Even before the tears dry and the innocent are laid to rest, the questions come. Why did this terrible tragedy take place? Could anyone have prevented it? And how do we comfort our own children? For answers to these and related questions provoked by this week’s tragedy in Newtown, Connecticut that killed 20 children and six adults, BaltimoreFishbowl turned to Michael Bogrov, M.D., the chief child and adolescent psychiatrist at Sheppard Pratt Hospital.
BFB: From news reports, a fragmented profile of the shooter, 20-year-old Adam Lanza, has emerged. We know he had Asperger’s, a high-functioning form of autism, and was considered “troubled,” though the precise nature of his mental state is unclear. What is clear is that he lived a fairly isolated life. Social isolation seems to be a huge risk factor at play in several recent shooting rampages or attempts by young adults. Could you speak to that?
Dr. Bogrov: Not only is social isolation one of the most significant risk factors, but it is one that people can do something about. People need to have some way of getting feedback about how they’re thinking. If someone is angry or feeling aggrieved, and no one is around as a sounding board, then that anger can escalate without anybody monitoring it.
BFB: Do you believe that the effects of social isolation alone are enough to drive someone to commit a heinous act like the one Adam Lanza carried out; why or why not?
Dr. Bogrov: The short answer is no. There are lots of people who are isolated. But people who are in some way ostracized, that’s a different kind of isolation. Even in that instance, I don’t think that is reason enough to act out. Other risk factors that I think are critical for people to understand include mood instability; people who are not resilient—they can’t tolerate a certain level of distress; impulsivity; and distorted thinking—this goes back to isolation.
But the most important risk factor to a violent act is access to a way of acting out. There are people who may have aggressive or violent thoughts, but if they don’t have a gun and they can’t get a gun, the likelihood of something bad happening is reduced significantly. If you put a gun in the hands of someone like this, the likelihood [of a violent act] goes up significantly.
BFB: Adam Lanza also had Asperger’s disorder, a less severe “cousin” to autism whose primary symptoms typically include problems with social skills and communication difficulties. Do individuals with Asperger’s have a higher-than-normal tendency towards violent outbursts?
Dr. Bogrov: Aspergrer’s is often misunderstood; a better term is high-functioning autism. What’s critical when someone has a psychiatric illness is how that illness is dealt with. Do they have a support system? Do they have a means of achieving their goals? Everyone agreed Adam Lanza was a bright young man, but as I understood it, he wasn’t in school anymore. In Maryland, there are many programs that help people with these disorders transition to college.
The condition doesn’t determine the fate of the person. As with any other medical problem, the strengths are what are so critical: access to care, the ability to achieve their goals, access to an educational system that will understand their unique needs, a means to reduce conflict. So no, I don’t think people with Asperger’s have a higher rate of violence. But because of their condition, individuals with Asperger’s are more prone to frustration, lack of access to appropriate education, and isolation.
BFB: “Mentally ill” is a broad term often used by the public to explain otherwise inexplicable acts of violence such as the one Adam Lanza executed. Is there a direct correlation between acts of violence and mental illness, or is this an unfair generalization?
Dr. Bogrov: When people act violently, the public then looks for a psychiatric illness. There’s a broad range of psychiatric conditions; some are associated with poor impulse control, poor mood stability. Those people are at greater risk for acting out. But people with psychiatric illnesses also are more vulnerable to being the object of violence: being bullied, experiencing stressful conditions; issues of stability. It’s multi-factorial. It’s absolutely not true that people with mental illness are more prone to violence.
BFB: Whether or not Adam Lanza had a specific mental illness diagnosis, he clearly was troubled. And this week, parents around the nation are watching their adolescent, teen-age, and young adult children a lot more closely than usual to discern whether their moody or sulky offspring could be described similarly. Are there certain “red flags” that parents should look for when attempting to determine whether their children’s attitude and behavior warrant professional attention?
Dr. Bogrov: The most important thing is to know that threats—an adolescent might make a threat to hurt himself or others—should be taken seriously. When people say things like “Oh, teenagers say things like that,” to some extent I think they’re anxious that if they engage the person that they’ll be feeding into them [violent threats]. The opposite is true.
It’s important to ask: Do you mean that? Have you ever done something like that before? These are absolutely reasonable questions to ask someone who says something, posts something on the Internet, or draws a picture suggesting a violent threat. Asking these questions is ultimately a very comforting thing to do for someone; it speaks to that social isolation. And if they say “I’m joking,” it’s perfectly fine to press them on it.
One other thing: a parent can look for a change in the level of functioning. Someone who was doing well in school and now is not, who was getting along with their friends and now is not—these are red flags.
BFB: If parents have reason to believe their children are troubled and require professional help, what should their first step be?
Dr. Bogrov: Families need to feel like there’s somebody who can help them. The pediatrician, the school itself, a mental health provider, a hotline or support network: the question isn’t so much where do you start, it’s just that you start somewhere. Start with someone who has some experience.
Sometimes parents or teachers hesitate to make a recommendation that a child see a professional, but I always tell them that most people are ultimately glad to be able to talk to somebody. Parents are not going to traumatize a child by sending them to a child psychiatrist. The risk is in not going.
BFB: What if a child resists treatment?
Dr. Bogrov: It is very common for a parent to worry that his or her child will be angry for the parent getting them into treatment, or putting them in the hospital. Dealing with this is part of the treatment process. I tell parents that when a child’s resistance resolves and treatment helps they will thank the parent’s for making the difficult decision. In a broader sense, if the anger doesn’t resolve, it is more a continued symptom of the underlying condition rather than a reflection of the appropriateness of the decision to seek help.
Resistance to treatment is not unexpected. Part of the skill set of the mental health provider is to recognize and respond to that resistance and create an alliance with the child. Most of the time, particularly when the child is in distress, this is not that difficult to do. Sometimes it is a long process. With a young adult it is more complicated. Intervening, addressing resistance and creating an alliance are still the focus, but in addition the clinician needs to support the patient’s autonomy (taking into account his/her age and developmental level) while working with the parents.
Parents do need to be aware that if they think the child has crossed the line of safety there are multiple avenues available and legal issues involved in getting care for their children. It is more difficult and complicated with a young adult. There are issues of an emergency petition through the police and the courts, and other issues such as placement, which can become complicated. Parents need to be prepared to utilize those external resources despite their anxiety about how it will affect their relationship with the child. Safety is always paramount. I would offer that making such a referral can sometimes help the relationship because the anger a child feels about the intervention can be diffused as it is redirected from the parent to the mental health providers. Mental health providers are trained to expect this and deal with this.
Dr. Bogrov: Absolutely. But again, mental health services treatment in isolation is not a panacea. It’s one element of a plan of care. People may need therapy, medication, sometimes vocational and living assistance, family therapy. But it can’t be done in isolation.
BFB: Everyone is affected by these tragic acts of violence, especially the children who have witnessed or heard about them and may be extremely fearful. What can a parent say to or do for their child to allay these fears, and how does that message change depending on the age of the child?
Dr. Bogrov: While I think we typically ask: What should I say to them? I think the more important question is: How do I listen? The most important thing is to express an interest. Ask your child: Is there anything you want to talk about? Have you and your friends been talking about what happened? This may sound counterintuitive, but if a child feels nervous going to school, parent can validate their feelings by saying things like: I understand your feelings.
I would also add that it’s an absolutely acceptable thing to ask: Jonny’s coming over to your house to play; are there any firearms in your house? Are they properly secured? I would hope the parent on the receiving end would say: Thank you for asking. There’s a temptation for people to believe that having a gun will make you safer. There’s no doubt that having a gun increases the odds of it being used in a way that makes the owner of the gun more vulnerable. Having a firearm around increases the risk of a firearm-related incident.
Michael Bogrov, M.D. is service chief of the Inpatient Child Unit at Sheppard Pratt Hospital, Towson and service chief of the Adolescent Inpatient Unit at Sheppard Pratt Hospital, Ellicott City.