“Always Protect the Children”
The recent episodes of teenage violence at the Marjory Stoneman Douglas High School in Parkland Florida, and Santa Fe High School in Santa Fe Texas, has reignited the debate over gun violence, and how to best protect our children. As the debate continues, an opportunity exists to examine both what is known about violence in this age group, and related issues regarding their emotional health.
Medically, an individual’s health is divisible into two parts: Physical and Mental. Mental health refers to “the state of the person’s emotional and psychological well-being”. Mental illness refers to conditions/diagnoses that adversely affect a person’s mental health.
Although physical and mental health are both critically important, and interrelated, mental health has historically been underdiagnosed and underappreciated for a variety of reasons. This must change. Consider the paradox that everything a person does, how we live our lives, our very essence, is associated with a variety of thoughts, feelings and emotions.
The development of the human psyche is an extremely complex process based on both nature (genetics), and to a greater extent nurture. The fundamental importance of nurture in promoting emotional health cannot be overstated. Human beings must have love, caring, support, unlimited acceptance, and bonding from at least one person throughout their lifetime. This is especially true during the first 5 years of life, the period of socialization, which provides the fundamental basis for our eventual emotional development. Since it is generally believed that the human brain does not fully develop mentally until approximately age 30, the role of parenting is critical at all stages of the process. The result of this process has an almost limitless array of outcomes. This heterogeneity is a law of nature and one of the basic tenants of medicine. “Everyone is different, no two people are exactly the same”. Everyone is a panoply of circumstances, experiences, thoughts, feelings, emotions, and genetics. And, to make it even more interesting, many of these qualities are quite discordant from each other, much like the multicolored patches of a quilt. It is the essence of who we are.
Parents often lament that “there is no manual on proper child rearing”. In our complex rapidly changing society, wrought with many dangers capable of leading our children astray, we certainly could use one. Left to our own devices, upbringing, beliefs, and imperfections, even with the best of circumstances and intentions, our actions have lifelong consequences on our children’s emotional well-being.
The vast majority of individuals with psychiatric disorders are not violent, and the mentally ill do not commit a substantial proportion of violent crimes in the United States (estimates range from 3-10%). When they do, it is usually unplanned, emotionally filled, and often represents a reaction to being provoked by another individual. This is in contrast to the school shooter, who has a plan, and often acts without emotion during the event.
It is estimated that 20% of children up to the age of 18 in the United States have a diagnosis of mental illness, and half of these, 10% of all children, have a serious mental disorder that impairs their functioning in school, and the community. That these children suffer from their conditions is evident from the myriad of symptoms they may experience:
- Twenty percent of America’s youth have been depressed by the age of 18, and 2.1% of them suffer with it in any given year. It tends to behave cyclically (occurring over months), and the age of onset seems to be decreasing.
- Depression in youth, like that in adults is characterized by either 1 or both of the following:
-Depressed mood, or sadness, “down in the dumps”, discouragement and hopelessness.
-Anhedonia, a loss of interest or enjoyment in nearly all activities.
- Additionally like adult depression, depression in youth is characterized by the following feelings:
.having less energy, feeling tired, speaking slower, or alternatively they may feel fidgety, restless, and move about more than usual (agitated depression)
.Concentrating and thinking may be difficult.
.Feelings of failure, or worthless, having a sense of letting themselves or others down, possibly with excessive feelings of guilt.
- In particular childhood depression is characterized by:
.Difficulty with relationships, and communication, as well as exhibiting a lack of interest in playing with their friends (social isolation).
.Extreme sensitivity to failure or rejection.
.Possibly cry or shout out without explanation.
.Complain of boredom, as well as physical complaints that are often vague, nonspecific, and frequent, including headache, stomach complaints, or muscle cramps.
.School attendance and performance can suffer; they may talk about or actually run away from home.
.Take unnecessary risks, use or abuse alcohol, and other drugs
.More likely to talk about a fear of dying, or feeling better off dead. And, although severe depression appears to play a role in motivating school mass shooters, depressed youngsters are much more likely to contemplate or attempt suicide rather than homicide.
It is second only to accidents as the leading cause of death of 15-19 year olds, and unfortunately the annual rate of teenage suicide has increased from the 1970s to 2014. In distinction to teenage homicide, more than 90% of suicide is committed by those with some form of mental disorder. And many psychiatric disorders are associated with an increased risk of suicide attempts. These include:
.Major depressive disorder (MDD), including bipolar depression, and dysthymia (a form of chronic depression).
.Generalized anxiety disorder (GAD), panic disorder, and social phobia (both anxiety disorders).
.Attention deficit hyperactivity disorder (ADHD)
.Substance abuse disorder.
(The rates of suicide increase with age for MDD, GAD, ADHD, and substance abuse disorder.)
- There is no clear profile of the suicidal child, however risk of suicide is associated with these:
.Thoughts of suicide, and or a family history of suicide.
.Impulsivity, rage, aggression, anti-social behavior.
.Stressors (current or expected) including family, or personal loss.
.Alcohol or substance abuse.
.Overall females are more likely to attempt suicide than men, but men are 3 times more likely to commit suicide, especially with firearms (2014).
.White males and females each are two times at greater risk for suicide than black males and females.
.Suicide usually occurs at home with firearms or pills found in the home.
.Sixty percent of the gunshot deaths in United States are attributable to suicide, and overall 41% of deaths are caused by fire arms (2014).
- It is the third most common cause of death in this age group after suicide and accidents. Fortunately, the overall rate of teenage homicide of 15-19-year-olds has decreased to its lowest level on record (2014).
- As is true for the suicidal teenager there is no profile to identify which teenager will go on to commit a violent act including homicide. Much of what we know of teenagers that commit mass school shootings has been derived from the 19 years of experience since Columbine
- Recent information (New York Times) on the mass school shooter’s psychological makeup, and motivation, appears to often link their actions to those of the Columbine mass shooters of almost 20 years ago. Again, heterogeneity is a major factor, as these individuals possess their own historical circumstances, events, emotions, and genetics. These adolescents are apparently attempting to achieve “dark folk hero status”, including copying and competing with each other. Feeling misunderstood, they feel a connection with shooters of the past, beginning with Columbine. Making matters even worse are the extensive news coverage of the events glorifying the perpetrator, social media, our fragmented society, and ready access to weapons.
- Many suffer from severe depression as well as a history of suicide attempts
- 2/3 were related to being bullied at school, either threatened, persecuted, or attacked.
- Many experienced a lack of social connection with family and peers, and displayed social isolation, withdrawal, and alienation. But these behaviors are common enough in the general population of this age group.
- School related homicide generally accounts for less than 2% of all homicides in this age group.
- 60% of firearm deaths were secondary to suicide.
- 75% of assailants knew their victims (48% were friends or acquaintances, 27% involved family members)
- 20% were committed with no apparent motive.
Many other characteristics may be present in teenagers capable of a violent act or
- Homicide begins to occur around the age of 13 or 14 years old, and continues to rise significantly during each year of adolescence.
- Men are involved in 90%, and females in 10% (and more likely to commit homicide of a parent, child, or boyfriend).
- Homicide rates in black males are 20 times greater than in white males, and 6 times greater in black females than in white females.
- Problems at school, including attendance and performance, the use of alcohol and drugs, and having a history of arrest
- They may commit cruelty to animals or other children.
- Ongoing family problems, including a family history of increased violence doubles the risk of homicide. Children are more likely to come from families where they observe, or experience violence. Violent behavior predicts future violence, the younger its onset the worse it’s prognosis. Having a gun at home triples the rate of violence.
- Anger, acting impulsively or passionately.
- Abuse, neglect, lack of consciousness, or empathy. “The non-empathic murderer” has spent the first year of life with either a non-nurturing mother, or in a poorly staffed institution. These individuals exhibit assaultive behavior, inability to cope with stress, and are generally not responsive to treatment.
- Nihilism, the rejection of all moral or religious principles, often with the belief that life has no meaning.
- ”Black and white” (concrete) thinking.
- Biology appears to contribute.
An individual child’s mental health is perhaps as varied as the heterogeneity of the human psyche itself. This essay provides a glimpse of the human side of mental illness, the suffering these individuals bear, and the related issues of violence. Hopefully a better understanding of the difficulties these children experience will result in a more humane, and empathetic approach to them. Diagnosing and treating these individuals is difficult and best left to psychiatric professionals. Untrained individuals should not attempt to provide these services. However, with a better appreciation of their plight, common sense concerns, and always in their best interest, it is both desirable and appropriate to relay any relevant information to the attention of appropriate social services, and mental health professionals. These individuals then have the responsibility to act always in the best interest of the child. We all need to come together and take the advice of the African proverb “it takes a village to raise a child”. The fundamental belief, “always protect the children”, is still one of the most widely held beliefs that still unites us today. Let it serve as the foundation for a more proactive societal approach to the issues of mental health and violence in our country. It is the most fundamental and best approach, as it attempts to help all our children.
Unfortunately, there are many obstacles making it difficult to evaluate and treat our nation’s mentally ill. And, this is extremely unfortunate because treatment, including therapy and medications, usually provides significant benefit, and improves quality of life. The question is, does the current approach to these patients serve their best interest? Consider the following:
The most significant obstacles in delaying or refusing to seek help, are the stigma and lack of understanding possessed by patients, their families, and the community. Simply stated, “We are unable to help you if you do not come to see us”. Psychological illnesses are considered diseases that must be treated. And often the earlier the treatment the better the outcome. Untreated, these disorders can be as debilitating and life changing as any medical malady, and in many instances even worse.
Our free society grants individuals 18 years and older the right to refuse medical and psychiatric evaluation and treatment, except if they are deemed to pose a current risk of harm to self (suicide), or others (homicide). This serves as the basis for the care and disposition (follow-up), of all patients, but unfortunately results in many individuals not receiving beneficial healthcare. From a medical perspective, relying on individuals with a multitude of heterogeneous psychiatric illnesses, who have not been deemed suicidal or homicidal, to act in their own best interests, may not result in the best care for them, their families, or society.
Clinical competencies and training varies among healthcare providers, including physicians. Also, healthcare providers have appropriate concerns that their actions in caring for this patient population might have legal and professional repercussions against them.
Cost and insurance issues often complicate the ability to provide care to these patients. We must make sure that appropriate ongoing care is available, affordable, and use our healthcare resources appropriately. We must maximize patient compliance, ensure that patients are receiving the care they need, and if necessary the medications prescribed.
Physician Forum supports common sense and reasonable gun laws and policies. It is a social issue that affects public health. We recognize that there are almost as many firearms as people in our country, and they are here to stay. The problem is not responsible gun owners.
However, the nation’s gun laws have evolved over the last 30 years. “The right to bear arms”, as originally granted by the second amendment pertained to our young nation’s militia, with an appreciation of the need to protect our country from foreign adversaries and threats. This remained in effect for approximately 200 years, until about 30 years ago. It was then that the National Rifle Association, (NRA), through the efforts of it’s representative Marian Hammer, succeeded in extending the “right to bear arms”, from the militia based, to the individual based “right”. By changing Florida state laws, and enacting “Conceal and Carry”, and “Stand Your Ground”, the NRA was able to expand an individual’s rights regarding gun portability and usage. Other states subsequently incorporated changes to their laws in much the same way.
Physician Forum is proud of and wishes to thank all individuals involved in combating hatred and violence. Paradoxically, it is the unified voice of our nation’s youth, and their absolute resolve to protect themselves, that appears to be finally uniting their elders to the shared belief that we must “always protect the children”. And in this way, the current efforts of our youth to change gun policy mirrors the efforts of the youth of a former generation in their opposition to what most people ultimately agreed was an unjust war in Vietnam. Stay focused, unified, motivated, to achieve your goals.
Physician Forum wishes to express our deepest sympathy to those touched by violence of any kind. We must all empathize with the emotional and physical pain of all human beings. All of us fortunate enough to have been nurtured and raised by another loving individual show them no greater gratitude.