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Editor's Note: On October 15, 2004, the U.S. Food and Drug Administration (FDA) directed manufacturers of all antidepressant drugs to add "black box" warnings that describe the increased risk of suicide and suicidal thoughts in children and teens who take the drugs. Black box warnings are the most serious type placed on prescription medications. Additionally, the FDA is working with manufacturers to ensure that every patient who receives a prescription for antidepressants will also be given a MedGuide -- a pamphlet that details risks associated with the drug and precautions to take.
It was just another Monday morning, the beginning of a normal school week, when 15-year-old Charles Andrew Williams whipped out a 22 caliber revolver in the bathroom of his high school in Santee, California and unleashed a barrage of fire at the students around him.
By the time police responded, two of the troubled teen's classmates were killed and 13 wounded in the ensuing melee. Tragically, this incident was only one in nearly two dozen shootings, massacres, or foiled attacks on schools by students that have sent shock waves through small towns across the United States since 1999, including the deadly massacre at Columbine High School in Littleton, Colorado.
In March 2005, after a brief lull, the violence broke out again. A youth in the rural Minnesota community of Red Lake gunned down 10 people at his high school, including five of his fellow classmates, before killing himself.
These baffling episodes involving adolescents-turned-killers raise disturbing questions: What leads school-age children to commit unconscionable acts of violence against their peers? As parents, we ponder the troubling question of what could possibly inspire a teenager -- usually a boy, usually white and middle-class -- to plot and, indeed, carry out a minutely detailed plan to assassinate or massacre his fellow students.
Although no one can say for sure what motivations lay behind the Santee shooting, it appears certain that Charles Williams -- known to his few friends and family as Andy -- endured merciless taunts and bullying from fellow classmates.
Explosive mixture
The mixture of adolescence, school bullying, and depression is explosive, say psychologists who've studied the issue. Teenage girls may become severely depressed and attempt suicide; in very rare cases, they may become violent. In susceptible teenage boys, bullying may result in depression, self-hatred, and a death wish that may one day explode in unfathomable violence. Some teens who are severely depressed and want to die may kill others before turning the guns on themselves, as did the boys who committed the Columbine massacre.
Depression often lurks just beneath the surface of even the most violent act. "If you do a role play with batterers and freeze the action before the lashing out and ask them how they feel, they'll say they feel betrayed, unloved. There's a millisecond of tolerance for those depressive feelings, and then the man flips up into dominance rage and lashes out," says Terrence Real, a Cambridge-based psychotherapist who works with perpetrators of abuse.
It might seem that such rage disappears with the onset of depression, but studies show that's not the case. According to a recent report in the Journal of Clinical Psychiatry, about one in three depressed people are also openly hostile. In addition, many depressed people have "anger attacks" -- characterized by a racing heart beat, sweating, hot flashes, and a tightness in the chest -- in response to even minor irritations. More than 60 percent of depressed patients who have anger attacks say they have physically or verbally attacked others during their fits of rage, according to the report.
Equally disturbing, the high level of violence in the United States encourages teens to act out in violent ways, experts say. The U.S. Surgeon General's 2001 mental health report on youth and violence noted that by the time they've reached adolescence, 16 million teens in this country "have witnessed some form of violent assault, including robbery, stabbing, shooting, murder, or domestic abuse." Discussing the rise in youth violence, the report concluded tersely: "What adults do to children and to each other, children will also do."
Glamorized violence
Real takes this argument a step further. In the United States unrealistic bravado -- or retaliation for perceived wrongs -- lies at the very heart of male identity, according to Real, whose latest book is entitled I Don't Want to Talk About It: Overcoming the Secret Legacy of Male Depression, a compelling study of the roots of violence in men and boys.
"There's been an overall escalation in the culture supporting the expression of violence as a glamorous thing. It's a core idea of manliness in America; if you're victimized, you can right the wrong through lashing out at the victimizer," he says.
Real adds that recent movies such as the Terminator films, as well as video games and other forms of entertainment that glorify extreme and murderous acts, fuel the acceptance of violence as noble. The teenagers who've recently committed heinous acts of violence against their classmates, he concludes, "are heroes in their own minds, taking heroic revenge."
How do we recognize the signs of acute distress in our children -- whether directed outward in searing hostility or inward in depression -- and help them find their way out of its grasp before it deforms their lives and those of others? We can start by examining teen depression, which affects more than 8 percent of adolescents in the United States and often goes unrecognized, according to the National Institute for Mental Health. Teenage girls are twice as likely as boys to suffer from depression, according to the NIMH, but depressed boys are more likely to act out in antisocial ways.
This is a key piece of the puzzle, explains William Pollack, the author of Real Boys and an assistant professor of clinical psychology at Harvard Medical School.
"Boys' communication of depression is through behavior; it's action-oriented," he says. "Some of the earliest signs that a boy is depressed or suicidal are acts of bravado or risk-taking -- like taking drugs or driving too fast -- that he didn't do before. Often we say these boys are bad or having a bad time, or 'boys will be boys,' when in fact, this is their way of telling us, 'Look, I'm really sad or helpless.'"
Signs of clinical depression
Certainly the teen years are unique. During adolescence, as teens struggle to figure out who they are in relation to the world around them, they'll naturally experience moody, irritable and antisocial times. In normal development, these are balanced out with just as many calm, happy periods, psychologists say. "If teens are depressed, they're increasingly and persistently irritable and withdrawn. There's up and down moodiness, but happy periods don't last," says child and adolescent psychiatrist Lynn Ponton, whose recent book, The Romance of Risk, explores risk-taking among adolescents. She points to an example of a depressed 14-year-old patient she saw recently. "She was happy for one minute when her mother said she could pierce her lip," explains Ponton. "The rest of the time she was irritable, and angry; combative with her mother, and said at least 10 times that she wanted to do herself in."
When to seek professional help
There are definite signs of depression that you can be on the alert for. Always get professional help immediately if your child seems suicidal and take any threats of suicide very seriously. Suicide -- the last act of many depressed teens -- is the third leading cause of death among adolescents between the age of 15 and 19.
In addition, call your doctor for a referral to a mental health professional immediately if your teen seems persistently depressed or sad and exhibits four of the following symptoms for a two-week period or longer:
If you find that your child has hurt or tormented animals or other children, see a mental health professional at once: Your child needs immediate help. Studies show that kids who torture animals run a higher than normal risk of becoming a violent adult.
Whether or not your child is violently acting out, you don't have to wait until he seems depressed to contact a therapist. If your family life seems unhappy or you're having persistent difficulty connecting with your teen, a therapist can often help you find better ways to communicate.
Why is my child depressed?
The causes of depression are complex. Current research in the field of mood disorders points to genetic predisposition as well as family dynamics, abuse at school, and trauma as major risk factors. A child with one depressed parent, for example, experiences a 50 percent greater chance of being struck by the debilitating illness than a child whose parents aren't depressed.
If both parents have struggled with depression, the odds are upped to 75 percent, according to the National Institute of Mental Health. When a child experiences sexual or physical abuse -- or is routinely ignored or neglected -- he may also become more vulnerable to the disease. What's most important to keep in mind is that depression is a serious disease that needs to be treated -- and that treatment can relieve your child's suffering. And whatever the causes of your child's depression, it doesn't mean you've done a bad job parenting.
How can I get help for my teen?
If you suspect that your teen is going through some form of intense emotional turmoil, first try to engage him in dialogue. This may be particularly challenging for parents with sons, but it may save their lives, according to Harvard psychiatrist Pollack.
Many boys and male teens, he says, are victims of what he calls the "Boy Code" -- old, outdated rules that demand stoicism and silence at enormous emotional cost. He suggests creating what he calls a shame-free zone or safety zone -- physically and emotionally -- for "action talk." It may be as simple as taking a ride in the car, or talking while you're playing Legos or Monopoly with your son -- anything activity that involves "action" so that you and your son are not simply facing each other across a table with your arms folded.
"Don't bombard your son with questions, just let him know you're there," Pollack says. "If he doesn't talk, you can give an entry like, 'You've seemed a little down lately,' or you can share something about yourself. This kind of safe encounter allows boys to open up."
If your teen is combative or refuses to talk to you, call your doctor for a referral to a mental health professional skilled at working with adolescents. Finding a psychiatrist or psychologist your teen is willing to talk to is the first step; it may require numerous telephone calls and visits to more than one professional before you and your teen find the "right fit." As the parents, you may be asked to participate in some of the sessions to work out problems that may be hurting your relationship with your teen. Ultimately, your therapist might be able to help you pinpoint potential triggers of your child's troubled behavior, such as the death of a close relative or bullying at school.
Finally, realize that no matter how bored, indifferent, moody, sarcastic, or rebellious a teen acts in your presence, he or she is still a child that needs your love and support. You can and should set limits on his behavior, and let your child know when you're hurt or upset by his behavior, but always reassure your teen that you still love him.
Should my child take antidepressants?
This should be decided on a case by case basis by parents and a therapist. The Food and Drug Association advises caution when antidepressants are prescribed for children and teens due to reports of increased suicidal thoughts and suicide attempts in some patients under age 18. In 2004, the FDA strengthened warning labels on all antidepressants.
Patients taking antidepressants -- particularly young patients -- should be monitored for a worsening of their depression or the development of suicidal tendencies. This monitoring is particularly important when the patient first begins taking the drug. Your doctor may prescribe a selective serotonin reuptake inhibitor (SSRI), a relatively new class of anti-depressants that have been shown to help reduce anxiety and severe depression in teens.
Antidepressants shouldn't be used in lieu of therapy, however, to treat children suffering from family conflicts or violence, conflicts at school, the death of a loved friend or relative, or the loss of an important relationship, according to psychologist Irwin Hyman of Temple University. In these cases, Hyman says, antidepressants alone can actually mask the cause of the depression and keep your child from getting the help she needs.
Are there alternative treatments?
Depression is a disease that requires professional help. Always consult with your doctor before trying alternative treatments or herbs; some supplements can interact in harmful ways with medication, including antidepressants.
Some therapists are exploring alternative treatments as adjunct to counseling, drugs, or a combination. This may changing your child's diet to include more fruits, vegetables, and whole grains, as well as fish oil or flaxseed oil supplements containing omega-3 fatty acids. Although the findings are not conclusive, some small, preliminary studies have suggested the supplements may be helpful in the treatment of depression and over-aggression.
How can I help prevent my teen from becoming violent?
Although the issue of violence is larger than any single family, and affects the society at large, parents can help diffuse potentially violent eruptions in their children. The Surgeon General's report noted that if your child has displayed violent or aggressive behavior in the past, you can help prevent other occurrences by acting as a role model and settling conflicts nonviolently.
This means avoiding verbal abuse and not hitting, slapping, pushing, shaking, or even spanking your child, because this kind of punishment teaches him that might makes right. If you have trouble enforcing effective limits without corporal punishment, talk with a counselor or pastoral advisor about non-violent forms of discipline.
One of the most important ways to protect your child is to keep firearms out of the house. This not only makes it less likely your child could get his hands on a gun, it helps prevent a tragic accident. If you do have guns, however, keep them unloaded and locked away. And make sure to keep the key on you at all times -- kids have an amazing ability to figure out where keys are hidden.
The Surgeon General's report also stresses that you should monitor your child's use of the Internet, television, and other media for violent shows and video games; supervise the activities of your children and know their schedule and friends; and make house rules that reward positive behavior. And spend as much time with your kids as you can.
How can we prevent more shootings in high schools?
This question is under hot debate, but two things are certain: We can work with teachers and principals to try to eliminate the bullying rampant in our the schools, and we can try to reach children before they explode. In families, that means encouraging your children -- particularly boys, who tend to keep troubles inside -- to talk about their feelings. According to Pollack, it's crucial that we free our sons from the straitjacket of the so-called "Boy Code" that forbids them to cry or show pain.
"Some boys who can't cry, cry bullets," Pollack says. "There are real aspects of traditional masculinity that are worth saving, and I think we should be giving boys the message that it's good to be heroic, to save others, to provide and protect. But if you want to be sad, if you want to hug your mother, if you want to shed tears when you feel pain, we want you to be able to do that -- to be a whole person, not a half-person.
"People ask, 'Do you think there will be more Columbines? Do you think there will be more shootings? I say, 'Yes -- until we change the way we deal with boys.'"
-- Laurie Udesky is an award-winning journalist who has covered health and medical issues for more than 15 years. She has filed stories for National Public Radio and served as a writer and editor for medical trade journals such as TB Monitor, AIDS Alert, and Subacute Care Monthly. Editor Blythe Woolston, who interviewed William Pollack, contributed to this story.
Further Resources
American Academy of Child and Adolescent Psychiatrists
www.aacap.org/violence/depress.htm
National Institutes of Health,
National Institute of Mental Health
www.nimh.him.gov/publicat/depstory02.cfm
References
U.S. Surgeon General. Youth and Violence: Setting the Stage.
www.aacap.org
Interview with Lynn E. Ponton, MD, professor of psychiatry at University of California San Francisco, specializes in child and adolescent psychiatry. Author of: The Romance of Risk: Why teenagers do the things they do, Basic Books, 1997, and The Sex Lives of Teens, Dutton, 2000.
Interview with Terrence Real, a Cambridge-based psychiatrist and the author of I Don't Want to Talk About It: Overcoming the Secret Legacy of Male Depression.
Interview with William Pollack, author of Real Boys and assistant professor of psychology at Harvard Medical School.
Mental Health: Report of the Surgeon General. January 3, 2001.
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