Engaging Youths for Accurate Risk Assessment in the Context of School Shootings

A series of high-profile school shootings, beginning in the 1990s, have focused the United States’ attention on the problem of school violence (1). Heavy news coverage and social media discussions about school shootings, such as the one in Parkland, Florida, in February of 2018, have stoked fears that the number of school shootings have increased dramatically in recent years. Indeed, “media contagion” may be a motivator for copycat shootings (2). On the other hand, many experts who study mass shootings, including those in schools, say that they are not happening more frequently but many of them are more deadly than past attacks. The numbers of school-associated violent deaths have not trended upward in the past 20 years (3). Additionally, the most recent federal data (4) show that other forms of student victimization are on a downward trend and that fewer students report fear of being hurt at school than in previous years. Children and youths remain much safer in schools than in the community. According to the National Center for Educational Statistics, “Between 1992–93 and 2015–2016, the percentage of youth homicides occurring at school each year remained at less than 3 percent of the total number of youth homicides. The percentage of youth suicides occurring at school each year remained at less than 1 percent of the total number of suicides” (3).

Extensive media coverage and the large number of deaths in high-profile school shootings have, understandably, generated a high level of public fear. This public fear “drove a dramatic shift in security-related policies and procedures in our nation’s schools. Many of those efforts proliferated in a desperate and well-intentioned effort to make schools safer, but they were often predicated on unrealistic appraisals of risk and misunderstanding about the nature of the actual threat” (1). Efforts such as zero tolerance—policies that seek to impose severe sanctions such as suspension and expulsion for minor offenses in the hopes of preventing more serious ones—have not demonstrated effectiveness. In fact, suspending and expelling children typically lead to worse overall outcomes for society in terms of healthy development and criminality (5). Measures such as arming teachers with guns also have yielded no evidence for effectiveness in decreasing school homicides (1).

Criminologists, media communications specialists, psychologists, and contagion-modeling mathematicians converge upon a similar conclusion: A key motivator of most mass shooters is the fame and power they perceive that they will achieve for their crimes. Many hope to garner as much or more media attention as the mass shooters who came before them and with whom they identify (6). A 2002 report of findings of the U.S. Secret Service Safe School Initiative (7) analyzed 37 school shootings and concluded that “there is no accurate or useful ‘profile’ of students who engaged in targeted school violence.” In the incidents analyzed, attackers were represented along the full social spectrum, from popular students to “loners.” The research found that the attacks were rarely, if ever, impulsive acts. In almost 80% of cases, the attackers communicated their ideas or plans before the incident. Typically, they told friends or other peer acquaintances—but rarely communicated a threat directly to the target of the attack. Few of these aware peers spoke up. “Kids get caught up in the code of silence that is so strong, they fail to see the larger picture” (8). In more than three-quarters of the incidents investigated, an adult had expressed concern about the attacker. “Many attackers felt bullied, persecuted, or injured by others prior to the attack” (p. 35), many had a history of suicide attempts or feelings of depression or desperation, and most had no history of criminal behavior (7). With this information, warning signs of violence may be identified and used to prevent serious premeditated violence.

Investigators have implemented automatic text-based analysis techniques to quantitatively and qualitatively analyze content of media messages sent by school shooters (8). Neuman and colleagues (9) identified a connection between social media and school shootings. Comparing texts written by six school shooters with 6,056 texts written by a comparison group of males using an automatic text-based analysis computer algorithm, they measured semantic similarities between words and texts. These semantic similarities (word vectors) represented four personality disorder dimensions: paranoid personality disorder, narcissistic personality disorder, schizotypal personality disorder, and depressivity. The words identified for text-based analysis were identified by Neuman et al. (9) based on the DSM-V criteria and Millon’s Personality Traits (10). They found that the shooters’ texts scored significantly higher on the Narcissistic Personality Disorder dimension, as well as the subcategories of the Humiliated and Revengeful dimensions (8, 9).

The Threat Assessment Model

It is important for schools to take all threats and concerns seriously, regardless of the profile of the student involved (3). The National Threat Assessment Center created a guide for implementing a comprehensive targeted violence prevention program in schools (11). This eight-step process (Box 1) includes a team-based identification and intervention plan for students who have been identified as possibly posing a risk to the school community.

Psychiatrists are often consulted by the school to assess dangerousness if a student says or posts online threatening content (12). Any student can make a threat, but few have a persisting violent intent that leads them to engage in the planning and preparation necessary to carry out an attack. The assessment of threat should include an appraisal of personality traits and behaviors, family dynamics, school dynamics, and social dynamics (13) and should consider protective factors as well as risk factors (12). Of particular importance is the clinician’s ability to therapeutically and honestly engage the student in the assessment to understand risk potential more fully (14).

Clinical Vignette

Joseph sat in the waiting room, his dark hoodie pulled up over his head and his eyes fixed on his cell phone. He appeared somewhat younger than his 16 years. His parents sat nearby, lines of worry on their faces. They smiled anxiously and stood up in anticipation when Dr. Tyler entered the room. Joseph did not acknowledge the entrance.

“Joseph, the doctor’s here,” his mother announced. She then asked, “Oh, should we all come in, or just Joseph?”

“How about if we all meet together initially to review plans for the assessment?” Dr. Tyler suggested.

“Joseph, come on,” Joseph’s father barked. Joseph stood up stiffly and walked behind his parents, not looking up from his device.

After introductions, Dr. Tyler said, “I’d like to hear your expectations of this assessment to make sure that we all agree on the purpose and process. Joseph, what were you told about coming here to meet with me today?”

After a pause and prodding by his parents, Joseph replied, “I don’t know. They just told me I had to come.”

“That’s not true, Joseph,” his mother blurted. “You know why you are here.”

“OK,” Joseph said monotonously. “They are afraid I am going to shoot up the school.”

“They said you needed a psychiatrist to say you were safe in order to be able to return to school,” his father added.

“I don’t want to go back to that stupid school,” Joseph announced.

“You told us you did,” his mother said sharply.

“Why would I want to go back there?” asked Joseph. “They called the cops on me just for writing a rap song.”

“Tell the doctor what the lyrics were,” his mother urged.

“Mom, I think she knows,” Joseph replied sarcastically. “They sent the records, you know.”

“Joseph, do what your mother says,” his father demanded.

Dr. Tyler sighed loudly to catch the family’s attention, as they became more upset. “Wow, this must be a really hard situation for everyone in the family,” she began.

“Duh,” Joseph said sarcastically, followed immediately by his parents’ admonishment.

Dr. Tyler began again, “Joseph, would you like to meet with me first or after I meet with your parents?”

“Go ahead and meet with my parents,” said Joseph. “No, I think I better go first so they don’t turn you against me.”

“It seems things have gotten tense between you and your parents. When did that start?” Dr. Tyler queried. Joseph grew mute and focused on his cell phone. He began to play a game on the device. “I guess you don’t want to be here,” Dr. Tyler opined. “I’m not here to get you in trouble. I want to get to know you and be sure that you’re OK and that everyone is safe. I see you are playing a game on your cell. Which one is it? I don’t recognize it. Are you good at them? Maybe I’m too old, but I just am not good at these games.”

“Yeah, I guess you could say I’m pretty good,” Joseph replied, trying not to smile. When asked about his aspirations for the future, Joseph replied, “I think I want to fly drones for the Air Force. Or be a rapper.”

Dr. Tyler asked about interests, strengths, friends, pets, and Internet use. She asked about family relationships. Joseph described his parents’ frequent fighting, with his father being verbally abusive to his mother. “I don’t really remember them ever getting along that well. My dad slapped my mom across the face once. My mom says they stay together for the kids. That’s stupid—it’s not helping us any.”

Once rapport began to be established and Joseph seemed to be more forthcoming, Dr. Tyler reviewed the questions from the Structured Assessment of Violence Risk in Youth (SAVRY). Joseph said that he had friends but that his parents thought they were “the bad kids.” He smoked marijuana twice weekly. He had been drunk a few times, but “I prefer grass.” His grades were falling. He didn’t see the point in doing well at school, since he just wanted to be in the military or be a rapper. He said that he was caught shoplifting when he was 12 but received no criminal charges. He hadn’t been in fights. He reported no specific traumas—he was spanked as a child but not hit with a belt or other object. He said there were no weapons in the home. He said he had not tried to get one, nor did he have the money to do so. Dr. Tyler and Joseph reviewed protective factors of community involvement, kindness to animals, attachments, and hopefulness.

Joseph was asked about the rap poem that led to the difficulties. He said he had shared the rap poem online with his friend, Peter. “Then Pete showed it to Max, even though he said he wouldn’t. I think it was Max who told the guidance counselor.” Dr. Tyler read the rap:

When asked about the meaning of the poem, Joseph said that rap songs “are always violent.” When asked if he had been hurt in a romantic relationship, he said that he had a crush on a girl, but “she didn’t like me. Sure, I wanted to get back at her. But I’m not going to shoot up the school about it. That was a long time ago, anyway.” He said that he had thoughts of suicide about a month ago, which was when he wrote the rap. He reported no current thoughts or plans.

Dr. Tyler took a detailed history from the family and consulted with school personnel. She reviewed social media posts and other records. Joseph did have risk factors on the SAVRY and a concerning lack of support. The police went through his computer and cell phone and did not find evidence of visiting weapons, shooter, or other violent Web sites. There were no weapons in the home.

Dr. Tyler diagnosed a depressive disorder. Joseph also had attention-deficit hyperactivity disorder, by history, but had not taken medication. Joseph had never been in mental health treatment. His parents said they wanted to get him help. The school team and parents devised a safety plan: They were referred to an intensive outpatient program/day hospital that included individual and group therapy, parent counseling, family treatment, and psychiatric care; and they set up a school plan for counseling, check-ins, and checking Joseph’s bag each morning for unsafe items. The school provided a mentor, a well-liked teacher who would meet with him regularly for support and encouragement, in addition to the school counselor.

Tips for Engaging and Assessing Youths Who Have Threatened Violence

An open-ended narrative, as well as structure to ensure a comprehensive evaluation, is indicated for a thorough psychiatric evaluation. For assessment of youth dangerousness and threat, rating instruments may provide more objective and comprehensive information. Perhaps the most commonly used is the SAVRY (15). The SAVRY is based on the structured professional judgment model and contains 24 items grouped into three domains of historical, social–contextual, and individual–clinical items.

U.S. Secret Service research identified 13 themes to explore when conducting a threat assessment investigation: motives; concerning or threatening communications; inappropriate interest in violence or weapons; access to weapons; stressful events; evidence of hopelessness/suicidality; the effect of emotional and developmental issues; whether the student views violence as an option for solving problems; concern by others about the student; evidence of planning; capacity to carry out an attack; consistency between the student’s statements and actions; and protective factors such as positive or prosocial influences or events (11). Although most threats are not likely to end in tragedy, psychiatrists must hone their skills in thorough risk assessment, with the caveat that there are limits to predictive ability.

The completion of a thorough threat assessment requires an honest doctor–patient relationship—which includes the physician’s specification of the limitations for confidentiality in the threat assessment domain (16). Many youths who threaten are in emotional distress and crisis. An attitude of caring, listening to a “cry for help,” and engaging around the youth’s aspirations and dreams are essential. It is also essential to engage caregivers in giving an honest history and specifying their concerns without unexpected repercussions.

Establishing a collaborative mutual partnership with the youth, family, school, and community providers can assist in the threat assessment and guide interventions that are most appropriate to meet the youth’s needs (11). The following are practical tips for a youth assessment:

1. Clarify the consultation question: Is it a “safety to return to school” assessment, an assessment of threatening behavior, social media, or other?

2. Meet and collaborate with the school team, primary care practitioner, guardians, outpatient treaters, and other individuals who know the youth well. Access all appropriate information about the threat(s), legal charges, and level of concern of school staff and peers.

3. When meeting with the youth and the parents or guardians, discuss the reason for the assessment and limitations of confidentiality up front. An assessment of probable risk to self or others is not confidential. Abuse or neglect by caretakers fall under mandated reporter statutes.

4. Reassure through words and actions that you are interested in understanding the youth and helping to determine what would be most helpful and appropriate. Clarify that a team is working together around this and that it is not just your assessment that will determine recommendations made.

5. Ask the youth directly his/her point of view about the events and the potential to harm himself/herself or others.

6. Assess the youth’s developmental level (cognitive, physical, and emotional) to make a more accurate assessment and recommendations. Use developmentally appropriate language and/or materials. Drawing a person or his/her family may be useful.

7. Assess for psychopathology, trauma, substances, and family and school environments. Ask about bullying or harassment.

8. Ask about Internet use—sites visited and “any sites you would rather your mother didn’t know about.” Ask specifically about weapons sites, sites about school shooters or other violent individuals, sites that promote self-harm, or meeting up online with individuals who could be stalking.

9. Use open-ended questions as well as a validated scale for risk assessment (e.g., the SAVRY).

10. Identify strengths, interests, and protective factors.

11. Ask about pets and how the individual treats animals. Ask about any relationship violence.

12. Elicit information about recent stressors (rejections, embarrassments, failures, etc.).

13. Ask the youth and caregivers about what they feel is going well and what is not going well and their ideas about what would be helpful.

14. Clarify with the team the timeline and what to expect after the assessment. Ensure that the family and youth understand the legal processes associated with school discipline (suspension, expulsion, out-of-district placement, etc.).

15. Make recommendations about the youth’s risks and needs, and plan to ensure safety as specific to the youth and as implementable as possible.