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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.
Opioids negatively affect breathing during sleep
SAN ANTONIO – Opioids do not mix well with sleep, interfering with breathing and increasing the risk of central sleep apnea, explained Anita Rajagopal, MD, a pulmonologist in private practice in Indianapolis.
“The chronic respiratory suppressant effects of opioids are well described,” Dr. Rajagopal told attendees at the annual meeting of the American College of Chest Physicians. “The most characteristic signs of chronic opioid effects are irregular central apneas, ataxic breathing, Biot’s respiration and hypoxemia, mainly during NREM sleep.”
Dr. Rajagopal reviewed the research on the effects of opioid use, primarily for therapeutic use, during sleep, especially highlighting the adverse respiratory effects.
In one small study of 24 patients, ages 18-75, who were taking long-term opioids for chronic pain, 46% had severe sleep-disordered breathing, defined as an apnea-hypopnea index greater than 30/hour (J Clin Sleep Med. 2014 Aug 15;10[8]:847-52).
When compared to sleep clinic patients referred for sleep disordered breathing, the participants taking opioids had a higher frequency of central apneas and a lower arousal index. Further, the researchers found that “morphine equivalent doses correlated with the severity of sleep-disordered breathing.”
In another study, a systematic review from 2015, researchers sought to characterize the clinical features of sleep-disordered breathing associated with chronic opioid therapy (Anesth Analg. 2015 Jun;120[6]:1273-85). They identified eight studies with 560 patients, about a quarter of whom (24%) had central sleep apnea.
Once again, “The morphine equivalent daily dose was strongly associated with the severity of the sleep disordered breathing, predominantly central sleep apnea, with a morphine equivalent daily dose of more than 200 mg being a threshold of particular concern,” the researchers reported.
Patients receiving methadone therapy for heroin addiction are not spared the respiratory risks of opioids during sleep. Dr. Rajagopal shared research revealing that patients receiving methadone treatment for at least two months had a blunted hypercapnic respiratory response and increased hypoxemic ventilatory response, changes related to respiratory rate but not tidal volume.
“All mu-opioid receptor agonists can cause complex and potentially lethal effects on respiration during sleep,” Dr. Rajagopal said as she shared evidence from a 2007 study that compared breathing patterns during sleep between 60 patients taking chronic opioids and 60 matched patients not taking opioids (J Clin Sleep Med. 2007 Aug 15;3[5]:455-61).
That study found chronic opioid use to be associated with increased central apneas and reduced arterial oxygen saturation during wakefulness and NREM sleep. Again, a dose-response relationship emerged between morphine dose equivalent and the apnea-hypopnea, obstructive apnea, hypopnea and central apnea indices (P less than .001).
Patients who took opioids long-term were also more likely to have ataxic or irregular breathing during NREM sleep, compared with patients not taking opioids.
In yet another meta-analysis and systematic review she related, researchers found across 803 patients in seven studies that long-term opioids users had a modestly increased risk for central sleep apnea but no similar increased risk for obstructive sleep apnea (J Clin Sleep Med. 2016 Apr 15;12[4]:617-25).
“REM and slow-wave sleep are decreased across all categories of opioid use — intravenous morphine, oral morphine, or methadone and heroin,” she said.
Since some patients are still going to need opioids, such as methadone therapy for those recovering from opioid use disorder, it’s important to understand appropriate effective treatments for central sleep apnea.
“CPAP [continuous positive airway pressure] is generally ineffective for opioid-induced sleep apnea and may augment central events,” Dr. Rajagopal explained, but adaptive servo ventilation (ASV) is effective for opioid-induced central apneas.
In one study of 20 patients receiving opioid therapy and referred for obstructive apnea, for example, the participants were diagnosed instead with central sleep apnea (J Clin Sleep Med. 2014 Jun 15;10[6]:637-43). The 16 patients who received CPAP continued to show central sleep apnea, with an AHI of 34 events/hour and central-apnea index (CAI) of 20 events/hour. Even after a four-week break before restarting CPAP, patients’ apnea did not resolve.
After receiving ASV, however, the average AHI dropped to 11 events/hour and CAI dropped to 0 events/hour. Those changes were accompanied by improvements in oxygen saturation, with the oxyhemoglobin saturation nadir increasing from 83% to 90%.
Similarly, a prospective multi-center observational trial assessed 27 patients with central apnea after they used ASV at home for three months (Chest. 2015 Dec;148[6]:1454-1461). The participants began with an average AHI of 55 and CAI of 23 at baseline. CPAP dropped these values only to an AHI of 33 and CAI of 10, but treatment with ASV dropped them to an AHI of 4 and CAI of 0 (P less than .001).
SAN ANTONIO – Opioids do not mix well with sleep, interfering with breathing and increasing the risk of central sleep apnea, explained Anita Rajagopal, MD, a pulmonologist in private practice in Indianapolis.
“The chronic respiratory suppressant effects of opioids are well described,” Dr. Rajagopal told attendees at the annual meeting of the American College of Chest Physicians. “The most characteristic signs of chronic opioid effects are irregular central apneas, ataxic breathing, Biot’s respiration and hypoxemia, mainly during NREM sleep.”
Dr. Rajagopal reviewed the research on the effects of opioid use, primarily for therapeutic use, during sleep, especially highlighting the adverse respiratory effects.
In one small study of 24 patients, ages 18-75, who were taking long-term opioids for chronic pain, 46% had severe sleep-disordered breathing, defined as an apnea-hypopnea index greater than 30/hour (J Clin Sleep Med. 2014 Aug 15;10[8]:847-52).
When compared to sleep clinic patients referred for sleep disordered breathing, the participants taking opioids had a higher frequency of central apneas and a lower arousal index. Further, the researchers found that “morphine equivalent doses correlated with the severity of sleep-disordered breathing.”
In another study, a systematic review from 2015, researchers sought to characterize the clinical features of sleep-disordered breathing associated with chronic opioid therapy (Anesth Analg. 2015 Jun;120[6]:1273-85). They identified eight studies with 560 patients, about a quarter of whom (24%) had central sleep apnea.
Once again, “The morphine equivalent daily dose was strongly associated with the severity of the sleep disordered breathing, predominantly central sleep apnea, with a morphine equivalent daily dose of more than 200 mg being a threshold of particular concern,” the researchers reported.
Patients receiving methadone therapy for heroin addiction are not spared the respiratory risks of opioids during sleep. Dr. Rajagopal shared research revealing that patients receiving methadone treatment for at least two months had a blunted hypercapnic respiratory response and increased hypoxemic ventilatory response, changes related to respiratory rate but not tidal volume.
“All mu-opioid receptor agonists can cause complex and potentially lethal effects on respiration during sleep,” Dr. Rajagopal said as she shared evidence from a 2007 study that compared breathing patterns during sleep between 60 patients taking chronic opioids and 60 matched patients not taking opioids (J Clin Sleep Med. 2007 Aug 15;3[5]:455-61).
That study found chronic opioid use to be associated with increased central apneas and reduced arterial oxygen saturation during wakefulness and NREM sleep. Again, a dose-response relationship emerged between morphine dose equivalent and the apnea-hypopnea, obstructive apnea, hypopnea and central apnea indices (P less than .001).
Patients who took opioids long-term were also more likely to have ataxic or irregular breathing during NREM sleep, compared with patients not taking opioids.
In yet another meta-analysis and systematic review she related, researchers found across 803 patients in seven studies that long-term opioids users had a modestly increased risk for central sleep apnea but no similar increased risk for obstructive sleep apnea (J Clin Sleep Med. 2016 Apr 15;12[4]:617-25).
“REM and slow-wave sleep are decreased across all categories of opioid use — intravenous morphine, oral morphine, or methadone and heroin,” she said.
Since some patients are still going to need opioids, such as methadone therapy for those recovering from opioid use disorder, it’s important to understand appropriate effective treatments for central sleep apnea.
“CPAP [continuous positive airway pressure] is generally ineffective for opioid-induced sleep apnea and may augment central events,” Dr. Rajagopal explained, but adaptive servo ventilation (ASV) is effective for opioid-induced central apneas.
In one study of 20 patients receiving opioid therapy and referred for obstructive apnea, for example, the participants were diagnosed instead with central sleep apnea (J Clin Sleep Med. 2014 Jun 15;10[6]:637-43). The 16 patients who received CPAP continued to show central sleep apnea, with an AHI of 34 events/hour and central-apnea index (CAI) of 20 events/hour. Even after a four-week break before restarting CPAP, patients’ apnea did not resolve.
After receiving ASV, however, the average AHI dropped to 11 events/hour and CAI dropped to 0 events/hour. Those changes were accompanied by improvements in oxygen saturation, with the oxyhemoglobin saturation nadir increasing from 83% to 90%.
Similarly, a prospective multi-center observational trial assessed 27 patients with central apnea after they used ASV at home for three months (Chest. 2015 Dec;148[6]:1454-1461). The participants began with an average AHI of 55 and CAI of 23 at baseline. CPAP dropped these values only to an AHI of 33 and CAI of 10, but treatment with ASV dropped them to an AHI of 4 and CAI of 0 (P less than .001).
SAN ANTONIO – Opioids do not mix well with sleep, interfering with breathing and increasing the risk of central sleep apnea, explained Anita Rajagopal, MD, a pulmonologist in private practice in Indianapolis.
“The chronic respiratory suppressant effects of opioids are well described,” Dr. Rajagopal told attendees at the annual meeting of the American College of Chest Physicians. “The most characteristic signs of chronic opioid effects are irregular central apneas, ataxic breathing, Biot’s respiration and hypoxemia, mainly during NREM sleep.”
Dr. Rajagopal reviewed the research on the effects of opioid use, primarily for therapeutic use, during sleep, especially highlighting the adverse respiratory effects.
In one small study of 24 patients, ages 18-75, who were taking long-term opioids for chronic pain, 46% had severe sleep-disordered breathing, defined as an apnea-hypopnea index greater than 30/hour (J Clin Sleep Med. 2014 Aug 15;10[8]:847-52).
When compared to sleep clinic patients referred for sleep disordered breathing, the participants taking opioids had a higher frequency of central apneas and a lower arousal index. Further, the researchers found that “morphine equivalent doses correlated with the severity of sleep-disordered breathing.”
In another study, a systematic review from 2015, researchers sought to characterize the clinical features of sleep-disordered breathing associated with chronic opioid therapy (Anesth Analg. 2015 Jun;120[6]:1273-85). They identified eight studies with 560 patients, about a quarter of whom (24%) had central sleep apnea.
Once again, “The morphine equivalent daily dose was strongly associated with the severity of the sleep disordered breathing, predominantly central sleep apnea, with a morphine equivalent daily dose of more than 200 mg being a threshold of particular concern,” the researchers reported.
Patients receiving methadone therapy for heroin addiction are not spared the respiratory risks of opioids during sleep. Dr. Rajagopal shared research revealing that patients receiving methadone treatment for at least two months had a blunted hypercapnic respiratory response and increased hypoxemic ventilatory response, changes related to respiratory rate but not tidal volume.
“All mu-opioid receptor agonists can cause complex and potentially lethal effects on respiration during sleep,” Dr. Rajagopal said as she shared evidence from a 2007 study that compared breathing patterns during sleep between 60 patients taking chronic opioids and 60 matched patients not taking opioids (J Clin Sleep Med. 2007 Aug 15;3[5]:455-61).
That study found chronic opioid use to be associated with increased central apneas and reduced arterial oxygen saturation during wakefulness and NREM sleep. Again, a dose-response relationship emerged between morphine dose equivalent and the apnea-hypopnea, obstructive apnea, hypopnea and central apnea indices (P less than .001).
Patients who took opioids long-term were also more likely to have ataxic or irregular breathing during NREM sleep, compared with patients not taking opioids.
In yet another meta-analysis and systematic review she related, researchers found across 803 patients in seven studies that long-term opioids users had a modestly increased risk for central sleep apnea but no similar increased risk for obstructive sleep apnea (J Clin Sleep Med. 2016 Apr 15;12[4]:617-25).
“REM and slow-wave sleep are decreased across all categories of opioid use — intravenous morphine, oral morphine, or methadone and heroin,” she said.
Since some patients are still going to need opioids, such as methadone therapy for those recovering from opioid use disorder, it’s important to understand appropriate effective treatments for central sleep apnea.
“CPAP [continuous positive airway pressure] is generally ineffective for opioid-induced sleep apnea and may augment central events,” Dr. Rajagopal explained, but adaptive servo ventilation (ASV) is effective for opioid-induced central apneas.
In one study of 20 patients receiving opioid therapy and referred for obstructive apnea, for example, the participants were diagnosed instead with central sleep apnea (J Clin Sleep Med. 2014 Jun 15;10[6]:637-43). The 16 patients who received CPAP continued to show central sleep apnea, with an AHI of 34 events/hour and central-apnea index (CAI) of 20 events/hour. Even after a four-week break before restarting CPAP, patients’ apnea did not resolve.
After receiving ASV, however, the average AHI dropped to 11 events/hour and CAI dropped to 0 events/hour. Those changes were accompanied by improvements in oxygen saturation, with the oxyhemoglobin saturation nadir increasing from 83% to 90%.
Similarly, a prospective multi-center observational trial assessed 27 patients with central apnea after they used ASV at home for three months (Chest. 2015 Dec;148[6]:1454-1461). The participants began with an average AHI of 55 and CAI of 23 at baseline. CPAP dropped these values only to an AHI of 33 and CAI of 10, but treatment with ASV dropped them to an AHI of 4 and CAI of 0 (P less than .001).
REPORTING FROM CHEST 2018
Questions about housing transgender inmates remain unresolved
AUSTIN, TEX. – The question of where and how to house transgender inmates is a challenging one that involves a range of factors and considerations, according to Ariana Nesbit, MD, a psychiatrist at San Diego Central Jail in California.
The transgender community makes up about 0.1%-0.5% of the U.S. population, but 19%-65% of transgender individuals have been* incarcerated, compared with just 3% of the cisgender U.S. population, she said at the annual meeting of the American Academy of Psychiatry and the Law. (“Cisgender” refers to individuals whose gender identity matches the sex assigned to them at birth.)
The high incarceration rate likely results from the difficult lives these individuals have led: “Pervasive stigma begins early in life,” Dr. Nesbit said.
More than a third (36%) of transgender individuals report having to leave school because of harassment related to their gender identity, and more 90% report experiencing discrimination at work. About one in seven transgender people are unemployed, and 19-30% have histories of homelessness.*
Their social marginalization leads many to seek illegal means of securing income and housing:
“There is a high comorbidity of mental illness and substance use in this population, which confounds the issue because these are also risk factors for incarceration,” Dr. Nesbit explained, though noting that being transgender itself is not a mental illness.
Once incarcerated, transgender people are at much higher risk for victimization because of the hierarchical, hypermasculine culture of the correctional environment, Dr. Nesbit said.
“Inmates rank-order one another based on how masculine they seem, and hypermasculinity is associated with sexual or physical aggression or bias toward women, and transgender people in these facilities are often classified as ‘queens,’ ” Dr. Nesbit said. They experience verbal harassment, beatings, and rape, and they might seek protection from other inmates to survive, she said.
“On the one hand, this may decrease their overall risk of violence,” Dr. Nesbit said. “On the other hand, to maintain this partnership, the transgender inmate is usually forced into subservience to this other partner and that often includes things such as performing sexual favors.”
Correctional staff also can contribute to victimization, by doing mandatory strip searches that humiliate them or placing them in administrative segregation, or ad seg, for protection, which then worsens their mental health, Dr. Nesbit said. Ad seg, also known as “the hole,” is solitary confinement in a tiny cell with little furniture and no windows.
Research also has shown far greater victimization among transgender inmates than the cisgender incarcerated population. A 2007 study involving one-on-one interviews with 322 cisgender and 39 transgender inmates showed that 59% of the transgender inmates had experienced sexual abuse, compared with 4.4% of the cisgender ones.
Similarly, 48% of the transgender respondents had been involved in “reluctant sexual acts,” in which consent was not full, compared with 1.3% of cisgender inmates. And half the transgender inmates had been raped, compared with 3.1% of the cisgender ones.
A similar 2009 study involving 315 interviews with transgender female inmates house in California men’s prisons found that 58% reported sexual abuse by other inmates and 13.6% reported sexual abuse by correctional staff.
This victimization also increases suicidality, as a 2018 study shows: Transgender victimization by another inmate led to a 42% increase in suicide attempts, and victimization by correctional staff led to a 48% increase in suicide attempts (J Correct Health Care. 2018 Apr;24[2]:171-182).
Dr. Nesbit then discussed laws and policies that have attempted to address these problems. Although society historically has “ignored or not cared about harm to inmates,” things began to change when Human Rights Watch came out with its 2001 report, “No Escape: Male Rape in U.S. Prisons.” Among the group’s findings were that certain prisoners targeted for sexual assault were those who were “young, small in size, gay … possessing ‘feminine characteristics,’ such as long hair or high voice.”
The report resulted in a congressional inquiry that led to the unanimously passed Prison Rape Elimination Act (PREA) in 2003, which mandated standards aimed at eliminating sexual assault and regulating detention rules for all state and federal correctional facilities.
Among the requirements were asking about inmates’ gender identity, sexual orientation, gender expression, and safety concerns in a quiet, private place. PREA also prohibited strip searches solely to determine genitalia or gender status and allowed it for a private general medical exam by a medical doctor only.
The act limited residential assignment based on genitalia only and mandated that residential assignments be made on a case-by-case basis, taking into consideration both the inmates’ gender identification and an assessment of their risk. If it were deemed necessary to segregate individuals because of their risk, they “should continue to receive the same opportunities and program access as other units,” Dr. Nesbit said.
Just as PREA’s requirements were being finalized in 2012, the U.S. Federal Bureau of Prisons also issued a Transgender Offender Manual to further clarify policies. Yet, some have contended that little has changed since the “primarily symbolic” PREA and prison manual: Genitalia-based policies still dominate inmate assignments (including at Dr. Nesbit’s facility) and ad seg still is frequently used. The facilities where changes have occurred, however, offer a blueprint on how to move forward. Some prisons have created transgender review committees that include an administrator, PREA coordinators, medical and mental health staff, and transgender advocates or community members. Those committees ask inmates about their housing preferences and make decisions based on individual needs and risks.
An exceptional example of an appropriate policy, though not in the United States, is one in Queensland, Australia. After initial placement in single-occupancy housing, inmate housing is determined by multiple factors:
- The person’s name, because it might pose to safety and security of facility.
- Charges against the inmate.
- The inmate’s personal characteristics.
- Risk to the inmate or other inmates at the facility.
- Hormone status.
- Recommendations by the inmate’s medical doctor.
- The inmate’s preference.
- Any concerns about staff threats to the inmate’s safety.
But it’s unlikely that the United States will see similar policies become widespread under the current administration: The Trump administration made changes in 2018 that mandate officials to “use biological sex as the initial determination” for housing placement decisions and allow consideration of gender identity only in “rare cases,” Dr. Nesbit said.
Despite protests from the National Center for Transgender Equality, which said the change directly defies PREA requirements, Bureau of Prisons spokesperson Nancy Ayers reportedly said that “the manual now addresses and articulates the balance of safety needs of transgender inmates as well as other inmates, including those with histories of trauma, privacy concerns, etc., on a case-by-case basis.” That leaves where to house transgender inmates as an open questions still. No data exist regarding the safest arrangements, and housing based only on genitalia is problematic, Dr. Nesbit said. Placement based on gender identity only is problematic also, since it’s not always the inmate’s preference and violence concerns remain, both for transgender males in male facilities and for transgender females in female facilities.
Though some advocate for placement in separate facilities entirely, which San Francisco does, this is a resource-intensive solution that “may limit access to educational, medical, rehabilitative, and vocational services,” Dr. Nesbit said.
“One-size-fit-all policies that rigidly assign housing do not work,” Dr. Nesbit said, yet no empirical studies exist on individualized approaches. Meanwhile, the best recommendations are to train correctional staff to improve their knowledge about transgender inmates, implement correctional intervention programs that address hypermasculinity, and recognize that transgender incarceration rates and inmate victimization are part of a larger problem of social marginalization, she said.
*Correction, 11/1/2018: An earlier version of this story misstated the timing of transgender individuals' incarceration and homelessness.
AUSTIN, TEX. – The question of where and how to house transgender inmates is a challenging one that involves a range of factors and considerations, according to Ariana Nesbit, MD, a psychiatrist at San Diego Central Jail in California.
The transgender community makes up about 0.1%-0.5% of the U.S. population, but 19%-65% of transgender individuals have been* incarcerated, compared with just 3% of the cisgender U.S. population, she said at the annual meeting of the American Academy of Psychiatry and the Law. (“Cisgender” refers to individuals whose gender identity matches the sex assigned to them at birth.)
The high incarceration rate likely results from the difficult lives these individuals have led: “Pervasive stigma begins early in life,” Dr. Nesbit said.
More than a third (36%) of transgender individuals report having to leave school because of harassment related to their gender identity, and more 90% report experiencing discrimination at work. About one in seven transgender people are unemployed, and 19-30% have histories of homelessness.*
Their social marginalization leads many to seek illegal means of securing income and housing:
“There is a high comorbidity of mental illness and substance use in this population, which confounds the issue because these are also risk factors for incarceration,” Dr. Nesbit explained, though noting that being transgender itself is not a mental illness.
Once incarcerated, transgender people are at much higher risk for victimization because of the hierarchical, hypermasculine culture of the correctional environment, Dr. Nesbit said.
“Inmates rank-order one another based on how masculine they seem, and hypermasculinity is associated with sexual or physical aggression or bias toward women, and transgender people in these facilities are often classified as ‘queens,’ ” Dr. Nesbit said. They experience verbal harassment, beatings, and rape, and they might seek protection from other inmates to survive, she said.
“On the one hand, this may decrease their overall risk of violence,” Dr. Nesbit said. “On the other hand, to maintain this partnership, the transgender inmate is usually forced into subservience to this other partner and that often includes things such as performing sexual favors.”
Correctional staff also can contribute to victimization, by doing mandatory strip searches that humiliate them or placing them in administrative segregation, or ad seg, for protection, which then worsens their mental health, Dr. Nesbit said. Ad seg, also known as “the hole,” is solitary confinement in a tiny cell with little furniture and no windows.
Research also has shown far greater victimization among transgender inmates than the cisgender incarcerated population. A 2007 study involving one-on-one interviews with 322 cisgender and 39 transgender inmates showed that 59% of the transgender inmates had experienced sexual abuse, compared with 4.4% of the cisgender ones.
Similarly, 48% of the transgender respondents had been involved in “reluctant sexual acts,” in which consent was not full, compared with 1.3% of cisgender inmates. And half the transgender inmates had been raped, compared with 3.1% of the cisgender ones.
A similar 2009 study involving 315 interviews with transgender female inmates house in California men’s prisons found that 58% reported sexual abuse by other inmates and 13.6% reported sexual abuse by correctional staff.
This victimization also increases suicidality, as a 2018 study shows: Transgender victimization by another inmate led to a 42% increase in suicide attempts, and victimization by correctional staff led to a 48% increase in suicide attempts (J Correct Health Care. 2018 Apr;24[2]:171-182).
Dr. Nesbit then discussed laws and policies that have attempted to address these problems. Although society historically has “ignored or not cared about harm to inmates,” things began to change when Human Rights Watch came out with its 2001 report, “No Escape: Male Rape in U.S. Prisons.” Among the group’s findings were that certain prisoners targeted for sexual assault were those who were “young, small in size, gay … possessing ‘feminine characteristics,’ such as long hair or high voice.”
The report resulted in a congressional inquiry that led to the unanimously passed Prison Rape Elimination Act (PREA) in 2003, which mandated standards aimed at eliminating sexual assault and regulating detention rules for all state and federal correctional facilities.
Among the requirements were asking about inmates’ gender identity, sexual orientation, gender expression, and safety concerns in a quiet, private place. PREA also prohibited strip searches solely to determine genitalia or gender status and allowed it for a private general medical exam by a medical doctor only.
The act limited residential assignment based on genitalia only and mandated that residential assignments be made on a case-by-case basis, taking into consideration both the inmates’ gender identification and an assessment of their risk. If it were deemed necessary to segregate individuals because of their risk, they “should continue to receive the same opportunities and program access as other units,” Dr. Nesbit said.
Just as PREA’s requirements were being finalized in 2012, the U.S. Federal Bureau of Prisons also issued a Transgender Offender Manual to further clarify policies. Yet, some have contended that little has changed since the “primarily symbolic” PREA and prison manual: Genitalia-based policies still dominate inmate assignments (including at Dr. Nesbit’s facility) and ad seg still is frequently used. The facilities where changes have occurred, however, offer a blueprint on how to move forward. Some prisons have created transgender review committees that include an administrator, PREA coordinators, medical and mental health staff, and transgender advocates or community members. Those committees ask inmates about their housing preferences and make decisions based on individual needs and risks.
An exceptional example of an appropriate policy, though not in the United States, is one in Queensland, Australia. After initial placement in single-occupancy housing, inmate housing is determined by multiple factors:
- The person’s name, because it might pose to safety and security of facility.
- Charges against the inmate.
- The inmate’s personal characteristics.
- Risk to the inmate or other inmates at the facility.
- Hormone status.
- Recommendations by the inmate’s medical doctor.
- The inmate’s preference.
- Any concerns about staff threats to the inmate’s safety.
But it’s unlikely that the United States will see similar policies become widespread under the current administration: The Trump administration made changes in 2018 that mandate officials to “use biological sex as the initial determination” for housing placement decisions and allow consideration of gender identity only in “rare cases,” Dr. Nesbit said.
Despite protests from the National Center for Transgender Equality, which said the change directly defies PREA requirements, Bureau of Prisons spokesperson Nancy Ayers reportedly said that “the manual now addresses and articulates the balance of safety needs of transgender inmates as well as other inmates, including those with histories of trauma, privacy concerns, etc., on a case-by-case basis.” That leaves where to house transgender inmates as an open questions still. No data exist regarding the safest arrangements, and housing based only on genitalia is problematic, Dr. Nesbit said. Placement based on gender identity only is problematic also, since it’s not always the inmate’s preference and violence concerns remain, both for transgender males in male facilities and for transgender females in female facilities.
Though some advocate for placement in separate facilities entirely, which San Francisco does, this is a resource-intensive solution that “may limit access to educational, medical, rehabilitative, and vocational services,” Dr. Nesbit said.
“One-size-fit-all policies that rigidly assign housing do not work,” Dr. Nesbit said, yet no empirical studies exist on individualized approaches. Meanwhile, the best recommendations are to train correctional staff to improve their knowledge about transgender inmates, implement correctional intervention programs that address hypermasculinity, and recognize that transgender incarceration rates and inmate victimization are part of a larger problem of social marginalization, she said.
*Correction, 11/1/2018: An earlier version of this story misstated the timing of transgender individuals' incarceration and homelessness.
AUSTIN, TEX. – The question of where and how to house transgender inmates is a challenging one that involves a range of factors and considerations, according to Ariana Nesbit, MD, a psychiatrist at San Diego Central Jail in California.
The transgender community makes up about 0.1%-0.5% of the U.S. population, but 19%-65% of transgender individuals have been* incarcerated, compared with just 3% of the cisgender U.S. population, she said at the annual meeting of the American Academy of Psychiatry and the Law. (“Cisgender” refers to individuals whose gender identity matches the sex assigned to them at birth.)
The high incarceration rate likely results from the difficult lives these individuals have led: “Pervasive stigma begins early in life,” Dr. Nesbit said.
More than a third (36%) of transgender individuals report having to leave school because of harassment related to their gender identity, and more 90% report experiencing discrimination at work. About one in seven transgender people are unemployed, and 19-30% have histories of homelessness.*
Their social marginalization leads many to seek illegal means of securing income and housing:
“There is a high comorbidity of mental illness and substance use in this population, which confounds the issue because these are also risk factors for incarceration,” Dr. Nesbit explained, though noting that being transgender itself is not a mental illness.
Once incarcerated, transgender people are at much higher risk for victimization because of the hierarchical, hypermasculine culture of the correctional environment, Dr. Nesbit said.
“Inmates rank-order one another based on how masculine they seem, and hypermasculinity is associated with sexual or physical aggression or bias toward women, and transgender people in these facilities are often classified as ‘queens,’ ” Dr. Nesbit said. They experience verbal harassment, beatings, and rape, and they might seek protection from other inmates to survive, she said.
“On the one hand, this may decrease their overall risk of violence,” Dr. Nesbit said. “On the other hand, to maintain this partnership, the transgender inmate is usually forced into subservience to this other partner and that often includes things such as performing sexual favors.”
Correctional staff also can contribute to victimization, by doing mandatory strip searches that humiliate them or placing them in administrative segregation, or ad seg, for protection, which then worsens their mental health, Dr. Nesbit said. Ad seg, also known as “the hole,” is solitary confinement in a tiny cell with little furniture and no windows.
Research also has shown far greater victimization among transgender inmates than the cisgender incarcerated population. A 2007 study involving one-on-one interviews with 322 cisgender and 39 transgender inmates showed that 59% of the transgender inmates had experienced sexual abuse, compared with 4.4% of the cisgender ones.
Similarly, 48% of the transgender respondents had been involved in “reluctant sexual acts,” in which consent was not full, compared with 1.3% of cisgender inmates. And half the transgender inmates had been raped, compared with 3.1% of the cisgender ones.
A similar 2009 study involving 315 interviews with transgender female inmates house in California men’s prisons found that 58% reported sexual abuse by other inmates and 13.6% reported sexual abuse by correctional staff.
This victimization also increases suicidality, as a 2018 study shows: Transgender victimization by another inmate led to a 42% increase in suicide attempts, and victimization by correctional staff led to a 48% increase in suicide attempts (J Correct Health Care. 2018 Apr;24[2]:171-182).
Dr. Nesbit then discussed laws and policies that have attempted to address these problems. Although society historically has “ignored or not cared about harm to inmates,” things began to change when Human Rights Watch came out with its 2001 report, “No Escape: Male Rape in U.S. Prisons.” Among the group’s findings were that certain prisoners targeted for sexual assault were those who were “young, small in size, gay … possessing ‘feminine characteristics,’ such as long hair or high voice.”
The report resulted in a congressional inquiry that led to the unanimously passed Prison Rape Elimination Act (PREA) in 2003, which mandated standards aimed at eliminating sexual assault and regulating detention rules for all state and federal correctional facilities.
Among the requirements were asking about inmates’ gender identity, sexual orientation, gender expression, and safety concerns in a quiet, private place. PREA also prohibited strip searches solely to determine genitalia or gender status and allowed it for a private general medical exam by a medical doctor only.
The act limited residential assignment based on genitalia only and mandated that residential assignments be made on a case-by-case basis, taking into consideration both the inmates’ gender identification and an assessment of their risk. If it were deemed necessary to segregate individuals because of their risk, they “should continue to receive the same opportunities and program access as other units,” Dr. Nesbit said.
Just as PREA’s requirements were being finalized in 2012, the U.S. Federal Bureau of Prisons also issued a Transgender Offender Manual to further clarify policies. Yet, some have contended that little has changed since the “primarily symbolic” PREA and prison manual: Genitalia-based policies still dominate inmate assignments (including at Dr. Nesbit’s facility) and ad seg still is frequently used. The facilities where changes have occurred, however, offer a blueprint on how to move forward. Some prisons have created transgender review committees that include an administrator, PREA coordinators, medical and mental health staff, and transgender advocates or community members. Those committees ask inmates about their housing preferences and make decisions based on individual needs and risks.
An exceptional example of an appropriate policy, though not in the United States, is one in Queensland, Australia. After initial placement in single-occupancy housing, inmate housing is determined by multiple factors:
- The person’s name, because it might pose to safety and security of facility.
- Charges against the inmate.
- The inmate’s personal characteristics.
- Risk to the inmate or other inmates at the facility.
- Hormone status.
- Recommendations by the inmate’s medical doctor.
- The inmate’s preference.
- Any concerns about staff threats to the inmate’s safety.
But it’s unlikely that the United States will see similar policies become widespread under the current administration: The Trump administration made changes in 2018 that mandate officials to “use biological sex as the initial determination” for housing placement decisions and allow consideration of gender identity only in “rare cases,” Dr. Nesbit said.
Despite protests from the National Center for Transgender Equality, which said the change directly defies PREA requirements, Bureau of Prisons spokesperson Nancy Ayers reportedly said that “the manual now addresses and articulates the balance of safety needs of transgender inmates as well as other inmates, including those with histories of trauma, privacy concerns, etc., on a case-by-case basis.” That leaves where to house transgender inmates as an open questions still. No data exist regarding the safest arrangements, and housing based only on genitalia is problematic, Dr. Nesbit said. Placement based on gender identity only is problematic also, since it’s not always the inmate’s preference and violence concerns remain, both for transgender males in male facilities and for transgender females in female facilities.
Though some advocate for placement in separate facilities entirely, which San Francisco does, this is a resource-intensive solution that “may limit access to educational, medical, rehabilitative, and vocational services,” Dr. Nesbit said.
“One-size-fit-all policies that rigidly assign housing do not work,” Dr. Nesbit said, yet no empirical studies exist on individualized approaches. Meanwhile, the best recommendations are to train correctional staff to improve their knowledge about transgender inmates, implement correctional intervention programs that address hypermasculinity, and recognize that transgender incarceration rates and inmate victimization are part of a larger problem of social marginalization, she said.
*Correction, 11/1/2018: An earlier version of this story misstated the timing of transgender individuals' incarceration and homelessness.
REPORTING FROM THE AAPL ANNUAL MEETING
Healthy, ethical environments can alleviate ‘moral distress’ in clinicians
SAN ANTONIO – Understanding the experience of “moral distress” in critical care is essential because of its potential negative effects on health care providers and the need to prevent or address those effects, according to Marian Altman, PhD, RN, a clinical practice specialist from the American Association of Critical Care Nurses.
Dr. Altman spoke about moral distress as part of a panel discussion at the annual meeting of the American College of Chest Physicians on how to handle nonbeneficial treatment requests from families, including the legal and ethical obligations of care providers when a patient is receiving life-sustaining treatment.
“The key point about moral distress is that these are personal constraints, and so the choices of what is best for a patient often conflicts with what is best for the organization,” Dr. Altman told CHEST 2018 attendees. “It could conflict with what’s best for the care providers, the family, or even other patients, and so it’s that personal experience of moral compromise that often originates in this broader practice of our routine.”
While it does not necessarily occur frequently, moral distress is intense when it does occur.
“It really threatens the identity and the integrity of those who experience it because they truly believe they are seriously compromised with this deep personal effect,” Dr. Altman said.
Dr. Altman credited Andrew Jameton, a bioethicist who authored a seminal book on ethical issues in nursing in 1984, with defining exactly what moral distress is: “painful feelings and/or the psychological disequilibrium that occurs when a person is conscious of the morally appropriate action a situation requires but cannot carry out that action because of the institutionalized obstacles, such as lack of time, lack of supervisory support, exercise of medical power, and institutional policy or legal limits.” Or, in plainer terms, “Moral distress occurs when one knows the ethically correct action to take but feels powerless to take that action,” as Elizabeth G. Epstein, PhD, RN, and Sarah Delgado, MSN, RN, wrote in the Online Journal of Issues in Nursing.
To understand moral distress, it’s important to know what it’s not, too, Dr. Altman said. It’s not the daily stress of work or compassion fatigue or even burnout, though it can lead to burnout.
“Burnout is the state of physical, emotional, and mental fatigue and exhaustion caused by long-term involvement in situations that are emotionally demanding,” Dr. Altman said. “Burnout has been linked with moral distress, but they are two very different things.”
It’s also not a disagreement among colleagues or “an excuse to avoid a challenging situation.” In fact, the No. 1 cause of moral distress, in study after study, Dr. Altman said, is providing medical care, particularly medically futile care.
“Providing really unnecessary treatments and providing end-of-life care can lead to it as well as complex patients and challenging situations,” Dr. Altman said. Other causes include inadequate staffing, incompetent providers, poor communication, and advanced technology used to sustain life.
Though people often associate moral distress with intensive care, it can occur “wherever care is provided” and can “affect all members of the health care team,” Dr. Altman said. Though the early research into moral distress focused on critical care nurses, the field has since exploded, across all medical disciplines and in countries around the world.
That research has revealed how intensely moral distress can impact the psychological, biological, and social health of people. Physical symptoms that can result from moral distress include diarrhea, headache, heart palpitations, neck pain, muscle aches, and vomiting. The emotions it rouses include frustration, fear, anger, anxiety, and, especially, powerlessness and guilt.
Moral distress can lead to burnout and dissatisfaction in individuals and, subsequently, reduced retention and productivity within institutions. Health care providers who experience moral distress may leave their position, their unit, or the profession altogether.
“That can have a huge impact in a time when we need many more health care providers to care for this exploding population,” Dr. Altman said. It can also negatively influence the patient-provider relationship, potentially affecting the quantity and safety of care delivered, she explained.
But there are ways to address moral distress, she said.
“We’re not going to eradicate it because we will never eradicate critical care or end-of-life care, and those are the causes that lead to moral distress,” Dr. Altman said. “But what we can do, and what the research is now focusing on, is concentrate on improving our work environment, and help people recognize that they’re experiencing moral distress before it gets to burnout … or mitigating moral distress when it occurs.”
Those improvements include fostering both a positive ethical environment, with ethics education, an ethics committee, and on-site ethics experts, and a healthy work environment with collaboration and skillful communication.
Research has shown that “a higher ethical work environment is correlated with a decrease in moral distress frequency,” Dr. Altman said. And structured communication processes should focus on the goals of care, she said. More formal programs may include moral distress workshops, a moral distress consult service, an ethics consult service, and distress debriefings, during which a facilitator leads providers in a structured, collaborative discussion about a distressing event that has occurred.
SAN ANTONIO – Understanding the experience of “moral distress” in critical care is essential because of its potential negative effects on health care providers and the need to prevent or address those effects, according to Marian Altman, PhD, RN, a clinical practice specialist from the American Association of Critical Care Nurses.
Dr. Altman spoke about moral distress as part of a panel discussion at the annual meeting of the American College of Chest Physicians on how to handle nonbeneficial treatment requests from families, including the legal and ethical obligations of care providers when a patient is receiving life-sustaining treatment.
“The key point about moral distress is that these are personal constraints, and so the choices of what is best for a patient often conflicts with what is best for the organization,” Dr. Altman told CHEST 2018 attendees. “It could conflict with what’s best for the care providers, the family, or even other patients, and so it’s that personal experience of moral compromise that often originates in this broader practice of our routine.”
While it does not necessarily occur frequently, moral distress is intense when it does occur.
“It really threatens the identity and the integrity of those who experience it because they truly believe they are seriously compromised with this deep personal effect,” Dr. Altman said.
Dr. Altman credited Andrew Jameton, a bioethicist who authored a seminal book on ethical issues in nursing in 1984, with defining exactly what moral distress is: “painful feelings and/or the psychological disequilibrium that occurs when a person is conscious of the morally appropriate action a situation requires but cannot carry out that action because of the institutionalized obstacles, such as lack of time, lack of supervisory support, exercise of medical power, and institutional policy or legal limits.” Or, in plainer terms, “Moral distress occurs when one knows the ethically correct action to take but feels powerless to take that action,” as Elizabeth G. Epstein, PhD, RN, and Sarah Delgado, MSN, RN, wrote in the Online Journal of Issues in Nursing.
To understand moral distress, it’s important to know what it’s not, too, Dr. Altman said. It’s not the daily stress of work or compassion fatigue or even burnout, though it can lead to burnout.
“Burnout is the state of physical, emotional, and mental fatigue and exhaustion caused by long-term involvement in situations that are emotionally demanding,” Dr. Altman said. “Burnout has been linked with moral distress, but they are two very different things.”
It’s also not a disagreement among colleagues or “an excuse to avoid a challenging situation.” In fact, the No. 1 cause of moral distress, in study after study, Dr. Altman said, is providing medical care, particularly medically futile care.
“Providing really unnecessary treatments and providing end-of-life care can lead to it as well as complex patients and challenging situations,” Dr. Altman said. Other causes include inadequate staffing, incompetent providers, poor communication, and advanced technology used to sustain life.
Though people often associate moral distress with intensive care, it can occur “wherever care is provided” and can “affect all members of the health care team,” Dr. Altman said. Though the early research into moral distress focused on critical care nurses, the field has since exploded, across all medical disciplines and in countries around the world.
That research has revealed how intensely moral distress can impact the psychological, biological, and social health of people. Physical symptoms that can result from moral distress include diarrhea, headache, heart palpitations, neck pain, muscle aches, and vomiting. The emotions it rouses include frustration, fear, anger, anxiety, and, especially, powerlessness and guilt.
Moral distress can lead to burnout and dissatisfaction in individuals and, subsequently, reduced retention and productivity within institutions. Health care providers who experience moral distress may leave their position, their unit, or the profession altogether.
“That can have a huge impact in a time when we need many more health care providers to care for this exploding population,” Dr. Altman said. It can also negatively influence the patient-provider relationship, potentially affecting the quantity and safety of care delivered, she explained.
But there are ways to address moral distress, she said.
“We’re not going to eradicate it because we will never eradicate critical care or end-of-life care, and those are the causes that lead to moral distress,” Dr. Altman said. “But what we can do, and what the research is now focusing on, is concentrate on improving our work environment, and help people recognize that they’re experiencing moral distress before it gets to burnout … or mitigating moral distress when it occurs.”
Those improvements include fostering both a positive ethical environment, with ethics education, an ethics committee, and on-site ethics experts, and a healthy work environment with collaboration and skillful communication.
Research has shown that “a higher ethical work environment is correlated with a decrease in moral distress frequency,” Dr. Altman said. And structured communication processes should focus on the goals of care, she said. More formal programs may include moral distress workshops, a moral distress consult service, an ethics consult service, and distress debriefings, during which a facilitator leads providers in a structured, collaborative discussion about a distressing event that has occurred.
SAN ANTONIO – Understanding the experience of “moral distress” in critical care is essential because of its potential negative effects on health care providers and the need to prevent or address those effects, according to Marian Altman, PhD, RN, a clinical practice specialist from the American Association of Critical Care Nurses.
Dr. Altman spoke about moral distress as part of a panel discussion at the annual meeting of the American College of Chest Physicians on how to handle nonbeneficial treatment requests from families, including the legal and ethical obligations of care providers when a patient is receiving life-sustaining treatment.
“The key point about moral distress is that these are personal constraints, and so the choices of what is best for a patient often conflicts with what is best for the organization,” Dr. Altman told CHEST 2018 attendees. “It could conflict with what’s best for the care providers, the family, or even other patients, and so it’s that personal experience of moral compromise that often originates in this broader practice of our routine.”
While it does not necessarily occur frequently, moral distress is intense when it does occur.
“It really threatens the identity and the integrity of those who experience it because they truly believe they are seriously compromised with this deep personal effect,” Dr. Altman said.
Dr. Altman credited Andrew Jameton, a bioethicist who authored a seminal book on ethical issues in nursing in 1984, with defining exactly what moral distress is: “painful feelings and/or the psychological disequilibrium that occurs when a person is conscious of the morally appropriate action a situation requires but cannot carry out that action because of the institutionalized obstacles, such as lack of time, lack of supervisory support, exercise of medical power, and institutional policy or legal limits.” Or, in plainer terms, “Moral distress occurs when one knows the ethically correct action to take but feels powerless to take that action,” as Elizabeth G. Epstein, PhD, RN, and Sarah Delgado, MSN, RN, wrote in the Online Journal of Issues in Nursing.
To understand moral distress, it’s important to know what it’s not, too, Dr. Altman said. It’s not the daily stress of work or compassion fatigue or even burnout, though it can lead to burnout.
“Burnout is the state of physical, emotional, and mental fatigue and exhaustion caused by long-term involvement in situations that are emotionally demanding,” Dr. Altman said. “Burnout has been linked with moral distress, but they are two very different things.”
It’s also not a disagreement among colleagues or “an excuse to avoid a challenging situation.” In fact, the No. 1 cause of moral distress, in study after study, Dr. Altman said, is providing medical care, particularly medically futile care.
“Providing really unnecessary treatments and providing end-of-life care can lead to it as well as complex patients and challenging situations,” Dr. Altman said. Other causes include inadequate staffing, incompetent providers, poor communication, and advanced technology used to sustain life.
Though people often associate moral distress with intensive care, it can occur “wherever care is provided” and can “affect all members of the health care team,” Dr. Altman said. Though the early research into moral distress focused on critical care nurses, the field has since exploded, across all medical disciplines and in countries around the world.
That research has revealed how intensely moral distress can impact the psychological, biological, and social health of people. Physical symptoms that can result from moral distress include diarrhea, headache, heart palpitations, neck pain, muscle aches, and vomiting. The emotions it rouses include frustration, fear, anger, anxiety, and, especially, powerlessness and guilt.
Moral distress can lead to burnout and dissatisfaction in individuals and, subsequently, reduced retention and productivity within institutions. Health care providers who experience moral distress may leave their position, their unit, or the profession altogether.
“That can have a huge impact in a time when we need many more health care providers to care for this exploding population,” Dr. Altman said. It can also negatively influence the patient-provider relationship, potentially affecting the quantity and safety of care delivered, she explained.
But there are ways to address moral distress, she said.
“We’re not going to eradicate it because we will never eradicate critical care or end-of-life care, and those are the causes that lead to moral distress,” Dr. Altman said. “But what we can do, and what the research is now focusing on, is concentrate on improving our work environment, and help people recognize that they’re experiencing moral distress before it gets to burnout … or mitigating moral distress when it occurs.”
Those improvements include fostering both a positive ethical environment, with ethics education, an ethics committee, and on-site ethics experts, and a healthy work environment with collaboration and skillful communication.
Research has shown that “a higher ethical work environment is correlated with a decrease in moral distress frequency,” Dr. Altman said. And structured communication processes should focus on the goals of care, she said. More formal programs may include moral distress workshops, a moral distress consult service, an ethics consult service, and distress debriefings, during which a facilitator leads providers in a structured, collaborative discussion about a distressing event that has occurred.
REPORTING FROM CHEST 2018
Most profiles of mass shooters do not include mental illness
AUSTIN, TEX. – Mass shootings make up only a tiny percentage of annual gun violence deaths in the United States, but they capture the attention of the nation – and of media that do not always accurately represent their context.
Experts tend to identify the first modern U.S. mass shooting event as the University of Texas Tower shooting in Austin by Charles Whitman in 1966, Corina Freitas, MD, said at the annual meeting of the American Academy of Psychiatry and the Law.
But two previous incidents preceded Whitman’s: Howard Unruh’s 12-minute killing spree in his neighborhood in Camden, N.J., in 1949, and Andrew Kehoe’s 1927 series of bombings that killed 43 people in the Bath School disaster in Michigan. Studies of these events and the hundreds since have led to a better understanding of what motivates mass shooters (or bombers in Kehoe’s case) and how to potentially identify them and prevent such events, said Dr. Freitas, of the department of psychiatry and behavioral sciences at George Washington University in Washington.
Dr. Freitas provided an overview of mass shooting history in the United States before Karen B. Rosenbaum, MD, clinical assistant professor at New York University and clinical instructor at New York Presbyterian–Weill Cornell Medical Center, spoke about the social, political, and legal implications of the intersection between mental illness and mass shootings.
She began by explaining how the FBI’s definition of mass shootings has changed from “four or more people at one location within one event” in 2005 to its redefinition in 2012-2013 to “three or more killings in a single incident and in a place of public use.”
Mass shootings usually are not impulse kills, Dr. Freitas said, noting that 77% of shooters plan their shooting for at least a week, and 46% of people spend about a week preparing. The perpetrators are potentially recognizable, typically displaying four to five concerning behaviors up to 1 year before the shooting, such as talking about their plans or purchasing supplies. But only a minority of people who observe these behaviors ever speak up about them or take any actions, she said.
, but they also display numerous other psychosocial characteristics, such as self-esteem issues, paranoia, narcissism, depression, and suicidality.
“Almost half of them are suicidal, and they actually proclaim it up to 1 year ahead of the shooting,” Dr. Freitas said. “We could catch them if we paid more attention to that.”
Mass killers tend to fall into three categories, as classified by psychiatrist Park Dietz, MD, in 1986:
- Family annihilators, such as George Banks, are typically depressed, paranoid, suicidal older males who might be intoxicated at the time of their attack. Banks shot 13 people, including 5 of his own children and 2 other children and their mothers, in Pennsylvania in 1982.
- Pseudocommandos, such as Charles Whitman, are usually preoccupied with firearms and plan heavily. “They usually end up killing themselves by cop,” Dr. Freitas said.
- Set-and-run killers, the rarest type, include perpetrators like Kehoe; their method of killing gives them an escape (though Kehoe blew himself up as well).
But mental illness is not a major feature of mass killers: Only about a quarter of mass shooters have a diagnosed mental illness, and the illness might not necessarily be related to their crime. Of that quarter, about 75% of mass shooters had a mood disorder, 25% had an anxiety disorder,19% had psychosis, and 1% had the developmental condition, such as autism spectrum disorder.
Yet, as mass shootings have dramatically increased, mental illness has become inextricably associated with these events in the media and popular opinion, Dr. Rosenbaum said. There have been 74 school shootings since the Newtown, Conn., tragedy, and mental illness is repeatedly brought up as a contributor, she said.
A 2014 study that analyzed 25% of a random sample of news stories from 1997 to 2012 on serious mental illness and gun violence (before Newtown) found that most of the coverage occurred after mass shootings and “ ‘dangerous people’ with serious mental illness were more likely to be mentioned than ‘dangerous weapons’ as a cause of gun violence” (Am J Public Health. 2014 Mar;104[3]:406-13).
Yet this association does not reflect reality, Dr. Rosenbaum said. One meta-analysis found that prevention of one stranger homicide by someone with psychosis would require detaining 35,000 people with schizophrenia who had been judged as being at high risk for violence (Schizophr Bull. 2011 May;37[3]:572-9).
Further, the relationship between violence and mental illness is not simple. Complex historical factors are usually involved, including past violence, juvenile detection, physical abuse, substance abuse, age, parental arrest record, and life circumstances – such as a recent divorce, unemployment, or victimization.
The greater danger of a person with mental illness is the harm they will do to themselves, research shows. A study of 255 recently discharged psychiatric patients and 490 matched community residents found that the patients were no more likely to perpetuate violence than were the community members, but they were significantly more likely to report being suicidal (Int J Law Psychiatry. 2018 Jan-Feb;56:44-9).
Rather than mental illness, what is associated with violence is substance use and access to weapons, Dr. Rosenbaum said.
“The United States is one of only three countries in the world with a constitutionally protected right to own firearms,” Dr. Rosenbaum said, citing a 2017 study by John S. Rozel, MD, and Edward P. Mulvey, PhD, (Annu Rev Clin Psychol. 2017 May 8;13:445-9). And the United States has few restrictions on that right. With more than 350 million privately owned firearms – approximately 30% of all privately owned firearms in the world – the U.S. population exceeds all other countries in both per capita and absolute gun ownership.
And research shows that guns don’t make a country safer: Guns per capita are significantly correlated with firearm-related deaths; mental illness is only of borderline significance (Am J Med. 2013 Oct;126[10]:873-6).
Substance use – including use of cocaine, hallucinogens, methamphetamine, ecstasy, and prescription medications – has a stronger correlation with gun-carrying and gun-related behaviors (Inj Prev. 2017 Dec; 23[6]:383-7 and Epidemiol Rev. 2016;38[1]:46-61). Both acute and chronic alcohol misuse also are linked to firearm ownership and violence toward others and one’s self (Prev Med. 2015 Oct;79:15-21).
Yet public misperceptions of mental illness as a contributor to violence persists, research shows (Aust N Z J Psychiatry. 2014 Aug;48[8]:764-71), further stigmatizing people with psychiatric conditions and potentially reducing the likelihood of their seeking treatment. Politicians contribute to these misperceptions; an example is House Speaker Paul Ryan’s comment after the Parkland, Fla., school shooting: “Mental health is often a big problem underlying these tragedies.”
“The media sensationalizes violent crimes committed by people with mental illness, especially after mass shooting, and this societal bias contributes to the stigma that leads to decreased treatment seeking and discrimination,” Dr. Rosenbaum said, citing research from Mohit Varshney, MD, and his associates (J Epidemiol Community Health. 2016 Mar;70[3]:223-5). “It is important to dissociate the concept of mental illness from dangerousness.”
AUSTIN, TEX. – Mass shootings make up only a tiny percentage of annual gun violence deaths in the United States, but they capture the attention of the nation – and of media that do not always accurately represent their context.
Experts tend to identify the first modern U.S. mass shooting event as the University of Texas Tower shooting in Austin by Charles Whitman in 1966, Corina Freitas, MD, said at the annual meeting of the American Academy of Psychiatry and the Law.
But two previous incidents preceded Whitman’s: Howard Unruh’s 12-minute killing spree in his neighborhood in Camden, N.J., in 1949, and Andrew Kehoe’s 1927 series of bombings that killed 43 people in the Bath School disaster in Michigan. Studies of these events and the hundreds since have led to a better understanding of what motivates mass shooters (or bombers in Kehoe’s case) and how to potentially identify them and prevent such events, said Dr. Freitas, of the department of psychiatry and behavioral sciences at George Washington University in Washington.
Dr. Freitas provided an overview of mass shooting history in the United States before Karen B. Rosenbaum, MD, clinical assistant professor at New York University and clinical instructor at New York Presbyterian–Weill Cornell Medical Center, spoke about the social, political, and legal implications of the intersection between mental illness and mass shootings.
She began by explaining how the FBI’s definition of mass shootings has changed from “four or more people at one location within one event” in 2005 to its redefinition in 2012-2013 to “three or more killings in a single incident and in a place of public use.”
Mass shootings usually are not impulse kills, Dr. Freitas said, noting that 77% of shooters plan their shooting for at least a week, and 46% of people spend about a week preparing. The perpetrators are potentially recognizable, typically displaying four to five concerning behaviors up to 1 year before the shooting, such as talking about their plans or purchasing supplies. But only a minority of people who observe these behaviors ever speak up about them or take any actions, she said.
, but they also display numerous other psychosocial characteristics, such as self-esteem issues, paranoia, narcissism, depression, and suicidality.
“Almost half of them are suicidal, and they actually proclaim it up to 1 year ahead of the shooting,” Dr. Freitas said. “We could catch them if we paid more attention to that.”
Mass killers tend to fall into three categories, as classified by psychiatrist Park Dietz, MD, in 1986:
- Family annihilators, such as George Banks, are typically depressed, paranoid, suicidal older males who might be intoxicated at the time of their attack. Banks shot 13 people, including 5 of his own children and 2 other children and their mothers, in Pennsylvania in 1982.
- Pseudocommandos, such as Charles Whitman, are usually preoccupied with firearms and plan heavily. “They usually end up killing themselves by cop,” Dr. Freitas said.
- Set-and-run killers, the rarest type, include perpetrators like Kehoe; their method of killing gives them an escape (though Kehoe blew himself up as well).
But mental illness is not a major feature of mass killers: Only about a quarter of mass shooters have a diagnosed mental illness, and the illness might not necessarily be related to their crime. Of that quarter, about 75% of mass shooters had a mood disorder, 25% had an anxiety disorder,19% had psychosis, and 1% had the developmental condition, such as autism spectrum disorder.
Yet, as mass shootings have dramatically increased, mental illness has become inextricably associated with these events in the media and popular opinion, Dr. Rosenbaum said. There have been 74 school shootings since the Newtown, Conn., tragedy, and mental illness is repeatedly brought up as a contributor, she said.
A 2014 study that analyzed 25% of a random sample of news stories from 1997 to 2012 on serious mental illness and gun violence (before Newtown) found that most of the coverage occurred after mass shootings and “ ‘dangerous people’ with serious mental illness were more likely to be mentioned than ‘dangerous weapons’ as a cause of gun violence” (Am J Public Health. 2014 Mar;104[3]:406-13).
Yet this association does not reflect reality, Dr. Rosenbaum said. One meta-analysis found that prevention of one stranger homicide by someone with psychosis would require detaining 35,000 people with schizophrenia who had been judged as being at high risk for violence (Schizophr Bull. 2011 May;37[3]:572-9).
Further, the relationship between violence and mental illness is not simple. Complex historical factors are usually involved, including past violence, juvenile detection, physical abuse, substance abuse, age, parental arrest record, and life circumstances – such as a recent divorce, unemployment, or victimization.
The greater danger of a person with mental illness is the harm they will do to themselves, research shows. A study of 255 recently discharged psychiatric patients and 490 matched community residents found that the patients were no more likely to perpetuate violence than were the community members, but they were significantly more likely to report being suicidal (Int J Law Psychiatry. 2018 Jan-Feb;56:44-9).
Rather than mental illness, what is associated with violence is substance use and access to weapons, Dr. Rosenbaum said.
“The United States is one of only three countries in the world with a constitutionally protected right to own firearms,” Dr. Rosenbaum said, citing a 2017 study by John S. Rozel, MD, and Edward P. Mulvey, PhD, (Annu Rev Clin Psychol. 2017 May 8;13:445-9). And the United States has few restrictions on that right. With more than 350 million privately owned firearms – approximately 30% of all privately owned firearms in the world – the U.S. population exceeds all other countries in both per capita and absolute gun ownership.
And research shows that guns don’t make a country safer: Guns per capita are significantly correlated with firearm-related deaths; mental illness is only of borderline significance (Am J Med. 2013 Oct;126[10]:873-6).
Substance use – including use of cocaine, hallucinogens, methamphetamine, ecstasy, and prescription medications – has a stronger correlation with gun-carrying and gun-related behaviors (Inj Prev. 2017 Dec; 23[6]:383-7 and Epidemiol Rev. 2016;38[1]:46-61). Both acute and chronic alcohol misuse also are linked to firearm ownership and violence toward others and one’s self (Prev Med. 2015 Oct;79:15-21).
Yet public misperceptions of mental illness as a contributor to violence persists, research shows (Aust N Z J Psychiatry. 2014 Aug;48[8]:764-71), further stigmatizing people with psychiatric conditions and potentially reducing the likelihood of their seeking treatment. Politicians contribute to these misperceptions; an example is House Speaker Paul Ryan’s comment after the Parkland, Fla., school shooting: “Mental health is often a big problem underlying these tragedies.”
“The media sensationalizes violent crimes committed by people with mental illness, especially after mass shooting, and this societal bias contributes to the stigma that leads to decreased treatment seeking and discrimination,” Dr. Rosenbaum said, citing research from Mohit Varshney, MD, and his associates (J Epidemiol Community Health. 2016 Mar;70[3]:223-5). “It is important to dissociate the concept of mental illness from dangerousness.”
AUSTIN, TEX. – Mass shootings make up only a tiny percentage of annual gun violence deaths in the United States, but they capture the attention of the nation – and of media that do not always accurately represent their context.
Experts tend to identify the first modern U.S. mass shooting event as the University of Texas Tower shooting in Austin by Charles Whitman in 1966, Corina Freitas, MD, said at the annual meeting of the American Academy of Psychiatry and the Law.
But two previous incidents preceded Whitman’s: Howard Unruh’s 12-minute killing spree in his neighborhood in Camden, N.J., in 1949, and Andrew Kehoe’s 1927 series of bombings that killed 43 people in the Bath School disaster in Michigan. Studies of these events and the hundreds since have led to a better understanding of what motivates mass shooters (or bombers in Kehoe’s case) and how to potentially identify them and prevent such events, said Dr. Freitas, of the department of psychiatry and behavioral sciences at George Washington University in Washington.
Dr. Freitas provided an overview of mass shooting history in the United States before Karen B. Rosenbaum, MD, clinical assistant professor at New York University and clinical instructor at New York Presbyterian–Weill Cornell Medical Center, spoke about the social, political, and legal implications of the intersection between mental illness and mass shootings.
She began by explaining how the FBI’s definition of mass shootings has changed from “four or more people at one location within one event” in 2005 to its redefinition in 2012-2013 to “three or more killings in a single incident and in a place of public use.”
Mass shootings usually are not impulse kills, Dr. Freitas said, noting that 77% of shooters plan their shooting for at least a week, and 46% of people spend about a week preparing. The perpetrators are potentially recognizable, typically displaying four to five concerning behaviors up to 1 year before the shooting, such as talking about their plans or purchasing supplies. But only a minority of people who observe these behaviors ever speak up about them or take any actions, she said.
, but they also display numerous other psychosocial characteristics, such as self-esteem issues, paranoia, narcissism, depression, and suicidality.
“Almost half of them are suicidal, and they actually proclaim it up to 1 year ahead of the shooting,” Dr. Freitas said. “We could catch them if we paid more attention to that.”
Mass killers tend to fall into three categories, as classified by psychiatrist Park Dietz, MD, in 1986:
- Family annihilators, such as George Banks, are typically depressed, paranoid, suicidal older males who might be intoxicated at the time of their attack. Banks shot 13 people, including 5 of his own children and 2 other children and their mothers, in Pennsylvania in 1982.
- Pseudocommandos, such as Charles Whitman, are usually preoccupied with firearms and plan heavily. “They usually end up killing themselves by cop,” Dr. Freitas said.
- Set-and-run killers, the rarest type, include perpetrators like Kehoe; their method of killing gives them an escape (though Kehoe blew himself up as well).
But mental illness is not a major feature of mass killers: Only about a quarter of mass shooters have a diagnosed mental illness, and the illness might not necessarily be related to their crime. Of that quarter, about 75% of mass shooters had a mood disorder, 25% had an anxiety disorder,19% had psychosis, and 1% had the developmental condition, such as autism spectrum disorder.
Yet, as mass shootings have dramatically increased, mental illness has become inextricably associated with these events in the media and popular opinion, Dr. Rosenbaum said. There have been 74 school shootings since the Newtown, Conn., tragedy, and mental illness is repeatedly brought up as a contributor, she said.
A 2014 study that analyzed 25% of a random sample of news stories from 1997 to 2012 on serious mental illness and gun violence (before Newtown) found that most of the coverage occurred after mass shootings and “ ‘dangerous people’ with serious mental illness were more likely to be mentioned than ‘dangerous weapons’ as a cause of gun violence” (Am J Public Health. 2014 Mar;104[3]:406-13).
Yet this association does not reflect reality, Dr. Rosenbaum said. One meta-analysis found that prevention of one stranger homicide by someone with psychosis would require detaining 35,000 people with schizophrenia who had been judged as being at high risk for violence (Schizophr Bull. 2011 May;37[3]:572-9).
Further, the relationship between violence and mental illness is not simple. Complex historical factors are usually involved, including past violence, juvenile detection, physical abuse, substance abuse, age, parental arrest record, and life circumstances – such as a recent divorce, unemployment, or victimization.
The greater danger of a person with mental illness is the harm they will do to themselves, research shows. A study of 255 recently discharged psychiatric patients and 490 matched community residents found that the patients were no more likely to perpetuate violence than were the community members, but they were significantly more likely to report being suicidal (Int J Law Psychiatry. 2018 Jan-Feb;56:44-9).
Rather than mental illness, what is associated with violence is substance use and access to weapons, Dr. Rosenbaum said.
“The United States is one of only three countries in the world with a constitutionally protected right to own firearms,” Dr. Rosenbaum said, citing a 2017 study by John S. Rozel, MD, and Edward P. Mulvey, PhD, (Annu Rev Clin Psychol. 2017 May 8;13:445-9). And the United States has few restrictions on that right. With more than 350 million privately owned firearms – approximately 30% of all privately owned firearms in the world – the U.S. population exceeds all other countries in both per capita and absolute gun ownership.
And research shows that guns don’t make a country safer: Guns per capita are significantly correlated with firearm-related deaths; mental illness is only of borderline significance (Am J Med. 2013 Oct;126[10]:873-6).
Substance use – including use of cocaine, hallucinogens, methamphetamine, ecstasy, and prescription medications – has a stronger correlation with gun-carrying and gun-related behaviors (Inj Prev. 2017 Dec; 23[6]:383-7 and Epidemiol Rev. 2016;38[1]:46-61). Both acute and chronic alcohol misuse also are linked to firearm ownership and violence toward others and one’s self (Prev Med. 2015 Oct;79:15-21).
Yet public misperceptions of mental illness as a contributor to violence persists, research shows (Aust N Z J Psychiatry. 2014 Aug;48[8]:764-71), further stigmatizing people with psychiatric conditions and potentially reducing the likelihood of their seeking treatment. Politicians contribute to these misperceptions; an example is House Speaker Paul Ryan’s comment after the Parkland, Fla., school shooting: “Mental health is often a big problem underlying these tragedies.”
“The media sensationalizes violent crimes committed by people with mental illness, especially after mass shooting, and this societal bias contributes to the stigma that leads to decreased treatment seeking and discrimination,” Dr. Rosenbaum said, citing research from Mohit Varshney, MD, and his associates (J Epidemiol Community Health. 2016 Mar;70[3]:223-5). “It is important to dissociate the concept of mental illness from dangerousness.”
REPORTING FROM THE AAPL ANNUAL MEETING
Pediatric OSA linked to abnormal metabolic values
SAN ANTONIO – Obstructive sleep apnea (OSA) in children is associated with an abnormal metabolic profile, but not with body mass index (BMI), according to new research.
“Screening for metabolic dysfunction in obese children with obstructive sleep apnea can help identify those at risk for cardiovascular complications,” Kanika Mathur, MD, of the Albert Einstein College of Medicine and the Children’s Hospital at Montefiore, both in New York, told attendees at the annual meeting of the American College of Chest Physicians. Dr. Mathur explained that no consensus currently exists regarding routine cardiac evaluation of children with OSA.
“The American Academy of Pediatrics does not mention any sort of cardiac evaluation in children with OSA while the most recent guidelines from the American Heart Association and the American Thoracic Society recommend echocardiographic evaluation in children with severe obstructive sleep apnea, specifically to evaluate for pulmonary hypertension and right ventricular dysfunction,” Dr. Mathur told attendees.
OSA’s association with obesity, diabetes, and hypertension is well established in adults. It is an independent risk factor for coronary artery disease, heart failure, stroke and atrial fibrillation, and research has suggested OSA treatment can reduce cardiovascular risk in adults, Dr. Mathur explained, but little data on children exist. She and her colleagues set out to understand the relationship of OSA in children with various measures of cardiovascular and metabolic health.
“Despite similar degrees of obesity and systemic blood pressure, pediatric patients with OSA had significantly higher diastolic blood pressure, heart rate, and abnormal metabolic profile, including elevated alanine transaminase, aspartate transaminase, triglycerides and hemoglobin A1c,” they found.
Their study included patients aged 3-21 years with a BMI of at least the 95th percentile who had undergone sleep study and an echocardiogram at the Children’s Hospital at Montefiore between November 2016 and November 2017.
They excluded those with comorbidities related to cardiovascular morbidity: heart disease, neuromuscular disease, sickle cell disease, rheumatologic diseases, significant cranial facial abnormalities, tracheostomy, and any lung disease. However, 7% of the patients had trisomy 21.
Among the 81 children who met their criteria, 37 were male and 44 were female, with an average age of 14 years old and a mean BMI of 39.4 kg/m2 (mean BMI z score of 2.22). Most of the patients (53.1%) had severe OSA (apnea-hypopnea index of at least 10), 21% had moderate OSA (AHI 5-9.9), 12.3% had mild OSA (AHI 2-4.9), and 13.6% did not have OSA. The median AHI of the children was 10.3.
Among all the children, “about half had elevated systolic blood pressure, which is already a risk factor for cardiovascular morbidity,” Mathur reported.
BMI, BMI z score, systolic blood pressure z score, oxygen saturation and cholesterol (overall and both HDL and LDL cholesterol levels) did not significantly differ between children who had OSA and those who did not, but diastolic blood pressure and heart rate did. Those with OSA had a diastolic blood pressure of 65 mm Hg, compared with 58 mm Hg without OSA (P = .008). Heart rate was 89 bpm in the children with OSA, compared with 78 bpm in those without (P = .004).
The children with OSA also showed higher mean levels of several other metabolic biomarkers:
- Alanine transaminase: 26 U/L with OSA vs. 18 U/L without (P = .01).
- Aspartate transaminase: 23 U/L with OSA vs. 18 U/L without (P = .03).
- Triglycerides: 138 mg/dL with OSA vs 84 mg/dL without (P = .004).
- Hemoglobin A1c: 6.2% with OSA vs. 5.4% without (P = .002).
Children with and without OSA did not have any significant differences in left atrial indexed volume, left ventricular volume, left ventricular ejection fraction, or left ventricular mass (measured by M-mode or 5/6 area length formula). Though research has shown these measures to differ in adults with and without OSA, evidence on echocardiographic changes in children has been conflicting, Dr. Mathur noted.
The researchers also conducted subanalyses according to OSA severity, but BMI, BMI Z-score, systolic or diastolic blood pressure Z-score, heart rate and oxygen saturation did not differ between those with mild OSA vs those with moderate or severe OSA. No differences in echocardiographic measurements existed between these subgroups, either.
However, children with moderate to severe OSA did have higher alanine transaminase (27 U/L with moderate to severe vs. 17 U/L with mild OSA; P = .005) and higher triglycerides (148 vs 74; P = .001).
“Certainly we need further evaluation to see the efficacy of obstructive sleep apnea therapies on metabolic dysfunction and whether weight loss needs to be an adjunct therapy for these patients,” Dr. Mathur told attendees. She also noted the need to define the role of echocardiography in managing children with OSA.
The study had several limitations, including its retrospective cross-sectional nature at a single center and its small sample size.
“Additionally, we have a wide variety of ages, which could represent different pathophysiology of the associated metabolic dysfunction in these patients,” Mathur said. “There is an inherent difficulty to performing echocardiograms in a very obese population as well.”
Both the moderators of the pediatrics section, Christopher Carroll, MD, FCCP, of Connecticut Children’s Medical Center in Hartford, and Shahid Sheikh, MD, FCCP, of Nationwide Children’s Hospital in Columbus, Ohio, were impressed with the research. Dr. Carroll called it a “very elegant” study, and Dr. Sheikh noted the need for these studies in pediatrics “so that we don’t have to rely on grown-up data,” which may or may not generalize to children.
SOURCE: CHEST 2018. https://journal.chestnet.org/article/S0012-3692(18)31935-4/fulltext
SAN ANTONIO – Obstructive sleep apnea (OSA) in children is associated with an abnormal metabolic profile, but not with body mass index (BMI), according to new research.
“Screening for metabolic dysfunction in obese children with obstructive sleep apnea can help identify those at risk for cardiovascular complications,” Kanika Mathur, MD, of the Albert Einstein College of Medicine and the Children’s Hospital at Montefiore, both in New York, told attendees at the annual meeting of the American College of Chest Physicians. Dr. Mathur explained that no consensus currently exists regarding routine cardiac evaluation of children with OSA.
“The American Academy of Pediatrics does not mention any sort of cardiac evaluation in children with OSA while the most recent guidelines from the American Heart Association and the American Thoracic Society recommend echocardiographic evaluation in children with severe obstructive sleep apnea, specifically to evaluate for pulmonary hypertension and right ventricular dysfunction,” Dr. Mathur told attendees.
OSA’s association with obesity, diabetes, and hypertension is well established in adults. It is an independent risk factor for coronary artery disease, heart failure, stroke and atrial fibrillation, and research has suggested OSA treatment can reduce cardiovascular risk in adults, Dr. Mathur explained, but little data on children exist. She and her colleagues set out to understand the relationship of OSA in children with various measures of cardiovascular and metabolic health.
“Despite similar degrees of obesity and systemic blood pressure, pediatric patients with OSA had significantly higher diastolic blood pressure, heart rate, and abnormal metabolic profile, including elevated alanine transaminase, aspartate transaminase, triglycerides and hemoglobin A1c,” they found.
Their study included patients aged 3-21 years with a BMI of at least the 95th percentile who had undergone sleep study and an echocardiogram at the Children’s Hospital at Montefiore between November 2016 and November 2017.
They excluded those with comorbidities related to cardiovascular morbidity: heart disease, neuromuscular disease, sickle cell disease, rheumatologic diseases, significant cranial facial abnormalities, tracheostomy, and any lung disease. However, 7% of the patients had trisomy 21.
Among the 81 children who met their criteria, 37 were male and 44 were female, with an average age of 14 years old and a mean BMI of 39.4 kg/m2 (mean BMI z score of 2.22). Most of the patients (53.1%) had severe OSA (apnea-hypopnea index of at least 10), 21% had moderate OSA (AHI 5-9.9), 12.3% had mild OSA (AHI 2-4.9), and 13.6% did not have OSA. The median AHI of the children was 10.3.
Among all the children, “about half had elevated systolic blood pressure, which is already a risk factor for cardiovascular morbidity,” Mathur reported.
BMI, BMI z score, systolic blood pressure z score, oxygen saturation and cholesterol (overall and both HDL and LDL cholesterol levels) did not significantly differ between children who had OSA and those who did not, but diastolic blood pressure and heart rate did. Those with OSA had a diastolic blood pressure of 65 mm Hg, compared with 58 mm Hg without OSA (P = .008). Heart rate was 89 bpm in the children with OSA, compared with 78 bpm in those without (P = .004).
The children with OSA also showed higher mean levels of several other metabolic biomarkers:
- Alanine transaminase: 26 U/L with OSA vs. 18 U/L without (P = .01).
- Aspartate transaminase: 23 U/L with OSA vs. 18 U/L without (P = .03).
- Triglycerides: 138 mg/dL with OSA vs 84 mg/dL without (P = .004).
- Hemoglobin A1c: 6.2% with OSA vs. 5.4% without (P = .002).
Children with and without OSA did not have any significant differences in left atrial indexed volume, left ventricular volume, left ventricular ejection fraction, or left ventricular mass (measured by M-mode or 5/6 area length formula). Though research has shown these measures to differ in adults with and without OSA, evidence on echocardiographic changes in children has been conflicting, Dr. Mathur noted.
The researchers also conducted subanalyses according to OSA severity, but BMI, BMI Z-score, systolic or diastolic blood pressure Z-score, heart rate and oxygen saturation did not differ between those with mild OSA vs those with moderate or severe OSA. No differences in echocardiographic measurements existed between these subgroups, either.
However, children with moderate to severe OSA did have higher alanine transaminase (27 U/L with moderate to severe vs. 17 U/L with mild OSA; P = .005) and higher triglycerides (148 vs 74; P = .001).
“Certainly we need further evaluation to see the efficacy of obstructive sleep apnea therapies on metabolic dysfunction and whether weight loss needs to be an adjunct therapy for these patients,” Dr. Mathur told attendees. She also noted the need to define the role of echocardiography in managing children with OSA.
The study had several limitations, including its retrospective cross-sectional nature at a single center and its small sample size.
“Additionally, we have a wide variety of ages, which could represent different pathophysiology of the associated metabolic dysfunction in these patients,” Mathur said. “There is an inherent difficulty to performing echocardiograms in a very obese population as well.”
Both the moderators of the pediatrics section, Christopher Carroll, MD, FCCP, of Connecticut Children’s Medical Center in Hartford, and Shahid Sheikh, MD, FCCP, of Nationwide Children’s Hospital in Columbus, Ohio, were impressed with the research. Dr. Carroll called it a “very elegant” study, and Dr. Sheikh noted the need for these studies in pediatrics “so that we don’t have to rely on grown-up data,” which may or may not generalize to children.
SOURCE: CHEST 2018. https://journal.chestnet.org/article/S0012-3692(18)31935-4/fulltext
SAN ANTONIO – Obstructive sleep apnea (OSA) in children is associated with an abnormal metabolic profile, but not with body mass index (BMI), according to new research.
“Screening for metabolic dysfunction in obese children with obstructive sleep apnea can help identify those at risk for cardiovascular complications,” Kanika Mathur, MD, of the Albert Einstein College of Medicine and the Children’s Hospital at Montefiore, both in New York, told attendees at the annual meeting of the American College of Chest Physicians. Dr. Mathur explained that no consensus currently exists regarding routine cardiac evaluation of children with OSA.
“The American Academy of Pediatrics does not mention any sort of cardiac evaluation in children with OSA while the most recent guidelines from the American Heart Association and the American Thoracic Society recommend echocardiographic evaluation in children with severe obstructive sleep apnea, specifically to evaluate for pulmonary hypertension and right ventricular dysfunction,” Dr. Mathur told attendees.
OSA’s association with obesity, diabetes, and hypertension is well established in adults. It is an independent risk factor for coronary artery disease, heart failure, stroke and atrial fibrillation, and research has suggested OSA treatment can reduce cardiovascular risk in adults, Dr. Mathur explained, but little data on children exist. She and her colleagues set out to understand the relationship of OSA in children with various measures of cardiovascular and metabolic health.
“Despite similar degrees of obesity and systemic blood pressure, pediatric patients with OSA had significantly higher diastolic blood pressure, heart rate, and abnormal metabolic profile, including elevated alanine transaminase, aspartate transaminase, triglycerides and hemoglobin A1c,” they found.
Their study included patients aged 3-21 years with a BMI of at least the 95th percentile who had undergone sleep study and an echocardiogram at the Children’s Hospital at Montefiore between November 2016 and November 2017.
They excluded those with comorbidities related to cardiovascular morbidity: heart disease, neuromuscular disease, sickle cell disease, rheumatologic diseases, significant cranial facial abnormalities, tracheostomy, and any lung disease. However, 7% of the patients had trisomy 21.
Among the 81 children who met their criteria, 37 were male and 44 were female, with an average age of 14 years old and a mean BMI of 39.4 kg/m2 (mean BMI z score of 2.22). Most of the patients (53.1%) had severe OSA (apnea-hypopnea index of at least 10), 21% had moderate OSA (AHI 5-9.9), 12.3% had mild OSA (AHI 2-4.9), and 13.6% did not have OSA. The median AHI of the children was 10.3.
Among all the children, “about half had elevated systolic blood pressure, which is already a risk factor for cardiovascular morbidity,” Mathur reported.
BMI, BMI z score, systolic blood pressure z score, oxygen saturation and cholesterol (overall and both HDL and LDL cholesterol levels) did not significantly differ between children who had OSA and those who did not, but diastolic blood pressure and heart rate did. Those with OSA had a diastolic blood pressure of 65 mm Hg, compared with 58 mm Hg without OSA (P = .008). Heart rate was 89 bpm in the children with OSA, compared with 78 bpm in those without (P = .004).
The children with OSA also showed higher mean levels of several other metabolic biomarkers:
- Alanine transaminase: 26 U/L with OSA vs. 18 U/L without (P = .01).
- Aspartate transaminase: 23 U/L with OSA vs. 18 U/L without (P = .03).
- Triglycerides: 138 mg/dL with OSA vs 84 mg/dL without (P = .004).
- Hemoglobin A1c: 6.2% with OSA vs. 5.4% without (P = .002).
Children with and without OSA did not have any significant differences in left atrial indexed volume, left ventricular volume, left ventricular ejection fraction, or left ventricular mass (measured by M-mode or 5/6 area length formula). Though research has shown these measures to differ in adults with and without OSA, evidence on echocardiographic changes in children has been conflicting, Dr. Mathur noted.
The researchers also conducted subanalyses according to OSA severity, but BMI, BMI Z-score, systolic or diastolic blood pressure Z-score, heart rate and oxygen saturation did not differ between those with mild OSA vs those with moderate or severe OSA. No differences in echocardiographic measurements existed between these subgroups, either.
However, children with moderate to severe OSA did have higher alanine transaminase (27 U/L with moderate to severe vs. 17 U/L with mild OSA; P = .005) and higher triglycerides (148 vs 74; P = .001).
“Certainly we need further evaluation to see the efficacy of obstructive sleep apnea therapies on metabolic dysfunction and whether weight loss needs to be an adjunct therapy for these patients,” Dr. Mathur told attendees. She also noted the need to define the role of echocardiography in managing children with OSA.
The study had several limitations, including its retrospective cross-sectional nature at a single center and its small sample size.
“Additionally, we have a wide variety of ages, which could represent different pathophysiology of the associated metabolic dysfunction in these patients,” Mathur said. “There is an inherent difficulty to performing echocardiograms in a very obese population as well.”
Both the moderators of the pediatrics section, Christopher Carroll, MD, FCCP, of Connecticut Children’s Medical Center in Hartford, and Shahid Sheikh, MD, FCCP, of Nationwide Children’s Hospital in Columbus, Ohio, were impressed with the research. Dr. Carroll called it a “very elegant” study, and Dr. Sheikh noted the need for these studies in pediatrics “so that we don’t have to rely on grown-up data,” which may or may not generalize to children.
SOURCE: CHEST 2018. https://journal.chestnet.org/article/S0012-3692(18)31935-4/fulltext
REPORTING FROM CHEST 2018
Key clinical point: Children with obesity and obstructive sleep apnea have an abnormal metabolic profile.
Major finding: Diastolic blood pressure (65 vs. 58 mm Hg), heart rate (89 vs. 78 bpm), triglycerides (138 vs. 84 mg/dL), alanine transaminase (26 vs. 18 U/L), aspartate transaminase (23 vs. 18 U/L) and hemoglobin A1c (6.2% vs. 5.4%) were all elevated in obese children with OSA, compared with obese children without OSA.
Study details: The findings are based on a retrospective analysis of 81 patients aged 3-21 years, from the Children’s Hospital at Montefiore between November 2016-November 2017.
Disclosures: No external funding was noted. The authors reported having no disclosures.