How many more children have to die?

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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