Sarah Elizabeth Richards

The violent imagery in the plays, and similar works by Cho, had alarmed faculty of the Virginia Tech English department, who repeatedly tried to get him help. In October 2005, one professor, poet Nikki Giovanni, kicked him out of her class because his work was “intimidating” and scared students. Her female students stopped coming to class after they said Cho was photographing their legs with his cellphone.

Former English chairwoman Lucinda Roy went to campus police, student affairs and the dean’s office. Without overt threats to himself or others, she was told, there was nothing they could do. Roy tutored him privately and tried to convince him to seek counseling. In the meantime, following accusations of harassment and another report that Cho might be suicidal, police referred him to a counselor, who unsuccessfully tried to commit him to a mental institution.

Cho continued writing horrific tales. Last fall, another English professor contacted a dean — to no avail. She stopped circulating his assignments in class and he stopped attending. Finally, this spring, Cho’s playwriting teacher, Ed Falco, contacted several faculty members after students said they didn’t want to read his work. “We did all that we thought it was reasonable to do,” Falco wrote to students in an e-mail, which he forwarded to Salon. “There was violence in Cho’s writing — but there is a huge difference between writing about violence and behaving violently. We could not have known what he would do.”

Creative writing teachers have long wrestled with what they should do with students who turn in gruesome stories, as many colleges do not have formal policies about how teachers should respond. Further, there are no set rules for determining whether a story is the product of a febrile artistic imagination or a potentially violent criminal. Or both.

“Lots of great literary works are deep and dark and disturbing — that would be Kafka,” says Deborah Landau, director of the creative writing program at New York University, who plans to discuss university protocol with her staff in the wake of Monday’s massacre. Yet teachers increasingly are being expected to distinguish between students’ pushing their creative boundaries or showing frightening warning signs. That’s a tall task, especially when students routinely hand in twisted texts dripping with bloodshed, cruelty, perversion and extreme sex scenes, say teachers.

“Traditionally, [instructors] have thought of themselves as nurturing academic or creative faculties. They don’t think of themselves as counselor or being warning systems for spotting mental health problems,” says Rob Jones, senior vice president and general counsel for claims management and risk research for United Educators, an insurance company for more than 1,000 educational institutions. “We’d like them to think of whether they could be gatekeepers for identifying students at risk.”

The company currently is making the rounds at colleges to present and discuss this training scenario: An English professor comes across the worrisome writing of a suicidal student. What should she do? The correct answer, according to Jones, is for the instructor to contact the student affairs office or campus counseling center. “You can’t expect an English professor to make those kinds of determinations based on someone’s writings,” he says. “But they are the ones who have a window into someone’s soul.”

But that window isn’t always so clear, and it’s easy to miss signals, explains Michelle Carter, professor of creative writing at San Francisco State University, who has taught the subject for nearly 20 years. Carter, who has read Cho’s plays (they are posted on AOL), says, “I’ve seen more disturbing stuff than that.” She says Cho’s expression of powerlessness and rage would make her worry that he was more of a danger to himself than others. “I wouldn’t have thought he’d get a gun and shoot people.”

“Sometimes you can tell they’re hurt puppies, and they’re writing to express deep woundedness,” says Carter. Often, students are experimenting with stylized violence à la Quentin Tarantino. “From the tone, you can tell it’s iconoclastic posturing, and it’s totally harmless,” she says. “They’re asking, ‘Can I get a rise out of people?’”

Teachers are usually guided only by instinct and a gnawing feeling that something is a little too unsettling. Carter has seen stories in which students create characters that commit violent acts or sexually humiliate characters who are clearly based on classmates. For her, that crosses the line. She tells those students, “This writing is aggressive. It’s targeting people in this class. That’s not permissible.” She tells them to stop the hostile writing or stop coming to class.

In 2000, Brian Thorstenson was an SFSU graduate student, teaching an undergraduate playwriting workshop, when an older student in his 60s wrote chilling plays portraying his classmates raping and dismembering babies. Students complained that they didn’t want to act out the roles in class. When the author started leaving notes on his assignments that read, “This story is true. This actually happened,” and offered to bring a gun to class to use as a prop, Thorstenson, now a lecturer in creative writing at the college, says he went straight to Maxine Chernoff, the chairwoman of the English department. Together, they went to the campus police.

Eventually, a dean, who is no longer there, ruled that the student had free speech rights and no official action was taken against him. “I was surprised by the dean’s reactions,” recalls Thorstenson. “I didn’t feel supported.” The dean did agree to remove the student from the playwriting class and Carter says she was asked to tutor him. Her conditions: She would never meet with him in person, he would drop off his homework to the English department, and he would never learn who was reading it. Afterward, the man stopped taking creative writing classes and they never saw him again. (Chernoff says current university practice is for concerned teachers to contact their department chair and write a report, which is sent to a dean who handles disciplinary matters.)

Controversy over whether creepy creative writing should be treated as artistic or dangerous made headlines in the San Francisco Bay Area in 2004. At the time, Jan Richman was a creative writing instructor at the Academy of Art University in San Francisco. She was so aghast with one student’s work that she literally didn’t know what to do. She went to her immediate supervisor for advice about a student’s story that started with a scene involving the narrator taking out his pocketknife and cutting off the nipples of his sex partner, and ended with him hacking off victims’ limbs and genitals, painting the room with their blood.

“I’ve read a lot of violence, [but] there was something about this,” explains Richman today. “The details were incredibly precise. There was such a passion behind the violence.” Richman now teaches at the continuing education program at City College of San Francisco.

Richman’s boss gave the story to his boss and on it went up the administrative ladder. The head of campus security called the city police and the Federal Bureau of Investigation over worries that the details were so vivid they could only be supplied by someone who committed such crimes. Next, the school expelled the writer. Then his parents complained that Richman had assigned readings that contained graphic violent scenes. Their son, they argued, was simply emulating one of them: “Girl With Curious Hair” by David Foster Wallace. In the story, a narrator talks about how he likes to burn women (and sometimes men) with matches or a lighter during sex.

After meetings with school officials, during which Richman says they questioned her reading selections, Richman was not invited back to teach the following semester. “I felt like they over-reacted by expelling this student and not helping him,” she says. “If they thought he was that big of a threat, you’d think they’d be glad that instead of handling it myself, I did bring it to the attention of superiors.”

Sallie Huntting, executive vice president of public relations at the Academy of Art University, says she can’t comment on the Richman case, but stresses that instructors of all art forms are encouraged to report disturbing work by students. “You must err on the side of caution,” she says.

Creative writing teachers point out that they’re not trained therapists and not equipped to determine when a student is potentially unstable. That’s why instructors aren’t held to the same liability standard as psychological counselors, explains Sheldon Steinbach, a higher education attorney with Dow Lohnes, in Washington, D.C. He advises that teachers report distressing writing to the dean of students, who would know how to evaluate students.

While writing instructors can’t ignore alarming screeds, a better barometer may be to see if a student’s behavior matches. “It’s one thing when [a student] hands in a disturbing story, and he’s friendly and nice,” explains Tamas Dobozy, a visiting scholar who teaches a fiction writing workshop at NYU. “He’s just trying to create a horrific story. Then you get a student who hands in normal work, but is strange. Is there a connection between the work and student? Sometimes yes and sometimes no.”

Landau, creative writing director at NYU, adds that a lot of students deal with troubling topics in their writing, from date rape to incest to mental illness. “Students are often bringing their lives to class in the form of their work,” she says. Teachers should worry, she says, when students also act troubled in the classroom. If a student seems dangerous, Landau immediately reports him or her to a dean. Otherwise, her first strategy is to call students into her office, ask if they need help, and remind them of counseling services.

At her new job, Richman tries to assess the level of horror at the outset. If students bring in disturbing work, she’s much quicker to tell them, “I think you put this in for shock value. There’s no literary merit.” She adds: “I don’t want to squelch anyone’s creativity. But there’s a tendency for young people to say, ‘I’m going to be as gross and twisted as I can be.’ [The goal] isn’t just to push limits. There are skills to be learned.”

Despite such guidelines, creative writing teachers still have to rely on their own imprecise judgment, especially in classes where students may be encouraged to write with intense emotion. What may be one student’s cause for concern may be another’s catharsis, says Carter. “Sometimes working through rage in that way can be healthy,” she says. “If students start worrying that every time they write something violent or aggressive or express anger or rage — or they fear they’ll be sent to an administrator or a therapist or their parents will be called — you can’t teach art classes with that hanging over them. Part of teaching in the arts is to push people to places of disturbance. It’s a really funny dance.”

Somehow, the school learned what Jane had done. So when she returned to campus a week later, a Brown dean and a campus psychologist called her into a meeting with this message: “We need to talk about where you’re going from here.” They meant it literally — the school would encourage her to take a leave of absence.

Overwhelmed by a rise of troubled students in the past several years, colleges are dealing with mental health issues with renewed intensity. A 2006 survey found that more than 9 percent of college students seriously contemplated suicide in the previous year. Further, college researchers estimate that more than 1,000 kill themselves each year, making it the second leading cause of death among college-age men and women (after auto accidents). Many colleges are responding by beefing up counseling centers, offering free therapy sessions and forming support groups on everything from body image to stress management. But they’re bewildered about what to do with students like Jane who quietly collect pills and attempt suicide under their noses. Increasingly, they are worried about their own institutional liabilities and policies regarding troubled students.

The main reason is that in 2002, the parents of MIT student Elizabeth Shin filed a $27 million wrongful-death lawsuit against the school after their daughter set herself on fire in her dorm room two years earlier. They claimed that the school’s counseling services didn’t adequately respond to her depression. Last spring, MIT settled for an undisclosed sum. Similarly, a Virginia federal court recently found that Ferrum College had a legal “duty of care” to a student who hanged himself on campus after his girlfriend showed a letter in which he threatened suicide to a resident assistant and other college officials.

To try to prevent suicides, colleges are taking the usual precautionary steps: controlling access to prescription drugs at medical schools, keeping track of lethal substances like cyanide at chemistry labs, blocking rooftop access to tall buildings. In 2003, NYU installed plastic windows on open-air crosswalks in Bobst Library after two students jumped onto the marble floor below. College counseling centers are also training dorm supervisors and campus staff to recognize the warning signs of suicidal behavior.

But universities are taking more drastic — and controversial — measures to head off legal trouble. Many schools are drafting or enforcing rigid withdrawal policies that could boot mentally ill students off campus at the first sign of worrisome behavior. Others, such as the University of Illinois and the University of Washington, are requiring students who even talk about suicide to meet with counselors or take medical leave. (In 2004, students from NYU and Columbia accused the schools of forcing them to take leave for seeking treatment for depression.) Some colleges, fearing malpractice lawsuits, have considered eliminating counseling services altogether.

The idea that universities are somehow responsible if a student takes his or her own life may seem preposterous — akin to suggesting they’re to blame for “freshman 15″ weight gain or too many tequila shooters. In fact, in the ’60s and ’70s, courts declared that colleges were no longer in loco parentis, or surrogate parents. Rather, 18-year-olds were to be considered full-fledged adults who were responsible for their own behavior. That’s news, however, to some of the current generation of “helicopter” parents, who expect colleges to be involved in nearly every aspect of their children’s well-being. “When anything goes awry on campus, parents will sue,” says Sheldon Steinbach, a higher education attorney with Dow Lohnes, in Washington, D.C.

So just what is a school’s legal obligation to try to prevent student suicide? That’s still up for debate, say legal experts. But one thing is clear: If a student behaves in a troublesome way that threatens the student or others, the university must respond, says Steinbach. “To have knowledge about a potential danger to the community and fail to act is opening an invitation to liability,” he says. But short of referring students to counseling, there’s no established protocol on what that response should be. Should schools call students’ parents? Should counselors alert administrators about a despondent student? What about teachers or dorm staff?

“This is something that every university mental health center is really grappling with,” says Todd Sevig, director of Counseling and Psychological Services at the University of Michigan. Schools must navigate confusing privacy laws that vary by state. “Some places notify parents when a student is in trouble and some only in extreme circumstances. A whole bunch are in between,” he says.

Colleges have no choice but putting suicide on their radar. A recent report found that 10 percent of students sought counseling for psychological problems, and some 40 percent of those students had severe problems — 8 percent of whom needed extensive help to stay in school, says Robert Gallagher, former director of the counseling center at the University of Pittsburgh, who has tracked college mental health trends for the past 25 years.

Despite the surge of troubled students, however, the actual number of suicides doesn’t appear to be increasing. (The most recent data, from 2004, shows that the rate of suicide for young adults ages 20 to 24 has stayed consistent over the past decade.) Observers credit everything from increased use of antidepressant drugs, earlier diagnoses of mental problems and less stigma for those seeking treatment to better and more services at college counseling centers.

Expanding services is relatively easy, though, compared with the task of trying to anticipate who will try to hurt themselves. Harvard relies on one indicator: Research shows that nearly 80 percent of successful suicides occur within a week of the person’s being hospitalized, so the school now screens all students when they leave the hospital and requires that they have a treatment plan before they’re allowed back in residence. The university has an involuntary leave policy that can be invoked if an administrator feels that a student is a danger to himself or herself or disruptive to community, but it has been used only once in the past 10 years, says Richard Kadison, chief of the campus Mental Health Service. “Most of the time, students recognize they need to take time off,” he says.

The problem is that suicidal students often don’t seek help. That’s why Paul Joffe, chairman of the suicide prevention team at the University of Illinois, favors a more paternalistic approach known as “mandated counseling” that he claims has cut his school’s suicide rate in half to 1.4 students a year. When Joffe started the program in 1982, he was astonished that of 19 suicides in the previous eight years, only one student had seen a counselor.

The University of Illinois’ rigid policy requires that any student who threatens or attempts suicide attend four sessions with a counselor or risk being withdrawn from the university. “We have standards you must adhere to, such as paying library fines, maintaining a GPA, not harming others and being able to take care of yourself,” Joffe explains. “A suicide threat or attempt is a breach of contract. We’re saying, ‘If you want to be a member of this community, then you need to take suicide off the table as an option.’”

The approach sounds heartless, but Joffe says the controversial program works because it challenges suicidal students’ assumptions that they have a right to end their lives. “I tell them, ‘You think you’re in charge, but you live in a community,’” he says. Of the roughly 2,000 students who have undergone mandatory counseling at Illinois, none has committed suicide to Joffe’s knowledge, and the school has withdrawn only 1 percent of them. Other schools are taking notice: Joffe estimates that 20 other colleges and universities have since adopted the model.

Critics say schools risk overstepping their bounds with such programs. “You can’t mandate treatment unless people show several criteria, such as being a danger to oneself or others,” says Gerald Amada, former mental health co-director of the City College of San Francisco. He agrees that troubled students need to be reminded that they’re part of a community. He has lectured at more than 100 schools, encouraging them to make use of their disciplinary system, which forbids disruptive behavior. After watching how upset students became around classmates who talked incessantly of death or cut their arms in self-mutilation, Amada concluded that a student’s suicidal behavior unavoidably disturbs others. “Most times if you have highly suicidal students, you’ll find people around them ripped apart,” says Amada.

Schools, he says, should inform suicidal students that they’re hurting others and warn them that they’ll lose their academic standing or campus housing if they continue their behavior. That message can snap them out of a suicidal mind-set. “It can be very psychologically awakening,” Amada says. “It disrupts the student’s narcissism.”

Such harsh policies aim to protect schools legally, but they may not actually be in their best interests, warns Gary Pavela, author of “Questions and Answers on College Student Suicide: A Law and Policy Perspective,” who estimates that hundreds of schools rewrote medical withdrawal statements in reaction to the Shin case. “They were making it as easy as possible to remove someone,” he says. “They were asking staff members to promptly report individuals at risk for suicide in order to remove them. Counselors feel under constant pressure to divulge confidential information. It’s not prudent risk management.”

Pavela says administrators are overreacting, especially given that other courts have maintained that schools aren’t responsible for student suicidal behavior. A Pennsylvania court ruled last year that Allegheny College was not liable for a student hanging death in 2002. In a case involving a student death at the University of Iowa, the state Supreme Court found that college administrators had no duty to prevent suicide.

Schools could be accused of violating the Americans With Disabilities Act, which protects students with mental impairments. “It’s really kind of crazy that many college administrators focused on a lower court ruling in one state, while they are blissfully ignorant of federal requirements that do apply nationwide,” Pavela says, adding that about half the schools he has consulted do not have ADA grievance procedures. “They risk losing federal funding. It’s really stupid.”

They also risk lawsuits from students who feel they were unfairly removed. Jordan Nott sued George Washington University after the school barred him from campus because he checked himself into a hospital with depression. He had been haunted by the recent suicide of a fellow student, who jumped out of his dorm window while Nott and two other friends were trying to open his door. According to court records, the university told Nott that his “endangering behavior” violated the student code of conduct and he was given a choice of taking medical leave or facing expulsion. If he showed up at school, he could be arrested as a trespasser. Nott withdrew from the school and last fall reached an undisclosed settlement.

In another case, Hunter College agreed to pay $165,000 to a student who sued after her suicide attempt resulted in her removal from school housing. Both schools have agreed to review their policies.

Karen Bower, a lawyer with the Bazelon Center for Mental Health Law, who helped litigate the Hunter case and represented Nott, is also bringing a suit on behalf of a student at a New England boarding school who was put on involuntary leave after being hospitalized with depression. She says all three schools’ responses are violations of the ADA, which requires individual assessments of each student, with input from a mental health provider. The Bazelon Center is currently drafting ADA-compliant guidelines for schools to follow.

“We’ve seen more schools implementing these policies, and I’m hoping that our lawsuits will stop that trend,” says Bower, explaining that school policies unnecessarily stigmatize students and may deter them from seeking help. Amada, the former college mental health co-director, agrees. “You can’t discipline someone for being depressed,” he says. Going the disciplinary route makes withdrawal about students’ disruptive behaviors — not their psychological ills.

At least four students have made similar complaints to the U.S. Department of Education’s Office for Civil Rights, claiming they were discriminated against because of a mental disability. The office ruled that two students had legitimate claims; their colleges refunded their tuition and changed their policies. In one of the cases, OCR found that Marietta College in Ohio discriminated when it withdrew a male freshman in 2004 after his counselor told an administrator about previous suicide attempts. OCR said a school cannot act based on a “slightly increased, speculative or remote risk.”

Lawmakers are now getting involved. In one of the first such measures of its kind, Virginia last month passed legislation preventing public universities from expelling or punishing students for attempting suicide or seeking treatment for suicidal thoughts or behaviors.

It’s unclear how many universities have withdrawn students on the grounds that they may be suicidal, but Bower says she has recently spoken with several dozen students or their parents in similar situations and knows of others suspended from campus housing who are now living in hotels, homeless shelters or even in cars.

Liability questions aside, what is best for students? Dr. Morton Silverman of the Jed Foundation, a nonprofit organization that focuses on college suicide prevention, says administrators may sometimes be wise to advocate a leave so students can get a break from academic stress and focus on getting better.

For Juliana of Johns Hopkins University, that was just the advice she needed. When Juliana told her therapist that she was thinking of overdosing on pills during her freshman year, both agreed she should take time off. Back in Virginia after a stay in the hospital, she basked in the cocoon of home. Her mom made her favorite French toast in the mornings and they watched “Law and Order” reruns together. Doctors tinkered with her drug regimen, and when she felt up to it, she picked up some babysitting gigs and earned her driver’s license. “By the time school started again, I was feeling good and was anxious to get back. I missed dorm life and being with my friends,” Juliana says. She promised school officials that she would continue therapy.

The difficulty for school officials is determining whether what’s healing for some students is harmful for others — especially if home is full of dysfunctional family members. College may be a pressure cooker, but it’s also a setting that provides a lot of structure, support, camaraderie and access to healthcare, says Silverman. “Removing [students] from that supportive environment may be detrimental to their ability to recover,” he says, adding that schools should try to keep students enrolled whenever possible. “Students come to college to be students. Removing that identity has its own set of problems — in one’s self-esteem, sense of the future and identification with the institution and what it stands for.”

When Brown University suggested that Jane go back home, she protested, explaining that her depression likely would get worse. She complained that her overprotective parents tried to control what she did, wouldn’t let her drive and made her feel suffocated. The administration listened and welcomed her back as long as she enrolled in counseling. Last spring, Jane had the best semester yet. She aced all her classes and hit it off with a new therapist. She’s on track to graduate next year.

“I can tell you that when you have a photo of what’s happening underneath your skin, you get committed to preserving it,” Helena Foulkes, senior vice president of marketing and advertising at CVS Corp., told the Journal. That undoubtedly means buying more bottles and jars to line up on your sink. The executive claims that the Vichy video microscope and hydrometer by L’Oréal helped boost sales in drugstores three years in a row. Other companies are getting in the game: Procter & Gamble plans to put microscopes in stores by winter. Estée Lauder will launch a new skin-analysis tool by next year. (Its Rodan & Fields division already uses cameras to show sun damage and other skin maladies.) And this week, beauty giant Sephora is unveiling devices that will evaluate your complexion and teeth brightness.

All this “science” is clearly meant to motivate consumers to fix things they weren’t aware needing fixing. (Take your pick: age spots, dryness, texture, pore size ) What’s interesting is that the companies must strive for just the right amount of alarm — such as prompting subtle self-doubt rather than a full-fledged panic attack. For example, P&G used a test a few years ago that assigned an “age” to one’s skin, but some women were so upset they didn’t purchase any products, reports the Journal. (Now, the company simply shows women scans of their facial skin compared with their inner forearm to highlight damage.) The Vichy machines are less subtle; they magnify your skin by 50 times to really drive home the point about clogged pores.

As expected, dermatologists weigh in with warnings about how much stock to place in such tests and how much good all these creams will do, since aging is, you know, normal. This marketing trend is disguised as consumer empowerment when it’s nothing more than consumer humiliation. Sometimes, a pore is just a pore.

Reuters: Women who work long hours are more likely to smoke, drink coffee and eat junk food than are men who work long hours, according to a British study.

Columbia Journalism Review: Interesting Q&A with Jemele Hill on what it’s like to be the only black female sportswriter in 305 newspapers surveyed. Says Hill: “I don’t mind being considered a ‘black columnist,’ because I bring those experiences to my column. On the other hand, it’s sad. What does it say about our business that I’m the only one?”

Associated Press: Enviromental group finds that canned tuna imported from Mexico and Ecuador has higher levels of mercury than U.S. federal guidelines allow.

Treehugger: “Two angry moms” are making a documentary to expose the poor quality of school lunches.

Associated Press: A new amendment to the law allows the Pakistani government to release 130 women (some on bail) who were jailed on charges of murder, theft and adultery. Some 1,300 more are eligible.

Reuters: Women who smoke are twice as likely as men who smoke to develop lung cancer, a study says.

According to Journal writer David Armstrong, Lee S. Cohen, who is the study’s lead author, a Harvard Medical School professor and director of the perinatal and reproductive psychiatry research program at Massachusetts General Hospital, has consulted for three drug firms that make antidepressants. He’s a paid speaker for seven pharmaceutical companies, and he has done research with funding from four drug makers. The researchers have lectured physicians on their study results and poked holes in other recent reports showing that antidepressant use during pregnancy may put babies at risk for breathing disorders, seizures and fetal death.

The researchers claim their affiliations do not affect their work or their comments during lectures. The drug companies say the researchers offer valuable expertise. The top editor at JAMA says researchers are required to disclose financial ties and JAMA wasn’t aware of Cohen’s affiliations. (The medical journal has asked Cohen for an explanation and plans to publish it, adds editor in chief Catherine D. DeAngelis.) However, Cohen told Armstrong that he doesn’t receive significant compensation from the drug companies and didn’t feel it was important to disclose his ties, since the research was funded by the government and not business.

The relationships among consultants, drug representatives and doctors have always been a little slippery. It’s an industry that thrives off spin and marketing. But the kinds of incestuous relationships the Journal describes are bigger than a researcher endorsing an antidepressant. The question of the impact of antidepressant use during pregnancy is a highly controversial and significant one that affects some of our most vulnerable populations — depressed women and newborns. Women depend on such information to make serious decisions about their and their babies’ health.

The researchers claim the ties don’t affect their opinions. How could they not? And what these people say matters. They’re “dominant authorities” in the field, explains Armstrong. “They help establish clinical guidelines, sit on editorial boards of medical journals, advise government agencies evaluating antidepressants and teach courses on the subject to other doctors,” he writes.

“Whether or not to keep taking an antidepressant during pregnancy is a critical question for pregnant women suffering from depression,” Adam Urato, an obstetrician who publicly questioned Cohen and his colleagues about their ties online, told the Journal. “What these pregnant women and the providers who care for them need is expert advice that is free from pharmaceutical industry influence or the suggestion of bias that results when these experts are being paid by so many antidepressant manufacturers.”

Yes, we all do. Broadsheet hopes the Wall Street Journal story sparks a firestorm.

Research on the disorder traditionally has focused on boys. But a recent federally funded study, in which researchers at the University of California at Berkeley tracked 200 girls ages 6 to 12 over five years, found that girls with ADHD are at increased risk for substance abuse, emotional difficulties and academic problems during their teen years.

Lead researcher Stephen Hinshaw, chairman of the psychology department at the University of California at Berkeley, which did the study, said the results were “surprising and discouraging” because of the “breadth of impairment” they observed in the 140 girls who had ADHD compared with the 88 who did not, according to the Post. The girls with the disorder, which is marked by inattention and impulsivity, were more likely to perform poorly in school, be depressed, develop eating disorders, have troubled relationships and have bad organizational skills than their peers in the control group. Another recent study, by researchers at Massachusetts General Hospital in Boston, confirmed that teen girls with ADHD were at risk for depression or anxiety.

Now here’s some good news. Girls responded as well as boys to treatment (usually Ritalin and Adderall paired with behavioral therapy) and showed fewer symptoms as they got older. But Hinshaw urges that girls get more specialized attention. “Girls have a different way of relating and deserve study in their own right,” Hinshaw told the Post. “This is not a short-term disorder.”

At least now it’s backed by a long-term study.