Troubled Adolescents Need a Double Safety Net

The Senate's vote in favor of stricter gun-control measures, cast in the shadow of another school shooting, is a milestone on the road to decreasing the use of guns by discouraged and alienated adolescents to impulsively act out anger. It is a reasonable inference that having less access to guns will decrease apparently spur-of-the-moment rejection and rage shootings such as the most recent one in Georgia. But it is only the beginning. The next two steps include mending our managed-care-torn safety net for at risk adolescents and a commitment to violence prevention programs in our schools.

The current bill alone will not prevent well planned, premeditated attacks, such as those in Littleton, Colorado last month, apparently spearheaded by a teenager with a history of being medicated for obsessive-compulsive disorder. Other aspects of the bill, which call for heavier penalties against young criminals, would not even touch the lives of youths such as the depressed young man arrested in the Georgia shooting--he apparently had no criminal record and seemed, by most accounts, to be a "regular kid" from a nice neighborhood. One needed next step is legislation to remove the increasing restrictions by all too many managed care organizations on the clinical care of seriously ill adolescents.

Parents and clinicians need to have the freedom to consider inpatient hospital treatment for severely distraught adolescents, where depression, Attention Deficit Disorder, or Obsessive-Compulsive Disorder may be precursors to, or may mask psychosis, the loss of boundary between fantasy and reality. Some adolescents could be helped by inpatient hospitalizations, which give clinicians the opportunity to observe the youth while finding the best combinations of medication and therapy. But currently, clinicians and patients' families' ability to access inpatient care is severely limited by managed care organizations. Their restrictions include near automatic rejection of requests for long term inpatient treatment, a Kafkaesque appeals process, and sometimes clinically irrelevant decision criteria designed to insulate the managed care organization from liability while denying inpatient care, burdensome documentation requirements. Some clinicians who recommend "too many" hospitalizations have been retaliated against, through chart audits and by being dropped from plans through "economic deselection." And while managed care companies no longer contractually impose gag clauses that would prevent clinicians from talking about the limits of a patient's insurance coverage, the roadblocks most companies have erected have left patients with the similar inability to follow through on the best choices for them.

Other at-risk adolescents could benefit from a combination of long-term outpatient counseling and medication. But health maintenance organizations routinely limit therapeutic visits to doctors, in favor of 15-minute medication management sessions. These short visits often prevent providers from being able to treat, or even discern, the complex layers of mental illness. For example, Depression or Obsessive Compulsive Disorder may mask or become complicated by another major mental illness. Depression may deepen into psychosis, or can be an early symptom of a Schizoaffective Disorder with both depressive and paranoid features. Adolescents are more likely than other patients to conceal their psychoses -- experiences where the line between reality and fantasy is erased -- because they are especially vulnerable to feelings of shame, pessimism and suspicion of authority. Without the safety net provided by a therapeutic community, or as a minimum, intensive individual, family and group psychotherapy coordinated by highly trained mental health professionals, the adolescent prone to violence is more likely to resort to it, as the only solution to their unbearable shame and rage.

Adolescent psychosis driven violence is most likely to be self-directed, and can take the form of risk taking behavior and suicide. But it can also mix with social reality to create a volatile solution readily sparked into violence by loss or humiliation. The Georgia 15-year-old who shot six of his classmates had recently broken up with his girlfriend. The two Colorado teenagers who killed 13 people, and then themselves, had become obsessed with symbols violence and hate -- including Hitler -- after they came to believe they had been made outcasts by athletically inclined classmates. Most adults who suffer disappointments of a similar scale know that life goes on. Most adolescents don't. If you think this is merely the result of the media or video games, take a look at one of the most famous works about teenagers -- Romeo and Juliet --written before "adolescence" was even a concept! The play takes us down a steep slippery slope of social conflict in the context of a factional dispute, all too common in adolescence. What begins as a sleight, plunges the participants towards a killing, and ends in a double suicide.

Suicide is the third leading cause of death for teenagers aged fifteen to nineteen in the United States. However, there is even good reason to believe that among adolescents, it may actually be the leading cause of death. The links between major mental illness, substance abuse, psychosis, suicide and homicide are real, but are often neglected in today's depleted clinical landscape. For example, depression can lead to substance abuse combined with other risky behavior -- such as drunk driving. So some fatalities stemming from drunk driving accidents can actually be part of the deadly toll of "accidental suicide."

As a second step for preventing adolescent suicide, violence and "accidental suicide," funding is needed to provide retraining for teachers and educators to respond appropriately to signs of teenage distress. Many such early warning signs are reported to have been present prior to the Littleton killings. When teenagers greet each other with "Heil Hitler" salutes in the hallways -- as they openly did in Columbine High School, educators have the responsibility and need the training to consider that identification with Hitler is a red flag. The boundary between private fantasy (feeling mortified by a rejection as in "I could have just died", "I could have killed him"), and social reality (suicide and homicide attempts), is never altogether fixed and is especially fluid in adolescence.

Major mental illness can erode the already porous adolescent boundaries between reality and fantasy. To rely on such boundaries and dismiss "Heil Hitler" salutes as "a phase" that will "go away if you ignore it" is a misconception. At a minimum, educators should identify behaviors which can be indications of adolescents at risk, and communicate their concerns to parents. Schools could hire trained counselors who would assist teachers, parents and teenagers by offering therapy and making referrals. Moreover, educators should watch for the emergence of school factions, gangs, and cults. In Littleton, the Nazi-Gothic cult used Hitler's birthday as a target date to retaliate against the perceived slights and attacks by another, so called "jock" faction. There are now a variety of age-appropriate programs, curricula, and educational materials designed to counter ideological distortions of history (which have made Hitler a hero to some) with real history, and which teach tolerance and conflict resolution. What is now needed is the political will to make mental health resources become genuinely accessible to those too ashamed, too frightened or too pessimistic to surmount the very real barriers to accessing care within our schools and our communities.

Harold Bursztajn, M.D. is a Director of the Program in Psychiatry & Law at Harvard Medical School. As a psychoanalyst in Cambridge he provides intensive treatment for adolescents and as a forensic psychiatrist consults nationally to courts, schools, and organizations on violence prevention and public safety. Irene Coletsos is a counselor in Boston with a long standing interest in the health care problems of the mentally ill and the homeless.