Ask The Experts

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The tragic shooting in Newtown, Connecticut on December 14, 2012 shook all of us, particularly caregivers, teachers, and students. It also has raised national concerns about gun policy and access to mental health services. Below, you will hear from two of our experts here at Duke who specialize in evidence-based treatment of child trauma and in gun violence and risk assessment.


Dr. FairbankJohn Fairbank, PhD, Professor of Psychiatry and Behavioral Sciences and Co-Director of the UCLA-Duke University National Center for Child Traumatic Stress

What can be done for children who have experienced a traumatic event?
What are the consequences for children who experience multiple events, and don’t get treatment?
What are the barriers to care for children who are exposed to trauma or violence?
Could untreated trauma in children contribute to violence, e.g., if children who experience violence don’t get help, will they go on to become violent themselves?
 

Jeffrey Swanson, PhD, Professor of Psychiatry and Behavioral Sciences and Center for Child and Family Policy Faculty Fellow

How is violence related to mental illness, if at all?
Can experts predict violent behavior in people with mental illness?
Could gun violence be reduced by improved mental health screening and access to treatment?
Specifically, how much of the gun injury problem relates to suicide, rather than violent acts against others?
How effective are laws that prohibit some people with mental illness from possessing firearms?


What can be done for children who have experienced a traumatic event?

DR. FAIRBANK: Helping children can begin at the scene of the event, such as a violent crime or natural disaster, although depending on the nature of the traumatic event and the child’s response, the help may need to continue for weeks or even longer. Some children may need help from a mental health professional; others receive support from parents or other relatives, teachers, religious leaders, close friends. Evidence-based treatments, such as Trauma-Focused Cognitive Behavioral Therapy or Child Parent Psychotherapy, have been developed to support a developmental and trauma focus as part of the therapeutic process. Such interventions often include components to help the child recover from the trauma, such as:

  • Teaching children stress management and relaxation skills
  • Creating a coherent narrative or story of what happened
  • Correcting untrue or distorted ideas about what happened and why
  • Changing unhealthy and wrong views that have resulted from the trauma
  • Involving parents in creating optimal recovery environments
     

What are the consequences for children who experience multiple events, and don’t get treatment?

DR. FAIRBANK: Research studies have identified childhood trauma and adversity as a major risk factor for many serious adult mental and physical health problems, in part because such events alter the child’s normal developmental path. The emerging epidemiological literature suggests that traumatic life events increase the risk of a range of psychopathological outcomes, including PTSD, substance abuse, depression, and poor health outcomes. The Adverse Childhood Experiences (ACEs) Study found a strong, graded relationship between number of ACEs and increased risk for alcoholism, drug abuse, suicide attempts, smoking, poor general health, poor mental health, severe obesity, sexual promiscuity, and sexually transmitted diseases among adult study participants. Trauma, strongly associated with health-risk behaviors, such as smoking and physical inactivity, contributes to multiple health problems, including heart disease, cancer, and liver disease.

What are the barriers to care for children who are exposed to trauma or violence?

DR. FAIRBANK: Many children and families face barriers to accessing appropriate mental health care. Access to mental health care is still not equal to access to physical health care, although the full implementation of the federal Affordable Care Act and the Mental Health Parity and Addiction Equity Act offer the possibility that improvements will be made in this area. At the same time, provider reimbursement rates are being cut for publically funded insurance programs, thus increasing the likelihood that fewer providers will be available to children and families who seek care through those systems. Insufficient numbers of trained mental health providers overall also contribute to an access problem, especially in specialties that focus on children, trauma, disability, or other areas. As HHS Secretary Sebelius recently stated, a stigma still exists around mental illness, and efforts are underway to bring forward a national dialogue around the important issues relation to mental illness, treatment, and support.

Could untreated trauma in children contribute to violence, e.g., if children who experience violence don’t get help, will they go on to become violent themselves?

DR. FAIRBANK: The relationship between mental illness and violence, as Dr. Swanson notes below, is complex, as is the relationship between trauma exposure and mental illnesses, such as major depression, PTSD, anxiety, panic disorder, and other disorders. Increased access to trauma-informed and evidence-based care will reduce the impact of traumatic events and related psychological disorders, and thus it has the potential to reduce illness-related violence, including suicide.

How is violence related to mental illness, if at all?

DR. SWANSON: The best research evidence shows that the large majority of people with serious mental illnesses are not violent, and most violence is not caused by psychopathology. Still, in relative terms, people with disorders such as schizophrenia, bipolar disorder, and major depression are about three times more likely to commit minor-to-serious violent acts than people without mental illness. In uncommon cases violence may be motivated by untreated psychotic symptoms, such as delusional threat perception. But for the most part, the risk factors for assaultive behavior towards others are the same in people with and without mental disorders. For example, being young, male, socially disadvantaged, and using illicit drugs or alcohol elevates the risk for violence far more than having a mental illness.

Can experts predict violent behavior in people with mental illness?

DR. SWANSON: Experts can identify significant risk factors for violence at the group level, but it’s very difficult to accurately predict which individual person will go out and harm someone else. Psychiatrists are not much better than chance at forecasting any violence in their patients. Clinicians’ predictions are more accurate when they are ruling out violence—predicting who is not going to be violent—partly because violence isn’t very common in general. Experts have developed structured risk assessment instruments, questionnaires or interview protocols that systematically collect and score information on known risk factors for violence; some of those instruments are more accurate than clinicians using their own judgment. Predicting relatively common, minor aggressive acts is difficult enough, but predicting mass shootings is virtually impossible; these are needle-in-a-haystack rare events. Description and profiling are not the same as prediction. You can profile the perpetrators of multiple-casualty shootings after the fact and you’ll get a description of troubled young men—which also matches the description of thousands of other troubled young men who would never do something like this. We can’t go out and lock up all the socially awkward young men in the world as a strategy to prevent gun violence.

Could gun violence be reduced by improved mental health screening and access to treatment?

DR. SWANSON: To the extent that some acts of gun violence are actually caused by mental illness, then yes, improving access to effective treatment could help “prevent the unpredicted.” But research shows that about 96% of violence is attributable to other factors besides mental illness. That means that even if we eliminated mental illness entirely—so that people with mental illness had the same risk of violence as everyone else—the overall amount of violence in society would go down by only about 4%. With gun suicide, it’s a different story. Mental illness, especially serious depression combined with alcohol or drug use, is a major factor in suicide. Better and more accessible treatment for depression—targeted to high-risk groups like college students, veterans, even the elderly—could have a big impact in reducing gun suicide, which accounts for the majority of firearm fatalities in the U.S.

Specifically, how much of the gun injury problem relates to suicide, rather than violent acts against others?

DR. SWANSON: Suicides accounted for 61 percent of all firearm fatalities in the U.S. in 2010. That’s about 19,000 of the approximately 32,000 gun-related deaths recorded by the CDC in one year. Suicide is the third leading cause of death in Americans aged 15 to 24, the age group when young people go off to college, join the military, and sometimes experience a first episode of mental illness. The majority of suicide victims had identified mental health problems and a history of some treatment. Suicide attempts with a gun almost always succeed—8 out of 10 are fatal—because they are almost always aimed at the brain at close range, and there is seldom anyone around to call 911.

How effective are laws that prohibit some people with mental illness from possessing firearms?

DR. SWANSON: We need more research to show how well these laws work. One problem is that the definition of a gun-disqualifying mental health record in federal law doesn’t correspond very precisely to dangerousness. For example, federal law prohibits anyone with a history of involuntary commitment from purchasing or possessing firearms. But that will include lots of people who are not dangerous, and it will fail to pick up some who are dangerous. Also, states vary a great deal in their use of involuntary commitment and their policies of reporting gun-disqualifying records to the background check database. If gun prohibition was focused more on evidence of elevated risk of violence or suicidality, and less on mental health background per se, the laws might work better.

In theory, law can be an effective public health tool for addressing the problem of gun violence. Laws can regulate what kinds of guns are available, where they can be used, by whom, and even how they are stored. But since the U.S. Constitution protects a citizen’s basic right to possess a gun, the law can’t go too far in limiting legal access to guns in the population. That means we have to focus more on trying to identify dangerous people who should not have guns. That’s very complicated, because violence is complicated and so are people. Evidence from our recent study in Connecticut suggests that the laws are working, to some extent, in reducing violent crime in some people with serious mental illness. But people with extensive criminal backgrounds may be undeterred by these laws. Fully implementing the laws on the books, and enacting sensible new policies to improve background checks, enhance gun safety, better regulate gun sales and licensing, beef up enforcement and impose stricter penalties on gun law violators, could all have a cumulative effect on reducing firearm injury and mortality.

Gun violence is a complex problem with many causes operating together; our legal and public policy solutions should try to target all of those causes. Mental health is important, especially where suicide is concerned, but it’s only a small part of the overall picture.