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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NRA’s defiant LaPierre dismisses critics of school gun plan

The NRA's Wayne LaPierre speaks at Friday's press conference. (Chip Somodevilla/Getty Images)

Two days after suggesting a "good guy with a gun" be stationed at every school in the country in response to the deadly shootings in Newtown, Conn., National Rifle Association executive vice president Wayne LaPierre blasted critics of his plan.

In an interview broadcast on Sunday's "Meet The Press," LaPierre reiterated the statements he made Friday at a press conference in Washington, when he said the answer to preventing shootings like the one at Sandy Hook Elementary Sch00l is armed security in every school--in effect, protecting children with guns.

“If it’s crazy to call for putting police in and securing our schools to protect our children, then call me crazy," LaPierre said. “I think the American people think it’s crazy not to do it."

At one point during the often contentious exchange, host David Gregory held up a high-capacity magazine clip that carries 30 bullets, asking if the NRA would support a federal limit on the capacity of such clips.

"Isn't it just possible that we could reduce the carnage in a situation like Newtown?" Gregory asked.

"I don't believe that's going to make one difference," LaPierre responded.

"You're telling me that it's not a matter of common sense that if you don't have an ability to shoot off 30 rounds without reloading, that, just possibly, you could reduce the loss of life?" Gregory asked.

"I don't buy your argument for a minute," LaPierre said. "There are so many different ways to evade that, even if you had that."

“Is there no new gun regulation you would support?” an exasperated Gregory asked. LaPierre refused to answer.

At Friday's press conference, LaPierre--who did not take questions from reporters--argued that had someone at the school been armed, "innocent lives might have been spared."

"The only thing that stops a bad guy with a gun is a good guy with a gun," he said.

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Bombing at political rally kills 9 in Pakistan

PESHAWAR, Pakistan (AP) — A suicide bomber in Pakistan killed nine people including a provincial government official at a political rally held Saturday by a party that has opposed the Taliban, officials said.

The rally in Peshawar, the capital of northwestern Khyber Pakhtunkhwa province, was held by the Awami National Party, whose members have been repeatedly targeted by the Taliban.

Among the dead was Bashir Bilour, the second most senior member of the provincial Cabinet, said Ghulam Ahmed Bilour, the politician's brother and federal railways minister.

Over 20 others were wounded by the blast, said local police officer Sabir Khan.

Bilour was leaving the rally after delivering the keynote speech when the attack occurred, said Nazir Khan, a local Awami National Party leader.

"There was smoke and dust all around, and dead and wounded people were lying on the ground," he said.

The suicide bomber was on foot, said another police officer, Imtiaz Khan.

Mian Iftikhar Hussain, the Khyber Pakhtunkhwa information minister and a member of the Awami National Party, said both he and Bilour had repeatedly received threats from militants. He condemned the attack and said the government needed to intensify its battle against the Taliban.

"Terrorism has engulfed our whole society," said Hussain. "They are targeting our bases, our mosques, our bazars, public meetings and our security checkpoints."

Ten Taliban militants attacked the military area of an international airport in Peshawar with rockets and car bombs a week ago, killing four people and wounding over 40 others. Five of the militants were killed during the attack, and five others died the next day in a gunbattle with security forces.

Also Saturday, police said a mob in southern Pakistan stormed a police station to seize a mentally unstable Muslim man accused of burning a copy of Islam's holy book. The crowd beat him to death, and then set fire to his body.

The case is likely to raise further concerns about the country's harsh blasphemy laws, which can result in a death sentence or life in prison to anyone found guilty. An accusation or investigation alone can lead to deaths, as people take the law into their own hands and kill those accused of violating it. Police stations and even courts have been attacked by mobs.

Police arrested the man on Friday after being informed by residents that he had burned a Quran inside a mosque where he had been staying for a night, said local police official Biharud Deen.

An angry mob of more than 200 people then broke into the police station in the southern town of Dadu and took the accused man, who they say was under questioning. Deen said police tried their best to save the man's life but were unable to stop the furious crowd.

Police have arrested 30 people for suspected involvement in the attack, said Deen. The head of the local police station and seven officers had been suspended, he said.

Past attempts by governments in predominantly Muslim Pakistan to review these laws have met with violent opposition from hardline Islamist parties.

In southwestern Pakistan, gunmen late Friday killed 11 Pakistanis and Afghans who were trying to cross into neighboring Iran to travel on to Europe as illegal immigrants, said local government official Zubair Ahmed. The shooting took place in Sunsar town in Baluchistan province, he said.

It was not immediately clear who was behind the attack, but hundreds of Pakistanis and Afghans are captured by Iranian border guards every year for illegally trying to travel to Europe to find better jobs.

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Associated Press writers Abdul Sattar in Quetta, Pakistan, and Adil Jawad in Karachi, Pakistan, contributed to this report.

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Ashton Kutcher files for divorce from Demi Moore

LOS ANGELES (AP) — Ashton Kutcher filed court papers Friday to end his seven-year marriage to actress Demi Moore.

The actor's divorce petition cites irreconcilable differences and does not list a date that the couple separated. Moore announced last year that she was ending her marriage to the actor 15 years her junior, but she never filed a petition.

Kutcher's filing does not indicate that the couple has a prenuptial agreement. The filing states Kutcher signed the document Friday, hours before it was filed in Los Angeles Superior Court.

Kutcher and Moore married in September 2005 and until recently kept their relationship very public, communicating with each other and fans on the social networking site Twitter. After their breakup, Moore changed her name on the site from (at)mrskutcher to (at)justdemi.

Kutcher currently stars on CBS' "Two and a Half Men."

Messages sent to Kutcher's and Moore's publicists were not immediately returned Friday.

Moore, 50, and Kutcher, 34, created the DNA Foundation, also known as the Demi and Ashton Foundation, in 2010 to combat the organized sexual exploitation of girls around the globe. They later lent their support to the United Nations' efforts to fight human trafficking, a scourge the international organization estimates affects about 2.5 million people worldwide.

Moore was previously married to actor Bruce Willis for 13 years. They had three daughters together — Rumer, Scout and Tallulah Belle — before divorcing in 2000. Willis later married model-actress Emma Heming in an intimate 2009 ceremony at his home in Parrot Cay in the Turks and Caicos Islands that attended by their children, as well as Moore and Kutcher.

Kutcher has been dating former "That '70s Show" co-star Mila Kunis.

The divorce filing was first reported Friday by People magazine.

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Anthony McCartney can be reached at http://twitter.com/mccartneyAP.

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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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Final day of funerals for Newtown shooting victims

The final three victims of the massacre at Sandy Hook Elementary School will be laid to rest today, ending a somber week funerals.

A mass will take place today at St. Rose of Lima Catholic Church for Josephine Gay, who had celebrated her 7th birthday on Dec. 11.

Friends and family have been asked to wear Josephine's favorite color, purple, in her honor.

PHOTOS: Victims of Sandy Hook Massacre

A homegoing celebration will take place at The First Cathedral in Bloomfield, Conn., for Ana Marquez-Greene. The 6-year-old with a beaming voice sang in a home video with her brother, who was also at Sandy Hook Elementary School during the massacre, and seemed destined to take after her father, a jazz musician.

Emilie Parker, the budding artist who carried her markers and pencils everywhere, will be laid to rest in Ogden, Utah today.

The 6-year-old would have been would one of the first to comfort her classmates at Sandy Hook Elementary School, had a gunman's bullets not claimed her life, her father said.

"My daughter Emilie would be one of the first ones to be standing and giving support to all the victims because that's the kind of kid she is," her father, Robbie Parker, said last Saturday.

"She always had something kind to say about anybody," Parker said. "We find comfort reflecting on the incredible person Emilie was and how many lives she was able to touch."

WATCH: Emilie's father speaks about his daughter

Also Read

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US budget negotiations setback drives stocks down

PARIS (AP) — A failed attempt find a compromise in U.S. budget negotiations sent global stock markets plummeting Friday, as investors feared the world's largest economy could teeter into recession if no deal is found.

Without an agreement, the U.S. economy will fall off the so-called "fiscal cliff" on Jan. 1 when Bush-era tax cuts expire and spending cuts kick in automatically. The measures were designed to have a negative effect on the U.S. economy, in the hopes that the feared outcome would push lawmakers and President Barack Obama to find a deal.

"We've seen Europe's politicians repeatedly flirt lemming-like with cliff-diving in 2012, and now it's the turn of U.S. 'leaders,'" said Kit Juckes, an analyst with Societe Generale. "The nagging fear is always there that someone, on one side of the Atlantic or the other, will forget to let rational thought take over at the last second."

Amid the uncertainty, European shares fell. France's CAC dropped 0.15 percent to close at 3,661, while the DAX in Germany dropped 0.5 percent to end the day 7,636. The FTSE index of leading British shares retreated 0.3 percent to 5,939.

The euro also fell sharply, dropping 0.5 percent to $1.3159.

In Asia, Japan's Nikkei 225 index closed 1 percent lower at 9,940.06. Hong Kong's Hang Seng lost 0.7 percent to 22,506.29. South Korea's Kospi shed 1 percent at 1,980.42. Australia's S&P/ASX 200 fell 0.2 percent to 4,623.60. Mainland Chinese stocks were mixed.

U.S. stock futures tumbled after rank-and-file Republican lawmakers failed to support an alternative tax plan by House Speaker John Boehner late Thursday in Washington. That plan would have allowed tax rates to rise on households earning $1 million and up. Obama wants the level to be $400,000.

In midday trading trading in New York, the Dow Jones industrial average dropped 1.25 percent to 13,147, while the broader Standard & Poor's index fell 1.3 percent at 1,424.

"The fiscal cliff is a real threat not just for U.S. growth next year but for the outlook for global growth," said Jane Foley, currency analyst with Rabobank.

When growth slows, energy demand does, too, and oil prices fell in anticipation.

Benchmark crude for February delivery fell $1.78 to $88.35 per barrel in electronic trading on the New York Mercantile Exchange.

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Pamela Sampson in Bangkok and Fu Ting in Shanghai contributed to this report.

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Nokia, RIM settle old disputes in new patent pact

HELSINKI (AP) — Nokia Corp. and Canadian smartphone rival Research In Motion have agreed on a new patent licensing pact which will end all existing litigation between the two struggling companies, the Finnish firm said Friday.

The agreement includes a “one-time payment and on-going payments, all from RIM to Nokia,” Nokia said, but did not disclose “confidential” terms.

Last month, Nokia sued the Blackberry maker for breach of contract in Britain, the United States and Canada over cellular patents they agreed in 2003. RIM claimed the license — which covered patents on “standards-essential” technologies for mobile devices— should also have covered patents for non-essential parts, but the Arbitration Institute of Stockholm Chamber of Commerce ruled against RIM’s claims.

Major manufacturers of phones and wireless equipment are increasingly turning to patent litigation as they jockey for an edge to expand their share of the rapidly growing smartphone market.

Nokia is among leading patent holders in the wireless industry. It has already received a $ 565 million royalty payment from Apple Inc. to settle long-standing patent disputes and filed claims in the United States and Germany alleging that products from HTC Corp. and Viewsonic Corp. infringe a number of its patents.

The company says it has invested €45 billion ($ 60 billion) during the last 20 years in research and development and has one of the wireless industry’s largest IPR portfolios claiming some 10,000 patent families.

Nokia’s share price closed down 3.5 percent at €3.05 on the Helsinki Stock Exchange.

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PSY's 'Gangnam Style' reaches 1B views on YouTube

NEW YORK (AP) — Viral star PSY has reached a new milestone on YouTube.

The South Korean rapper's video for "Gangnam Style" has reached 1 billion views, according to YouTube's own counter. It's the first time any clip has surpassed that mark on the streaming service owned by Google Inc.

It shows the enduring popularity of the self-deprecating video that features Park Jae-sang's giddy up-style dance moves. The video has been available on YouTube since July 15, averaging more than 200 million views per month.

Justin Bieber's video for "Baby" held the previous YouTube record at more than 800 million views.

PSY wasn't just popular on YouTube, either. Earlier this month Google announced "Gangnam Style" was the second highest trending search of 2012 behind Whitney Houston, who passed away in February.

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AP IMPACT: Big Pharma cashes in on HGH abuse

A federal crackdown on illicit foreign supplies of human growth hormone has failed to stop rampant misuse, and instead has driven record sales of the drug by some of the world's biggest pharmaceutical companies, an Associated Press investigation shows.

The crackdown, which began in 2006, reduced the illegal flow of unregulated supplies from China, India and Mexico.

But since then, Big Pharma has been satisfying the steady desires of U.S. users and abusers, including many who take the drug in the false hope of delaying the effects of aging.

From 2005 to 2011, inflation-adjusted sales of HGH were up 69 percent, according to an AP analysis of pharmaceutical company data collected by the research firm IMS Health. Sales of the average prescription drug rose just 12 percent in that same period.

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EDITOR'S NOTE — Whether for athletics or age, Americans from teenagers to baby boomers are trying to get an edge by illegally using anabolic steroids and human growth hormone, despite well-documented risks. This is the second of a two-part series.

___

Unlike other prescription drugs, HGH may be prescribed only for specific uses. U.S. sales are limited by law to treat a rare growth defect in children and a handful of uncommon conditions like short bowel syndrome or Prader-Willi syndrome, a congenital disease that causes reduced muscle tone and a lack of hormones in sex glands.

The AP analysis, supplemented by interviews with experts, shows too many sales and too many prescriptions for the number of people known to be suffering from those ailments. At least half of last year's sales likely went to patients not legally allowed to get the drug. And U.S. pharmacies processed nearly double the expected number of prescriptions.

Peddled as an elixir of life capable of turning middle-aged bodies into lean machines, HGH — a synthesized form of the growth hormone made naturally by the human pituitary gland — winds up in the eager hands of affluent, aging users who hope to slow or even reverse the aging process.

Experts say these folks don't need the drug, and may be harmed by it. The supposed fountain-of-youth medicine can cause enlargement of breast tissue, carpal tunnel syndrome and swelling of hands and feet. Ironically, it also can contribute to aging ailments like heart disease and Type 2 diabetes.

Others in the medical establishment also are taking a fat piece of the profits — doctors who fudge prescriptions, as well as pharmacists and distributors who are content to look the other way. HGH also is sold directly without prescriptions, as new-age snake oil, to patients at anti-aging clinics that operate more like automated drug mills.

Years of raids, sports scandals and media attention haven't stopped major drugmakers from selling a whopping $1.4 billion worth of HGH in the U.S. last year. That's more than industry-wide annual gross sales for penicillin or prescription allergy medicine. Anti-aging HGH regimens vary greatly, with a yearly cost typically ranging from $6,000 to $12,000 for three to six self-injections per week.

Across the U.S., the medication is often dispensed through prescriptions based on improper diagnoses, carefully crafted to exploit wiggle room in the law restricting use of HGH, the AP found.

HGH is often promoted on the Internet with the same kind of before-and-after photos found in miracle diet ads, along with wildly hyped claims of rapid muscle growth, loss of fat, greater vigor, and other exaggerated benefits to adults far beyond their physical prime. Sales also are driven by the personal endorsement of celebrities such as actress Suzanne Somers.

Pharmacies that once risked prosecution for using unauthorized, foreign HGH — improperly labeled as raw pharmaceutical ingredients and smuggled across the border — now simply dispense name brands, often for the same banned uses. And usually with impunity.

Eight companies have been granted permission to market HGH by the U.S. Food and Drug Administration, which reviews the benefits and risks of new drug products. By contrast, three companies are approved for the diabetes drug insulin.

The No. 1 maker, Roche subsidiary Genentech, had nearly $400 million in HGH sales in the U.S. last year, up an inflation-adjusted two-thirds from 2005. Pfizer and Eli Lilly were second and third with $300 million and $220 million in sales, respectively, according to IMS Health. Pfizer now gets more revenue from its HGH brand, Genotropin, than from Zoloft, its well-known depression medicine that lost patent protection.

On their face, the numbers make no sense to the recognized hormone doctors known as endocrinologists who provide legitimate HGH treatment to a small number of patients.

Endocrinologists estimate there are fewer than 45,000 U.S. patients who might legitimately take HGH. They would be expected to use roughly 180,000 prescriptions or refills each year, given that typical patients get three months' worth of HGH at a time, according to doctors and distributors.

Yet U.S. pharmacies last year supplied almost twice that much HGH — 340,000 orders — according to AP's analysis of IMS Health data.

While doctors say more than 90 percent of legitimate patients are children with stunted growth, 40 percent of 442 U.S. side-effect cases tied to HGH over the last year involved people age 18 or older, according to an AP analysis of FDA data. The average adult's age in those cases was 53, far beyond the prime age for sports. The oldest patients were in their 80s.

Some of these medical records even give explicit hints of use to combat aging, justifying treatment with reasons like fatigue, bone thinning and "off-label," which means treatment of an unapproved condition

Even Medicare, the government health program for older Americans, allowed 22,169 HGH prescriptions in 2010, a five-year increase of 78 percent, according to data released by the Centers for Medicare and Medicaid Services in response to an AP public records request.

"There's no question: a lot gets out," said hormone specialist Dr. Mark Molitch of Northwestern University, who helped write medical standards meant to limit HGH treatment to legitimate patients.

And those figures don't include HGH sold directly by doctors without prescriptions at scores of anti-aging medical practices and clinics around the country. Those numbers could only be tallied by drug makers, who have declined to say how many patients they supply and for what conditions.

First marketed in 1985 for children with stunted growth, HGH was soon misappropriated by adults intent on exploiting its modest muscle- and bone-building qualities. Congress limited HGH distribution to the handful of rare conditions in an extraordinary 1990 law, overriding the generally unrestricted right of doctors to prescribe medicines as they see fit.

Despite the law, illicit HGH spread around the sports world in the 1990s, making deep inroads into bodybuilding, college athletics, and professional leagues from baseball to cycling. The even larger banned market among older adults has flourished more recently.

FDA regulations ban the sale of HGH as an anti-aging drug. In fact, since 1990, prescribing it for things like weight loss and strength conditioning has been punishable by 5 to 10 years in prison.

Steve Kleppe, of Scottsdale, Ariz., a restaurant entrepreneur who has taken HGH for almost 15 years to keep feeling young, said he noticed a price jump of about 25 percent after the block on imports. He now buys HGH directly from a doctor at an annual cost of about $8,000 for himself and the same amount for his wife.

Many older patients go for HGH treatment to scores of anti-aging practices and clinics heavily concentrated in retirement states like Florida, Nevada, Arizona and California.

These sites are affiliated with hundreds of doctors who are rarely endocrinologists. Instead, many tout certification by the American Board of Anti-Aging and Regenerative Medicine, though the medical establishment does not recognize the group's bona fides.

The clinics offer personalized programs of "age management" to business executives, affluent retirees, and other patients of means, sometimes coupled with the amenities of a vacation resort. The operations insist there are few, if any, side effects from HGH. Mainstream medical authorities say otherwise.

A 2007 review of 31 medical studies showed swelling in half of HGH patients, with joint pain or diabetes in more than a fifth. A French study of about 7,000 people who took HGH as children found a 30 percent higher risk of death from causes like bone tumors and stroke, stirring a health advisory from U.S. authorities.

For proof that the drug works, marketers turn to images like the memorable one of pot-bellied septuagenarian Dr. Jeffry Life, supposedly transformed into a ripped hulk of himself by his own program available at the upscale Las Vegas-based Cenegenics Elite Health. (He declined to be interviewed.)

These promoters of HGH say there is a connection between the drop-off in growth hormone levels through adulthood and the physical decline that begins in late middle age. Replace the hormone, they say, and the aging process slows.

"It's an easy ruse. People equate hormones with youth," said Dr. Tom Perls, a leading industry critic who does aging research at Boston University. "It's a marketing dream come true."

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Associated Press Writer David B. Caruso reported from New York and AP National Writer Jeff Donn reported from Plymouth, Mass. AP Writer Troy Thibodeaux provided data analysis assistance from New Orleans.

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AP's interactive on the HGH investigation: http://hosted.ap.org/interactives/2012/hgh

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The AP National Investigative Team can be reached at investigate(at)ap.org

EDITOR'S NOTE _ Whether for athletics or age, Americans from teenagers to baby boomers are trying to get an edge by illegally using anabolic steroids and human growth hormone, despite well-documented risks. This is the second of a two-part series.

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