Kenya hospital imprisons new mothers with no money

NAIROBI, Kenya (AP) — The director of the Pumwani Maternity Hospital, located in a hardscrabble neighborhood of downtown Nairobi, freely acknowledges what he's accused of: detaining mothers who can't pay their bills. Lazarus Omondi says it's the only way he can keep his medical center running.

Two mothers who live in a mud-wall and tin-roof slum a short walk from the maternity hospital, which is affiliated with the Nairobi City Council, told The Associated Press that Pumwani wouldn't let them leave after delivering their babies. The bills the mothers couldn't afford were $60 and $160. Guards would beat mothers with sticks who tried to leave without paying, one of the women said.

Now, a New York-based group has filed a lawsuit on the women's behalf in hopes of forcing Pumwani to stop the practice, a practice Omondi is candid about.

"We hold you and squeeze you until we get what we can get. We must be self-sufficient," Omondi said in an interview in his hospital office. "The hospital must get money to pay electricity, to pay water. We must pay our doctors and our workers."

"They stay there until they pay. They must pay," he said of the 350 mothers who give birth each week on average. "If you don't pay the hospital will collapse."

The Center for Reproductive Rights, which filed the suit this month in the High Court of Kenya, says detaining women for not paying is illegal. Pumwani is associated with the Nairobi City Council, one reason it might be able to get away with such practices, and the patients are among Nairobi's poorest with hardly anyone to stand up for them.

Maimouna Awuor was an impoverished mother of four when she was to give birth to her fifth in October 2010. Like many who live in Nairobi's slums, Awuor performs odd jobs in the hopes of earning enough money to feed her kids that day. Awuor, who is named in the lawsuit, says she had saved $12 and hoped to go to a lower-cost clinic but was turned away and sent to Pumwani. After giving birth, she couldn't pay the $60 bill, and was held with what she believes was about 60 other women and their infants.

"We were sleeping three to a bed, sometimes four," she said. "They abuse you, they call you names," she said of the hospital staff.

She said saw some women tried to flee but they were beaten by the guards and turned back. While her husband worked at a faraway refugee camp, Awuor's 9-year-old daughter took care of her siblings. A friend helped feed them, she said, while the children stayed in the family's 50-square-foot shack, where rent is $18 a month. She says she was released after 20 days after Nairobi's mayor paid her bill. Politicians in Kenya in general are expected to give out money and get a budget to do so.

A second mother named in the lawsuit, Margaret Anyoso, says she was locked up in Pumwani for six days in 2010 because she could not pay her $160 bill. Her pregnancy was complicated by a punctured bladder and heavy bleeding.

"I did not see my child until the sixth day after the surgery. The hospital staff were keeping her away from me and it was only when I caused a scene that they brought her to me," said Anyoso, a vegetable seller and a single mother with five children who makes $5 on a good day.

Anyoso said she didn't have clothes for her child so she wrapped her in a blood-stained blouse. She was released after relatives paid the bill.

One woman says she was detained for nine months and was released only after going on a hunger strike. The Center for Reproductive Rights says other hospitals also detain non-paying patients.

Judy Okal, the acting Africa director for the Center for Reproductive Rights, said her group filed the lawsuit so all Kenyan women, regardless of socio-economic status, are able to receive health care without fear of imprisonment. The hospital, the attorney general, the City Council of Nairobi and two government ministries are named in the suit.

___

Associated Press reporter Tom Odula contributed to this report.

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Consumer sentiment weakens as fiscal crisis looms

WASHINGTON (Reuters) - U.S. consumer confidence fell more than expected in December, hitting a four-month low as a looming fiscal crisis sapped what had been a growing sense of optimism about the economy.

The report heightened concerns that a failure by Washington to avert planned tax hikes and spending cuts could lead households to close their wallets, threatening an economic recovery that has been steady albeit lackluster.

Other data on Thursday highlighted the positive momentum building in the economy, with the number of Americans filing new claims for jobless benefits falling to a nearly 4-1/2 year low and new home sales hitting their highest level since April 2010.

But gauges of business sentiment have weakened recently on worries Washington will go forward with plans to slash the federal deficit by about $600 billion in 2013.

Now consumers also appear apprehensive, a sign worries about the so-called "fiscal cliff" could bite into household spending.

The Conference Board, an industry group, said its index of consumer attitudes fell to 65.1 from 71.5 in November.

A sub-index measuring how consumers feel about their present situation rose to its highest level in more than four years, but a gauge of sentiment about the future plunged to its lowest point in more than a year.

"Consumers are increasingly preoccupied with the potential damage the fiscal cliff will cause to the economy and to their wallets if a deal is not reached soon," economists at RBS in Stamford, Connecticut, wrote in a research note.

Separately, the Labor Department said initial claims for state unemployment benefits dropped 12,000 last week to a seasonally adjusted 350,000, the Labor Department said.

"This recent improvement in the claims data is potentially a favorable signal for the labor market," said Daniel Silver, an economist at JPMorgan in New York.

After spiking in the wake of a mammoth storm that ravaged the East Coast in late October, new claims have dropped to their lowest levels since the early days of the 2007-09 recession. The four-week moving average fell 11,250 last week to 356,750, the lowest since March 2008.

The claims data has no direct relation to the government's monthly employment report, but it suggests the surge in layoffs since the recession has at least run its course.

Still, many economists think hiring may remain sluggish even as the pace of layoffs ease.

Companies in recent months have been adding to their payrolls at a lackluster pace, and analysts expect the employment report due on January 4 will show 143,000 jobs were created in December, down from 146,000 in November.

"A significant improvement in labor market conditions ahead of any resolution to the fiscal cliff is unlikely," said Michael Gapen, an economist at Barclays in New York.

U.S. stocks opened flat but turned lower as the Senate Democratic leader derided Republicans for the lack of progress in budget talks and warned that a fall off the "cliff" appeared inevitable. Investors sought safety by buying U.S. Treasury debt and the dollar, which rose against the euro.

Following a truncated holiday break in Hawaii, U.S. President Barack Obama returned to Washington to restart talks to avoid the brunt of the fiscal cliff's impact, which would likely put the U.S. economy back into recession if not lessened.

HOLIDAY CAVEAT

The signs of progress in the claims data also included a caveat, at least for the latest week.

Obama declared Monday a holiday for federal workers and many state offices followed suit and were unable to provide complete data for last week's jobless claims. Data for 19 states was estimated, although 14 of those states submitted their own estimates, which tend to be fairly accurate.

The holiday season can make it more difficult to adjust the claims data for normal seasonal fluctuations, another reason to be cautious about the report for last week.

Separately, the Commerce Department said new U.S. single-family home sales rose in November to a 377,000-unit annual rate, while the median sales price jumped 14.9 percent from the same month in 2011, the latest signs the U.S. housing recovery is gaining some steam.

In a fourth report, the Chicago Federal Reserve Bank said its index of factory activity in the U.S. Midwest increased in November to 93.7 from a revised 92.2 in October.

(Reporting by Jason Lange; Additional reporting by Richard Leong and Ryan Vlastelica in New York; Editing by Neil Stempleman)

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Iran Raises Level of Islamic Law Enforcement

The call to prayer, a five-times-a-day ritual for strict adherents to Islam, is reaching new heights in Iran.

Under a directive announced Wednesday by Iran’s Civil Aviation Organization, all aircraft will be prohibited from flying across the country during the Adhan, or call to prayer, when many devout Muslims pause to face toward Mecca and pray. The directive also requires that planes scheduled for takeoff in Iran will now have to wait at least 30 minutes until after the day’s first call to prayer, before sunrise, known as Al-Fajr.

Hamid Reza Pahlevani, the head of the aviation organization, was quoted as telling the Iranian Students’ News Agency that the directive was meant to give air travelers the time “to carry out their religious duties.”

The directive appeared to be part of a strengthened effort in Iran to enforce obedience to orthodox Islamic codes of conduct in all manner of life. Ali Taheri, a spokesman for Parliament’s cultural committee, was quoted by Reuters as saying that in addition to the new restrictions on aircraft flights, serious attention will be given to observing the strict Islamic dress code for women working at airports or airline companies. The code requires women to cover their hair and wear loosely fitting clothes that will cloak their figures.

It was unclear, however, how Iranian aviation officials intended to resolve possible scheduling complications created by the call-to-prayer flight restrictions. The Civil Aviation Organization directive also did not explain whether flights in midair would be forced to land or be rerouted in order to satisfy the requirement that no aircraft fly during the call to prayer.

According to Islamicfinder.org, which provides information on daily call-to-prayer times worldwide, they vary significantly in Iran. In Tehran, for example, they are at 5:38 a.m., 12:03 p.m., 2:40 p.m., 4:58 p.m. and 6:23 p.m. In the holy city of Qom, they are 5:42 a.m., 12:08 p.m., 2:45 p.m., 5:03 p.m. and 6:28 p.m.

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Kate Winslet Marries in Secret

By Mike Fleeman

12/26/2012 at 09:10 PM EST

Talk about a Titanic secret.

Kate Winslet has tied the knot with Richard Branson's nephew, Ned Rocknroll, her rep tells PEOPLE.

"I can confirm that Kate Winslet married Ned Rock'nRoll in NY earlier this month in a private ceremony attended by her two children and a very few friends and family," the rep says. "The couple had been engaged since the summer."

According to British media reports, Leonardo DiCaprio gave away the bride in a ceremony so secret that the bride and groom's parents didn't know about it.

The Oscar-, Golden Globe- and Emmy-winning actress, 37, has been dating Rocknroll, 34, (his legal name) since fall of 2011.

In August 2011, she and Rocknroll were on the same Caribbean island owned by Branson when a fire broke out and Winslet rescued Branson's 90-year-old mother.

Winslet previously was married to Sam Mendes and Jim Threapleton.

• Reporting by JULIE JORDAN

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Predicting who's at risk for violence isn't easy

CHICAGO (AP) — It happened after Columbine, Virginia Tech, Aurora, Colo., and now Sandy Hook: People figure there surely were signs of impending violence. But experts say predicting who will be the next mass shooter is virtually impossible — partly because as commonplace as these calamities seem, they are relatively rare crimes.

Still, a combination of risk factors in troubled kids or adults including drug use and easy access to guns can increase the likelihood of violence, experts say.

But warning signs "only become crystal clear in the aftermath, said James Alan Fox, a Northeastern University criminology professor who has studied and written about mass killings.

"They're yellow flags. They only become red flags once the blood is spilled," he said.

Whether 20-year-old Adam Lanza, who used his mother's guns to kill her and then 20 children and six adults at their Connecticut school, made any hints about his plans isn't publicly known.

Fox said that sometimes, in the days, weeks or months preceding their crimes, mass murderers voice threats, or hints, either verbally or in writing, things like "'don't come to school tomorrow,'" or "'they're going to be sorry for mistreating me.'" Some prepare by target practicing, and plan their clothing "as well as their arsenal." (Police said Lanza went to shooting ranges with his mother in the past but not in the last six months.)

Although words might indicate a grudge, they don't necessarily mean violence will follow. And, of course, most who threaten never act, Fox said.

Even so, experts say threats of violence from troubled teens and young adults should be taken seriously and parents should attempt to get them a mental health evaluation and treatment if needed.

"In general, the police are unlikely to be able to do anything unless and until a crime has been committed," said Dr. Paul Appelbaum, a Columbia University professor of psychiatry, medicine and law. "Calling the police to confront a troubled teen has often led to tragedy."

The American Academy of Child & Adolescent Psychiatry says violent behavior should not be dismissed as "just a phase they're going through."

In a guidelines for families, the academy lists several risk factors for violence, including:

—Previous violent or aggressive behavior

—Being a victim of physical or sexual abuse

—Guns in the home

—Use of drugs or alcohol

—Brain damage from a head injury

Those with several of these risk factors should be evaluated by a mental health expert if they also show certain behaviors, including intense anger, frequent temper outbursts, extreme irritability or impulsiveness, the academy says. They may be more likely than others to become violent, although that doesn't mean they're at risk for the kind of violence that happened in Newtown, Conn.

Lanza, the Connecticut shooter, was socially withdrawn and awkward, and has been said to have had Asperger's disorder, a mild form of autism that has no clear connection with violence.

Autism experts and advocacy groups have complained that Asperger's is being unfairly blamed for the shootings, and say people with the disorder are much more likely to be victims of bullying and violence by others.

According to a research review published this year in Annals of General Psychiatry, most people with Asperger's who commit violent crimes have serious, often undiagnosed mental problems. That includes bipolar disorder, depression and personality disorders. It's not publicly known if Lanza had any of these, which in severe cases can include delusions and other psychotic symptoms.

Young adulthood is when psychotic illnesses typically emerge, and Appelbaum said there are several signs that a troubled teen or young adult might be heading in that direction: isolating themselves from friends and peers, spending long periods alone in their rooms, plummeting grades if they're still in school and expressing disturbing thoughts or fears that others are trying to hurt them.

Appelbaum said the most agonizing calls he gets are from parents whose children are descending into severe mental illness but who deny they are sick and refuse to go for treatment.

And in the case of adults, forcing them into treatment is difficult and dependent on laws that vary by state.

All states have laws that allow some form of court-ordered treatment, typically in a hospital for people considered a danger to themselves or others. Connecticut is among a handful with no option for court-ordered treatment in a less restrictive community setting, said Kristina Ragosta, an attorney with the Treatment Advocacy Center, a national group that advocates better access to mental health treatment.

Lanza's medical records haven't been publicly disclosed and authorities haven't said if it is known what type of treatment his family may have sought for him. Lanza killed himself at the school.

Jennifer Hoff of Mission Viejo, Calif. has a 19-year-old bipolar son who has had hallucinations, delusions and violent behavior for years. When he was younger and threatened to harm himself, she'd call 911 and leave the door unlocked for paramedics, who'd take him to a hospital for inpatient mental care.

Now that he's an adult, she said he has refused medication, left home, and authorities have indicated he can't be forced into treatment unless he harms himself — or commits a violent crime and is imprisoned. Hoff thinks prison is where he's headed — he's in jail, charged in an unarmed bank robbery.

___

Online:

American Academy of Child & Adolescent Psychiatry: http://www.aacap.org

___

AP Medical Writer Lindsey Tanner can be reached at http://www.twitter.com/LindseyTanner

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Wall Street drops in thin session, led by retailers

NEW YORK (Reuters) - Stocks fell for a third straight day on Wednesday, dragged lower by retail stocks after a report showed consumers spent less in the holiday shopping season than last year.

Trading was light, with volume at a mere 4.01 billion shares traded on the New York Stock Exchange, the Nasdaq and NYSE MKT, well below the daily average so far this year of about 6.48 billion shares. The day's volume was the lightest full day of trading so far in 2012. Many senior traders were still on vacation during this holiday-shortened week and major European markets were closed for the day.

Many investors said concerns about the "fiscal cliff" kept shoppers away from stores, suggesting markets may struggle to gain any ground until that issue is resolved. The CBOE Volatility Index <.vix> or VIX, Wall Street's favorite barometer of investor anxiety, rose 4.46 percent, closing above 19 for the first time since November 7.

A number of 2012's strongest performers advanced, a sign that portfolio managers may be engaging in "window dressing," a practice where market participants buy securities with big gains to improve the appearance of their holdings before presenting the results to clients. Bank of America Corp , which has more than doubled in 2012, added 2.6 percent to $11.54 on Wednesday.

Holiday-related sales rose 0.7 percent from October 28 through December 24, compared with a 2 percent increase last year, according to data from MasterCard Advisors SpendingPulse. The Morgan Stanley retail index <.mvr> skidded 1.8 percent while the SPDR S&P Retail Trust slipped 1.7 percent.

"With the 'fiscal cliff' hanging over our heads, it was hard to convince people to shop, and now it's hard to convince investors that there's any reason to buy going into year-end," said Rick Fier, director of trading at Conifer Securities in New York, which has about $12 billion in assets under administration.

President Barack Obama is due back in Washington early Thursday for a final effort to negotiate a deal with Congress to bridge a series of tax increases and government spending cuts set to begin next week, the so-called "fiscal cliff" many economists worry could push the U.S. economy into recession if it takes effect.

Coach Inc fell 5.9 percent to $54.13 as the S&P 500's biggest decliner, followed by Amazon.com , down 3.9 percent at $248.63, and Abercrombie & Fitch , off 3.5 percent at $45.44. Ralph Lauren Corp , Limited Brands and Gap Inc also ranked among the S&P 500's biggest decliners.

The Dow Jones industrial average <.dji> slipped 24.49 points, or 0.19 percent, to 13,114.59 at the close. The Standard & Poor's 500 Index <.spx> shed 6.83 points, or 0.48 percent, to 1,419.83. The Nasdaq Composite Index <.ixic> dropped 22.44 points, or 0.74 percent, to 2,990.16.

J.C. Penney Co was a notable exception to the weakness in retail stocks, surging 4.4 percent to $20.75 as the S&P 500's biggest gainer. It was followed closely by Bank of America and Genworth Financial , which each gained nearly 3 percent for the day.

"People want to show they own names like these, making them prime 'window dressing' candidates," said Wayne Kaufman, chief market analyst at John Thomas Financial in New York.

"Bank of America keeps going up even though it's overbought and you'd expect a pullback at these levels. No one wanted it when it was under $10 a share, but they want it now."

The S&P 500 has fallen 1.5 percent over the past three sessions, the worst three-day decline since mid-November. The Dow Jones Transportation Average <.djt>, viewed as a proxy for business activity, fell 0.6 percent.

A Republican plan that failed to gain traction last week triggered the S&P 500's recent drop, highlighting the market's sensitivity to headlines centered on the budget talks.

During the last five trading days of the year and the first two of next year, it's possible for a "Santa rally" to occur. Since 1928, the S&P 500 has averaged a gain of 1.8 percent during that period and risen 79 percent of the time, according to data from PrinceRidge.

"While it's unlikely there could be a budget deal at any time, no one wants to get in front of that trade," said Conifer's Fier. "Investors can easily make up for any gains when there's more action in 2013."

Data showed U.S. single-family home prices rose in October, reinforcing the view that the domestic real estate market is improving, as the S&P/Case-Shiller composite index of 20 metropolitan areas gained 0.7 percent in October on a seasonally adjusted basis.

Decliners outnumbered advancers on the New York Stock Exchange by a ratio of about 2 to 1, while on the Nasdaq, more than five stocks fell for every three that rose.

(Editing by Jan Paschal)

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The TV Watch: Indian Soap Operas, Ruled by Mothers-in-Law

Kuni Takahashi for The New York Times

The Bhats, of Mumbai, watch soap operas together.

MUMBAI, India — Mothers-in-law are not a joke on Indian TV.

They are the law.

Soap operas dominate prime time here and the mother-in-law reigns in almost all of them. However plucky the heroine or serpentine the plot, every love story seems to circle back to marriage and the many relatives who come with the words “I do.”

The extended family is still the bedrock of Indian society, where modernization meets its match. Soap operas here are outlandish — some so stylized and wildly melodramatic they verge on camp. But they are also oddly prosaic; expressions of duty, deference and parental obligation that inform everyday lives.

Television isn’t an insurrectionist force in India. It’s a relatively young medium struggling to adapt to a vast viewing audience that respects tradition and suspects change. Like many an Indian bride, television here occasionally tests the boundaries but mostly finds its way by following the rules and not making too many waves.

The rules can seem confounding to outsiders: India is a country where female infanticide can be a soap opera plot point in prime time but scenes of casual dating are taboo. In this realm it is the mother-in-law who is the metronome of Indian family values, issuing orders, giving advice and setting the rhythm of acceptable change.

Speed-clicking the remote after 8 p.m. is like watching a PowerPoint display of passion in hot pink, glimmering tears and the occasional stinging slap across the face. Sweet, noble Sandhya dreams of entering the Civil Service on “The Light and the Lamp Are We,” one of the top-rated shows in India, and her handsome husband, a humble candy shop owner, is all for it. But there’s an obstacle that drives the narrative: Her mother-in-law is adamantly opposed.

The basic plot of “Child Bride” is evident from its title, and this soap about an under-age wife is also a top-rated show — under-age marriage is still prevalent enough to wedge its way into the family hour. More shocking, perhaps, is that in more recent episodes the in-laws accept the young heroine as their own and — brace for it — encourage her to leave her husband (he’s a philanderer) and find a better match.

That may be a fantasy, but matriarchal interference (call it guidance) is marriage Indian-style. When Indian women discuss the need to “adjust” to matrimony, they don’t just mean adapting to a new husband. They mean moving in with his parents, grandparents and siblings, a custom that is still the norm, even in prosperous families. In a country with 1.2 billion people, about 148 million households have television and that amounts to as many as 600 million viewers. In the slums of Mumbai even sections without running water sport satellite dishes on corrugated roofs. Almost everywhere, Indians gather in front of the family television and the mother-in-law controls the remote.

“Women like to see their favorite characters express their own feelings, so the mother-in-law identifies with the mother-in-law, the daughter-in-law with the daughter-in-law,” is how Ekta Kapoor explains soap opera transference. Ms. Kapoor, a 37-year-old television and film producer who currently has five shows on the air, became queen of the Indian soap world with her breakthrough series, “The Mother-in-Law Was Once a Daughter-in-Law, Too,”one of the all-time hits of Indian television that ran from 2000 to 2008.

Male children are favored in Indian society, and wives join the husband’s family at the low end of the pecking order, often relegated to kitchen drudge work while the mother-in-law rules over the grandchildren. “We live with our parents until we are married, then we live with someone else’s parents,” Ms. Kapoor said. “There is pressure to give everything to the son. It’s a source of conflict in so many homes.” (Ms. Kapoor, the daughter of well-known actors, is single and owns her own house but lives with her parents in their home anyway.)

Alessandra Stanley, chief television critic of The New York Times, has gone abroad to watch foreign TV this year.

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Jessica Simpson’s Christmas tweet seems to confirm pregnancy rumor

(Reuters) – U.S. actress, singer and fashion designer Jessica Simpson sent a Christmas Twitter message that apparently confirms media rumors that she is pregnant – showing a photo of her daughter Maxwell with the words “Big Sis” spelled out in sand.

The picture’s caption reads “Merry Christmas from my family to yours.”

Simpson had her first child, Maxwell Drew Johnson, in May. She has since become a spokeswoman for Weight Watchers.

A representative for Simpson was not immediately available for comment.

Simpson rose to fame as a teen pop star and became a household name after starring in a TV reality show with her then-husband Nick Lachey, a member of the boy band 98 Degrees. The pair divorced after three years of marriage.

She went on to star in the 2005 film version of “The Dukes of Hazzard” and re-invented herself as a country singer in 2008. She currently designs apparel, accessories and other fashion products and is a mentor on the TV contest “Fashion Star.”

Simpson’s fiancé, Eric Johnson, is a former U.S. professional football player whose career spanned seven seasons for both the San Francisco 49ers and New Orleans Saints. (Reporting By Mary Wisniewski and Paul Simao)

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Giada De Laurentiis: My Daughter Still Believes in Santa

Courtesy Giada De Laurentiis

The tree’s done. The stockings are hung. Giada De Laurentiis and her family — husband Todd Thompson and their daughter Jade Marie — are officially ready to host the holidays.

“Christmas Eve is the big tradition in an Italian family. It’s when my entire family gets together,” the newest face of Clairol tells PEOPLE exclusively.

“This year, for the first time, it will be held at my house … so Jade and I and my husband are very excited.”

On the menu for the family festivities is “a big fish dinner,” one that no doubt Jade will help her mother to prepare. After all, adds the celebrity chef, she is the unofficial taste tester.

“My daughter loves to cook. We have a lot of laughs together. I spend a lot of time in the kitchen and she loves hanging out with me,” De Laurentiis, 42, shares. “The reason she loves it so much is because she can stick her finger in everything and taste it as she goes along.”

Once the big dinner is done with, and the evening starts to wind down, De Laurentiis and Jade will start to prepare for the night’s biggest guest to arrive: Santa Claus. At 4½-years-old, her little girl is still a strong believer in the magic of it all, notes her proud mama.

“She leaves him little treats — for the reindeer and for him too — and she’s very much a believer in Santa,” De Laurentiis says. “I hope she’ll be a believer for a long time, I think it’s really fun for kids to be able to do that.”

Recently, the pair sat down to write out Jade’s wish list, but after much pleading on Jade’s part over the past few weeks, it’s no surprise as to what she hopes to find under the tree this year.

“The one thing she keeps asking me for over and over again is clip-on earrings. She must have seen them on somebody else, but she has asked me for clip-on earrings for the past month,” De Laurentiis notes. “I am on a mission to find clip-on earrings for her because I don’t think she’ll ever forgive me if I don’t.”

But based on her newly transformed play space, the “girly girl’s” specific accessory request should come as no surprise.

“She’s opened up her own little salon in her playroom. She gives free makeovers, she curls people’s hair and gives them little manicures as well,” De Laurentiis says. “I’ve always been a girly girl my whole life — maybe she will, maybe she won’t — but it’s a lot of fun to play with her right now.”

– Anya Leon with reporting by Kate Hogan

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Predicting who's at risk for violence isn't easy

CHICAGO (AP) — It happened after Columbine, Virginia Tech, Aurora, Colo., and now Sandy Hook: People figure there surely were signs of impending violence. But experts say predicting who will be the next mass shooter is virtually impossible — partly because as commonplace as these calamities seem, they are relatively rare crimes.

Still, a combination of risk factors in troubled kids or adults including drug use and easy access to guns can increase the likelihood of violence, experts say.

But warning signs "only become crystal clear in the aftermath, said James Alan Fox, a Northeastern University criminology professor who has studied and written about mass killings.

"They're yellow flags. They only become red flags once the blood is spilled," he said.

Whether 20-year-old Adam Lanza, who used his mother's guns to kill her and then 20 children and six adults at their Connecticut school, made any hints about his plans isn't publicly known.

Fox said that sometimes, in the days, weeks or months preceding their crimes, mass murderers voice threats, or hints, either verbally or in writing, things like "'don't come to school tomorrow,'" or "'they're going to be sorry for mistreating me.'" Some prepare by target practicing, and plan their clothing "as well as their arsenal." (Police said Lanza went to shooting ranges with his mother in the past but not in the last six months.)

Although words might indicate a grudge, they don't necessarily mean violence will follow. And, of course, most who threaten never act, Fox said.

Even so, experts say threats of violence from troubled teens and young adults should be taken seriously and parents should attempt to get them a mental health evaluation and treatment if needed.

"In general, the police are unlikely to be able to do anything unless and until a crime has been committed," said Dr. Paul Appelbaum, a Columbia University professor of psychiatry, medicine and law. "Calling the police to confront a troubled teen has often led to tragedy."

The American Academy of Child & Adolescent Psychiatry says violent behavior should not be dismissed as "just a phase they're going through."

In a guidelines for families, the academy lists several risk factors for violence, including:

—Previous violent or aggressive behavior

—Being a victim of physical or sexual abuse

—Guns in the home

—Use of drugs or alcohol

—Brain damage from a head injury

Those with several of these risk factors should be evaluated by a mental health expert if they also show certain behaviors, including intense anger, frequent temper outbursts, extreme irritability or impulsiveness, the academy says. They may be more likely than others to become violent, although that doesn't mean they're at risk for the kind of violence that happened in Newtown, Conn.

Lanza, the Connecticut shooter, was socially withdrawn and awkward, and has been said to have had Asperger's disorder, a mild form of autism that has no clear connection with violence.

Autism experts and advocacy groups have complained that Asperger's is being unfairly blamed for the shootings, and say people with the disorder are much more likely to be victims of bullying and violence by others.

According to a research review published this year in Annals of General Psychiatry, most people with Asperger's who commit violent crimes have serious, often undiagnosed mental problems. That includes bipolar disorder, depression and personality disorders. It's not publicly known if Lanza had any of these, which in severe cases can include delusions and other psychotic symptoms.

Young adulthood is when psychotic illnesses typically emerge, and Appelbaum said there are several signs that a troubled teen or young adult might be heading in that direction: isolating themselves from friends and peers, spending long periods alone in their rooms, plummeting grades if they're still in school and expressing disturbing thoughts or fears that others are trying to hurt them.

Appelbaum said the most agonizing calls he gets are from parents whose children are descending into severe mental illness but who deny they are sick and refuse to go for treatment.

And in the case of adults, forcing them into treatment is difficult and dependent on laws that vary by state.

All states have laws that allow some form of court-ordered treatment, typically in a hospital for people considered a danger to themselves or others. Connecticut is among a handful with no option for court-ordered treatment in a less restrictive community setting, said Kristina Ragosta, an attorney with the Treatment Advocacy Center, a national group that advocates better access to mental health treatment.

Lanza's medical records haven't been publicly disclosed and authorities haven't said if it is known what type of treatment his family may have sought for him. Lanza killed himself at the school.

Jennifer Hoff of Mission Viejo, Calif. has a 19-year-old bipolar son who has had hallucinations, delusions and violent behavior for years. When he was younger and threatened to harm himself, she'd call 911 and leave the door unlocked for paramedics, who'd take him to a hospital for inpatient mental care.

Now that he's an adult, she said he has refused medication, left home, and authorities have indicated he can't be forced into treatment unless he harms himself — or commits a violent crime and is imprisoned. Hoff thinks prison is where he's headed — he's in jail, charged in an unarmed bank robbery.

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Online:

American Academy of Child & Adolescent Psychiatry: http://www.aacap.org

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AP Medical Writer Lindsey Tanner can be reached at http://www.twitter.com/LindseyTanner

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