Doris Fischer-Sanchez DNP, MSN, APN-BC, CPHRM
Assistant Vice President, Healthcare and Psychiatry Risk Management Group
No one will forget the images of students, parents, teachers, and first responders after the school shootings in Parkland, FL, Sandy Hook, CT, Columbine, CO, and Virginia Tech, VA, … to name only a few of the recent mass school shootings.
One of the first questions with tragedies like these is whether psychiatrists or other behavioral health providers knew or should have known that the youths involved in the shootings or with other acts of school violence were at high risk for such violent acts. What is not recognized is that mass shootings by people with serious mental illness represent one percent of all gun homicides each year according to “Gun Violence and Mental Illness” published by the American Psychiatric Association.1 However, there are opportunities for the psychiatrist and behavioral health providers to recognize and treat youths at risk for violence.
The Center for Disease Control (CDC) defines school violence as youth violence that occurs on school property.2 The violence can occur on the way to or from school or at school-sponsored events. A student/young person can be a victim, perpetrator or a witness of school violence. This violence may also involve/impact adults.3 Youth violence takes on various forms including: bullying, pushing, and shoving and in some cases assault with various types of weapons which can result in injury or death.4
Referrals for a psychiatric consultation for a child or adolescent come from a variety of sources, such as the school counselor, family, or law enforcement. These referrals may be based upon a concern with the individual’s behavior, such as postings on social media, interactions with or isolation from peers, and threats of violence. In addition, the minor may have other providers that he/she works with. Make sure that you obtain proper informed, written consent from all appropriate parties. If there are court documents or legal papers regarding who can consent for the minor and/or receive information, make sure you have a copy of the order for your files.
Discuss in advance with the parents or legal guardian and other providers what you can and cannot discuss with them regarding treatment. Obtain records from previous and current mental health providers and school counselors for effective care coordination.
Profile of a Violent Youth Offender
There is no accurate or stereotypical profile of a violent youth offender. Assessment is key. In 2002, the Secret Service report on Preventing School Shootings, concluded that there is no real profile of the violent youth offender.5 Of the identifiable violent youth offender characteristics, 25% of the student population have similar characteristics.6 Assessing and documenting patterns of behavior and frank communication, including access to firearms and thoughts of suicide or depression, are more concrete indicators of violence potential.7 In 75% of youth violence cases, at least one adult expressed behavioral concerns and in 50% of cases, at least two adults had expressed concerns over a youth who ended up becoming an offender.8
When a child or adolescent is suspected at being “high risk” for violence, documentation should reflect the assessment elements that have emerged as common themes among violent youth offenders.9 These elements, while not exhaustive, should be considered in a risk assessment of a potential violent youth offender and documented in the medical record:
- Change in behavior, such as social alienation, increased risk-taking, bizarre or erratic behavior
- Signs of being bullied or cyberbullied or perpetrating bullying/cyberbullying
- Recent loss of status or loss of a relationship – girl/boyfriend, pet, parent
- Personal failure and poor coping skills
- Suicide thought or attempt
- Thoughts of revenge
- Access to firearms/weapons
- Changes in or unstable home life
- Prior history of violence/cruelty to animals
- Drug, alcohol or tobacco use
- Preoccupation with weapons or violent video games
- Negative social media postings: bullying, “selfies” with weapons, announcing threats or plans for hurting others, cryptic messages
HIPAA/Duty to Warn
In 2013, after the events at Newton, CT and Aurora, CO, the Department of Health and Human Services clarified that HIPAA does not prevent the ability of mental health care providers to warn or report that persons may be at risk of harm.10 HIPAA allows the provider to advise family, law enforcement and those persons whom the provider believes will lessen the threat. This includes disclosing patient information from the mental health record if necessary.11 HIPAA does permit disclosure for these purposes, but it is important to understand your duty to warn/protect obligations under your individual state laws as they may differ.
The majority of the jurisdictions in the US follow one of three approaches for the obligations of a mental health provider to warn/protect third parties: mandatory duty to warn, permissive duty to warn and no duty to warn. There are differences among the states about: 1) whether you must disclose and 2) to whom you must disclose in order to meet your obligations. Keep in mind that many states are in the midst of examining/changing their duty to warn/protect laws as well as firearms access laws. It is important to stay up to date on any pending/enacted legislative changes. Seek risk management or legal advice before taking steps to disclose information.
Requests for Predictive Information
There may be times where you will be asked to assess the relative dangerousness of an at risk youth. This may be prompted by discussions the youth may have had among peers or others. Discussions may include violent fantasies or fantasy responses to violent video gaming. There is no definitive body of knowledge to determine whether fantasies will evolve into reality.12 Routine comprehensive assessment of the elements noted above establish the foundation for a diagnosis and treatment plan.
Avoid being cornered into affirming a profile pattern.13 Many violent youth have come from stable homes and had no observed behavior problems. The one commonality that has been identified is that the violent youth plans the attack, tells at least one person, and needs time to gather weapons- usually from their home or the home of a relative.14
Work with the family and various authorities to continue measures to prevent access to weapons and dissuade them from the unrealistic and false sense of security psychiatric treatment and medications alone will keep the at risk youth “under control.”
In the event that a patient makes a threat and encounters school difficulties (such as expulsion or suspension), prior to providing a written opinion on whether he/she is at risk or to reinstate him/her, consider consulting a risk management or legal professional. A letter predicting whether a patient is at risk of future harm should be carefully considered.
Psychiatrists have an important role in the assessment and treatment of at risk youth. While there is no stereotype or profile of the violent youth offender, there are specific areas for heightened concentration when assessing and attempting to determine the potential violent action a young patient may take. It is critical to keep in mind the relationship the patient has with significant adults in their lives, the relationship between the school and the detection of deviant behavior, institutional trust, the role that social media is playing in his/her life, isolation tendencies, access to firearms or other weapons, and the school based support available so that at risk youth have access to resources for conflict resolution.15 Remember to document consistently and weigh clinically whether communicating your findings to appropriate authorities may be necessary. Do not hesitate to contact risk management or seek legal advice if you have further concerns.
1 American Psychiatric Association Publishing. (2016). Gun Violence and Mental Illness. www.appi.org
2 CDC. (2016). Understanding School Violence Fact Sheet www.cdc.gov/violenceprevention
5 United States Secret Service. (2002). Preventing School Shootings: A Summary of a U.S. Secret Service Safe Schools Initiative Report. NIJ Journal, no. 248, 11-15.
10 45 CFR §164.512(j)
12 Bushman, B., et al. (2013). Youth Violence What We Need To Know Report of the Subcommittee on Youth Violence of the Advisory Committee to the Social, Behavioral and Economic Sciences Directorate, National Science Foundation, 1-43. https://www.nsf.gov/sbe/reports/Youth_Violence_What_We_Need_To_Know.pdf
13 Secret Service Report, 2002.
15 Bushman, et al.