School Shooters: Troubled Teens or Cold-Blooded Killers?

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Case Example: An Overt Threat Made in Passing

It is Friday afternoon, and the last patient of the day walks in for a follow-up appointment at an outpatient psychiatric clinic. “Matthew” is 18 years old and has generalized anxiety disorder and major depressive disorder. At the end of the appointment, Matthew tells his psychiatrist that he is mad at his math teacher for giving him a failing grade. He says he would like to get his father’s AK-47 out of the gun cabinet and “shoot up the school.” How should the psychiatrist react?

Conceptualizing the Risk Assessment

There is no accurate profile of who will become a school shooter.¹ Although there are certain factors found at elevated rates, such as childhood adversity and social stressors, these things are also commonly found in nonviolent peers.² Rather than looking to see whether a patient matches a profile, psychiatrists should react as they would with any patient threatening violence: inquire, gain collateral data, assess, and respond.

In this article, we use the term school shooter narrowly: a current or former student who uses a firearm at a K-12 school in an act of targeted violence with the goal of killing 3 or more individuals. Targeted violence occurs when a shooter has a specific person or location in mind.³ Such violence is not impulsive or due to an unrelated criminal motive (eg, drugs or theft). Some sources use the term school shooter more broadly,⁴ including episodes where a firearm is brandished or discharged on school grounds.⁵

When assessing violence risk in a patient who has made a school shooting threat or innuendo, risk factors can be classified as either static or dynamic. Static factors, such as childhood abuse, are historical. Their impact may vary over time,⁶ but they cannot be erased. Dynamic factors, such as depression, are changeable. Psychiatrists treat dynamic risk factors while remaining aware of the static ones.

A risk factor is an attribute that increases the risk of violence, but the fact that a patient has risk factors does not mean they will engage in violence. When assessing a patient’s concerning statement, it is crucial to assess their behavior and obtain collateral information from family and school officials. A student’s behavior provides the best information about how far they are on the path from a concerning statement to a violent act.

Static Risk Factors

School shooters are overwhelmingly male.^2,3 They have higher-than-average static risk factors of childhood adversity, past violence, and school discipline.^2,3,7

Personality traits and emotionality are also relevant. Anecdotally, school shooters tend to have more antisocial, paranoid, and narcissistic traits. They can misperceive persecution and disrespect, blame things on those around them, and become easily enraged. This way of perceiving the world can lead to grievances that motivate school shootings. Another common motive is a desire for notoriety or fame.^2,3,7

Dynamic Risk Factors

Dynamic risk factors for school shooters fall into 5 main categories: stressors, violent interests, psychiatric symptoms, substance use, and firearm access.^2,7 Retrospective evaluations of averted and actual school shooters show numerous stressors before the attack, especially bullying.^2,7 Shooters often have a pathological interest in extreme violence (eg, weapons, previous mass shootings, and assassinations).^2,7

Perpetrators of targeted school violence have elevated rates of mental health diagnoses.² Most violence is not due to mental illness.⁸ Clinicians should focus on psychiatric symptoms and behaviors rather than diagnoses. Depression and suicidality are frequently found in school shooters.^2,3,9

In conducting a violence risk assessment, psychiatrists should always ask about firearm access. A large number of shooters obtain their weapon from their parents or another relative’s house.² Some guns have been secured in a gun safe, but the shooter knows the combination or where the keys are kept.

Warning Behaviors

All school shooters, in hindsight, display concerning behaviors before the attack.² These range from poor grades to isolation to overt threats of a school shooting. Most school shooters tell others before committing the act, usually a classmate.² Threats and even innuendos must be thoroughly investigated. However, the vast majority of individuals who threaten to commit a school shooting do not do so.^9-11

In the psychiatric assessment, it is important to pay close attention to the student’s behaviors, especially those that indicate a student is moving from a grievance (the most common motive for school shootings) to an attack.⁹ This is known as the pathway to violence.^12,13 Any movement along that pathway (eg, researching, planning, preparing, or practicing) requires immediate intervention.⁹ Behaviors showing that a student is taking on a warrior identity (or identifying with past mass shooters), displaying desperation, or believing that violence is the only option are also concerning.⁹

How to Respond

In the hypothetical case of Matthew described at the beginning of this article, the psychiatrist should first ask the patient to elaborate on his thoughts. Clinicians should assess whether the statement was made with intent and how far the patient has gone in thinking it through. Gathering collateral information is key when assessing for psychiatric symptoms as well as for homicidality and suicidality. Individuals who are planning a massacre, similar to those planning to die by suicide, may regret saying too much and then allege that they were only joking.

After an assessment, the psychiatrist will decide whether the patient needs hospitalization and whether the statements have triggered a legal duty to protect. A clinician’s capacity to protect the public involves 4 main areas: treatment (eg, treating depression), incapacitation (eg, hospitalizing a violent patient), warning potential victims (eg, calling the school), and restricting lethal means. When a patient makes a statement indicating they pose a threat of firearm violence, psychiatrists should seek to have the patient’s access to firearms restricted. This can usually be done voluntarily with family assistance or, if necessary, involuntarily through red flag laws now present in 21 states.^14,15

The steps detailed in the Table should be carefully charted, and the violence risk mitigation plan should be documented. The documentation is a means of showing that the clinician’s response was reasonable under the circumstances, and it reduces the likelihood of a malpractice suit. It also helps the psychiatrist to systematically consider risk factors and the means to mitigate the risk.

Table. Addressing a Patient’s School Shooting Threat

Even when there is not a legal duty to warn a student’s school, clinicians should consider seeking the school’s involvement. In the case of a minor, this can be done through parental consent. With adult students (eg, college students), it can—in appropriate circumstances—be done with the student’s consent. A large portion of schools now have threat assessment teams,¹⁶ which have protocols for preventing school violence and addressing threats such as Matthew’s.¹⁷

Case Example: Covert Threats and Communication Failures

“Brett,” a 16-year-old adolescent boy, is brought to an outpatient psychiatric clinic by his parents on a Thursday. He was suspended from school earlier that day for passing a “concerning note” to 2 girls. He is not allowed to return to school until he receives psychiatric clearance. His parents do not have any concerns. They are not sure exactly what the note said or why the school principal appeared worried.

During the psychiatrist’s evaluation, the student says he was just joking around and that the notes only said how much he cared about the 2 girls. No psychiatric symptoms are evident. The psychiatrist, without asking to look at the “concerning notes,” writes a letter of clearance and instructs the parents to search the adolescent’s room and computer for signs of potential violence. The parents decide to wait until the weekend to conduct the search. They send the student back to school the next day. The student proceeds to shoot 6 peers at school; 3 of them die.

If the parents had searched the student’s room on Thursday night, they would have found guns and 200 rounds of ammunition. If they had searched his computer, they would have seen his internet searches for school shootings and Columbine. If the psychiatrist had called the school before writing a letter of clearance, he would have learned that the notes said, “If anything big happens tomorrow, I want you to know that it’s not your fault. I care deeply for you.”

As psychiatrists, it is our job to probe, get the information we need to assess risk, and make clinically appropriate judgment calls. This case example—modeled on a true case—shows just how dangerous communication failures and missed information can be. The psychiatrist had a duty to gather information from the school and should have conveyed to the parents the need to search their son’s room and computer that same night. If he had, the school shooting might have been averted.

Concluding Thoughts

School shooters cannot be characterized as either troubled teenagers or cold-blooded killers. Many threats are cries for help. There is no profile of who will become a school shooter. Violence is multifactorial. Certain factors escalate risk and specific warning behaviors can convey accelerating risk,⁹ but they are not accurate predictors. As psychiatrists, our job is to assess violence risk when there is an identified concern and respond in a clinically and legally appropriate manner. In appropriate cases, this response should include involvement of a student’s school threat assessment team. When a serious threat has been made, a team approach becomes key to violence prevention. A sole clinician’s judgment is always improved by additional perspectives.

Dr VanDercar is an assistant professor of psychiatry at University Hospitals Cleveland Medical Center/Case Western Reserve University School of Medicine in Ohio, where she serves as associate program director for the forensic psychiatry fellowship. Dr Resnick is a professor of psychiatry at Case Western Reserve University School of Medicine and has been a consultant on many high-profile cases, including those involving school shootings.

References

1. O’Toole ME. The School Shooter: A Threat Assessment Perspective. Federal Bureau of Investigation Academy. 1999. Accessed September 16, 2024. https://www.fbi.gov/file-repository/stats-services-publications-school-shooter-school-shooter

2. Alathari L, Drysdale D, Driscoll S, et al. Protecting America’s Schools: A U.S. Secret Service Analysis of Targeted School Violence. US Secret Service National Threat Assessment Center. November 2019. Accessed September 16, 2024. https://www.secretservice.gov/sites/default/files/2020-04/Protecting_Americas_Schools.pdf

3. Vossekuil B, Fein RA, Reddy M, Borum R, Modzeleski W. The Final Report and Findings of the Safe School Initiative: Implications for the Prevention of School Attacks in the United States. United States Secret Service. May 2002. Accessed September 16, 2024. https://www.secretservice.gov/sites/default/files/2020-04/ssi_final_report.pdf

4. Freilich JD, Chermak SM, Connell NM, et al. Overview of the American School Shooting Study (TASSS). Rockefeller Institute of Government. August 2022. Accessed September 16, 2024. https://rockinst.org/wp-content/uploads/2022/08/Overview-American-School-Shooting-Study-TASSS.pdf

5. Riedman D. K-12 School Shooting Database. (David Reidman, .XLS file sent via email communication, June 2, 2024).

6. Office of the Surgeon General; National Center for Injury Prevention and Control; National Institute of Mental Health; Center for Mental Health Services. Risk factors for youth violence. In: Youth Violence: A Report of the Surgeon General. Office of the Surgeon General; 2001.

7. Alathari L, Drysdale D, Driscoll S, et al. Averting Targeted School Violence: A U.S. Secret Service Analysis of Plots Against Schools. US Secret Service National Threat Assessment Center. March 2021. Accessed September 16, 2024. https://www.secretservice.gov/sites/default/files/reports/2021-03/USSS%20Averting%20Targeted%20School%20Violence.2021.03.pdf

8. Fazel S, Grann M. The population impact of severe mental illness on violent crime. Am J Psychiatry. 2006;163(8):1397-1403.

9. Meloy JR, Hoffman J, Roshdi K, Guldimann A. Some warning behaviors discriminate between school shooters and other students of concern. J Threat Assess Manag. 2014;1(3):203-211.

10. Peterson J, Densley J, Riedman D, et al. An exploration of K–12 school shooting threats in the United States. J Threat Assess Manag. 2024;11(2):106-120.

11. Weisbrot DM, Carlson GA, Ettinger AB, et al. Psychiatric characteristics of students who make threats toward others at School. J Am Acad Child Adolesc Psychiatry. 2023;62(7):764-776.

12. Calhoun FS, Weston S. Contemporary Threat Management: A Practical Guide for Identifying, Assessing, and Managing Individuals of Violent Intent. Specialized Training Services; 2003.

13. Calhoun FS, Weston SW. Perspectives on threat management. J Threat Assess Manag. 2015;2(3-4):258-267.

14. The effects of extreme-risk protection orders. RAND. Updated July 16, 2024. Accessed September 16, 2024. https://www.rand.org/research/gun-policy/analysis/extreme-risk-protection-orders.html

15. Fact sheet: Vice President Kamala Harris announces two gun safety solutions while continuing efforts to keep schools safe from gun violence. News release. The White House. March 23, 2024. Accessed September 16, 2024. https://www.whitehouse.gov/briefing-room/statements-releases/2024/03/23/fact-sheet-vice-president-harris-announces-gun-safety-solutions-while-continuing-efforts-to-keep-schools-safe-from-gun-violence/

16. Burr R, Kemp J, Wang K, Swan D. Crime, Violence, Discipline and Safety in U.S. Public Schools: Findings From the School Survey on Crime and Safety: 2021-22. National Center for Education Statistics at IES. January 2024. Accessed August 20, 2024. https://nces.ed.gov/pubs2024/2024043.pdf

17. Jackson JR, Viljoen JL. Preventing school violence: a review of school threat assessment models. J Threat Assess Manag. 2024;11(1):48-65.