AMA Journal of Ethics^®

School shootings such as the Columbine and Virginia Tech tragedies have heightened administrators' and teachers' fear that their students are capable of lethal violence. Initiatives to ensure safety have ranged from zero tolerance for weapons and expanded security measures (e.g., metal detectors or school resource police officers) to student threat assessments by multidisciplinary teams. Some schools have taken extreme measures and garnered national media attention for their response to the threat of student violence. For example, one school district in Texas certified its teachers to carry weapons in the classroom and sanctioned them to respond to a threat with deadly force if necessary [1].

Arming teachers can give schools a false sense of security and may distract staff from critical preventive efforts. Despite the amount of media attention they receive, school shootings are rare events; schools are one of the safest places for children to be. Indeed, a child has a greater chance of being hit by lightning than being shot in school [2]. Less than 1 percent of all homicides among children ages 5 to 19 years occur in and around the school [3]. Still, lethal violence occurs in American schools more often than in schools in other developed industrial countries. But a teacher's discharging a weapon in response to a student's threat creates a potentially dangerous scenario that could escalate an already volatile situation. Although it is difficult to predict with accuracy what will deter potential school assailants, many school shooters also killed themselves. In such cases an armed teacher may not have been a successful deterrent.

Arming teachers is a desperate school policy initiative, one that illustrates the degree to which some school personnel feel under siege. Frightened teachers describe walking on eggshells and waking up at night afraid of the secret volatility of students. Concerns for the safety of both students and staff should not be dismissed. Schools are struggling with the urgent and pressing need to differentiate between students who are sounding an alarm when in crisis and those who may jeopardize the safety of themselves and others.

Better Approaches to Reducing Violence in Schools

In response to the schools' needs to address possible threats to safety, it is critical to employ a multifaceted strategy that, among other approaches, makes it more difficult for students to bring weapons to school. This strategy is analogous to public health interventions for reducing traffic fatalities that put the emphasis not only on the driver but also on changing the car by, for example, improving the window strength or the flexibility of the steering wheel. Similarly, control of firearms can improve safety in schools. A 1995 study of a nationally representative school-based sample of adolescents in grades 7 through 12 found that access to a gun at home was associated with carrying a gun to school [4]. Educational and medical organizations could advocate together for more stringent gun-control laws that restricted access and banned the sale of military-style assault weapons like those used in the Virginia Tech, Columbine, and Northern Illinois University killings.

While restricting access to guns is a critical step in reducing the threat of student violence, schools need to implement policies to identify and help students who may pose a threat to staff or students. Efforts such as infectious-disease control and mandatory immunizations have set a solid precedent. Following these models, school and medical organizations could develop consensus guidelines for safety measures that, if enacted and enforced, would reduce school violence. Schools can build on the numerous programmatic options they have already implemented, including conflict-resolution programs, bullying-prevention programs that discourage students from ostracizing others, programs that teach student bystanders to deter aggression, and incentives to encourage positive behavior [5, 6]. Yet schools have a long way to go; the implementation of sound policies is inconsistent and relies on the confidence, knowledge, and perceived self-efficacy of school personnel.

Physicians can partner effectively with schools through advocacy, encouraging preventive measures, and helping respond to individual students. Indeed, clinicians (e.g., physicians, psychiatrists, psychologists, interns) who work in or with schools may encounter students who have threatened a peer or teacher with violence, gotten into a physical fight with another student, carried a weapon to school, or thought of obtaining a weapon for self-defense. It is critical that these clinicians have guidelines for determining how to care for students who may pose a threat to others or be in danger of being the victim of violence. Some promising approaches follow for clinicians who work with or consult to schools on matters of safety.

Threat Assessment

Clinicians who work with schools have a valuable resource to offer when consulting with staff and administrators on threat and safety assessment. Staff members frequently witness a variety of behaviors from students that are cause for concern, such as a poem written in an English class that mentions harming a teacher, a message on a MySpace page threatening another student, or hallway gossip about a student's weapon in his locker. It can often be difficult for staff to differentiate between behaviors that are harmless expressions of frustration and those that pose a more serious threat. At the same time, it is unrealistic that the medical professional will “clear” the student to return to school. It is not possible for anyone to predict with certainty a student's potential for violence. Schools should have a clear understanding of both the utility and limitations of physicians' evaluations and use them as opportunities to improve the safety net for vulnerable students.

Over the last 9 years, Nancy Rappaport has supervised or examined more than 150 students who were identified as potential safety risks to help schools with decision making and accessing resources. These safety assessments include home visits; interviews with the child, parents, and teachers; and analysis of reports of the violent incidents and school records [7]. Some of the fundamental concepts of threat assessment that are particularly useful for physicians, interns, and other clinicians working with schools can also be adopted by physicians who find themselves involved in threat assessment. Pediatricians and emergency room physicians may be asked to evaluate a student who has a physical injury that occurred during a school fight. A psychiatrist in an emergency room may evaluate an explosive student who has made inflammatory threats. A medical student may have a frightened teenager confide that her ex-boyfriend is planning to bring a gun to school to “even the score.”

Frameworks for Examining Threats and Aggression

A team of FBI experts created principles for conducting threat assessments based on their careful analysis of school events in which students killed multiple individuals [8]. Rather than presenting a checklist to profile students, the guidelines emphasize the process of evaluation, providing questions for uncovering a student's motives and goals as a means for determining the extent to which the student has the motivation, intent, and resources to carry out the threat. Currently, there are no standardized guidelines for clinicians regarding the information they should obtain before sharing responsibility with the school about the safety of a student, what kind of follow-up should be provided, and who takes responsibility for ensuring this happens. It would be useful for physicians to create such guidelines, based on a case consultation model, as a standard of medical care when working with aggressive students [9]. These standards of care would clarify expectations and responsibilities for both clinicians and schools.

While it is beyond the scope of this article to enumerate all guidelines that would be helpful, some recommendations follow for assessing situations that involve violence or threats of violence.

Distinguishing between Transient and Substantive Threats. One way to classify threats is to distinguish them as transient or substantive [10]. Transient threats are those that are made while a student is upset but has no real intent or plan. An example is the student who says, “I wish I could blow up this school” after he earns detention time. When the student is questioned about the statement, it is discovered that he has no motive to blow up the school and has no access to explosive materials. A substantive threat involves a more formalized plan with means and intent to carry it out. Here an example is the student who posts a threat online to harm a peer and, when questioned, has access to a gun and has planned how and when the attack will occur. Clearly, substantive threats require immediate action, and the clinician should work with the school to notify the parents and police for the safety of all parties involved. Most transient threats require monitoring rather than urgent intervention.

Evaluating and Treating Students with Aggressive Behavior. Clinicians are not only called upon to assess a formal threat; sometimes they are asked to evaluate a student who has a pattern of aggression to help determine risk for further dangerous behavior. When assessing such students, a distinction should be made between proactive and reactive aggression. Reactive aggression is characterized by a response to a threat or perceived threat (e.g., a student flipping over a desk when he finds out he failed a class). In contrast, proactive aggression typically involves premeditated aggression toward an intended victim (e.g., an adolescent waiting after school to “jump” a peer). Proactive aggression is of greater concern in threat assessment; students who exhibit past instances of it are considered more capable of carrying out a planned assault [11].

The student who is aggressive in school warrants a comprehensive diagnosis and treatment plan. Schools often do not have resources to contain students' aggression. At the same time, practicing clinicians rarely have the flexibility to mobilize intensive resources quickly enough to stabilize an escalating crisis. This can cause clinicians who are not familiar with school policies to feel powerless in trying help families advocate for necessary resources [12]. Accessing mental health services and community resources is often daunting even for the most savvy consumers and seasoned clinicians, but in these precarious situations where timely access is essential, it can be even more difficult to acquire appropriate, timely therapeutic support. Schools have sometimes responded with on-site services, although frequently these services do not involve necessary family treatment [13]. To successfully manage these students, communities need to develop continuity of services from easy access to clinicians, home-based family services, emergency services, and hospitalizations. Strong partnerships between schools and mental health services will improve the treatment for these vulnerable students.

Identifying At-Risk Students. In addition to assessing individual students or events, clinicians should be aware of resources for both students who are at risk for carrying out a violent act and for those at risk of being the victim of such an act. By linking students to resources, clinicians can help prevent violence or the threat of it before it occurs. Following are two programs that have demonstrated early success in helping prevent youth violence.

Gun Buyback Programs

Clinicians are afforded the opportunity to provide a confidential space where students can talk about the threats and fears they experience and the steps they take to feel safe. Some students obtain firearms as a means to feel safe or to defend themselves in their neighborhoods but later recognize the dangers of possessing an illegal firearm and do not know where to turn for help. Clinicians should be aware of resources for students to turn in weapons—one being the Boston Gun Buyback Program, which provides a location for Boston residents to turn in guns, no questions asked, in exchange for a $200 Target gift card. This program has demonstrated success in getting guns off the street; between 1993 and 1996, when the program originally ran, approximately 2,800 guns were turned in to authorities [14].

Anonymous Reporting of Threats

While many violence-prevention efforts in schools understandably focus on identifying possible offenders, students who are victims of threats or harassment and those aware of students who may threaten violence should not be overlooked. Indeed, other students are often the best source of information about possible violence perpetrated by their peers; many, however, are reluctant to notify adults of a possible threat due to fear of retaliation. Moreover, a “no snitching” culture in schools deters students from informing adult supports of threats. One innovation to combat this is the use of anonymous web- and text-message-based reporting of threats. A student can log on to a web site such as http://www.schooltipline.com and post an anonymous message alerting school officials to a potential threat. While anonymous tips present the risk of false accusations and alarms, using new technologies to offer students a safe and reliable way to report possible deadly threats has shown promise in pilot programs [15].

Publicized incidents of school violence, especially school shootings, can cause school officials to believe that they must explore every possible option for deterring violence. We believe that extreme measures, such as arming teachers, are not likely to be effective and actually may put students and staff at greater risk. Instead, a coordinated, systemic approach to responding to threats is considered the best practice, and psychiatrists, psychologists, interns, and medical students can play key roles in the process. Clinicians can be front-line defenses—identifying and classifying a threat and mobilizing resources to respond without carrying a weapon. The threat of aggression warrants a rapid and thorough response by the medical profession which mobilizes services to schools and students to guarantee safety.