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.

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Associated Press reporter Tom Odula contributed to this report.

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Senator Reid: U.S. is poised to go off 'fiscal cliff'

WASHINGTON, Dec 27 - Senate Majority Leader Harry Reid on Thursday warned that the United States looks to be headed over the "fiscal cliff" of tax hikes and spending cuts that will start next week if squabbling politicians do not reach a deal.

Reid, the top Democrat in Congress, criticized Republicans for refusing to go along with any tax increases as part of a budget remedy as he sketched out a pessimistic outlook.

"It looks like that is where we're headed," Reid said of the likelihood of the U.S. economy going over the "fiscal cliff" - with tax increases on most working Americans and automatic spending cuts kicking in next month.

Reid made his comments in a Senate floor speech at the opening of a post-Christmas session, adding that time was running out ahead of a December 31 deadline to act to avert the "fiscal cliff."

Reid urged House of Representatives Speaker John Boehner, the top Republican in Congress, to bring his chamber back into session and to avoid the biggest impact of the "fiscal cliff" by passing a Democratic-backed bill extending low income tax rates for all Americans except those with net household incomes above $250,000 a year.

House Republicans are expected to hold a telephone conference call on the fiscal cliff on Thursday afternoon, a House Republican aide said, adding that a schedule for returning to Washington would be discussed.

Should Congress fail to act by December 31, tax rates for all Americans would snap sharply higher, back to pre-2001 levels, and two days later, $109 billion in automatic spending cuts would start to take effect. Together, the higher taxes and lower spending would suck about $600 billion out of the U.S. economy, potentially causing a new recession in 2013.

On Wednesday, it was Boehner who urged the Democratic-controlled Senate to act first to avoid the fiscal cliff, offering to at least consider anything that the Senate produced.

Reid returned the volley on Thursday, saying that the Senate had already acted, and the Democrats' solution needs the consent of both Boehner and Senate Republican Leader Mitch McConnell.

Reid said Boehner "has just a few days left to change his mind" on the Senate bill. "I don't know time-wise how it can happen now."

(Reporting by David Lawder and Richard Cowan; Editing by Alistair Bell and Will Dunham)

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Air Bagan survivors tell of terrifying landing

YANGON, Myanmar (AP) — Survivors of a Christmas Day crash-landing of an airliner in Myanmar told terrifying tales of escape Wednesday as carrier Air Bagan apologized for what it called the worst accident since it started flying in 2004.

Details of the crash remain unclear but airline officials told a news conference Wednesday that they found the plane's two black boxes and were investigating what went wrong. So far, officials have blamed heavy fog for the aircraft's crash into a rice paddy field where it burst into flames. Two died and 11 were injured, including four foreigners.

The Fokker 100 jet was 21 years old but passed inspections at annual renewals of its air worthiness certificate, the officials said. On Tuesday, it was carrying 71 people, including 48 foreigners, from the city of Yangon via Mandalay to Heho airport, which is the gateway to the popular tourist destination Inle Lake.

"We felt the first bump, then a few big bumps and then (started) sliding very fast," said 31-year-old Australian advertising executive Anna Bartsch. Her boyfriend, Stuart Benson, described the landing like "a roller coaster" ride.

The plane came to a stop and they felt relief — then panic.

"In my window I saw the flames, and it was hot and we knew straight away we didn't have much time to get out," Bartsch said during an interview at a Yangon hotel where the airline lodged passengers after evacuating them from the scene.

Passengers rushed up the aisle to the front door, which was initially stuck shut, she said.

"We didn't know then that the wings had come off," Bartsch said.

The door was quickly forced open and passengers raced from the plane, some in shock and some suffering smoke inhalation, she said. Once on safe ground, Bartsch said she saw the pilot and co-pilot with bloodied faces and other people with serious burns.

"It's amazing that the injuries were not more serious," she said. "It could have been much worse."

A flight attendant told reporters Wednesday that the crew realized something was wrong only when the plane hit the ground.

"We shouted, 'This is an emergency'," said flight attendant Khaing Su Naing, adding that despite one of the two doors initially getting stuck the crew evacuated the plane 90 seconds after it stopped moving.

The accident has raised concerns about the safety standards of Myanmar's overburdened airlines as foreign visitors have flocked to the Southeast Asian country which is emerging from a half-century of military rule.

Air Bagan is one of a half dozen private airlines that fly domestic routes in Myanmar. After one plane was destroyed in Tuesday's crash its fleet now consists of five planes, including four ATR turboprops and another Fokker 100, which is no longer made.

"We deeply apologize to all our passengers and to their family members," the airline's managing director Htoo Thet Htwe told the news conference. All passengers were paid $2,300, he said.

"This is the most serious accident Air Bagan has ever had," he said. In 2008, one of its planes overshot a provincial airport's runway, spun out of control and crashed, causing the wings and tail to snap off. Many passengers were injured but none died.

Air Bagan has said "the plane hit electrical cables about a mile (1.6 kilometers) from Heho airport as it descended and landed in rice fields."

The Information Ministry said the pilot mistook a road near the airport for the runway before stopping in a nearby rice paddy. It was unclear if the plane made its crash landing on the road or the rice field.

All fatalities were Myanmar citizens, including a man riding a motorcycle where the plane came down and a tour guide aboard the plane. There were earlier reports of an 11-year-old child also among the dead.

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Associated Press writer Jocelyn Gecker contributed to this report from Bangkok.

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Carlyle takes on KKR in race for Reynolds and Reynolds: sources

NEW YORK (Reuters) – Private equity firms Carlyle Group LP and KKR & Co LP have emerged as the lead contenders to take over Reynolds and Reynolds, a software company hoping to sell itself for $ 5 billion, three people familiar with the matter said.

Dayton, Ohio-based Reynolds, which provides business management software for auto dealers in North America and Europe, had hired technology-focused investment bank Qatalyst Partners to run a sale, people familiar with the matter told Reuters in October.

The process has progressed and is now in its final stages, though no decision is expected before January, the sources said.

Reynolds may be sold to Carlyle or KKR for between $ 4 billion and $ 5 billion, less than the company had hoped, one of the people added.

The people spoke on condition of anonymity because the negotiations are confidential. Spokesmen for Reynolds, Carlyle and KKR declined to comment.

Reynolds sells software tools that allow car dealers to run their operations, including providing car dealer websites, digital advertising and marketing services, as well as data archiving.

Reynolds was founded in 1866 by Lucius Reynolds and his brother-in-law as a company that prints standardized business forms. It started to serve automotive retailers as major clients in the 1920s.

In October 2006, the company was acquired by Universal Computer Systems (UCS) for $ 2.8 billion. The merged company retained the Reynolds name and is currently headed by Chairman and Chief Executive Bob Brockman, who used to run UCS.

Brockman’s $ 2.8 billion buyout was funded primarily by a group of investors that included Goldman Sachs Capital Partners, the private equity arm of Goldman Sachs Group Inc, and Vista Equity Partners.

(Reporting by Greg Roumeliotis and Soyoung Kim in New York; editing by John Wallace)

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Marvel's Peter Parker in perilous predicament

PHILADELPHIA (AP) — After 50 years of spinning webs and catching a who's who of criminals, Peter Parker is out of the hero game.

But Spider-Man is still slinging from building to building — reborn, refreshed and revived with a new sense of the old maxim that Ben Parker taught his then-fledgling nephew that "with great power, comes great responsibility."

Writer Dan Slott, who's been penning Spidey adventures for the better part of the last 100 issues for Marvel Entertainment, said the culmination of the story is a new, dramatically different direction for the Steve Ditko and Stan Lee-created hero.

"This is an epic turn," Slott said. "I've been writing Spider-Man for 70-plus issues. Every now and then, you have to shake it up. ... The reason Spider-Man is one of the longest running characters is they always find a way to keep it fresh. Something to shake up the mix."

And in the pages of issue 700, out Wednesday, it's not just shaken up, it's turned head over heels, spun in circles, kicked sky high and cracked wide open.

Parker's mind is trapped in the withered, decaying dying body of his nemesis, Doctor Octopus aka Otto Octavius. Where's Doc Ock? Inside Parker's super-powered shell, learning what life is like for the brilliant researcher who happens to count the Avengers and Fantastic Four as friends and family.

The two clash mightily in the pages of issue 700, illustrated by Humberto Ramos and Victor Olazaba. But it's Octavius who wins out and Parker is, at least for now, gone for good, but not before one more act of heroism.

Slott said that it's Parker, whose memories envelop Octavius, who shows the villain what it means to be a hero.

"Gone are his days of villainy, but since it's Doc Ock and he has that ego, he's not going to try and just be Spider-man, he's going to try to be the best Spider-Man ever," said Slott.

Editor Stephen Wacker said that while Parker is gone, his permanence remains and his life casts a long shadow.

"His life is still important to the book because it affects everything that Doctor Octopus does as Spider-Man. Seeing a supervillain go through this life is the point — trying to be better than the hero he opposed," Wacker said.

"Doc has sort of inspired by Peter's life. That's what I mean when he talks about the shadow he casts," he said.

The sentiment echoes what Uncle Ben said in the pages of "Amazing Fantasy" No. 15, Slott said.

Editor Stephen Wacker called it a fitting end to the old series, which sets the stage for a new one — "The Superior Spider-Man" early next year — because it brings Peter Parker full circle, from the start of his crime-fighting career to the end.

"In his very first story, his uncle died because of something he did so the book has always been aimed at making Peter's life as difficult as possible," Wacker said. "The book has always worked best when it's about Peter Parker's life, not Spider-Man's."

And with Octavius influenced by Parker's life — from Aunt May to Gwen Stacy to Mary Jane — it will make him a better person, too.

"Because Doctor Octopus knows all of those things and will make decisions on what he saw Peter going through," Wacker said. "In a way, he gets the ultimate victory as he becomes a better hero."

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Follow Matt Moore at www.twitter.com/MattMooreAP

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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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As winter storm bears down on Midwest, death toll climbs

OKLAHOMA CITY (AP) -- A winter storm system that blew through Christmas Day with Gulf Coast tornadoes and snow in the nation's midsection headed for the Northeast on Wednesday, spreading blizzard conditions that slowed holiday travel.

The death toll rose to six with car accidents on snow and sleet-slickened highways in Arkansas and Oklahoma.

Post-Christmas travelers braced for flight delays and a raft of weather warnings for drivers, a day after rare winter twisters damaged buildings in Louisiana, Mississippi and Alabama.

Snow blew across southern Illinois and southern Indiana early Wednesday as the storm tracked up the Ohio River valley toward the Eastern seaboard and New England.

There were whiteout conditions in parts of southwestern Indiana, where 6 inches or more of snow had fallen by midmorning around Evansville. State police reported dozens of vehicles stuck after not being able to get up a hill on a central Indiana highway, while some roads around Evansville were impassable with wind gusts around 30 mph.

A blizzard warning was in effect for much of the state's southern two-thirds and more than a dozen counties issued travel watches asking residents to make only essential driving trips.

"People need to not travel. They need to just go where they're going to be and stay there," said Rachel Trevino, a meteorologist at the National Weather Service bureau in Paducah, Ky., which covers southwestern Indiana.

In snowy Arkansas, the storm left more than 189,000 customers without electricity Wednesday, utility Entergy Arkansas said.

Severe thunderstorms were forecast for the Carolinas while a line of blizzard and winter storm warnings stretched from Arkansas up the Ohio River to New York and on to Maine.

Thirty-four tornadoes were reported in Texas, Louisiana, Mississippi and Alabama during the outbreak Tuesday, the National Weather Service said.

Rick Cauley's family was hosting relatives for Christmas when tornado sirens went off in Mobile. Not taking any chances, he and his wife, Ashley, hustled everyone down the block to take shelter at the athletic field house at Mobile's Murphy High School in Mobile.

It turns out, that wasn't the place to head.

"As luck would have it, that's where the tornado hit," Cauley said. "The pressure dropped and the ears started popping and it got crazy for a second." They were all fine, though the school was damaged, as were a church and several homes, but officials say no one was seriously injured.

Camera footage captured the approach of the large funnel cloud.

Mobile was the biggest city hit by numerous twisters. Along with brutal, straight-line winds, the storms knocked down countless trees, blew the roofs off homes and left many Christmas celebrations in the dark. Torrential rains drenched the region and several places saw flash flooding.

More than 750 flights around the U.S. were canceled as of Wednesday morning, according to the flight tracker FlightAware.com. The cancelations were mostly spread around airports that had been or soon would be in the path of the storm.

Holiday travelers in the nation's much colder midsection battled treacherous driving conditions from freezing rain and blizzard conditions from the same fast-moving storms. In Arkansas, highway department officials said the state was fortunate the snowstorm hit on Christmas Day when many travelers were already at their destinations.

Two passengers in a car on a sleet-slickened Arkansas highway died Wednesday when the vehicle crossed the center line and struck an SUV head-on. In Oklahoma, the Highway Patrol said a 76-year-old Wisconsin woman died Tuesday when the car she was riding in was hit head-on by a pickup truck on Interstate 44.

The Oklahoma Highway Patrol had earlier reported that a 28-year-old woman was killed in another crash Tuesday on a snowy highway. The storm's winds were blamed Tuesday for toppling a tree onto a pickup truck in Texas, killing the driver, and another tree onto a house in Louisiana, killing a man there.

Trees fell on homes and across roadways in several communities in southern Mississippi and Louisiana. Mississippi Gov. Phil Bryant declared a state of emergency, saying eight counties reported damages and some injuries.

It included McNeill, where a likely tornado damaged a dozen homes and sent eight people to the hospital, none with life-threatening injuries, said Pearl River County emergency management agency director Danny Manley.

The snowstorm that caused numerous accidents pushed out of Oklahoma late Tuesday, carrying with it blizzard warnings for parts of northeast Arkansas, where 10 inches of snow was forecast. Freezing rain clung to trees and utility lines in Arkansas and winds gusts up to 30 mph whipped them around, causing about 71,000 customers to lose electricity for a time.

Christmas lights also were knocked out with more than 100,000 customers without power for at least a time in Texas, Arkansas, Oklahoma, Mississippi, Louisiana and Alabama.

Blizzard conditions were possible for parts of Illinois, Indiana and Kentucky up to Cleveland with predictions of several inches to a foot of snow. By the end of the week, that snow was expected to move into the Northeast with again up to a foot predicted

Jason Gerth said the Mobile tornado passed by in a few moments and from his porch, he saw about a half-dozen green flashes in the distance as transformers blew. His home was spared.

"It missed us by 100 feet and we have no damage," Gerth said.

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Kazakhstan military plane crashes, killing 27

MOSCOW (AP) — Kazakhstan's acting border service chief was among 27 people killed in a military plane crash Tuesday near a southern city, another blow to the agency after he was appointed in June to deal with the aftermath of a mass killing involving a conscript.

The Russian-made An-72 crashed at 1255 GMT (7:55 a.m. EST) about 20 kilometers (12 miles) away from the city of Shymkent near the border with Uzbekistan, Kazakhstan's Committee for National Security said in a statement.

The fatalities included a crew of seven and 20 border guards, including the acting head of the ex-Soviet nation's border protection service, Col. Turganbek Stambekov, the statement said.

Without specifying further details, authorities said an investigation was opened into the crash. No cause was given, but southern Kazakhstan over recent weeks has been buffeted by winds, heavy snows and low temperatures, causing widespread flight delays.

Stambekov was appointed acting head of the border service in June, after a mass killing of 14 frontier troops in a remote Kazakh outpost near China the month before. Vladislav Chelakh, a 20-year-old conscript, was sentenced earlier this month to life in prison after being found solely responsible for the killings.

The border service has come under close scrutiny in Kazakhstan since the killings, which many argued showed the lack of readiness and professionalism among serving troops. Legislation approved Thursday by the upper house of parliament and supported by Stambekov was designed to improve the process for selecting conscripts for the service.

The Kazakh-Uzbek border stretches 2,200 kilometers (1,350 miles) of Central Asian steppes and deserts.

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Reaction to the death of actor Jack Klugman

Celebrities on Monday reacted to the death of "Odd Couple" star Jack Klugman, who died Monday at age 90. Here are samples of sentiments expressed on Twitter:

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"R.I.P. Jack Klugman, Oscar, Quincy a man whose career spanned almost 50 years. I first saw him on the Twilight Zone. Cool guy wonderful actor." — Whoopi Goldberg.

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"You made my whole family laugh together." — Actor Jon Favreau, of "Swingers," ''Iron Man" and other films.

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"I worked with Jack Klugman several years ago. He was a wonderful man and supremely talented actor. He will be missed" — Actor Max Greenfield, of the "New Girl" on Fox.

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"So sorry to hear that Jack Klugman passed away. I learned a lot, watching him on television" — Dan Schneider, creator of Nickelodeon TV shows "iCarly," ''Drake and Josh" ''Good Burger," ''Drake & Josh."

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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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