When school shootings take place, especially after Newtown, Asperger’s Syndrome is often suspected. Both the Florida Sun Sentinel and the New York Times reported comments that Cruz was diagnosed with autism.  It’s important to make this clear – research has shown that people with Asperger’s Syndrome or autism are no more violent than the general population. In fact, they’re much more likely to be the victims of bullying and violence.

People can mistake the lack of social skills and social withdrawal of young adults with Aspergers for hostility. Their withdrawal has little to do with hostility and often has much more to do with anxiety. An Asperger’s student may say something inappropriate if bullied beyond his or her tolerance, but that student is unlikely to act in a violent way. I have unfortunately seen students with Asperger’s expelled or indefinitely removed from the mainstream for such statements.

People with Aspergers can have coexisting psychiatric problems, most commonly ADHD, depression and anxiety disorders. Other coexisting conditions are certainly possible. People often are diagnosed with more than one disorder.

So who does school shootings? The people who kill groups of innocent people (outside military actions) are those who have no regard for other people, no capacity for empathy or remorse. The popular term for this is psychopath; the psychiatric term is antisocial personality disorder. Tony Farrenkopf, a forensic psychologist, studied the profiles of mass shooters. He found that killers often exhibit risk factors that are linked to criminal behavior: a history of problematic parenting, a tendency to set fires or hurt animals, a sadistic streak, self-centeredness and a lack of compassion. Other common symptoms include a fascination with guns and violence and rule breaking.

School shooters are loners, not members of gangs or cults condoning violence. Shooting innocent people does not make them psychotic. They are not jealous husbands killing ex-wives and their lovers.

According to the New York TImes, Cruz’s mother Lynda Cruz had told investigators that her son had been diagnosed with autism and attention deficit hyperactivity disorder. He was being treated for depression, had a behavioral disorder and had been taking medication for the ADHD, according to these reports. I can’t speak to the accuracy of these diagnoses.  However, other behaviors reported by multiple media – bragging about killing animals, social media posts of dead animals and comments about school shootings – are not typical of depression, autism or ADHD. They suggest antisocial personality disorder, which would be diagnosed as a separate disorder coexisting with any others. Other students say it was “common knowledge” that he was capable of a school shooting.

Research has shown that people with antisocial personality disorder have little or no anxiety, unlike those with an ASD. There are studies pointing to the contribution of biological factors to antisocial personality disorder; research has shown that “psychopaths” lack the proper neurological frameworks to develop a sense of ethics and morality. For example, people with this disorder, unlike the mainstream population, do not respond to classical conditioning.  If a “normal” person hears a bell and is given an electric shock, he will experience anxiety and his body’s autonomic nervous system will show changes at the sound of the bell. An individual with an antisocial personality has no reaction; he does not have the underlying capacity of fear or anxiety.  It is important to recognize that not all people with antisocial personality disorders commit mass shootings. Even if there was a biological marker, this would not predict future behavior.

In a Psych Central blog “Treatment for Antisocial Personality Disorder” , Donald Black, MD, suggests that therapy is difficult. According to Black, “People with antisocial personality tend to blame others, have a low tolerance for frustration, are impulsive and rarely form trusting relationships. People with ASP often lack the motivation to improve and are notoriously poor self-observers. They simply do not see themselves as others do.” There is no evidence of medication as a solution, and what research there is on therapeutic communities has been done in prisons and points to limited effectiveness.

Cruz had posted a video of cutting himself after the breakup of a relationship, and a mobile crisis team had been called out to see if he needed to be committed to psychiatric hospitalization under the Florida Baker Act, which allows involuntary hospitalization of someone at risk of harming himself or others. The team found he did not meet those criteria for hospitalization. According to a New York Times report, the Florida Department of Children and Families investigated Cruz in 2016; they closed the case about two months later. The agency determined that the “final level of risk is low” for hurting himself or others because his mother was caring for him, he was enrolled in school and he was receiving counseling. At the time of the shooting, he had lost his mother but had a job; It is unclear if he was still seeing a counselor.

Cruz was a complex young man, probably suffering from multiple disorders. However, the evidence of the limited effectiveness of therapy for antisocial personality disorder suggests that it is questionable that counseling for his antisocial traits would have worked. Despite all the calls for necessary changes to the mental health system so more treatment is readily available, which definitely is sorely needed, another answer is necessary for Cruz’s threat to society.  People with Asperger’s, ADHD and depression who do not have coexisting antisocial personality traits do not shoot people.

There is no “silver bullet” or easy answer to a threat like Cruz. We have to refrain from responding to this issue as though there is only one solution (mental health). Above all else, this is a public health issue raising many questions that must be discussed and not dismissed.