User login
Child gun deaths lowest in states with strictest firearm laws
ORLANDO – and laws restricting children’s access to firearms are linked to reduced pediatric firearm suicide rates, according to research.
“State-level legislation could play an important role in reducing pediatric firearm-related deaths,” concluded Jordan S. Taylor, MD, of Stanford (Calif.) University and his colleagues.
Dr. Taylor earned top honors among the American Academy of Pediatrics (AAP) Council on Injury, Violence and Poison Prevention research abstracts when he presented his findings at the annual meeting of the American Academy of Pediatrics.
Firearm injuries account for the second leading cause of death among U.S. children: 3,155 youth ages 19 years and younger died from gunshot injuries in 2016, and more than 17,000 were injured. Yet state laws governing the purchase, ownership, carriage, and storage of guns vary widely across the country. Dr. Taylor and his colleagues conducted two studies to assess the effects of firearm legislation on firearm-related injuries and deaths in U.S. children.
In their first study, they analyzed pediatric inpatient admissions for firearm injuries in 2012 relative to the stringency of state firearm legislation. They relied on five data sources for the analysis: the Kids’ Inpatient Database (KID), the Healthcare Cost and Utilization Project, the Agency for Healthcare Research and Quality, the U.S. Census Bureau, and the 2013 Brady scorecard.
The Brady scorecard provides scores for each state based on the presence and strictness of firearm-related laws, including legislation on background checks, ability of dangerous individuals to purchase guns, trafficking laws, and laws governing the sales, carrying, and purchasing of firearms.
The 10 states with the strictest laws (highest Brady scores) are California, Connecticut, Delaware, Hawaii, Illinois, Maryland, Massachusetts, New Jersey, New York, and Rhode Island. The 10 states with the lowest scores (least-strict legislation) are Alaska, Arizona, Arkansas, Florida, Kentucky, Louisiana, Montana, Nevada, Virginia, and Wyoming.
Among the 6,941 youth (aged 0-20 years) hospitalized in 2012 for firearm injuries, 7% died. More than a third of these (36%) occurred in the South, 25% in the Midwest, 22% in the West, and 17% in the Northeast.
Children most likely to be injured were boys, older children, black and Latino children, and children living in low-income zip codes.
The Midwest and South, which have lower average Brady scores (more lax legislation on guns), had 8.30 injuries per 100,000 children, compared with 7.54 injuries per 100,000 children in the Northeast and West, which have higher average Brady scores (more stringent gun laws). This was a difference of 0.76 injuries per 100,000 children (95% confidence interval, 0.38-1.13; P less than 0.001).
Then the researchers conducted a second analysis that looked specifically at firearm mortality within the context of both child access prevention (CAP) laws and states’ Brady scores. CAP laws include safe storage laws and gun lock laws, for example.
This analysis used the Web-Based Injury Statistics Query and Reporting System to capture pediatric firearm deaths from 2014-2015 and compared these to the 2014 Brady scores and CAP laws.
An estimated 2,715 child gun deaths occurred during the study period, of which 62% were homicides and 31% were suicides. The researchers identified “a significant negative correlation between states’ firearm legislation stringency and pediatric firearm mortality (Spearman correlation coefficient = –0.66) and between presence of CAP laws and firearm suicide rates (Spearman correlation coefficient = –0.56).”
Dr. Taylor said in an interview, “states that have both types of child access prevention laws [had] suicide rates four times lower than states that did not have either of those.”
Positive correlations also showed up between unemployment rate and firearm homicide rate (Spearman correlation coefficient = 0.55) and teen tobacco use and firearm suicide rate (Spearman correlation coefficient = 0.50).
The association between Brady scores and pediatric mortality from firearms remained significant after adjustment for poverty, unemployment, and substance abuse (P less than .01). Similarly, the association between the pediatric firearm suicide rate and CAP laws remained significant after controlling for socioeconomic factors and other firearm legislation (P less than .01).
In a video interview, Dr. Taylor discussed his research findings and their importance in clinical practice.
“It’s absolutely important for pediatricians to talk to families about firearms in their home and also in the homes of their friends that they visit,” Dr. Taylor said. “We try to approach it as a public health issue similar to seat belts and car seats.”
No external funding was used, and Dr. Taylor reported no conflicts of interest.
ORLANDO – and laws restricting children’s access to firearms are linked to reduced pediatric firearm suicide rates, according to research.
“State-level legislation could play an important role in reducing pediatric firearm-related deaths,” concluded Jordan S. Taylor, MD, of Stanford (Calif.) University and his colleagues.
Dr. Taylor earned top honors among the American Academy of Pediatrics (AAP) Council on Injury, Violence and Poison Prevention research abstracts when he presented his findings at the annual meeting of the American Academy of Pediatrics.
Firearm injuries account for the second leading cause of death among U.S. children: 3,155 youth ages 19 years and younger died from gunshot injuries in 2016, and more than 17,000 were injured. Yet state laws governing the purchase, ownership, carriage, and storage of guns vary widely across the country. Dr. Taylor and his colleagues conducted two studies to assess the effects of firearm legislation on firearm-related injuries and deaths in U.S. children.
In their first study, they analyzed pediatric inpatient admissions for firearm injuries in 2012 relative to the stringency of state firearm legislation. They relied on five data sources for the analysis: the Kids’ Inpatient Database (KID), the Healthcare Cost and Utilization Project, the Agency for Healthcare Research and Quality, the U.S. Census Bureau, and the 2013 Brady scorecard.
The Brady scorecard provides scores for each state based on the presence and strictness of firearm-related laws, including legislation on background checks, ability of dangerous individuals to purchase guns, trafficking laws, and laws governing the sales, carrying, and purchasing of firearms.
The 10 states with the strictest laws (highest Brady scores) are California, Connecticut, Delaware, Hawaii, Illinois, Maryland, Massachusetts, New Jersey, New York, and Rhode Island. The 10 states with the lowest scores (least-strict legislation) are Alaska, Arizona, Arkansas, Florida, Kentucky, Louisiana, Montana, Nevada, Virginia, and Wyoming.
Among the 6,941 youth (aged 0-20 years) hospitalized in 2012 for firearm injuries, 7% died. More than a third of these (36%) occurred in the South, 25% in the Midwest, 22% in the West, and 17% in the Northeast.
Children most likely to be injured were boys, older children, black and Latino children, and children living in low-income zip codes.
The Midwest and South, which have lower average Brady scores (more lax legislation on guns), had 8.30 injuries per 100,000 children, compared with 7.54 injuries per 100,000 children in the Northeast and West, which have higher average Brady scores (more stringent gun laws). This was a difference of 0.76 injuries per 100,000 children (95% confidence interval, 0.38-1.13; P less than 0.001).
Then the researchers conducted a second analysis that looked specifically at firearm mortality within the context of both child access prevention (CAP) laws and states’ Brady scores. CAP laws include safe storage laws and gun lock laws, for example.
This analysis used the Web-Based Injury Statistics Query and Reporting System to capture pediatric firearm deaths from 2014-2015 and compared these to the 2014 Brady scores and CAP laws.
An estimated 2,715 child gun deaths occurred during the study period, of which 62% were homicides and 31% were suicides. The researchers identified “a significant negative correlation between states’ firearm legislation stringency and pediatric firearm mortality (Spearman correlation coefficient = –0.66) and between presence of CAP laws and firearm suicide rates (Spearman correlation coefficient = –0.56).”
Dr. Taylor said in an interview, “states that have both types of child access prevention laws [had] suicide rates four times lower than states that did not have either of those.”
Positive correlations also showed up between unemployment rate and firearm homicide rate (Spearman correlation coefficient = 0.55) and teen tobacco use and firearm suicide rate (Spearman correlation coefficient = 0.50).
The association between Brady scores and pediatric mortality from firearms remained significant after adjustment for poverty, unemployment, and substance abuse (P less than .01). Similarly, the association between the pediatric firearm suicide rate and CAP laws remained significant after controlling for socioeconomic factors and other firearm legislation (P less than .01).
In a video interview, Dr. Taylor discussed his research findings and their importance in clinical practice.
“It’s absolutely important for pediatricians to talk to families about firearms in their home and also in the homes of their friends that they visit,” Dr. Taylor said. “We try to approach it as a public health issue similar to seat belts and car seats.”
No external funding was used, and Dr. Taylor reported no conflicts of interest.
ORLANDO – and laws restricting children’s access to firearms are linked to reduced pediatric firearm suicide rates, according to research.
“State-level legislation could play an important role in reducing pediatric firearm-related deaths,” concluded Jordan S. Taylor, MD, of Stanford (Calif.) University and his colleagues.
Dr. Taylor earned top honors among the American Academy of Pediatrics (AAP) Council on Injury, Violence and Poison Prevention research abstracts when he presented his findings at the annual meeting of the American Academy of Pediatrics.
Firearm injuries account for the second leading cause of death among U.S. children: 3,155 youth ages 19 years and younger died from gunshot injuries in 2016, and more than 17,000 were injured. Yet state laws governing the purchase, ownership, carriage, and storage of guns vary widely across the country. Dr. Taylor and his colleagues conducted two studies to assess the effects of firearm legislation on firearm-related injuries and deaths in U.S. children.
In their first study, they analyzed pediatric inpatient admissions for firearm injuries in 2012 relative to the stringency of state firearm legislation. They relied on five data sources for the analysis: the Kids’ Inpatient Database (KID), the Healthcare Cost and Utilization Project, the Agency for Healthcare Research and Quality, the U.S. Census Bureau, and the 2013 Brady scorecard.
The Brady scorecard provides scores for each state based on the presence and strictness of firearm-related laws, including legislation on background checks, ability of dangerous individuals to purchase guns, trafficking laws, and laws governing the sales, carrying, and purchasing of firearms.
The 10 states with the strictest laws (highest Brady scores) are California, Connecticut, Delaware, Hawaii, Illinois, Maryland, Massachusetts, New Jersey, New York, and Rhode Island. The 10 states with the lowest scores (least-strict legislation) are Alaska, Arizona, Arkansas, Florida, Kentucky, Louisiana, Montana, Nevada, Virginia, and Wyoming.
Among the 6,941 youth (aged 0-20 years) hospitalized in 2012 for firearm injuries, 7% died. More than a third of these (36%) occurred in the South, 25% in the Midwest, 22% in the West, and 17% in the Northeast.
Children most likely to be injured were boys, older children, black and Latino children, and children living in low-income zip codes.
The Midwest and South, which have lower average Brady scores (more lax legislation on guns), had 8.30 injuries per 100,000 children, compared with 7.54 injuries per 100,000 children in the Northeast and West, which have higher average Brady scores (more stringent gun laws). This was a difference of 0.76 injuries per 100,000 children (95% confidence interval, 0.38-1.13; P less than 0.001).
Then the researchers conducted a second analysis that looked specifically at firearm mortality within the context of both child access prevention (CAP) laws and states’ Brady scores. CAP laws include safe storage laws and gun lock laws, for example.
This analysis used the Web-Based Injury Statistics Query and Reporting System to capture pediatric firearm deaths from 2014-2015 and compared these to the 2014 Brady scores and CAP laws.
An estimated 2,715 child gun deaths occurred during the study period, of which 62% were homicides and 31% were suicides. The researchers identified “a significant negative correlation between states’ firearm legislation stringency and pediatric firearm mortality (Spearman correlation coefficient = –0.66) and between presence of CAP laws and firearm suicide rates (Spearman correlation coefficient = –0.56).”
Dr. Taylor said in an interview, “states that have both types of child access prevention laws [had] suicide rates four times lower than states that did not have either of those.”
Positive correlations also showed up between unemployment rate and firearm homicide rate (Spearman correlation coefficient = 0.55) and teen tobacco use and firearm suicide rate (Spearman correlation coefficient = 0.50).
The association between Brady scores and pediatric mortality from firearms remained significant after adjustment for poverty, unemployment, and substance abuse (P less than .01). Similarly, the association between the pediatric firearm suicide rate and CAP laws remained significant after controlling for socioeconomic factors and other firearm legislation (P less than .01).
In a video interview, Dr. Taylor discussed his research findings and their importance in clinical practice.
“It’s absolutely important for pediatricians to talk to families about firearms in their home and also in the homes of their friends that they visit,” Dr. Taylor said. “We try to approach it as a public health issue similar to seat belts and car seats.”
No external funding was used, and Dr. Taylor reported no conflicts of interest.
REPORTING FROM AAP 2018
Key clinical point: Stricter state firearm legislation was associated with reduced firearm-related pediatric mortality.
Major finding: 8.3 injuries per 100,000 children occurred in the Midwest and South, compared with 7.5 injuries per 100,000 children in the Northeast and West.
Study details: The findings are based on two separate analyses that analyzed state Brady scores along with 6,941 firearm-related hospitalizations in 2012 and 2,715 pediatric deaths from firearms in 2014-2015.
Disclosures: No external funding was used, and Dr. Taylor reported no conflicts of interest.
Sofa and bed injuries very common among young children
ORLANDO – Injuries related to beds and sofas in children aged under 5 years occur more than twice as frequently than injuries related to stairs, according to new research.
“Findings from our analysis reveal that it is an important source of injury to young children and a leading cause of trauma to infants,” concluded David S. Liu, of Baylor College of Medicine, Houston, who presented the findings at the annual meeting of the American Academy of Pediatrics.
“The rate of bed- and sofa-related injuries is increasing, which underscores the need for increased prevention efforts, including parental education and improved safety design, to decrease soft furniture injuries among young children,” Mr. Liu and his colleagues wrote.
The researchers used the National Electronic Injury Surveillance System of the U.S. Consumer Product Safety Commission to conduct a retrospective analysis of injuries related to sofas and beds from 2007 to 2016.
They found that an estimated 2.3 million children aged under 5 years were treated for injuries related to soft furniture during those years, an average of 230,026 injuries a year, or 115 injuries per 10,000 children. To the surprise of the researchers, injuries related to beds and sofas were the most common types of accidental injury in that age group, occurring 2.5 times more often than stair-related injuries, which occurred at a rate of 47 per 10,000 population.
Boys were slightly more likely to be injured, making up 56% of all the cases. Soft tissue/internal organ injuries were most common, comprising 28% of all injuries, followed by lacerations in 24% of cases, abrasions in 15%, and fractures in 14%.
More than half the children (61%) sustained injuries to the head or face, and 3% were hospitalized for their injuries. Although infants (under 1 year old) only accounted for 28% of children injured, they were twice as likely to be hospitalized than older children.
The researchers also identified increases in injuries over the time period studied. Bed-related injuries increased 17% from 2007 to 2016, and sofa/couch-related injuries increased 17% during that period.
Although the vast majority of children were treated and released, approximately 4% of children were admitted or treated and transferred to another facility. Overall, an estimated 3,361 children died during the 9-year period, translating to a little over 370 children a year.
In a video interview, Mr. Liu discussed the implications of these findings.
“We know how dangerous car accidents and staircases are, and we often recommend car seats and stair gates for those,” Mr. Liu said. “Obviously we can’t put a gate or a barrier on every single sofa, couch, and bed in America, so as clinicians and parents, the best we can do is keep aware of how dangerous these items are. Just because of their soft nature doesn’t mean they’re inherently safer.”
The researchers reported no disclosures and the research received no external funding.
ORLANDO – Injuries related to beds and sofas in children aged under 5 years occur more than twice as frequently than injuries related to stairs, according to new research.
“Findings from our analysis reveal that it is an important source of injury to young children and a leading cause of trauma to infants,” concluded David S. Liu, of Baylor College of Medicine, Houston, who presented the findings at the annual meeting of the American Academy of Pediatrics.
“The rate of bed- and sofa-related injuries is increasing, which underscores the need for increased prevention efforts, including parental education and improved safety design, to decrease soft furniture injuries among young children,” Mr. Liu and his colleagues wrote.
The researchers used the National Electronic Injury Surveillance System of the U.S. Consumer Product Safety Commission to conduct a retrospective analysis of injuries related to sofas and beds from 2007 to 2016.
They found that an estimated 2.3 million children aged under 5 years were treated for injuries related to soft furniture during those years, an average of 230,026 injuries a year, or 115 injuries per 10,000 children. To the surprise of the researchers, injuries related to beds and sofas were the most common types of accidental injury in that age group, occurring 2.5 times more often than stair-related injuries, which occurred at a rate of 47 per 10,000 population.
Boys were slightly more likely to be injured, making up 56% of all the cases. Soft tissue/internal organ injuries were most common, comprising 28% of all injuries, followed by lacerations in 24% of cases, abrasions in 15%, and fractures in 14%.
More than half the children (61%) sustained injuries to the head or face, and 3% were hospitalized for their injuries. Although infants (under 1 year old) only accounted for 28% of children injured, they were twice as likely to be hospitalized than older children.
The researchers also identified increases in injuries over the time period studied. Bed-related injuries increased 17% from 2007 to 2016, and sofa/couch-related injuries increased 17% during that period.
Although the vast majority of children were treated and released, approximately 4% of children were admitted or treated and transferred to another facility. Overall, an estimated 3,361 children died during the 9-year period, translating to a little over 370 children a year.
In a video interview, Mr. Liu discussed the implications of these findings.
“We know how dangerous car accidents and staircases are, and we often recommend car seats and stair gates for those,” Mr. Liu said. “Obviously we can’t put a gate or a barrier on every single sofa, couch, and bed in America, so as clinicians and parents, the best we can do is keep aware of how dangerous these items are. Just because of their soft nature doesn’t mean they’re inherently safer.”
The researchers reported no disclosures and the research received no external funding.
ORLANDO – Injuries related to beds and sofas in children aged under 5 years occur more than twice as frequently than injuries related to stairs, according to new research.
“Findings from our analysis reveal that it is an important source of injury to young children and a leading cause of trauma to infants,” concluded David S. Liu, of Baylor College of Medicine, Houston, who presented the findings at the annual meeting of the American Academy of Pediatrics.
“The rate of bed- and sofa-related injuries is increasing, which underscores the need for increased prevention efforts, including parental education and improved safety design, to decrease soft furniture injuries among young children,” Mr. Liu and his colleagues wrote.
The researchers used the National Electronic Injury Surveillance System of the U.S. Consumer Product Safety Commission to conduct a retrospective analysis of injuries related to sofas and beds from 2007 to 2016.
They found that an estimated 2.3 million children aged under 5 years were treated for injuries related to soft furniture during those years, an average of 230,026 injuries a year, or 115 injuries per 10,000 children. To the surprise of the researchers, injuries related to beds and sofas were the most common types of accidental injury in that age group, occurring 2.5 times more often than stair-related injuries, which occurred at a rate of 47 per 10,000 population.
Boys were slightly more likely to be injured, making up 56% of all the cases. Soft tissue/internal organ injuries were most common, comprising 28% of all injuries, followed by lacerations in 24% of cases, abrasions in 15%, and fractures in 14%.
More than half the children (61%) sustained injuries to the head or face, and 3% were hospitalized for their injuries. Although infants (under 1 year old) only accounted for 28% of children injured, they were twice as likely to be hospitalized than older children.
The researchers also identified increases in injuries over the time period studied. Bed-related injuries increased 17% from 2007 to 2016, and sofa/couch-related injuries increased 17% during that period.
Although the vast majority of children were treated and released, approximately 4% of children were admitted or treated and transferred to another facility. Overall, an estimated 3,361 children died during the 9-year period, translating to a little over 370 children a year.
In a video interview, Mr. Liu discussed the implications of these findings.
“We know how dangerous car accidents and staircases are, and we often recommend car seats and stair gates for those,” Mr. Liu said. “Obviously we can’t put a gate or a barrier on every single sofa, couch, and bed in America, so as clinicians and parents, the best we can do is keep aware of how dangerous these items are. Just because of their soft nature doesn’t mean they’re inherently safer.”
The researchers reported no disclosures and the research received no external funding.
REPORTING FROM AAP 2018
Key clinical point: Injuries from beds and sofas/couches are common in children aged under 5 years, occurring 2.5 times more frequently than stairs-related injuries.
Major finding: An estimated 115 bed/sofa-related injuries per 10,000 children occur every year.
Study details: The findings are based on a retrospective analysis of injuries related to sofas and beds from 2007 to 2016.
Disclosures: The researchers reported no disclosures and the research received no external funding.
Substance use increases likelihood of psychiatric hold in pregnancy
AUSTIN, TEX. – Providers are no more likely to put an involuntary psychiatric hold on someone who is pregnant than not unless she is using substances, recent research shows.
“This raises a question regarding who psychiatrists consider to be their patients: the mother, the unborn child, or both?” Samuel J. House, MD, of the University of Arkansas, Little Rock, said at the annual meeting of the American Academy of Psychiatry and the Law (AAPL).
Dr. House sent out a survey to members of the AAPL to learn their attitudes toward involuntary psychiatric holds on pregnant women, with and without evidence of substance use, and he presented the results at the meeting.
“We know that the rates of involuntary hospitalizations very widely” across different jurisdictions and practice settings, Dr. House said, but research has shown that age, unmarried status, psychotic symptoms, aggression, and a low level of social function are associated with involuntary commitment. He wanted to explore where pregnancy fit.
Dr. House became interested in clinicians’ perspectives on this issue when he realized how few psychiatric holds he saw among pregnant women during the 4 years he spent at a university hospital’s level 1 trauma center. He included questions about substance use in his survey because of the “recent push to criminalize substance use during pregnancy, mainly in response to the significant impact substance use during pregnancy can have on the fetus or developing child,” he said.
Dr. House received 68 survey responses from AAPL members, most of whom were male with an average age of 47 years. The 7-question survey presented various clinical scenarios and asked what the respondent would do.
The first question concerned being called to the emergency department to evaluate a 28-year-old white woman with clinical signs of depression, history of a suicide attempt, and a mother who had committed suicide when the patient was 15. However, she states during evaluation: “I could never actually kill myself. My family would be too upset, and I would go to hell.”
Two-thirds of respondents (67.6%) said they would admit the woman to an inpatient unit for stabilization, and the others would discharge her with close follow-up.
The second question asked what the clinician would do if the patient declined admission: 41.2% would discharge, and 58.8% would place the woman on a psychiatric hold.
The third question introduced a positive pregnancy test for the woman, but none of the respondents said they would cancel the psychiatric hold. Most were split between proceeding with a hold (42.6%) or proceeding with a discharge (47.1%), though 10.3% would cancel the discharge and place the patient on a hold. Ultimately, respondents were no more likely to put the woman on a hold whether she was pregnant or not.
Then the survey repeated the scenario, but instead of a positive pregnancy test, the question asked what clinicians would do if her drug screen were positive after she had refused admission. In that scenario, the woman reported daily methamphetamine use to the emergency physician.
Among respondents, 48.5% would proceed with a psychiatric hold, 42.6% would proceed with a discharge, and 8.8% would cancel the discharge and put the patient on a hold.
The final question asks clinicians’ course of action if the woman’s pregnancy test were positive after the positive drug screen. Now, only a little over a quarter of respondents (26.5%) would proceed with a discharge and follow-up. More than half (57.4%) would proceed with a hold, and 16.2% would cancel the discharge and place a psychiatric hold.
Therefore, 73.6% of clinicians would place a pregnant woman with a history of substance use on a psychiatric hold, compared with 52.9% if the woman were pregnant but not using methamphetamine.
Laws on pregnancy, substance use
Dr. House considered those findings within the context of current laws governing substance use during pregnancy., with prosecution usually requiring detection of the substance at birth or during pregnancy, or evidence of risk to the child’s health.
Tennessee is unique in considering substance abuse in pregnancy assault if the child is born with dependence or other harm from the drug use. Women in Minnesota, South Dakota, and Wisconsin can be subject to civil commitment, including required inpatient drug treatment, for substance abuse during pregnancy (Am J Psychiatry. 2016 Nov 1;173[11]:1077-80).
Mandatory reporting laws for suspected substance abuse during pregnancy exist in 15 states, mostly in the Southwest, northern Midwest, and states around the District of Columbia. And four states – Kentucky, Iowa, Minnesota, and North Dakota – require pregnant women suspected of substance abuse to be tested.
Yet, most major relevant medical associations oppose criminalization of substance use during pregnancy, including the American Psychiatric Association, the American Academy of Addiction Psychiatry, the American Medical Association, and the American College of Obstetricians and Gynecologists.
“They are generally for increasing access for people, like voluntary screening, but against criminalization because it creates a barrier to accessing prenatal care,” Dr. House explained.
Aside from the question of whom psychiatrists consider their patients – the woman, her fetus, or both – the results raise another question, Dr. House said: “While studies have shown that criminalizing substance use during pregnancy discourages mothers from seeking prenatal care, does the threat of an involuntary psychiatric admission have a similar consequence?” That’s a question for further research.
No external funding was used. Dr. House was a clinical investigator without compensation for Janssen Pharmaceuticals from 2015 to 2017.
AUSTIN, TEX. – Providers are no more likely to put an involuntary psychiatric hold on someone who is pregnant than not unless she is using substances, recent research shows.
“This raises a question regarding who psychiatrists consider to be their patients: the mother, the unborn child, or both?” Samuel J. House, MD, of the University of Arkansas, Little Rock, said at the annual meeting of the American Academy of Psychiatry and the Law (AAPL).
Dr. House sent out a survey to members of the AAPL to learn their attitudes toward involuntary psychiatric holds on pregnant women, with and without evidence of substance use, and he presented the results at the meeting.
“We know that the rates of involuntary hospitalizations very widely” across different jurisdictions and practice settings, Dr. House said, but research has shown that age, unmarried status, psychotic symptoms, aggression, and a low level of social function are associated with involuntary commitment. He wanted to explore where pregnancy fit.
Dr. House became interested in clinicians’ perspectives on this issue when he realized how few psychiatric holds he saw among pregnant women during the 4 years he spent at a university hospital’s level 1 trauma center. He included questions about substance use in his survey because of the “recent push to criminalize substance use during pregnancy, mainly in response to the significant impact substance use during pregnancy can have on the fetus or developing child,” he said.
Dr. House received 68 survey responses from AAPL members, most of whom were male with an average age of 47 years. The 7-question survey presented various clinical scenarios and asked what the respondent would do.
The first question concerned being called to the emergency department to evaluate a 28-year-old white woman with clinical signs of depression, history of a suicide attempt, and a mother who had committed suicide when the patient was 15. However, she states during evaluation: “I could never actually kill myself. My family would be too upset, and I would go to hell.”
Two-thirds of respondents (67.6%) said they would admit the woman to an inpatient unit for stabilization, and the others would discharge her with close follow-up.
The second question asked what the clinician would do if the patient declined admission: 41.2% would discharge, and 58.8% would place the woman on a psychiatric hold.
The third question introduced a positive pregnancy test for the woman, but none of the respondents said they would cancel the psychiatric hold. Most were split between proceeding with a hold (42.6%) or proceeding with a discharge (47.1%), though 10.3% would cancel the discharge and place the patient on a hold. Ultimately, respondents were no more likely to put the woman on a hold whether she was pregnant or not.
Then the survey repeated the scenario, but instead of a positive pregnancy test, the question asked what clinicians would do if her drug screen were positive after she had refused admission. In that scenario, the woman reported daily methamphetamine use to the emergency physician.
Among respondents, 48.5% would proceed with a psychiatric hold, 42.6% would proceed with a discharge, and 8.8% would cancel the discharge and put the patient on a hold.
The final question asks clinicians’ course of action if the woman’s pregnancy test were positive after the positive drug screen. Now, only a little over a quarter of respondents (26.5%) would proceed with a discharge and follow-up. More than half (57.4%) would proceed with a hold, and 16.2% would cancel the discharge and place a psychiatric hold.
Therefore, 73.6% of clinicians would place a pregnant woman with a history of substance use on a psychiatric hold, compared with 52.9% if the woman were pregnant but not using methamphetamine.
Laws on pregnancy, substance use
Dr. House considered those findings within the context of current laws governing substance use during pregnancy., with prosecution usually requiring detection of the substance at birth or during pregnancy, or evidence of risk to the child’s health.
Tennessee is unique in considering substance abuse in pregnancy assault if the child is born with dependence or other harm from the drug use. Women in Minnesota, South Dakota, and Wisconsin can be subject to civil commitment, including required inpatient drug treatment, for substance abuse during pregnancy (Am J Psychiatry. 2016 Nov 1;173[11]:1077-80).
Mandatory reporting laws for suspected substance abuse during pregnancy exist in 15 states, mostly in the Southwest, northern Midwest, and states around the District of Columbia. And four states – Kentucky, Iowa, Minnesota, and North Dakota – require pregnant women suspected of substance abuse to be tested.
Yet, most major relevant medical associations oppose criminalization of substance use during pregnancy, including the American Psychiatric Association, the American Academy of Addiction Psychiatry, the American Medical Association, and the American College of Obstetricians and Gynecologists.
“They are generally for increasing access for people, like voluntary screening, but against criminalization because it creates a barrier to accessing prenatal care,” Dr. House explained.
Aside from the question of whom psychiatrists consider their patients – the woman, her fetus, or both – the results raise another question, Dr. House said: “While studies have shown that criminalizing substance use during pregnancy discourages mothers from seeking prenatal care, does the threat of an involuntary psychiatric admission have a similar consequence?” That’s a question for further research.
No external funding was used. Dr. House was a clinical investigator without compensation for Janssen Pharmaceuticals from 2015 to 2017.
AUSTIN, TEX. – Providers are no more likely to put an involuntary psychiatric hold on someone who is pregnant than not unless she is using substances, recent research shows.
“This raises a question regarding who psychiatrists consider to be their patients: the mother, the unborn child, or both?” Samuel J. House, MD, of the University of Arkansas, Little Rock, said at the annual meeting of the American Academy of Psychiatry and the Law (AAPL).
Dr. House sent out a survey to members of the AAPL to learn their attitudes toward involuntary psychiatric holds on pregnant women, with and without evidence of substance use, and he presented the results at the meeting.
“We know that the rates of involuntary hospitalizations very widely” across different jurisdictions and practice settings, Dr. House said, but research has shown that age, unmarried status, psychotic symptoms, aggression, and a low level of social function are associated with involuntary commitment. He wanted to explore where pregnancy fit.
Dr. House became interested in clinicians’ perspectives on this issue when he realized how few psychiatric holds he saw among pregnant women during the 4 years he spent at a university hospital’s level 1 trauma center. He included questions about substance use in his survey because of the “recent push to criminalize substance use during pregnancy, mainly in response to the significant impact substance use during pregnancy can have on the fetus or developing child,” he said.
Dr. House received 68 survey responses from AAPL members, most of whom were male with an average age of 47 years. The 7-question survey presented various clinical scenarios and asked what the respondent would do.
The first question concerned being called to the emergency department to evaluate a 28-year-old white woman with clinical signs of depression, history of a suicide attempt, and a mother who had committed suicide when the patient was 15. However, she states during evaluation: “I could never actually kill myself. My family would be too upset, and I would go to hell.”
Two-thirds of respondents (67.6%) said they would admit the woman to an inpatient unit for stabilization, and the others would discharge her with close follow-up.
The second question asked what the clinician would do if the patient declined admission: 41.2% would discharge, and 58.8% would place the woman on a psychiatric hold.
The third question introduced a positive pregnancy test for the woman, but none of the respondents said they would cancel the psychiatric hold. Most were split between proceeding with a hold (42.6%) or proceeding with a discharge (47.1%), though 10.3% would cancel the discharge and place the patient on a hold. Ultimately, respondents were no more likely to put the woman on a hold whether she was pregnant or not.
Then the survey repeated the scenario, but instead of a positive pregnancy test, the question asked what clinicians would do if her drug screen were positive after she had refused admission. In that scenario, the woman reported daily methamphetamine use to the emergency physician.
Among respondents, 48.5% would proceed with a psychiatric hold, 42.6% would proceed with a discharge, and 8.8% would cancel the discharge and put the patient on a hold.
The final question asks clinicians’ course of action if the woman’s pregnancy test were positive after the positive drug screen. Now, only a little over a quarter of respondents (26.5%) would proceed with a discharge and follow-up. More than half (57.4%) would proceed with a hold, and 16.2% would cancel the discharge and place a psychiatric hold.
Therefore, 73.6% of clinicians would place a pregnant woman with a history of substance use on a psychiatric hold, compared with 52.9% if the woman were pregnant but not using methamphetamine.
Laws on pregnancy, substance use
Dr. House considered those findings within the context of current laws governing substance use during pregnancy., with prosecution usually requiring detection of the substance at birth or during pregnancy, or evidence of risk to the child’s health.
Tennessee is unique in considering substance abuse in pregnancy assault if the child is born with dependence or other harm from the drug use. Women in Minnesota, South Dakota, and Wisconsin can be subject to civil commitment, including required inpatient drug treatment, for substance abuse during pregnancy (Am J Psychiatry. 2016 Nov 1;173[11]:1077-80).
Mandatory reporting laws for suspected substance abuse during pregnancy exist in 15 states, mostly in the Southwest, northern Midwest, and states around the District of Columbia. And four states – Kentucky, Iowa, Minnesota, and North Dakota – require pregnant women suspected of substance abuse to be tested.
Yet, most major relevant medical associations oppose criminalization of substance use during pregnancy, including the American Psychiatric Association, the American Academy of Addiction Psychiatry, the American Medical Association, and the American College of Obstetricians and Gynecologists.
“They are generally for increasing access for people, like voluntary screening, but against criminalization because it creates a barrier to accessing prenatal care,” Dr. House explained.
Aside from the question of whom psychiatrists consider their patients – the woman, her fetus, or both – the results raise another question, Dr. House said: “While studies have shown that criminalizing substance use during pregnancy discourages mothers from seeking prenatal care, does the threat of an involuntary psychiatric admission have a similar consequence?” That’s a question for further research.
No external funding was used. Dr. House was a clinical investigator without compensation for Janssen Pharmaceuticals from 2015 to 2017.
REPORTING FROM THE AAPL ANNUAL MEETING
Key clinical point: Women are more likely to receive a psychiatric hold if they are pregnant and using a substance.
Major finding: Almost 53% of clinicians would place a suicidal pregnant woman on a psychiatric hold, but 73.6% would do so if she were using methamphetamines.
Study details: The findings are based on an Internet survey of 68 members of the American Academy of Psychiatry and the Law.
Disclosures: No external funding was used. Dr. House was a clinical investigator without compensation for Janssen Pharmaceuticals from 2015 to 2017.
A paradigm shift in medical research is necessary
ORLANDO – What doctors think they know to be true in medicine has changed dramatically in the past several decades and will be different again in the decades to come, leaving them with a dilemma, according to Kevin T. Powell, MD, PhD, a pediatric hospitalist in St. Louis. If half of what doctors teach or know in medicine today will ultimately end up not being true, how do they know what to believe or accept?
While there is not a single satisfactory answer to that question, researchers can select research that gets doctors closer to reliable findings and steer them away from the barrage of poor-quality research that emerges from the current publish-or-perish system, Dr. Powell told his colleagues at the annual meeting of the American Academy of Pediatrics.
During his talk, Dr. Powell discussed the challenges and flaws with medical research as it is currently conducted, citing Doug Altman’s writings on these problems as early as 1994.
“The poor quality of much medical research is widely acknowledged, yet disturbingly the leaders of the medical profession seem only minimally concerned about the problem and make no apparent effort to find a solution,” wrote Mr. Altman, an English medical statistician (BMJ. 1994;308:283).
“We need less research, better research, and research done for the right reasons,” Mr. Altman concluded. “Abandoning using the number of publications as a measure of ability would be a start.”
In an interview, Dr. Powell described an unfortunate consequence of the publish-or-perish pressure in academic medicine: A glut of short-term, small studies with little clinical utility that researchers can complete in 1 or 2 years rather than the large, multicenter studies that take several years – and produce higher-quality findings – but cannot be turned into as many publications.
“We’re generating a lot of medical research findings that end up being false,” he said. “It’s a random walk in terms of getting to the truth rather than having an accurate process of getting to truth through evidence-based medicine.”
But he was hopeful, not cynical, about the way forward. By persuading people that medical research has changed for the worse over time and can change into something better, Dr. Powell saw potential for future research resulting in the same sort of public health achievements that research produced in the past, such as big reductions in smoking or sudden infant death syndrome.
Dr. Powell concluded his talk with a riff on Martin Luther’s 95 Theses, the 9.5 Theses, for a reformation of evidence-based medicine that together address the various shortcomings he discussed.
1. Recognize academic promotion as a bias, just like drug money.
2. Don’t confound statistically significant and clinically significant.
3. Use only significant figures.
4. Use the phrase “we did not DETECT a difference” and include power calculations.
5. Use confidence intervals instead of P values.
6. Use number needed to harm and number needed to treat instead of relative risk.
7. Absence of proof is not proof of absence. When there is insufficient randomized, controlled trial evidence, have an independent party estimate an effect based on non-RCT articles.
8. Any article implying clinical practice should change must include a counterpoint and a benefit cost analysis. Consider both effectiveness and safety.
9. Use postmarketing peer review.
9.5. Beware of research based on surveys.
Dr. Powell reported no relevant financial disclosures.
ORLANDO – What doctors think they know to be true in medicine has changed dramatically in the past several decades and will be different again in the decades to come, leaving them with a dilemma, according to Kevin T. Powell, MD, PhD, a pediatric hospitalist in St. Louis. If half of what doctors teach or know in medicine today will ultimately end up not being true, how do they know what to believe or accept?
While there is not a single satisfactory answer to that question, researchers can select research that gets doctors closer to reliable findings and steer them away from the barrage of poor-quality research that emerges from the current publish-or-perish system, Dr. Powell told his colleagues at the annual meeting of the American Academy of Pediatrics.
During his talk, Dr. Powell discussed the challenges and flaws with medical research as it is currently conducted, citing Doug Altman’s writings on these problems as early as 1994.
“The poor quality of much medical research is widely acknowledged, yet disturbingly the leaders of the medical profession seem only minimally concerned about the problem and make no apparent effort to find a solution,” wrote Mr. Altman, an English medical statistician (BMJ. 1994;308:283).
“We need less research, better research, and research done for the right reasons,” Mr. Altman concluded. “Abandoning using the number of publications as a measure of ability would be a start.”
In an interview, Dr. Powell described an unfortunate consequence of the publish-or-perish pressure in academic medicine: A glut of short-term, small studies with little clinical utility that researchers can complete in 1 or 2 years rather than the large, multicenter studies that take several years – and produce higher-quality findings – but cannot be turned into as many publications.
“We’re generating a lot of medical research findings that end up being false,” he said. “It’s a random walk in terms of getting to the truth rather than having an accurate process of getting to truth through evidence-based medicine.”
But he was hopeful, not cynical, about the way forward. By persuading people that medical research has changed for the worse over time and can change into something better, Dr. Powell saw potential for future research resulting in the same sort of public health achievements that research produced in the past, such as big reductions in smoking or sudden infant death syndrome.
Dr. Powell concluded his talk with a riff on Martin Luther’s 95 Theses, the 9.5 Theses, for a reformation of evidence-based medicine that together address the various shortcomings he discussed.
1. Recognize academic promotion as a bias, just like drug money.
2. Don’t confound statistically significant and clinically significant.
3. Use only significant figures.
4. Use the phrase “we did not DETECT a difference” and include power calculations.
5. Use confidence intervals instead of P values.
6. Use number needed to harm and number needed to treat instead of relative risk.
7. Absence of proof is not proof of absence. When there is insufficient randomized, controlled trial evidence, have an independent party estimate an effect based on non-RCT articles.
8. Any article implying clinical practice should change must include a counterpoint and a benefit cost analysis. Consider both effectiveness and safety.
9. Use postmarketing peer review.
9.5. Beware of research based on surveys.
Dr. Powell reported no relevant financial disclosures.
ORLANDO – What doctors think they know to be true in medicine has changed dramatically in the past several decades and will be different again in the decades to come, leaving them with a dilemma, according to Kevin T. Powell, MD, PhD, a pediatric hospitalist in St. Louis. If half of what doctors teach or know in medicine today will ultimately end up not being true, how do they know what to believe or accept?
While there is not a single satisfactory answer to that question, researchers can select research that gets doctors closer to reliable findings and steer them away from the barrage of poor-quality research that emerges from the current publish-or-perish system, Dr. Powell told his colleagues at the annual meeting of the American Academy of Pediatrics.
During his talk, Dr. Powell discussed the challenges and flaws with medical research as it is currently conducted, citing Doug Altman’s writings on these problems as early as 1994.
“The poor quality of much medical research is widely acknowledged, yet disturbingly the leaders of the medical profession seem only minimally concerned about the problem and make no apparent effort to find a solution,” wrote Mr. Altman, an English medical statistician (BMJ. 1994;308:283).
“We need less research, better research, and research done for the right reasons,” Mr. Altman concluded. “Abandoning using the number of publications as a measure of ability would be a start.”
In an interview, Dr. Powell described an unfortunate consequence of the publish-or-perish pressure in academic medicine: A glut of short-term, small studies with little clinical utility that researchers can complete in 1 or 2 years rather than the large, multicenter studies that take several years – and produce higher-quality findings – but cannot be turned into as many publications.
“We’re generating a lot of medical research findings that end up being false,” he said. “It’s a random walk in terms of getting to the truth rather than having an accurate process of getting to truth through evidence-based medicine.”
But he was hopeful, not cynical, about the way forward. By persuading people that medical research has changed for the worse over time and can change into something better, Dr. Powell saw potential for future research resulting in the same sort of public health achievements that research produced in the past, such as big reductions in smoking or sudden infant death syndrome.
Dr. Powell concluded his talk with a riff on Martin Luther’s 95 Theses, the 9.5 Theses, for a reformation of evidence-based medicine that together address the various shortcomings he discussed.
1. Recognize academic promotion as a bias, just like drug money.
2. Don’t confound statistically significant and clinically significant.
3. Use only significant figures.
4. Use the phrase “we did not DETECT a difference” and include power calculations.
5. Use confidence intervals instead of P values.
6. Use number needed to harm and number needed to treat instead of relative risk.
7. Absence of proof is not proof of absence. When there is insufficient randomized, controlled trial evidence, have an independent party estimate an effect based on non-RCT articles.
8. Any article implying clinical practice should change must include a counterpoint and a benefit cost analysis. Consider both effectiveness and safety.
9. Use postmarketing peer review.
9.5. Beware of research based on surveys.
Dr. Powell reported no relevant financial disclosures.
EXPERT ANALYSIS FROM AAP 18
Sandy Hook Promise: Four programs help people recognize signs of a threat
ORLANDO – “The caretaker of all living things” – that was the good-natured moniker 7-year-old Daniel Barden had earned from his family – according to his dad, Mark Barden. Daniel would pick up black ants and take them outside “to be with their families,” even when the ant bit his fingers.
A walk down the sidewalk after a rain would take three times longer than it should because Daniel stopped to pick up every worm on the pavement and put it in the grass, lest it dry out in the sun, Mr. Barden said with a chuckle at the annual meeting of the American Academy of Pediatrics.
Daniel was his youngest and full of pure joy, Mr. Barden said, but that ended with his son’s murder during the Sandy Hook Elementary mass shooting Dec. 14, 2012. To honor his son and work to reduce the likelihood of similar mass shootings, Mr. Barden, now the managing director of Sandy Hook Promise in Newtown, Conn., shared with the pediatrician audience the work of the organization formed by Sandy Hook parents to attempt to prevent gun violence before it happens.
“We’re moms and dads and a couple of families who have lost loved ones in that tragedy, and we are growing as an organization,” Mr. Barden said. “Our basic, most fundamental objective is to prevent other families from living with the pain I will live with for the rest of my life.”
Their mission involves “creating a culture engaged and committed to identifying, intervening, and getting help for individuals who may be at risk of hurting themselves or others,” Mr. Barden said.
Sandy Hook Promise accomplishes this goal by educating and empowering communities through their four programs: Start with Hello, SOS Suicide Prevention Program, SaySomething, and Safety Assessment & Intervention. The organization delivers these programs through multiple platforms, including national and local trainers, digital curriculum downloads, interactive online training videos, and using multilingual presenters and English and Spanish materials.
The organization also especially works with schools and student’s clubs to change their culture and feel empowered to speak up and do their part to prevent gun violence too.
These programs resulted from extensive qualitative and quantitative research that Sandy Hook Promise conducted after the shooting with academic researchers, law enforcement, educators, school administrators, mental health professionals, and social movement experts.
“As we see these stories play themselves out over and over again, we start to reveal the story of somebody who didn’t just snap overnight,” Mr. Barden said. Signs that a person may be at risk for committing mass violence include suicidality, preoccupation with weapons, talking about committing violent acts, and general signs of depression and anxiety. “If we can train people how to not only recognize but to look for those signs, we can make a sustainable difference,” he said.
Most mass shootings are planned at least 6 months in advance, he said. About 80% of school shooters tell someone about their plans, and 69% tell multiple people. Similarly, up to 70% of people who die by suicide tell someone they plan to do it or give some other warning sign.
Further, more than a third of violent threats and bullying occurs electronically, so students are well equipped to watch for the signs and report them if they know how and feel comfortable doing so.
Mr. Barden outlined the goals of each of the four Sandy Hook Promise programs.
Start With Hello
This program “teaches youth how to identify and minimize social isolation, marginalization, and rejection in order to create an inclusive, connected community,” Mr. Barden explained. The goals of the program are to reduce bullying, foster socialization, increase engagement, and change a culture from within.
SOS Signs of Suicide
This is Sandy Hook Promise’s newest program and is built on a program developed by the Federal Bureau of Investigation following the Virginia Tech shooting and adapted for school-based applications.
“It also develops a multidisciplinary team within the school who acts as various touch points who know how to recognize a potential warning sign and then triage that information and take steps to get to the root cause of that behavior and not just bandage the wound,” Mr. Barden explained.
SaySomething
The organization’s flagship program does the most to recruit student involvement in recognizing the signs of a potential threat, particularly in social media, and report the individual and their behavior to a trusted adult or through Sandy Hook Promise’s Anonymous Reporting System.
“The kids take this one, and they run with it and do amazing things with it,” Mr. Barden said, noting that it particularly helps students recognize warning signs on social media. “We have growing evidence of kids following this model, and we’ve already prevented mass shootings and numerous suicides with this.”
Safety Assessment & Intervention (SAI) program
This program “trains a multidisciplinary team how to identify, assess, and respond to threats and observed at-risk behaviors,” Mr. Barden said. SAI aims to create a safer, more open school environment with less violence, bullying, and threats. That includes reducing educators’ fear and anxiety, and leading students to have a more positive view of teachers and staff.
Students can report tips to the Anonymous Reporting System through the website, calling the hot line or via a free mobile app. Regardless of the method, the anonymous tips go to a 24/7 multilingual crisis center and, if needed, law enforcement. The crisis center contacts the appropriate school official via text, email, or a phone call, and the case is tracked in real time until it’s addressed, resolved, and closed.
All of these programs are freely available to any school or institution who wants to use them, Mr. Barden said, because the organization does not want cost to get in the way of any school or community that is taking advantage of tools to reduce the risk of violence.
In fact, more than 3.5 million youth and adults in more than 7,000 schools in every state have been trained in these programs, helping hundreds of youth access mental health and wellness help, he said. The program has reduced truancy, bullying, and other forms of violence and victimization, and it has intervened in multiple school shooting plans across the United States.
Mr. Barden wrapped up his address with his gratitude for pediatricians’ willingness to be partners in reducing gun violence.
“I want to tell you how much it means to me that you took the time to come here and listen to my story and the work I’m doing,” he said, “and how proud I am to be able to share it with you, and how proud I am to be able to honor that little kid who truly was the caretaker of all living things and to continue that spirit in his honor and in his absence.”
ORLANDO – “The caretaker of all living things” – that was the good-natured moniker 7-year-old Daniel Barden had earned from his family – according to his dad, Mark Barden. Daniel would pick up black ants and take them outside “to be with their families,” even when the ant bit his fingers.
A walk down the sidewalk after a rain would take three times longer than it should because Daniel stopped to pick up every worm on the pavement and put it in the grass, lest it dry out in the sun, Mr. Barden said with a chuckle at the annual meeting of the American Academy of Pediatrics.
Daniel was his youngest and full of pure joy, Mr. Barden said, but that ended with his son’s murder during the Sandy Hook Elementary mass shooting Dec. 14, 2012. To honor his son and work to reduce the likelihood of similar mass shootings, Mr. Barden, now the managing director of Sandy Hook Promise in Newtown, Conn., shared with the pediatrician audience the work of the organization formed by Sandy Hook parents to attempt to prevent gun violence before it happens.
“We’re moms and dads and a couple of families who have lost loved ones in that tragedy, and we are growing as an organization,” Mr. Barden said. “Our basic, most fundamental objective is to prevent other families from living with the pain I will live with for the rest of my life.”
Their mission involves “creating a culture engaged and committed to identifying, intervening, and getting help for individuals who may be at risk of hurting themselves or others,” Mr. Barden said.
Sandy Hook Promise accomplishes this goal by educating and empowering communities through their four programs: Start with Hello, SOS Suicide Prevention Program, SaySomething, and Safety Assessment & Intervention. The organization delivers these programs through multiple platforms, including national and local trainers, digital curriculum downloads, interactive online training videos, and using multilingual presenters and English and Spanish materials.
The organization also especially works with schools and student’s clubs to change their culture and feel empowered to speak up and do their part to prevent gun violence too.
These programs resulted from extensive qualitative and quantitative research that Sandy Hook Promise conducted after the shooting with academic researchers, law enforcement, educators, school administrators, mental health professionals, and social movement experts.
“As we see these stories play themselves out over and over again, we start to reveal the story of somebody who didn’t just snap overnight,” Mr. Barden said. Signs that a person may be at risk for committing mass violence include suicidality, preoccupation with weapons, talking about committing violent acts, and general signs of depression and anxiety. “If we can train people how to not only recognize but to look for those signs, we can make a sustainable difference,” he said.
Most mass shootings are planned at least 6 months in advance, he said. About 80% of school shooters tell someone about their plans, and 69% tell multiple people. Similarly, up to 70% of people who die by suicide tell someone they plan to do it or give some other warning sign.
Further, more than a third of violent threats and bullying occurs electronically, so students are well equipped to watch for the signs and report them if they know how and feel comfortable doing so.
Mr. Barden outlined the goals of each of the four Sandy Hook Promise programs.
Start With Hello
This program “teaches youth how to identify and minimize social isolation, marginalization, and rejection in order to create an inclusive, connected community,” Mr. Barden explained. The goals of the program are to reduce bullying, foster socialization, increase engagement, and change a culture from within.
SOS Signs of Suicide
This is Sandy Hook Promise’s newest program and is built on a program developed by the Federal Bureau of Investigation following the Virginia Tech shooting and adapted for school-based applications.
“It also develops a multidisciplinary team within the school who acts as various touch points who know how to recognize a potential warning sign and then triage that information and take steps to get to the root cause of that behavior and not just bandage the wound,” Mr. Barden explained.
SaySomething
The organization’s flagship program does the most to recruit student involvement in recognizing the signs of a potential threat, particularly in social media, and report the individual and their behavior to a trusted adult or through Sandy Hook Promise’s Anonymous Reporting System.
“The kids take this one, and they run with it and do amazing things with it,” Mr. Barden said, noting that it particularly helps students recognize warning signs on social media. “We have growing evidence of kids following this model, and we’ve already prevented mass shootings and numerous suicides with this.”
Safety Assessment & Intervention (SAI) program
This program “trains a multidisciplinary team how to identify, assess, and respond to threats and observed at-risk behaviors,” Mr. Barden said. SAI aims to create a safer, more open school environment with less violence, bullying, and threats. That includes reducing educators’ fear and anxiety, and leading students to have a more positive view of teachers and staff.
Students can report tips to the Anonymous Reporting System through the website, calling the hot line or via a free mobile app. Regardless of the method, the anonymous tips go to a 24/7 multilingual crisis center and, if needed, law enforcement. The crisis center contacts the appropriate school official via text, email, or a phone call, and the case is tracked in real time until it’s addressed, resolved, and closed.
All of these programs are freely available to any school or institution who wants to use them, Mr. Barden said, because the organization does not want cost to get in the way of any school or community that is taking advantage of tools to reduce the risk of violence.
In fact, more than 3.5 million youth and adults in more than 7,000 schools in every state have been trained in these programs, helping hundreds of youth access mental health and wellness help, he said. The program has reduced truancy, bullying, and other forms of violence and victimization, and it has intervened in multiple school shooting plans across the United States.
Mr. Barden wrapped up his address with his gratitude for pediatricians’ willingness to be partners in reducing gun violence.
“I want to tell you how much it means to me that you took the time to come here and listen to my story and the work I’m doing,” he said, “and how proud I am to be able to share it with you, and how proud I am to be able to honor that little kid who truly was the caretaker of all living things and to continue that spirit in his honor and in his absence.”
ORLANDO – “The caretaker of all living things” – that was the good-natured moniker 7-year-old Daniel Barden had earned from his family – according to his dad, Mark Barden. Daniel would pick up black ants and take them outside “to be with their families,” even when the ant bit his fingers.
A walk down the sidewalk after a rain would take three times longer than it should because Daniel stopped to pick up every worm on the pavement and put it in the grass, lest it dry out in the sun, Mr. Barden said with a chuckle at the annual meeting of the American Academy of Pediatrics.
Daniel was his youngest and full of pure joy, Mr. Barden said, but that ended with his son’s murder during the Sandy Hook Elementary mass shooting Dec. 14, 2012. To honor his son and work to reduce the likelihood of similar mass shootings, Mr. Barden, now the managing director of Sandy Hook Promise in Newtown, Conn., shared with the pediatrician audience the work of the organization formed by Sandy Hook parents to attempt to prevent gun violence before it happens.
“We’re moms and dads and a couple of families who have lost loved ones in that tragedy, and we are growing as an organization,” Mr. Barden said. “Our basic, most fundamental objective is to prevent other families from living with the pain I will live with for the rest of my life.”
Their mission involves “creating a culture engaged and committed to identifying, intervening, and getting help for individuals who may be at risk of hurting themselves or others,” Mr. Barden said.
Sandy Hook Promise accomplishes this goal by educating and empowering communities through their four programs: Start with Hello, SOS Suicide Prevention Program, SaySomething, and Safety Assessment & Intervention. The organization delivers these programs through multiple platforms, including national and local trainers, digital curriculum downloads, interactive online training videos, and using multilingual presenters and English and Spanish materials.
The organization also especially works with schools and student’s clubs to change their culture and feel empowered to speak up and do their part to prevent gun violence too.
These programs resulted from extensive qualitative and quantitative research that Sandy Hook Promise conducted after the shooting with academic researchers, law enforcement, educators, school administrators, mental health professionals, and social movement experts.
“As we see these stories play themselves out over and over again, we start to reveal the story of somebody who didn’t just snap overnight,” Mr. Barden said. Signs that a person may be at risk for committing mass violence include suicidality, preoccupation with weapons, talking about committing violent acts, and general signs of depression and anxiety. “If we can train people how to not only recognize but to look for those signs, we can make a sustainable difference,” he said.
Most mass shootings are planned at least 6 months in advance, he said. About 80% of school shooters tell someone about their plans, and 69% tell multiple people. Similarly, up to 70% of people who die by suicide tell someone they plan to do it or give some other warning sign.
Further, more than a third of violent threats and bullying occurs electronically, so students are well equipped to watch for the signs and report them if they know how and feel comfortable doing so.
Mr. Barden outlined the goals of each of the four Sandy Hook Promise programs.
Start With Hello
This program “teaches youth how to identify and minimize social isolation, marginalization, and rejection in order to create an inclusive, connected community,” Mr. Barden explained. The goals of the program are to reduce bullying, foster socialization, increase engagement, and change a culture from within.
SOS Signs of Suicide
This is Sandy Hook Promise’s newest program and is built on a program developed by the Federal Bureau of Investigation following the Virginia Tech shooting and adapted for school-based applications.
“It also develops a multidisciplinary team within the school who acts as various touch points who know how to recognize a potential warning sign and then triage that information and take steps to get to the root cause of that behavior and not just bandage the wound,” Mr. Barden explained.
SaySomething
The organization’s flagship program does the most to recruit student involvement in recognizing the signs of a potential threat, particularly in social media, and report the individual and their behavior to a trusted adult or through Sandy Hook Promise’s Anonymous Reporting System.
“The kids take this one, and they run with it and do amazing things with it,” Mr. Barden said, noting that it particularly helps students recognize warning signs on social media. “We have growing evidence of kids following this model, and we’ve already prevented mass shootings and numerous suicides with this.”
Safety Assessment & Intervention (SAI) program
This program “trains a multidisciplinary team how to identify, assess, and respond to threats and observed at-risk behaviors,” Mr. Barden said. SAI aims to create a safer, more open school environment with less violence, bullying, and threats. That includes reducing educators’ fear and anxiety, and leading students to have a more positive view of teachers and staff.
Students can report tips to the Anonymous Reporting System through the website, calling the hot line or via a free mobile app. Regardless of the method, the anonymous tips go to a 24/7 multilingual crisis center and, if needed, law enforcement. The crisis center contacts the appropriate school official via text, email, or a phone call, and the case is tracked in real time until it’s addressed, resolved, and closed.
All of these programs are freely available to any school or institution who wants to use them, Mr. Barden said, because the organization does not want cost to get in the way of any school or community that is taking advantage of tools to reduce the risk of violence.
In fact, more than 3.5 million youth and adults in more than 7,000 schools in every state have been trained in these programs, helping hundreds of youth access mental health and wellness help, he said. The program has reduced truancy, bullying, and other forms of violence and victimization, and it has intervened in multiple school shooting plans across the United States.
Mr. Barden wrapped up his address with his gratitude for pediatricians’ willingness to be partners in reducing gun violence.
“I want to tell you how much it means to me that you took the time to come here and listen to my story and the work I’m doing,” he said, “and how proud I am to be able to share it with you, and how proud I am to be able to honor that little kid who truly was the caretaker of all living things and to continue that spirit in his honor and in his absence.”
EXPERT ANALYSIS FROM AAP 18
Sibling abuse more common than child, domestic abuse combined
AUSTIN, TEX. – Sibling violence is the most common form of family violence – more prevalent than child abuse and domestic abuse combined – according to new research.
A review of the literature shows that it occurs in anywhere from 42% to 80%-90% of families, according to an abstract by Peter S. Martin, MD, MPH, of the University of Buffalo, New York.
Nearly 50% of siblings engaged in severe violence in the past year, though emotional aggression is more common than is physical aggression, Dr. Martin shared at the annual meeting of the American Academy of Psychiatry and the Law.
“Both perpetrators and victims are at risk for poor outcomes,” Dr. Martin wrote, listing distress, low self-esteem, developmental delays, depression, anxiety, posttraumatic stress disorder, substance use disorders, eating disorders, and suicidality, sometimes reaching into adulthood. Those symptoms typically can be as severe as those experienced by victims of peer bullying, he wrote.
Males involved in sibling violence tend to show more aggression and delinquency, while females experience more difficulties with psychological adjustment, he wrote. Sibling violence also is a predictor for college dating violence.
Siblings – whether biological, half, step, adoptive, foster or even fictive (like chosen family) – spend more time with each other than anyone else growing up. Those relationships provide companionship, support, and opportunities for play and engagement against an adversary, but they remain unique from other family relationships.
Healthy sibling relationships are linked to increased social competence, independence, self-control, companionship, general life skills, support, and overall social, cognitive, and emotional growth, Dr. Martin noted in his abstract.
On the flip side, “,” he wrote.
Yet, despite the prevalence of sibling aggression and the commonness of having a sibling in general, studying sibling violence is challenging because neither the academic research nor legal realms have a standardized definition for it.
To better understand the phenomenon, Dr. Martin conduced a literature review using Medline, Web of Sciences, PsycINFO, and Google Scholar. He identified 158 articles from peer-reviewed journals or textbooks.
Dr. Martin described sibling rivalry and sibling aggression and abuse separately, though overlap certainly occurs. Sibling rivalry – conflict over something the other sibling wants or a lack of balance between them – generally stems from resentment related to birth order and competition.
Common sources include favoritism or preferential treatment that one child perceives a parent to grant another sibling, problems with sharing possessions, and “fair” or “even” division of household chores.
“Usually the biggest problems is an impaired sibling relationship,” Dr. Martin wrote. But the experience can contribute to low self-esteem into adulthood if individuals believe themselves to be their parents’ less favored children, and sibling rivalry often can develop into sibling abuse.
Sibling aggression often is unrecognized with poor measures of prevalence, frequently relying on recall from college students. Yet, when paired with peer violence, sibling violence increases the likelihood of worse mental health outcomes, Dr. Martin found. Further, youth who fight with their siblings are 2.5 times more likely to fight with their peers.
The frequency of sibling violence is highest before age 9, but its “severity peaks in adolescence,” Dr. Martin wrote. Clinicians evaluating someone as a perpetrator or victim of sibling violence need to consider perception, intention, and severity in their assessments.
“Psychological aggression is often a precursor to physical aggression and often more damaging,” Dr. Martin wrote. Older siblings are more likely to be the aggressors, and males and females are equally likely to be victims and perpetrators of less severe abuse.
But “presence of a male child increases the likelihood of violence between siblings,” Dr. Martin found, and males are more likely to be perpetrators of more severe abuse – with one exception: Females are more likely to be perpetrators of sexual abuse. Although sexual abuse often is excluded from discussions of sibling violence, it is the most common form of familial sexual abuse.
Many psychological schools of thought can be used to explore causes from a theoretical perspective, but the list of interacting factors is long. It includes factors related to the parent-child relationship as well as individuals and the family as a whole.
Among the parent-child factors Dr. Martin lists are “parental differential treatment (particularly by fathers), active and direct judgmental comparison by parents, negative and conflictual parent-child relationships, lack of parental reinforcement of prosocial behavior, polarized definitions of good and bad children,” and rejecting or overcontrolling mothers. Other factors include coercive parenting, inadequate parental supervision, parental child abuse, parental approval of physical aggression between siblings, and lack of acknowledgment of children’s concerns.
In terms of the family unit, sibling violence is linked to domestic partner violence, marital conflict, poor family cohesion, living with a stepfamily, and lack of family resources and/or “lack of clear and consistent family rules,” Dr. Martin found.
While a “perpetrator’s lack of empathy, low self-esteem, and aggressive temperament” all are risk factors for sibling violence, protective factors include greater warmth in family relationships.
Sibling murder accounts for 1% of all homicide arrests and 8%-10% of all familial murders. The majority of these, about 75%, are brothers killing brothers. The remaining quarter include, in decreasing prevalence, brothers killing sisters, sisters killing brothers, and sisters killing sisters.
Though no evidence-based treatments exist for sibling violence, prevention strategies might include “secondary prevention, including family and individual approaches,” and “primary prevention with parenting programs for those at risk to abuse,” such as Successful Parenting, Systematic Training for Effective Parenting, and Parent Effectiveness Training.
Clinicians also have the option to modify existing tools, address sibling conflict through mediation, work to improve all family members’ communication skills, and establish rules for appropriate behaviors. Other treatment approaches may include “structured family therapy, task-centered approaches, utilizing social learning theory or nonviolent resistance,” Dr. Martin reported.
AUSTIN, TEX. – Sibling violence is the most common form of family violence – more prevalent than child abuse and domestic abuse combined – according to new research.
A review of the literature shows that it occurs in anywhere from 42% to 80%-90% of families, according to an abstract by Peter S. Martin, MD, MPH, of the University of Buffalo, New York.
Nearly 50% of siblings engaged in severe violence in the past year, though emotional aggression is more common than is physical aggression, Dr. Martin shared at the annual meeting of the American Academy of Psychiatry and the Law.
“Both perpetrators and victims are at risk for poor outcomes,” Dr. Martin wrote, listing distress, low self-esteem, developmental delays, depression, anxiety, posttraumatic stress disorder, substance use disorders, eating disorders, and suicidality, sometimes reaching into adulthood. Those symptoms typically can be as severe as those experienced by victims of peer bullying, he wrote.
Males involved in sibling violence tend to show more aggression and delinquency, while females experience more difficulties with psychological adjustment, he wrote. Sibling violence also is a predictor for college dating violence.
Siblings – whether biological, half, step, adoptive, foster or even fictive (like chosen family) – spend more time with each other than anyone else growing up. Those relationships provide companionship, support, and opportunities for play and engagement against an adversary, but they remain unique from other family relationships.
Healthy sibling relationships are linked to increased social competence, independence, self-control, companionship, general life skills, support, and overall social, cognitive, and emotional growth, Dr. Martin noted in his abstract.
On the flip side, “,” he wrote.
Yet, despite the prevalence of sibling aggression and the commonness of having a sibling in general, studying sibling violence is challenging because neither the academic research nor legal realms have a standardized definition for it.
To better understand the phenomenon, Dr. Martin conduced a literature review using Medline, Web of Sciences, PsycINFO, and Google Scholar. He identified 158 articles from peer-reviewed journals or textbooks.
Dr. Martin described sibling rivalry and sibling aggression and abuse separately, though overlap certainly occurs. Sibling rivalry – conflict over something the other sibling wants or a lack of balance between them – generally stems from resentment related to birth order and competition.
Common sources include favoritism or preferential treatment that one child perceives a parent to grant another sibling, problems with sharing possessions, and “fair” or “even” division of household chores.
“Usually the biggest problems is an impaired sibling relationship,” Dr. Martin wrote. But the experience can contribute to low self-esteem into adulthood if individuals believe themselves to be their parents’ less favored children, and sibling rivalry often can develop into sibling abuse.
Sibling aggression often is unrecognized with poor measures of prevalence, frequently relying on recall from college students. Yet, when paired with peer violence, sibling violence increases the likelihood of worse mental health outcomes, Dr. Martin found. Further, youth who fight with their siblings are 2.5 times more likely to fight with their peers.
The frequency of sibling violence is highest before age 9, but its “severity peaks in adolescence,” Dr. Martin wrote. Clinicians evaluating someone as a perpetrator or victim of sibling violence need to consider perception, intention, and severity in their assessments.
“Psychological aggression is often a precursor to physical aggression and often more damaging,” Dr. Martin wrote. Older siblings are more likely to be the aggressors, and males and females are equally likely to be victims and perpetrators of less severe abuse.
But “presence of a male child increases the likelihood of violence between siblings,” Dr. Martin found, and males are more likely to be perpetrators of more severe abuse – with one exception: Females are more likely to be perpetrators of sexual abuse. Although sexual abuse often is excluded from discussions of sibling violence, it is the most common form of familial sexual abuse.
Many psychological schools of thought can be used to explore causes from a theoretical perspective, but the list of interacting factors is long. It includes factors related to the parent-child relationship as well as individuals and the family as a whole.
Among the parent-child factors Dr. Martin lists are “parental differential treatment (particularly by fathers), active and direct judgmental comparison by parents, negative and conflictual parent-child relationships, lack of parental reinforcement of prosocial behavior, polarized definitions of good and bad children,” and rejecting or overcontrolling mothers. Other factors include coercive parenting, inadequate parental supervision, parental child abuse, parental approval of physical aggression between siblings, and lack of acknowledgment of children’s concerns.
In terms of the family unit, sibling violence is linked to domestic partner violence, marital conflict, poor family cohesion, living with a stepfamily, and lack of family resources and/or “lack of clear and consistent family rules,” Dr. Martin found.
While a “perpetrator’s lack of empathy, low self-esteem, and aggressive temperament” all are risk factors for sibling violence, protective factors include greater warmth in family relationships.
Sibling murder accounts for 1% of all homicide arrests and 8%-10% of all familial murders. The majority of these, about 75%, are brothers killing brothers. The remaining quarter include, in decreasing prevalence, brothers killing sisters, sisters killing brothers, and sisters killing sisters.
Though no evidence-based treatments exist for sibling violence, prevention strategies might include “secondary prevention, including family and individual approaches,” and “primary prevention with parenting programs for those at risk to abuse,” such as Successful Parenting, Systematic Training for Effective Parenting, and Parent Effectiveness Training.
Clinicians also have the option to modify existing tools, address sibling conflict through mediation, work to improve all family members’ communication skills, and establish rules for appropriate behaviors. Other treatment approaches may include “structured family therapy, task-centered approaches, utilizing social learning theory or nonviolent resistance,” Dr. Martin reported.
AUSTIN, TEX. – Sibling violence is the most common form of family violence – more prevalent than child abuse and domestic abuse combined – according to new research.
A review of the literature shows that it occurs in anywhere from 42% to 80%-90% of families, according to an abstract by Peter S. Martin, MD, MPH, of the University of Buffalo, New York.
Nearly 50% of siblings engaged in severe violence in the past year, though emotional aggression is more common than is physical aggression, Dr. Martin shared at the annual meeting of the American Academy of Psychiatry and the Law.
“Both perpetrators and victims are at risk for poor outcomes,” Dr. Martin wrote, listing distress, low self-esteem, developmental delays, depression, anxiety, posttraumatic stress disorder, substance use disorders, eating disorders, and suicidality, sometimes reaching into adulthood. Those symptoms typically can be as severe as those experienced by victims of peer bullying, he wrote.
Males involved in sibling violence tend to show more aggression and delinquency, while females experience more difficulties with psychological adjustment, he wrote. Sibling violence also is a predictor for college dating violence.
Siblings – whether biological, half, step, adoptive, foster or even fictive (like chosen family) – spend more time with each other than anyone else growing up. Those relationships provide companionship, support, and opportunities for play and engagement against an adversary, but they remain unique from other family relationships.
Healthy sibling relationships are linked to increased social competence, independence, self-control, companionship, general life skills, support, and overall social, cognitive, and emotional growth, Dr. Martin noted in his abstract.
On the flip side, “,” he wrote.
Yet, despite the prevalence of sibling aggression and the commonness of having a sibling in general, studying sibling violence is challenging because neither the academic research nor legal realms have a standardized definition for it.
To better understand the phenomenon, Dr. Martin conduced a literature review using Medline, Web of Sciences, PsycINFO, and Google Scholar. He identified 158 articles from peer-reviewed journals or textbooks.
Dr. Martin described sibling rivalry and sibling aggression and abuse separately, though overlap certainly occurs. Sibling rivalry – conflict over something the other sibling wants or a lack of balance between them – generally stems from resentment related to birth order and competition.
Common sources include favoritism or preferential treatment that one child perceives a parent to grant another sibling, problems with sharing possessions, and “fair” or “even” division of household chores.
“Usually the biggest problems is an impaired sibling relationship,” Dr. Martin wrote. But the experience can contribute to low self-esteem into adulthood if individuals believe themselves to be their parents’ less favored children, and sibling rivalry often can develop into sibling abuse.
Sibling aggression often is unrecognized with poor measures of prevalence, frequently relying on recall from college students. Yet, when paired with peer violence, sibling violence increases the likelihood of worse mental health outcomes, Dr. Martin found. Further, youth who fight with their siblings are 2.5 times more likely to fight with their peers.
The frequency of sibling violence is highest before age 9, but its “severity peaks in adolescence,” Dr. Martin wrote. Clinicians evaluating someone as a perpetrator or victim of sibling violence need to consider perception, intention, and severity in their assessments.
“Psychological aggression is often a precursor to physical aggression and often more damaging,” Dr. Martin wrote. Older siblings are more likely to be the aggressors, and males and females are equally likely to be victims and perpetrators of less severe abuse.
But “presence of a male child increases the likelihood of violence between siblings,” Dr. Martin found, and males are more likely to be perpetrators of more severe abuse – with one exception: Females are more likely to be perpetrators of sexual abuse. Although sexual abuse often is excluded from discussions of sibling violence, it is the most common form of familial sexual abuse.
Many psychological schools of thought can be used to explore causes from a theoretical perspective, but the list of interacting factors is long. It includes factors related to the parent-child relationship as well as individuals and the family as a whole.
Among the parent-child factors Dr. Martin lists are “parental differential treatment (particularly by fathers), active and direct judgmental comparison by parents, negative and conflictual parent-child relationships, lack of parental reinforcement of prosocial behavior, polarized definitions of good and bad children,” and rejecting or overcontrolling mothers. Other factors include coercive parenting, inadequate parental supervision, parental child abuse, parental approval of physical aggression between siblings, and lack of acknowledgment of children’s concerns.
In terms of the family unit, sibling violence is linked to domestic partner violence, marital conflict, poor family cohesion, living with a stepfamily, and lack of family resources and/or “lack of clear and consistent family rules,” Dr. Martin found.
While a “perpetrator’s lack of empathy, low self-esteem, and aggressive temperament” all are risk factors for sibling violence, protective factors include greater warmth in family relationships.
Sibling murder accounts for 1% of all homicide arrests and 8%-10% of all familial murders. The majority of these, about 75%, are brothers killing brothers. The remaining quarter include, in decreasing prevalence, brothers killing sisters, sisters killing brothers, and sisters killing sisters.
Though no evidence-based treatments exist for sibling violence, prevention strategies might include “secondary prevention, including family and individual approaches,” and “primary prevention with parenting programs for those at risk to abuse,” such as Successful Parenting, Systematic Training for Effective Parenting, and Parent Effectiveness Training.
Clinicians also have the option to modify existing tools, address sibling conflict through mediation, work to improve all family members’ communication skills, and establish rules for appropriate behaviors. Other treatment approaches may include “structured family therapy, task-centered approaches, utilizing social learning theory or nonviolent resistance,” Dr. Martin reported.
REPORTING FROM THE AAPL ANNUAL MEETING
United States must join with world to protect refugee children
ORLANDO – The United States is one of the wealthiest nations on the planet, yet it does not always stand with the rest of the global community in promoting universally accepted principles on the health and well-being of children across the world, particularly refugee children, according to Francis E. Rushton Jr., MD.
In an interview at the annual meeting of the American Academy of Pediatrics, Dr. Rushton discussed the importance of seeing American exceptionalism for what it is – a flaw rather than a virtue – and joining with the rest of the world in upholding the tenets of the Budapest Declaration On the Rights, Health and Well-being of Children and Youth on the Move.
In the three-page Budapest document, created by the International Society for Social Pediatrics and Child Health (ISSOP) in October 2017 and endorsed by the AAP, pediatricians from across the world acknowledge the realities of worldwide refugee crises and accept their detailed responsibilities in meeting and advocating for those children’s needs.
Although the current administration’s decision earlier this year to split children from their families at the border caught everyone attention, . He particularly stressed the “importance of working with the global community on clinical services, programs and policy.”
Dr. Rushton, clinical professor of pediatrics at the University of South Carolina, Columbia, and medical director of the Quality Through Innovation in Pediatrics network, also discussed the need to commit to the United Nations Convention on the Rights of the Child and to join the global community in following the UN’s Sustainable Development Goals and the principles in the World Health Organization’s publication, “Nurturing care for early childhood development.”
The former is a “blueprint” to overcoming challenges related to “poverty, inequality, climate, environmental degradation, prosperity and peace and justice” by achieving targets by 2030, and the latter is “a framework for helping children survive and thrive to transform health and human potential.”
“This is our issue as child health professionals. We need to continue applying pressure on our political leaders,” Dr. Rushton told his colleagues. He advocated taking the long view: “Let’s build a system that respects the human rights of all children.”
ORLANDO – The United States is one of the wealthiest nations on the planet, yet it does not always stand with the rest of the global community in promoting universally accepted principles on the health and well-being of children across the world, particularly refugee children, according to Francis E. Rushton Jr., MD.
In an interview at the annual meeting of the American Academy of Pediatrics, Dr. Rushton discussed the importance of seeing American exceptionalism for what it is – a flaw rather than a virtue – and joining with the rest of the world in upholding the tenets of the Budapest Declaration On the Rights, Health and Well-being of Children and Youth on the Move.
In the three-page Budapest document, created by the International Society for Social Pediatrics and Child Health (ISSOP) in October 2017 and endorsed by the AAP, pediatricians from across the world acknowledge the realities of worldwide refugee crises and accept their detailed responsibilities in meeting and advocating for those children’s needs.
Although the current administration’s decision earlier this year to split children from their families at the border caught everyone attention, . He particularly stressed the “importance of working with the global community on clinical services, programs and policy.”
Dr. Rushton, clinical professor of pediatrics at the University of South Carolina, Columbia, and medical director of the Quality Through Innovation in Pediatrics network, also discussed the need to commit to the United Nations Convention on the Rights of the Child and to join the global community in following the UN’s Sustainable Development Goals and the principles in the World Health Organization’s publication, “Nurturing care for early childhood development.”
The former is a “blueprint” to overcoming challenges related to “poverty, inequality, climate, environmental degradation, prosperity and peace and justice” by achieving targets by 2030, and the latter is “a framework for helping children survive and thrive to transform health and human potential.”
“This is our issue as child health professionals. We need to continue applying pressure on our political leaders,” Dr. Rushton told his colleagues. He advocated taking the long view: “Let’s build a system that respects the human rights of all children.”
ORLANDO – The United States is one of the wealthiest nations on the planet, yet it does not always stand with the rest of the global community in promoting universally accepted principles on the health and well-being of children across the world, particularly refugee children, according to Francis E. Rushton Jr., MD.
In an interview at the annual meeting of the American Academy of Pediatrics, Dr. Rushton discussed the importance of seeing American exceptionalism for what it is – a flaw rather than a virtue – and joining with the rest of the world in upholding the tenets of the Budapest Declaration On the Rights, Health and Well-being of Children and Youth on the Move.
In the three-page Budapest document, created by the International Society for Social Pediatrics and Child Health (ISSOP) in October 2017 and endorsed by the AAP, pediatricians from across the world acknowledge the realities of worldwide refugee crises and accept their detailed responsibilities in meeting and advocating for those children’s needs.
Although the current administration’s decision earlier this year to split children from their families at the border caught everyone attention, . He particularly stressed the “importance of working with the global community on clinical services, programs and policy.”
Dr. Rushton, clinical professor of pediatrics at the University of South Carolina, Columbia, and medical director of the Quality Through Innovation in Pediatrics network, also discussed the need to commit to the United Nations Convention on the Rights of the Child and to join the global community in following the UN’s Sustainable Development Goals and the principles in the World Health Organization’s publication, “Nurturing care for early childhood development.”
The former is a “blueprint” to overcoming challenges related to “poverty, inequality, climate, environmental degradation, prosperity and peace and justice” by achieving targets by 2030, and the latter is “a framework for helping children survive and thrive to transform health and human potential.”
“This is our issue as child health professionals. We need to continue applying pressure on our political leaders,” Dr. Rushton told his colleagues. He advocated taking the long view: “Let’s build a system that respects the human rights of all children.”
REPORTING FROM AAP 2018
Identifying and stopping a likely mass shooter: A case study
AUSTIN, TEX. – While the media relentlessly reports on every mass shooting that occurs, the public hears less often about the shootings that never happened – because people were paying attention and taking action, according to James L. Knoll, IV, MD, director of forensic psychiatry at the State University of New York, Syracuse.
“We’ve learned a lot about risk factors [for mass shootings], we’ve learned a lot about associations and correlations, and it’s gotten us so far,” Dr. Knoll told attendees at the annual meeting of the American Academy of Psychiatry and the Law. “I want to invite you to look at this from the angle of those shootings that were able to be prevented or disrupted.” (Dr. Knoll said he used the term “disrupted” because it’s impossible to ever know for certain that a shooting was thwarted.)
It is difficult to track mass homicides that would have occurred but were disrupted, but one study Dr. Knoll cited combed through news reports and identified 57 interrupted mass homicides (Aggress Viol Behav. 2016 Sep-Oct;30:88-93). Most of those (77%) had been interrupted by family and friends or the general public reporting suspicious behavior.
It was while Dr. Knoll was leading the threat assessment subcommittee of the Syracuse School Safety Task Force that a potential school shooting threat arose.
A 22-year-old Chinese international student named Xiaofeng “Lincoln” Zhan walked into AJ’s Archery/The Gun Shop on March 12, asking to buy an AR-15. The AR-15 is the semiautomatic weapon of choice for most mass shooters.
Mr. Zhan should have been barred from purchasing a gun because he was an international student on a temporary visa. Under U.S. code, it is “unlawful for any person to sell or otherwise dispose of any firearm or ammunition to any person knowing or having reasonable cause to believe that such person” is an alien who is “illegally or unlawfully in the United States” or “ has been admitted to the United States under a nonimmigrant visa.”
But the second provision was subject to certain exceptions, the first of which was that the person had been “admitted to the United States for lawful hunting or supporting purposes“ or was “in possession of a hunting license or permit lawfully issued in the United States.”
Mr. Zhan had a hunting license. He had taken a hunter safety course on March 11, the day before he entered the gun shop, and then bought a hunting license.
But the gun shop owner was not so easily persuaded. Mr. Zhan asked about “high-capacity shotguns” and said he belonged to a shooting club, yet he did not appear familiar with firearms. The gun shop owner was also skeptical because it didn’t make sense to use a high-capacity shotgun for hunting, and Mr. Zhan had just gotten his hunting license and didn’t know how to use the gun. Further, Mr. Zhan claimed that Syracuse University offered a class on how to use the gun – but the gun store owner knew that the university did not offer such a class.
The gun shop owner’s first thought was not that Mr. Zhan was a potential mass shooter but that he was a “secret shopper,” which Dr. Knoll defined as an undercover law enforcement officer who attempts to buy guns in a manner that should arouse suspicion in the store owner.
Ultimately, Zhan’s behavior was concerning and he made the owner feel uncomfortable. The owner captured Mr. Zhan’s information on U.S. ATF form 4473 and recorded his license plate. Then the gun shop owner contacted the Madison County Sheriff’s Office with the information.
The police opened an investigation that established that Mr. Zhan was a student enrolled at Syracuse University, which was on spring break at the time. The Syracuse Police Department arranged a joint meeting between the Onondaga County district attorney, Syracuse University Department of Public Safety, Onondaga County Sheriff’s Office, and the FBI to present their findings, including the fact that local high schools were planning walk-outs that might be potential targets.
Further investigation revealed that Mr. Zhan had been a student at Northeastern University in Boston in 2015, where he had asked a teacher how to get guns. The teacher emailed his supervisor, but the university police found no concerns.
Meanwhile, the police obtained a subpoena to get Mr. Zhan’s mental health records from Syracuse University. Mr. Zhan had sought psychiatric care at two facilities, Northeastern University in 2015 and Syracuse University in 2018. His mental health records revealed alcohol abuse, depression, suicidal thinking, anger problems, feelings of isolation and withdrawal, and his feeling that he might lose control or act violently, said Dr. Knoll, who is also professor of psychiatry at the university.
On March 13, the day after he had attempted to buy the gun, Syracuse University’s mental health services were contacted and briefed on Mr. Zhan. They filled out the paperwork for New York’s SAFE Act, which prevents people from buying a gun if a mental health professional makes the reasonable judgment that the individual might harm themselves or someone else.
The police investigation continued and found that Mr. Zhan had previously tried to buy an AR-15 at a Dick’s Sporting Goods store. He was denied because the SAFE Act prevents their sale.
Mr. Zhan, meanwhile, had gone to Mexico for the break and was due to return March 19. While he was away, an alarm allegedly went off in his apartment on March 16, leading the landlord to check on the apartment since he remembered previous police inquiries. He knocked on the door but there was no answer, so the landlord entered to do a safety check. He found ammunition and other concerning supplies.
The same day the landlord was checking Mr. Zhan’s apartment, students traveling with him in Mexico emailed Syracuse University about concerning behavior they observed in him. This behavior included signs of severe depression, verbalizing extremely negative thoughts, discussing suicide, drinking heavily, and making cuts to his forearms with the knife he possessed.
They also shared screenshots of messages they had seen him post in a social media group about feeling compelled to buy a gun and bulletproof vest and practice shooting.
Three days later, the police obtained a search warrant for Mr. Zhan’s apartment and vehicle. They found in his apartment high-powered optics, scopes, ammunition, targets from shooting ranges, receipts from shooting ranges, and similar equipment.
Ultimately, authorities revoked Mr. Zhan’s visa, enabling them to detain him at the airport when he returned from Mexico and deport him back to China.
After Mr. Zhan had returned to China, further investigation uncovered a series of texts between Mr. Zhan and his girlfriend in which he openly talks about wanting to shoot people.
“So, what went right here instead of what went wrong?” Dr. Knoll rhetorically asked. A lot of things: leakage of Mr. Zhan’s plans; fellow students seeing and reporting his electronic messages and concerning behaviors; the gun store owner’s skepticism and contact with the police; the landlord’s check on Mr. Zhan’s apartment; and the cooperation among local police, school authorities, and the school’s mental health services.
“There was also good communication among the threat assessment teams and law enforcement and the collaboration across disciplines,” Dr. Knoll said. Mass shootings have now “taken on more of a sociocultural phenomenon,” and “sociocultural problems require sociocultural solutions. I like these laws focusing on behaviors, not psychiatric diagnoses.”
He then reviewed potential interventions that might help identify or interfere with a planned incident or intent to commit one, including increased attention paid to suspicious behavior, third-party reporting of a potential shooter’s intent, and suicide prevention programs.
Dr. Knoll shared recent FBI research on 63 active shooters between 2000 and 2013 showing that the majority (77%) had been planning their attack for at least 1 week. Further, 46% have been preparing for 1 week before. The majority of those likely shooters also obtained their guns legally.
Although a quarter of those in the FBI study had some mental health diagnosis – predominantly depression or anxiety – the agency uncovered no significant correlation between mental illness and becoming a shooter.
The study concluded that,“absent specific evidence, careful consideration should be given to social and contextual factors that might interact with any mental health issue before concluding that an active shooting was ‘caused’ by a mental illness. In short, declarations that all active shooters must simply be mentally ill are misleading and unhelpful.”
Dr. Knoll reported no conflicts of interest.
AUSTIN, TEX. – While the media relentlessly reports on every mass shooting that occurs, the public hears less often about the shootings that never happened – because people were paying attention and taking action, according to James L. Knoll, IV, MD, director of forensic psychiatry at the State University of New York, Syracuse.
“We’ve learned a lot about risk factors [for mass shootings], we’ve learned a lot about associations and correlations, and it’s gotten us so far,” Dr. Knoll told attendees at the annual meeting of the American Academy of Psychiatry and the Law. “I want to invite you to look at this from the angle of those shootings that were able to be prevented or disrupted.” (Dr. Knoll said he used the term “disrupted” because it’s impossible to ever know for certain that a shooting was thwarted.)
It is difficult to track mass homicides that would have occurred but were disrupted, but one study Dr. Knoll cited combed through news reports and identified 57 interrupted mass homicides (Aggress Viol Behav. 2016 Sep-Oct;30:88-93). Most of those (77%) had been interrupted by family and friends or the general public reporting suspicious behavior.
It was while Dr. Knoll was leading the threat assessment subcommittee of the Syracuse School Safety Task Force that a potential school shooting threat arose.
A 22-year-old Chinese international student named Xiaofeng “Lincoln” Zhan walked into AJ’s Archery/The Gun Shop on March 12, asking to buy an AR-15. The AR-15 is the semiautomatic weapon of choice for most mass shooters.
Mr. Zhan should have been barred from purchasing a gun because he was an international student on a temporary visa. Under U.S. code, it is “unlawful for any person to sell or otherwise dispose of any firearm or ammunition to any person knowing or having reasonable cause to believe that such person” is an alien who is “illegally or unlawfully in the United States” or “ has been admitted to the United States under a nonimmigrant visa.”
But the second provision was subject to certain exceptions, the first of which was that the person had been “admitted to the United States for lawful hunting or supporting purposes“ or was “in possession of a hunting license or permit lawfully issued in the United States.”
Mr. Zhan had a hunting license. He had taken a hunter safety course on March 11, the day before he entered the gun shop, and then bought a hunting license.
But the gun shop owner was not so easily persuaded. Mr. Zhan asked about “high-capacity shotguns” and said he belonged to a shooting club, yet he did not appear familiar with firearms. The gun shop owner was also skeptical because it didn’t make sense to use a high-capacity shotgun for hunting, and Mr. Zhan had just gotten his hunting license and didn’t know how to use the gun. Further, Mr. Zhan claimed that Syracuse University offered a class on how to use the gun – but the gun store owner knew that the university did not offer such a class.
The gun shop owner’s first thought was not that Mr. Zhan was a potential mass shooter but that he was a “secret shopper,” which Dr. Knoll defined as an undercover law enforcement officer who attempts to buy guns in a manner that should arouse suspicion in the store owner.
Ultimately, Zhan’s behavior was concerning and he made the owner feel uncomfortable. The owner captured Mr. Zhan’s information on U.S. ATF form 4473 and recorded his license plate. Then the gun shop owner contacted the Madison County Sheriff’s Office with the information.
The police opened an investigation that established that Mr. Zhan was a student enrolled at Syracuse University, which was on spring break at the time. The Syracuse Police Department arranged a joint meeting between the Onondaga County district attorney, Syracuse University Department of Public Safety, Onondaga County Sheriff’s Office, and the FBI to present their findings, including the fact that local high schools were planning walk-outs that might be potential targets.
Further investigation revealed that Mr. Zhan had been a student at Northeastern University in Boston in 2015, where he had asked a teacher how to get guns. The teacher emailed his supervisor, but the university police found no concerns.
Meanwhile, the police obtained a subpoena to get Mr. Zhan’s mental health records from Syracuse University. Mr. Zhan had sought psychiatric care at two facilities, Northeastern University in 2015 and Syracuse University in 2018. His mental health records revealed alcohol abuse, depression, suicidal thinking, anger problems, feelings of isolation and withdrawal, and his feeling that he might lose control or act violently, said Dr. Knoll, who is also professor of psychiatry at the university.
On March 13, the day after he had attempted to buy the gun, Syracuse University’s mental health services were contacted and briefed on Mr. Zhan. They filled out the paperwork for New York’s SAFE Act, which prevents people from buying a gun if a mental health professional makes the reasonable judgment that the individual might harm themselves or someone else.
The police investigation continued and found that Mr. Zhan had previously tried to buy an AR-15 at a Dick’s Sporting Goods store. He was denied because the SAFE Act prevents their sale.
Mr. Zhan, meanwhile, had gone to Mexico for the break and was due to return March 19. While he was away, an alarm allegedly went off in his apartment on March 16, leading the landlord to check on the apartment since he remembered previous police inquiries. He knocked on the door but there was no answer, so the landlord entered to do a safety check. He found ammunition and other concerning supplies.
The same day the landlord was checking Mr. Zhan’s apartment, students traveling with him in Mexico emailed Syracuse University about concerning behavior they observed in him. This behavior included signs of severe depression, verbalizing extremely negative thoughts, discussing suicide, drinking heavily, and making cuts to his forearms with the knife he possessed.
They also shared screenshots of messages they had seen him post in a social media group about feeling compelled to buy a gun and bulletproof vest and practice shooting.
Three days later, the police obtained a search warrant for Mr. Zhan’s apartment and vehicle. They found in his apartment high-powered optics, scopes, ammunition, targets from shooting ranges, receipts from shooting ranges, and similar equipment.
Ultimately, authorities revoked Mr. Zhan’s visa, enabling them to detain him at the airport when he returned from Mexico and deport him back to China.
After Mr. Zhan had returned to China, further investigation uncovered a series of texts between Mr. Zhan and his girlfriend in which he openly talks about wanting to shoot people.
“So, what went right here instead of what went wrong?” Dr. Knoll rhetorically asked. A lot of things: leakage of Mr. Zhan’s plans; fellow students seeing and reporting his electronic messages and concerning behaviors; the gun store owner’s skepticism and contact with the police; the landlord’s check on Mr. Zhan’s apartment; and the cooperation among local police, school authorities, and the school’s mental health services.
“There was also good communication among the threat assessment teams and law enforcement and the collaboration across disciplines,” Dr. Knoll said. Mass shootings have now “taken on more of a sociocultural phenomenon,” and “sociocultural problems require sociocultural solutions. I like these laws focusing on behaviors, not psychiatric diagnoses.”
He then reviewed potential interventions that might help identify or interfere with a planned incident or intent to commit one, including increased attention paid to suspicious behavior, third-party reporting of a potential shooter’s intent, and suicide prevention programs.
Dr. Knoll shared recent FBI research on 63 active shooters between 2000 and 2013 showing that the majority (77%) had been planning their attack for at least 1 week. Further, 46% have been preparing for 1 week before. The majority of those likely shooters also obtained their guns legally.
Although a quarter of those in the FBI study had some mental health diagnosis – predominantly depression or anxiety – the agency uncovered no significant correlation between mental illness and becoming a shooter.
The study concluded that,“absent specific evidence, careful consideration should be given to social and contextual factors that might interact with any mental health issue before concluding that an active shooting was ‘caused’ by a mental illness. In short, declarations that all active shooters must simply be mentally ill are misleading and unhelpful.”
Dr. Knoll reported no conflicts of interest.
AUSTIN, TEX. – While the media relentlessly reports on every mass shooting that occurs, the public hears less often about the shootings that never happened – because people were paying attention and taking action, according to James L. Knoll, IV, MD, director of forensic psychiatry at the State University of New York, Syracuse.
“We’ve learned a lot about risk factors [for mass shootings], we’ve learned a lot about associations and correlations, and it’s gotten us so far,” Dr. Knoll told attendees at the annual meeting of the American Academy of Psychiatry and the Law. “I want to invite you to look at this from the angle of those shootings that were able to be prevented or disrupted.” (Dr. Knoll said he used the term “disrupted” because it’s impossible to ever know for certain that a shooting was thwarted.)
It is difficult to track mass homicides that would have occurred but were disrupted, but one study Dr. Knoll cited combed through news reports and identified 57 interrupted mass homicides (Aggress Viol Behav. 2016 Sep-Oct;30:88-93). Most of those (77%) had been interrupted by family and friends or the general public reporting suspicious behavior.
It was while Dr. Knoll was leading the threat assessment subcommittee of the Syracuse School Safety Task Force that a potential school shooting threat arose.
A 22-year-old Chinese international student named Xiaofeng “Lincoln” Zhan walked into AJ’s Archery/The Gun Shop on March 12, asking to buy an AR-15. The AR-15 is the semiautomatic weapon of choice for most mass shooters.
Mr. Zhan should have been barred from purchasing a gun because he was an international student on a temporary visa. Under U.S. code, it is “unlawful for any person to sell or otherwise dispose of any firearm or ammunition to any person knowing or having reasonable cause to believe that such person” is an alien who is “illegally or unlawfully in the United States” or “ has been admitted to the United States under a nonimmigrant visa.”
But the second provision was subject to certain exceptions, the first of which was that the person had been “admitted to the United States for lawful hunting or supporting purposes“ or was “in possession of a hunting license or permit lawfully issued in the United States.”
Mr. Zhan had a hunting license. He had taken a hunter safety course on March 11, the day before he entered the gun shop, and then bought a hunting license.
But the gun shop owner was not so easily persuaded. Mr. Zhan asked about “high-capacity shotguns” and said he belonged to a shooting club, yet he did not appear familiar with firearms. The gun shop owner was also skeptical because it didn’t make sense to use a high-capacity shotgun for hunting, and Mr. Zhan had just gotten his hunting license and didn’t know how to use the gun. Further, Mr. Zhan claimed that Syracuse University offered a class on how to use the gun – but the gun store owner knew that the university did not offer such a class.
The gun shop owner’s first thought was not that Mr. Zhan was a potential mass shooter but that he was a “secret shopper,” which Dr. Knoll defined as an undercover law enforcement officer who attempts to buy guns in a manner that should arouse suspicion in the store owner.
Ultimately, Zhan’s behavior was concerning and he made the owner feel uncomfortable. The owner captured Mr. Zhan’s information on U.S. ATF form 4473 and recorded his license plate. Then the gun shop owner contacted the Madison County Sheriff’s Office with the information.
The police opened an investigation that established that Mr. Zhan was a student enrolled at Syracuse University, which was on spring break at the time. The Syracuse Police Department arranged a joint meeting between the Onondaga County district attorney, Syracuse University Department of Public Safety, Onondaga County Sheriff’s Office, and the FBI to present their findings, including the fact that local high schools were planning walk-outs that might be potential targets.
Further investigation revealed that Mr. Zhan had been a student at Northeastern University in Boston in 2015, where he had asked a teacher how to get guns. The teacher emailed his supervisor, but the university police found no concerns.
Meanwhile, the police obtained a subpoena to get Mr. Zhan’s mental health records from Syracuse University. Mr. Zhan had sought psychiatric care at two facilities, Northeastern University in 2015 and Syracuse University in 2018. His mental health records revealed alcohol abuse, depression, suicidal thinking, anger problems, feelings of isolation and withdrawal, and his feeling that he might lose control or act violently, said Dr. Knoll, who is also professor of psychiatry at the university.
On March 13, the day after he had attempted to buy the gun, Syracuse University’s mental health services were contacted and briefed on Mr. Zhan. They filled out the paperwork for New York’s SAFE Act, which prevents people from buying a gun if a mental health professional makes the reasonable judgment that the individual might harm themselves or someone else.
The police investigation continued and found that Mr. Zhan had previously tried to buy an AR-15 at a Dick’s Sporting Goods store. He was denied because the SAFE Act prevents their sale.
Mr. Zhan, meanwhile, had gone to Mexico for the break and was due to return March 19. While he was away, an alarm allegedly went off in his apartment on March 16, leading the landlord to check on the apartment since he remembered previous police inquiries. He knocked on the door but there was no answer, so the landlord entered to do a safety check. He found ammunition and other concerning supplies.
The same day the landlord was checking Mr. Zhan’s apartment, students traveling with him in Mexico emailed Syracuse University about concerning behavior they observed in him. This behavior included signs of severe depression, verbalizing extremely negative thoughts, discussing suicide, drinking heavily, and making cuts to his forearms with the knife he possessed.
They also shared screenshots of messages they had seen him post in a social media group about feeling compelled to buy a gun and bulletproof vest and practice shooting.
Three days later, the police obtained a search warrant for Mr. Zhan’s apartment and vehicle. They found in his apartment high-powered optics, scopes, ammunition, targets from shooting ranges, receipts from shooting ranges, and similar equipment.
Ultimately, authorities revoked Mr. Zhan’s visa, enabling them to detain him at the airport when he returned from Mexico and deport him back to China.
After Mr. Zhan had returned to China, further investigation uncovered a series of texts between Mr. Zhan and his girlfriend in which he openly talks about wanting to shoot people.
“So, what went right here instead of what went wrong?” Dr. Knoll rhetorically asked. A lot of things: leakage of Mr. Zhan’s plans; fellow students seeing and reporting his electronic messages and concerning behaviors; the gun store owner’s skepticism and contact with the police; the landlord’s check on Mr. Zhan’s apartment; and the cooperation among local police, school authorities, and the school’s mental health services.
“There was also good communication among the threat assessment teams and law enforcement and the collaboration across disciplines,” Dr. Knoll said. Mass shootings have now “taken on more of a sociocultural phenomenon,” and “sociocultural problems require sociocultural solutions. I like these laws focusing on behaviors, not psychiatric diagnoses.”
He then reviewed potential interventions that might help identify or interfere with a planned incident or intent to commit one, including increased attention paid to suspicious behavior, third-party reporting of a potential shooter’s intent, and suicide prevention programs.
Dr. Knoll shared recent FBI research on 63 active shooters between 2000 and 2013 showing that the majority (77%) had been planning their attack for at least 1 week. Further, 46% have been preparing for 1 week before. The majority of those likely shooters also obtained their guns legally.
Although a quarter of those in the FBI study had some mental health diagnosis – predominantly depression or anxiety – the agency uncovered no significant correlation between mental illness and becoming a shooter.
The study concluded that,“absent specific evidence, careful consideration should be given to social and contextual factors that might interact with any mental health issue before concluding that an active shooting was ‘caused’ by a mental illness. In short, declarations that all active shooters must simply be mentally ill are misleading and unhelpful.”
Dr. Knoll reported no conflicts of interest.
EXPERT ANALYSIS FROM THE AAPL ANNUAL MEETING
Most kids can’t tell real firearms from toy guns
ORLANDO – Less than half of children could identify a real gun from a toy gun in photos, regardless of whether their parents owned a gun or had talked to them about firearm safety, according to a new study.
“That is very concerning to us because a large percentage of these parents are actually storing their firearms insecurely and then their children cannot tell the difference,” study investigator Kiesha Fraser Doh, MD, reported at the annual conference of the American Academy of Pediatrics.
Dr. Fraser Doh, assistant professor of pediatrics and emergency medicine physician at Emory University School of Medicine and Children’s Healthcare of Atlanta said she was inspired to conduct this study after she noticed she was seeing approximately one firearm injury in children about every 2½ weeks in her institution. She also realized that her own child frequently went on play dates, but she did not always think to ask about firearms in the home of the friends her child visited.
An estimated one in three U.S. children live in homes with a firearm, she explained, and many of these guns are left loaded and/or unlocked.
The researchers enrolled a convenience sample of 297 English-speaking caregivers who presented at one of three pediatrics EDs over 3 months. Two were suburban departments, and one was urban.
Overall, most respondents (79%) were female and 56% were black, while 33% were white. Most of the caregivers responding had some college education (72%), and just over half (51%) had an income greater than $50,000.
The researchers asked caregivers whether they had guns in their own home and whether their child had access to firearms in their own or other homes. They also asked if their child played with toy guns and whether they believed their child could tell the difference between a real gun and a toy one.
Compared with those who did not own guns, gun owners were significantly more likely to be white and have both an income over $50,000 and some college education.
Meanwhile, researchers showed the children, aged 7-17 years, photos of a toy gun and a real gun and asked which was which.
A quarter of the caregivers (25%) owned guns, and half of them (50%) allowed their children to play with guns, compared with 26% of the non-gun owners.
In addition, 86% of the gun owners had discussed gun safety with their children, and the same proportion believed their children could correctly distinguish between a real gun and a toy gun.
By comparison, 58% of the non-gun owners had discussed gun safety with their children, and the same percentage believed their children could tell the difference between real and fake guns.
The children’s confidence in being able to tell the difference was similar regardless of whether their parents owned guns (79%) or didn’t (76%).
Yet less than half of all children correctly identified the real gun in the photos: 39% of the gun owners’ children and 42% of the non-gun owners’ children correctly pointed out the real gun, a nonsignificant difference.
Throughout the entire sample, more than 8 in 10 respondents, both gun owners (86%) and not (84%), believed there should be a law that requires caregivers to store their guns safely. A similar proportion (85% of gun owners and 80% of non-gun owners) believed legal penalties should exist for caregivers “if a child encounters an unsecured firearm.”
Overall, 5% of the respondents (14% of gun owners and 4% of non-gun owners) believed their child could get a gun within 24 hours if desired.
“So what does this mean to us as clinicians? It behooves [pediatricians] to actually continue to educate families at well-child visits on the guidelines about how to store firearms safely, locked up, unloaded, separate from ammunition,” Dr. Fraser Doh said. “On the flip side, parents need to be asking about the presence of firearms in the homes their children visit and also make sure that they’re storing their weapons safety.”
Dr. Fraser Doh said she had no relevant conflicts of interest.
Key clinical point: Less than half of children could distinguish between photos of a real gun versus pictures of a toy gun.
Major finding: 39% of the gun owners’ children and 42% of the non–gun owners’ children correctly identified the photo of a real gun versus a toy gun.
Study details: The findings are based on a study involving 297 English-speaking children, aged 7-17 years, and their parents.
Key clinical point: Less than half of children could distinguish between photos of a real gun versus pictures of a toy gun.
Major finding: 39% of the gun owners’ children and 42% of the non–gun owners’ children correctly identified the photo of a real gun versus a toy gun.
Study details: The findings are based on a study involving 297 English-speaking children, aged 7-17 years, and their parents.
Key clinical point: Less than half of children could distinguish between photos of a real gun versus pictures of a toy gun.
Major finding: 39% of the gun owners’ children and 42% of the non–gun owners’ children correctly identified the photo of a real gun versus a toy gun.
Study details: The findings are based on a study involving 297 English-speaking children, aged 7-17 years, and their parents.
ORLANDO – Less than half of children could identify a real gun from a toy gun in photos, regardless of whether their parents owned a gun or had talked to them about firearm safety, according to a new study.
“That is very concerning to us because a large percentage of these parents are actually storing their firearms insecurely and then their children cannot tell the difference,” study investigator Kiesha Fraser Doh, MD, reported at the annual conference of the American Academy of Pediatrics.
Dr. Fraser Doh, assistant professor of pediatrics and emergency medicine physician at Emory University School of Medicine and Children’s Healthcare of Atlanta said she was inspired to conduct this study after she noticed she was seeing approximately one firearm injury in children about every 2½ weeks in her institution. She also realized that her own child frequently went on play dates, but she did not always think to ask about firearms in the home of the friends her child visited.
An estimated one in three U.S. children live in homes with a firearm, she explained, and many of these guns are left loaded and/or unlocked.
The researchers enrolled a convenience sample of 297 English-speaking caregivers who presented at one of three pediatrics EDs over 3 months. Two were suburban departments, and one was urban.
Overall, most respondents (79%) were female and 56% were black, while 33% were white. Most of the caregivers responding had some college education (72%), and just over half (51%) had an income greater than $50,000.
The researchers asked caregivers whether they had guns in their own home and whether their child had access to firearms in their own or other homes. They also asked if their child played with toy guns and whether they believed their child could tell the difference between a real gun and a toy one.
Compared with those who did not own guns, gun owners were significantly more likely to be white and have both an income over $50,000 and some college education.
Meanwhile, researchers showed the children, aged 7-17 years, photos of a toy gun and a real gun and asked which was which.
A quarter of the caregivers (25%) owned guns, and half of them (50%) allowed their children to play with guns, compared with 26% of the non-gun owners.
In addition, 86% of the gun owners had discussed gun safety with their children, and the same proportion believed their children could correctly distinguish between a real gun and a toy gun.
By comparison, 58% of the non-gun owners had discussed gun safety with their children, and the same percentage believed their children could tell the difference between real and fake guns.
The children’s confidence in being able to tell the difference was similar regardless of whether their parents owned guns (79%) or didn’t (76%).
Yet less than half of all children correctly identified the real gun in the photos: 39% of the gun owners’ children and 42% of the non-gun owners’ children correctly pointed out the real gun, a nonsignificant difference.
Throughout the entire sample, more than 8 in 10 respondents, both gun owners (86%) and not (84%), believed there should be a law that requires caregivers to store their guns safely. A similar proportion (85% of gun owners and 80% of non-gun owners) believed legal penalties should exist for caregivers “if a child encounters an unsecured firearm.”
Overall, 5% of the respondents (14% of gun owners and 4% of non-gun owners) believed their child could get a gun within 24 hours if desired.
“So what does this mean to us as clinicians? It behooves [pediatricians] to actually continue to educate families at well-child visits on the guidelines about how to store firearms safely, locked up, unloaded, separate from ammunition,” Dr. Fraser Doh said. “On the flip side, parents need to be asking about the presence of firearms in the homes their children visit and also make sure that they’re storing their weapons safety.”
Dr. Fraser Doh said she had no relevant conflicts of interest.
ORLANDO – Less than half of children could identify a real gun from a toy gun in photos, regardless of whether their parents owned a gun or had talked to them about firearm safety, according to a new study.
“That is very concerning to us because a large percentage of these parents are actually storing their firearms insecurely and then their children cannot tell the difference,” study investigator Kiesha Fraser Doh, MD, reported at the annual conference of the American Academy of Pediatrics.
Dr. Fraser Doh, assistant professor of pediatrics and emergency medicine physician at Emory University School of Medicine and Children’s Healthcare of Atlanta said she was inspired to conduct this study after she noticed she was seeing approximately one firearm injury in children about every 2½ weeks in her institution. She also realized that her own child frequently went on play dates, but she did not always think to ask about firearms in the home of the friends her child visited.
An estimated one in three U.S. children live in homes with a firearm, she explained, and many of these guns are left loaded and/or unlocked.
The researchers enrolled a convenience sample of 297 English-speaking caregivers who presented at one of three pediatrics EDs over 3 months. Two were suburban departments, and one was urban.
Overall, most respondents (79%) were female and 56% were black, while 33% were white. Most of the caregivers responding had some college education (72%), and just over half (51%) had an income greater than $50,000.
The researchers asked caregivers whether they had guns in their own home and whether their child had access to firearms in their own or other homes. They also asked if their child played with toy guns and whether they believed their child could tell the difference between a real gun and a toy one.
Compared with those who did not own guns, gun owners were significantly more likely to be white and have both an income over $50,000 and some college education.
Meanwhile, researchers showed the children, aged 7-17 years, photos of a toy gun and a real gun and asked which was which.
A quarter of the caregivers (25%) owned guns, and half of them (50%) allowed their children to play with guns, compared with 26% of the non-gun owners.
In addition, 86% of the gun owners had discussed gun safety with their children, and the same proportion believed their children could correctly distinguish between a real gun and a toy gun.
By comparison, 58% of the non-gun owners had discussed gun safety with their children, and the same percentage believed their children could tell the difference between real and fake guns.
The children’s confidence in being able to tell the difference was similar regardless of whether their parents owned guns (79%) or didn’t (76%).
Yet less than half of all children correctly identified the real gun in the photos: 39% of the gun owners’ children and 42% of the non-gun owners’ children correctly pointed out the real gun, a nonsignificant difference.
Throughout the entire sample, more than 8 in 10 respondents, both gun owners (86%) and not (84%), believed there should be a law that requires caregivers to store their guns safely. A similar proportion (85% of gun owners and 80% of non-gun owners) believed legal penalties should exist for caregivers “if a child encounters an unsecured firearm.”
Overall, 5% of the respondents (14% of gun owners and 4% of non-gun owners) believed their child could get a gun within 24 hours if desired.
“So what does this mean to us as clinicians? It behooves [pediatricians] to actually continue to educate families at well-child visits on the guidelines about how to store firearms safely, locked up, unloaded, separate from ammunition,” Dr. Fraser Doh said. “On the flip side, parents need to be asking about the presence of firearms in the homes their children visit and also make sure that they’re storing their weapons safety.”
Dr. Fraser Doh said she had no relevant conflicts of interest.
REPORTING FROM AAP 2018
Playing harmonica improves COPD
SAN ANTONIO – Playing while also boosting their quality of life, suggest the findings from a small pilot study.
Three months of playing the harmonica about a half hour a day most days of the week led to several improved pulmonary outcome measures in participants, Mary Hart, RRT, MS, of Baylor Scott & White Health in Dallas, reported at the annual meeting of the American College of Chest Physicians.
Ms. Hart played a bit of harmonica during her presentation to demonstrate how playing can help with breathing.
“The harder I push with my diaphragm, the louder I was blowing,” she told attendees. “There’s actually a different amount of effort that you have to use to create sounds with using the harmonica notes.”
Hart said her team found a news article from 1999 about the benefits of playing harmonica, and they became interested in exploring whether it might be a helpful adjunct to respiratory therapy.
Though some previous research has explored potential benefits of harmonica playing in patients with lung disease, one study was too short to demonstrate significant improvement and the other looked at multiple different pulmonary conditions, Ms. Hart said.
The cohort study began with 14 former smokers, average age 72 years, who had completed pulmonary rehabilitation at least 6 months prior to joining the “Harmaniacs,” as the group eventually called themselves.
All participants received a harmonica, an instruction booklet with audio and video supplements, and sheet music for a harmonica in the key of C.
They attended a 2-hour group session once a week with a respiratory therapist and music therapist. The classes focused initially on breathing and relaxation techniques, pacing, and basic harmonica instruction, but the amount of actual playing time increased as the 12-week course went on. Participants were expected to practice their playing for at least a half hour 5 days a week at home.
The group began with the songs “Taps” and “Happy Birthday” because these songs were easy to play. Then they added a song each week, such as “America the Beautiful” and “You Are My Sunshine,” then seasonal favorites such as “We Wish You a Merry Christmas” and “Silent Night,” and easy pop tunes.
The researchers measured both respiratory and quality of life outcomes. Assessments included spirometry, the Six Minute Walk Test, maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP), the COPD Assessment Test, the modified Medical Research Council Dyspnea Scale, the Patient Health Questionnaire for depression, the St. George’s Respiratory Questionnaire for quality of life, perceived exertion using the Borg scale and assessments by the respiratory therapist and music therapist.
The music therapist listened to and documented participants’ “stories about how they felt about life living with COPD,” and Ms. Hart and her colleagues conducted a respiratory assessment that included data on medication management, adherence to medication, previous hospitalizations and length of stay, perceived shortness of breath, and daily living activities.
In addition to those assessments, the researchers collected data on the length of practice sessions, Borg scores before and after playing, the percentage of time taken for participation in class, the participants’ ability to make a sound, their challenges and triumphs, their tiredness and/or soreness after playing, and the number of people who continued playing after training.
Among the 11 participants who completed the training and all evaluations, the MIP increased by an average 15.36 cmH20 (P = .0017), and their MEP increased by an average 14.36 cmH20 (P = .0061).
Participants increased their distance in the Six Minute Walk Test by an average 60.55 meters (P = .0280), and Ms. Hart reported an improvement in quality of life scores.
In addition to home practice, participants were expected to keep a daily log of how it felt to play and what their biggest challenges and rewards were. The comments they wrote revealed benefits that sometimes surprised even the researchers:
“I can do laundry now.”
“I am more confident.”
“It is relaxing.”
“I want to keep playing forever.”
“It helps me cough up phlegm.”
“I lose track of time and enjoy my playing.”
“I played Happy Birthday at a party for my friend.”
Others express their difficulties as well, such as one person who wrote of being “really frustrated” and another who claimed to “have a hard time playing just one note.”
But the players learned to play as a group as well, even ordering T-shirts for themselves to give concerts. The group now has about 30 songs in its repertoire, Ms. Hart said, and they recently gave a 2-hour concert during which they played all 30 songs twice.
One consistent theme that emerged, Ms. Hart said, was improved control of breathing since playing the harmonica required participants to purse their lips (similar to the way needed for expiratory maneuvers), breathe from their diaphragms, and pace themselves. Playing exercised “the muscles that help pull air in and push air out of the lungs,” Ms. Hart said, and strengthened participants’ abdominal muscles, allowing more effective coughing.
Playing harmonica also increased self-confidence. It provided stress relief for some, and others simply found it fun or enjoyed the socializing opportunities.
The study’s small size and lack of a control group limit the generalizability of its findings.
Baylor Scott & White Central Texas Foundation funded the research. Ms. Hart reported no conflicts of interest.
SOURCE: Hart M et al. CHEST 2018. doi: 10.1016/j.chest.2018.08.669.
SAN ANTONIO – Playing while also boosting their quality of life, suggest the findings from a small pilot study.
Three months of playing the harmonica about a half hour a day most days of the week led to several improved pulmonary outcome measures in participants, Mary Hart, RRT, MS, of Baylor Scott & White Health in Dallas, reported at the annual meeting of the American College of Chest Physicians.
Ms. Hart played a bit of harmonica during her presentation to demonstrate how playing can help with breathing.
“The harder I push with my diaphragm, the louder I was blowing,” she told attendees. “There’s actually a different amount of effort that you have to use to create sounds with using the harmonica notes.”
Hart said her team found a news article from 1999 about the benefits of playing harmonica, and they became interested in exploring whether it might be a helpful adjunct to respiratory therapy.
Though some previous research has explored potential benefits of harmonica playing in patients with lung disease, one study was too short to demonstrate significant improvement and the other looked at multiple different pulmonary conditions, Ms. Hart said.
The cohort study began with 14 former smokers, average age 72 years, who had completed pulmonary rehabilitation at least 6 months prior to joining the “Harmaniacs,” as the group eventually called themselves.
All participants received a harmonica, an instruction booklet with audio and video supplements, and sheet music for a harmonica in the key of C.
They attended a 2-hour group session once a week with a respiratory therapist and music therapist. The classes focused initially on breathing and relaxation techniques, pacing, and basic harmonica instruction, but the amount of actual playing time increased as the 12-week course went on. Participants were expected to practice their playing for at least a half hour 5 days a week at home.
The group began with the songs “Taps” and “Happy Birthday” because these songs were easy to play. Then they added a song each week, such as “America the Beautiful” and “You Are My Sunshine,” then seasonal favorites such as “We Wish You a Merry Christmas” and “Silent Night,” and easy pop tunes.
The researchers measured both respiratory and quality of life outcomes. Assessments included spirometry, the Six Minute Walk Test, maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP), the COPD Assessment Test, the modified Medical Research Council Dyspnea Scale, the Patient Health Questionnaire for depression, the St. George’s Respiratory Questionnaire for quality of life, perceived exertion using the Borg scale and assessments by the respiratory therapist and music therapist.
The music therapist listened to and documented participants’ “stories about how they felt about life living with COPD,” and Ms. Hart and her colleagues conducted a respiratory assessment that included data on medication management, adherence to medication, previous hospitalizations and length of stay, perceived shortness of breath, and daily living activities.
In addition to those assessments, the researchers collected data on the length of practice sessions, Borg scores before and after playing, the percentage of time taken for participation in class, the participants’ ability to make a sound, their challenges and triumphs, their tiredness and/or soreness after playing, and the number of people who continued playing after training.
Among the 11 participants who completed the training and all evaluations, the MIP increased by an average 15.36 cmH20 (P = .0017), and their MEP increased by an average 14.36 cmH20 (P = .0061).
Participants increased their distance in the Six Minute Walk Test by an average 60.55 meters (P = .0280), and Ms. Hart reported an improvement in quality of life scores.
In addition to home practice, participants were expected to keep a daily log of how it felt to play and what their biggest challenges and rewards were. The comments they wrote revealed benefits that sometimes surprised even the researchers:
“I can do laundry now.”
“I am more confident.”
“It is relaxing.”
“I want to keep playing forever.”
“It helps me cough up phlegm.”
“I lose track of time and enjoy my playing.”
“I played Happy Birthday at a party for my friend.”
Others express their difficulties as well, such as one person who wrote of being “really frustrated” and another who claimed to “have a hard time playing just one note.”
But the players learned to play as a group as well, even ordering T-shirts for themselves to give concerts. The group now has about 30 songs in its repertoire, Ms. Hart said, and they recently gave a 2-hour concert during which they played all 30 songs twice.
One consistent theme that emerged, Ms. Hart said, was improved control of breathing since playing the harmonica required participants to purse their lips (similar to the way needed for expiratory maneuvers), breathe from their diaphragms, and pace themselves. Playing exercised “the muscles that help pull air in and push air out of the lungs,” Ms. Hart said, and strengthened participants’ abdominal muscles, allowing more effective coughing.
Playing harmonica also increased self-confidence. It provided stress relief for some, and others simply found it fun or enjoyed the socializing opportunities.
The study’s small size and lack of a control group limit the generalizability of its findings.
Baylor Scott & White Central Texas Foundation funded the research. Ms. Hart reported no conflicts of interest.
SOURCE: Hart M et al. CHEST 2018. doi: 10.1016/j.chest.2018.08.669.
SAN ANTONIO – Playing while also boosting their quality of life, suggest the findings from a small pilot study.
Three months of playing the harmonica about a half hour a day most days of the week led to several improved pulmonary outcome measures in participants, Mary Hart, RRT, MS, of Baylor Scott & White Health in Dallas, reported at the annual meeting of the American College of Chest Physicians.
Ms. Hart played a bit of harmonica during her presentation to demonstrate how playing can help with breathing.
“The harder I push with my diaphragm, the louder I was blowing,” she told attendees. “There’s actually a different amount of effort that you have to use to create sounds with using the harmonica notes.”
Hart said her team found a news article from 1999 about the benefits of playing harmonica, and they became interested in exploring whether it might be a helpful adjunct to respiratory therapy.
Though some previous research has explored potential benefits of harmonica playing in patients with lung disease, one study was too short to demonstrate significant improvement and the other looked at multiple different pulmonary conditions, Ms. Hart said.
The cohort study began with 14 former smokers, average age 72 years, who had completed pulmonary rehabilitation at least 6 months prior to joining the “Harmaniacs,” as the group eventually called themselves.
All participants received a harmonica, an instruction booklet with audio and video supplements, and sheet music for a harmonica in the key of C.
They attended a 2-hour group session once a week with a respiratory therapist and music therapist. The classes focused initially on breathing and relaxation techniques, pacing, and basic harmonica instruction, but the amount of actual playing time increased as the 12-week course went on. Participants were expected to practice their playing for at least a half hour 5 days a week at home.
The group began with the songs “Taps” and “Happy Birthday” because these songs were easy to play. Then they added a song each week, such as “America the Beautiful” and “You Are My Sunshine,” then seasonal favorites such as “We Wish You a Merry Christmas” and “Silent Night,” and easy pop tunes.
The researchers measured both respiratory and quality of life outcomes. Assessments included spirometry, the Six Minute Walk Test, maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP), the COPD Assessment Test, the modified Medical Research Council Dyspnea Scale, the Patient Health Questionnaire for depression, the St. George’s Respiratory Questionnaire for quality of life, perceived exertion using the Borg scale and assessments by the respiratory therapist and music therapist.
The music therapist listened to and documented participants’ “stories about how they felt about life living with COPD,” and Ms. Hart and her colleagues conducted a respiratory assessment that included data on medication management, adherence to medication, previous hospitalizations and length of stay, perceived shortness of breath, and daily living activities.
In addition to those assessments, the researchers collected data on the length of practice sessions, Borg scores before and after playing, the percentage of time taken for participation in class, the participants’ ability to make a sound, their challenges and triumphs, their tiredness and/or soreness after playing, and the number of people who continued playing after training.
Among the 11 participants who completed the training and all evaluations, the MIP increased by an average 15.36 cmH20 (P = .0017), and their MEP increased by an average 14.36 cmH20 (P = .0061).
Participants increased their distance in the Six Minute Walk Test by an average 60.55 meters (P = .0280), and Ms. Hart reported an improvement in quality of life scores.
In addition to home practice, participants were expected to keep a daily log of how it felt to play and what their biggest challenges and rewards were. The comments they wrote revealed benefits that sometimes surprised even the researchers:
“I can do laundry now.”
“I am more confident.”
“It is relaxing.”
“I want to keep playing forever.”
“It helps me cough up phlegm.”
“I lose track of time and enjoy my playing.”
“I played Happy Birthday at a party for my friend.”
Others express their difficulties as well, such as one person who wrote of being “really frustrated” and another who claimed to “have a hard time playing just one note.”
But the players learned to play as a group as well, even ordering T-shirts for themselves to give concerts. The group now has about 30 songs in its repertoire, Ms. Hart said, and they recently gave a 2-hour concert during which they played all 30 songs twice.
One consistent theme that emerged, Ms. Hart said, was improved control of breathing since playing the harmonica required participants to purse their lips (similar to the way needed for expiratory maneuvers), breathe from their diaphragms, and pace themselves. Playing exercised “the muscles that help pull air in and push air out of the lungs,” Ms. Hart said, and strengthened participants’ abdominal muscles, allowing more effective coughing.
Playing harmonica also increased self-confidence. It provided stress relief for some, and others simply found it fun or enjoyed the socializing opportunities.
The study’s small size and lack of a control group limit the generalizability of its findings.
Baylor Scott & White Central Texas Foundation funded the research. Ms. Hart reported no conflicts of interest.
SOURCE: Hart M et al. CHEST 2018. doi: 10.1016/j.chest.2018.08.669.
REPORTING FROM CHEST 2018
Key clinical point: Playing harmonica improved pulmonary and quality of life outcomes in patients with COPD.
Major finding: Maximal inspiratory pressure increased by an average 15.36 cmH20, maximal expiratory pressure increased by an average 14.36 cmH20, and Six Minute Walk Test distance increased by an average 60.55 meters.
Data source: Cohort study completed by 11 participants with COPD, at least 45 years old, who completed a 12-week harmonica training course.
Disclosures: Baylor Scott & White Central Texas Foundation funded the research. Ms. Hart reported no conflicts of interest.
Source: Hart M et al. CHEST 2018. 10.1016/j.chest.2018.08.669.