can also cause an aggressive response. Mass murderers might act out their hallucinations and delusions, as in the attempted assassination of congresswoman Gabrielle Gifford and murder of five bystanders, and in the Columbine, Batman, and Virginia Tech massacres.

Lack of time often precludes pediatric professionals from seeing children without their parents and detecting early warning signs of homicidal or suicidal plans. Similarly, physicians might have time to talk to adolescents but not to their parents. As a result, they might miss hearing about red flags of possible aggression by the youth and/or his peers.

The Affordable Care Act (Obamacare) will provide health insurance for more people, but what about quality mental health care? Few mentally ill patients are able to fight for their sorely needed unmet mental health care needs. Due to the stigma of mental illness and the related financial and heavy emotional burden, their families seldom have the power and resources needed to lobby elected officials or use the Internet and other media to publicize their plight.

How can we recognize the red flags of a potential mass murderer? In addition to well-trained mental health professionals with expertise, clinical acumen, and sufficient time with their patients, there is a need to educate the public about severe mental illness. Parents, family members, teachers, community groups, and religious leaders all need instruction to recognize possible early signs of mental illness. This knowledge will help them understand the plight and suffering of individuals with severe mental illness. And, most importantly, this awareness can lead to early referral, treatment, and prevention of violence due to mental illness.

Prompt recognition and early treatment of these symptoms are essential because firearms are so easily obtained in the United States. To get a driver’s license, individuals complete a Driver’s Ed course, pass a knowledge test, take driving lessons, drive a car with an adult for a fixed period, and then take a driving test. The underlying assumption is that irresponsible driving can physically harm others, the driver, and property. For this reason, individuals with epilepsy who experienced a seizure within the past year are barred from driving. Shouldn’t the same principles apply to guns? Yet, individuals can obtain guns without prior psychiatric evaluations, and there are no laws and regulations to safeguard these weapons in homes to prevent children and individuals with severe mental illness from gaining access to them. Reports on accidents caused by children and suicide by adolescents with their parents’ guns are common. According to a Center for Disease Control study, 1.6 million homes have loaded and unlocked firearms (Okoro et al., 2005).

As a child psychiatrist and parent, I regard the Newtown horrific mass murder of elementary age children as a final wake up call so that we will never again ask, “How many more children have to die?” Nothing can justify this preventable tragedy to the parents and families of their murdered beloved ones. The time has come to halt the unrelentless chipping away of our mental health care services and quality of care for mental illness, to educate the community about severe mental illness, and to implement strict controls on access to firearms.

Rochelle Caplan, M.D. is UCLA Professor Emeritus of Psychiatry and past Director the UCLA Pediatric Neuropsychiatry Program. She is co-author of “How many more questions?” : Techniques for Clinical interviews of Young Medically Ill Children (Oxford University Press) and author of Manual for Parents of Children with Epilepsy (Epilepsy Foundation). She studies thinking and behavior in pediatric neurobehavioral disorders (schizophrenia, epilepsy, attention-deficit hyperactivity disorder, high functioning autism) and related brain structure and function; unmet mental health need in pediatric epilepsy; and pediatric non-epileptic seizures.

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