Is This Student Safe to Return to School?

VChalup_AdobeStock

Since the 1990s, more than 350,000 students have experienced gun violence in their schools. As of 2018, more than 500 pupils have lost their lives. These statistics only tell part of the story, as they do not include the number of students and teachers who have been injured and traumatized in these tragedies.^1,2

Soberingly, with firearms being the leading cause of death for children and teens,³ school shootings account for not even 2% of the overall death toll from guns.² Even so, the impact of targeted school violence contributes to public mistrust of school safety.⁴

Many child and adolescent psychiatrists, especially those in ambulatory and emergency settings, may run into situations where they are asked to evaluate a student who has threatened violence.

For physicians who are not accustomed to working in a school setting or performing threat assessments, it is imperative to be familiar with the basic concepts of quickly assessing students’ behavior that seems threatening while being mindful of the common pitfalls that can occur with incomplete evaluations or student “profiling.”

To this point, in the fall of 2023, hundreds attended an institute at the American Academy of Child & Adolescent Psychiatry (AACAP) 70th annual meeting entitled, “Is This Student Safe to Return to School? Critical Strategies for Threat Assessment and Management in K-12 Schools.”

A team of experts in school threat assessments—which included Nancy Rappaport, MD; Sarah Goodrum, PhD; Deborah Weisbrot, MD; Vera Feuer, MD; Kostas Katsavdakis, ABPP, PhD; and Meredith Gansner, MD—educated conference attendees on a range of subjects.

Some of these subjects included the latest evidence-based procedures relating to the process of school threat assessments; the psychiatrist’s role in assessing the psychiatric status of children and adolescents making threats; response management of school threats, including psychiatric and educational interventions beyond the threat; and advocacy for the adoption of evidence-based threat assessment procedures in schools.⁵

Many psychiatrists are already familiar with documenting risk assessments for clinical cases in outpatient, inpatient, and emergency settings. These assessments aim to examine the risk and protective factors present in individuals to determine the overall probability for suicide and homicide compared to a known group.⁵

Risk assessments are not threat assessments, and they do not accurately predict a student’s risk of engaging in targeted violence. In situations where students are sent to the emergency room for a “threat assessment,” there is an increased likelihood of clinicians reaching a false negative conclusion if their evaluation does not involve the team-based, investigative approach described below.⁵

The institute’s speakers highlighted the importance of encouraging schools to form threat assessment teams and/or become familiar with existing teams in their state to avoid the potential pitfalls of an incomplete evaluation and/or after-monitoring.³ The Comprehensive School Threat Assessment Guidelines recommend a framework for establishing school-based threat assessment programs.²

Media portrayals and common myths of there being a “profile” of a school shooter are pervasive and not based on fact. Singling out students who make a threat determined to be insignificant during threat assessment, or who dress and behave differently from their peers, can lead to perpetuation of further anger, resentment, or isolation for them.⁴ Instead, warning signs and patterns of behavior are better predictors of targeted school violence.

What happens when a student makes a threat to take a gun to school? What if the threat was made in an angry outburst at recess, or in a social media post while holding a gun? Threats of violence can be broadly divided into 2 categories: transient and substantive.

Transient threats are often made in the heat of the moment and can easily be resolved by a thorough threat assessment. Substantive threats can range from serious (eg, physical fights) to very serious (eg, threat of harm with a weapon).^2,4,5

When threats are made, it is understandable that staff, parents, and other students can be flooded with anxiety. Some schools have a “zero tolerance” approach that can lead to suspension and/or expulsion without consideration of the context of the student making the threat.

Although this may temporarily lead to a sense of resolution, this punitive approach has not shown improvement in safety outcomes because it can often lead to unnecessary justice system involvement and higher rates of academic failure.^2,4

School threat assessment teams have the goal of understanding why a threat was made by a student and then working together to provide timely intervention to address the student’s underlying social, emotional, and/or behavioral needs.

Crucial steps in this investigative process include a review of relevant records such as the incident report, academic records, IEP/504 records, psychological and neurological testing, and law enforcement records; and interviews with the at-risk student, the student’s parents or guardians, and school personnel.^2,5,7

Drawn from the Safe School Initiative, a 2004 collaboration between the FBI and the Department of Education that examined school shootings, the 11 most important questions to determine a student’s threat level are^5,7:

1. What are the student’s motives and goals for making the threat?
2. Have there been any communications that suggest an idea or intent to attack?
3. Has the student shown inappropriate interest in school attacks or attackers, weapons, and/or incidents of mass violence?
4. Has the student already engaged in attack-related behaviors?
5. Does the student have the capacity to carry out an act of targeted violence?
6. Is the student experiencing hopelessness, desperation, and/or despair?
7. Does the student have a trusting relationship with at least 1 responsible adult?
8. Does the student see violence as acceptable, desirable, or the only way to solve problems?
9. Is the student’s conversation and story consistent with their actions?
10. Are others concerned about the student’s potential for violence?
11. What circumstances might affect the likelihood of an attack?

For a student deemed to be at an imminent risk of violence that could result in bodily injury, incarceration or immediate hospitalization is often indicated. For less acute, but still significant threat risks, a forensic inpatient evaluation can help determine the need for a therapeutic residential or day-treatment setting.

If the threat assessment rules out imminent risk of harm, it is important to meet with school administration prior to the student’s return and coordinate ongoing monitoring by a trained school counselor and/or outpatient mental health provider.⁶

For the transient threats made in the context of untreated mental health, learning, or social/communication challenges, the threat assessment can be a powerful way to help students access much-needed psychiatric and educational resources.⁴

Outside of familiarity with threat assessments, comfort in discussing gun safety planning with families is another way to prevent deaths by firearm in young people.³ Clinicians can use the events in the news as a starting point to initiate these dialogues.

Open and nonjudgmental questions regarding the number of firearms in the home can lead to productive conversations regarding safe firearm storage via lockbox, gun safe, and/or cable lock as ways to prevent children’s access to guns.⁵

Psychiatrists can go further to learn more about the “red flag” or extreme risk protection orders in their states to know if and when to file one for individuals at risk of violence.⁸ These orders are issued by a court when someone is at risk of violence to themselves or others as a means to prevent tragedies.

If this order is in place, purchasing or possessing guns is prohibited for an amount of time, usually ranging from less than a month to up to a year, depending on the state.⁹ Psychiatrists who work in school consultations can also encourage schools to teach their pupils about gun safety.⁵

The day after the AACAP annual meeting, attendees received the tragic news of another mass shooting—this time in Lewiston, Maine. Some of the victims were adolescents, which was a grim reminder that more than 98% of deaths of youth by firearms do not occur in the school setting.²

Although threats of violence can be frightening and do require investigation, it is important to remember that the majority of threats made by children and adolescents are not substantive and are made in the context of growing youth who are still learning to manage their emotions and peer interactions.²

Moreover, “zero tolerance” policies and overreactions to threats can lead to harmful consequences such as school disengagement or stigmatization by peers and/or teachers.^2,4,5 Every child and adolescent psychiatrist should feel empowered to know that school threat assessments are a proactive way to address the underlying stressors and mental health struggles of students before violence occurs.^2,4,5

Dr Caldwell is a CAP1 child and adolescent psychiatry fellow in the Department of Psychiatry Cambridge Health Alliance at Harvard Medical School. Her undergraduate degree is in biology with minor specializations in chemistry, music, and Spanish from the University of Akron. During her time there, she founded a student organization, DreamAKRON, to address discrepancies in education access for students, especially those who are underrepresented and minoritized.

She was accepted to medical school at the University of Toledo College of Medicine and Life Sciences, as a junior in college via their MedStart program. She later completed her residency in adult psychiatry at The University of Florida. Her professional areas of interest are in therapy modalities (play, DBT, group, and family), collaborative and school-based care models, and mood, anxiety, and attentional disorders.

References

1. Cox JW, Rich S, Chong L, et al. There have been 389 school shootings since Columbine. The Washington Post. Updated January 25, 2024. Accessed November 3, 2023. https://www.washingtonpost.com/education/interactive/school-shootings-database/?itid=sf_%2Fschool-shootings_subnav

2. Training in school-based threat assessment. Comprehensive School Threat Assessment Guidelines. Accessed November 14, 2023. https://www.schoolta.com/

3. Children & teens. Everytown for Gun Safety. September 27, 2023. Accessed November 10, 2023. https://everytownresearch.org/issue/child-and-teens/

4. Weisbrot DM. “The need to see and respond”: The role of the child and adolescent psychiatrist in School Threat Assessment. JAACAP. 2020;59(1):20-26.

5. Institute 4: is this student safe to return to school? critical strategies for threat assessment and management in K-12 schools. American Academy of Child & Adolescent Psychiatry. Accessed November 13, 2023. https://aacap.confex.com/aacap/2023/meetingapp.cgi/Session/30443

6. Goodrum S, Evans MK, Thompson AJ, Woodward W. Learning from a failure in threat assessment: 11 questions and not enough answers. Behavioral Sciences & the Law. 2019;37(4):353-371.

7. Vossekuil B, Fein RA, Reddy M, et al. The final report and findings of the Safe School Initiative: implications for the prevention of school attacks in the US. United States Secret Service and United States Department of Education. July 1, 2004. Accessed November 3, 2023. https://www2.ed.gov/admins/lead/safety/preventingattacksreport.pdf

8. Extreme risk laws. Everytown for Gun Safety. July 7, 2023. Accessed November 7, 2023. https://www.everytown.org/solutions/extreme-risk-laws/

9. Frattaroli S, Horwitz J. Extreme risk protection order. Bloomberg American Health Initiative. August 1, 2023. Accessed November 13, 2023. https://americanhealth.jhu.edu/implementERPO