Can We Intervene With Troubled Adolescents?
Can We Intervene With Troubled Adolescents?
After the Columbine High School massacre in 1999, the National Threat Assessment Center completed a comprehensive study of targeted (well-planned, premeditated) school violence. Their report concluded that "Almost three-quarters of the attackers felt persecuted, bullied, threatened, attacked or injured by others, prior to the incident." In the decade since Columbine, a more comprehensive, general profile has emerged that may help identify adolescents at high risk for violence -- though not necessarily targeted violence. It must also be emphasized that placing adolescents in a high risk category is far from being able to "predict" who will carry out a violent act. This is especially true of relatively rare events, such as mass shootings. As my colleague, Dr. James Knoll, notes in a companion piece, "The reality is that mass murder cannot be 'predicted' as such, particularly by persons outside the perpetrator's social circle. Any hopes of prevention must rely on various approaches acting together to provide a widely cast safety net."
Nevertheless, psychiatrists and primary care physicians should become familiar with the risk factors for adolescent violence and carefully assess these risks in their practice. In a recent book chapter on violent children and adolescents, psychiatrist Dr. Peter Ash lists a number of sociodemographic, familial, and neuropsychological factors that increase the risk for violence in younger populations. Some of the salient risk factors are summarized in the following Table.
Table. Selected Risk Factors for Violence in Adolescents
Modified from Ash P.
A detailed history of the adolescent's violent acts is critical. In addition, the physician's assessment ought to consider protective factors (such as a closely involved school or family); the intent and pattern of the adolescent's violent acts (are they mainly impulsive or predatory?); and the adolescent's potential for carrying out lethal violence (eg, possession of or easy access to firearms).
As Dr. Ash notes, "The assessment should take place in an environment where both the clinician and patient can feel safe. For high-risk youth, this requires a setting where the youth can be screened for weapons, is free of objects which can be used as weapons, and where others are rapidly available in the case of an impending assault from the patient."
Furthermore, "In discussing past violence with a youth, the interviewer may be hearing about criminal acts, and since such information could potentially be utilized to further criminal prosecution, issues regarding informed consent and confidentiality need to be thought through carefully."
Legal consultation may be advisable if the clinician is not familiar with appropriate safeguards and procedures in such cases. For mental health professionals, more detailed guidelines for assessing risk for violence are provided in Dr. Knoll's chapter on this subject.
With respect to structured assessment scales for determining violence risk in adolescents, Ash believes that the best-validated tools are the PCL:YV (Psychopathy Checklist: Youth Version) and the SAVRY (Structured Assessment of Violence Risk in Youth). Recently, Andershed and Andershed introduced ESTER, a research-based and computerized risk-need assessment system for youths (0-18 years) with or at risk for conduct problems. The ESTER system includes a useful screening tool/questionnaire, but more research is needed to establish the clinical utility of the ESTER system.
It is important to note that most of the research and assessment tools discussed have application to the "ordinary" violent behavior seen among school-age adolescents -- for example, impulsive or unplanned aggressive acts. We are still some distance from having reliable screening tools for planned or targeted violence, such as what occurred in Newtown. As a study by the National Threat Assessment Center and the US Secret Service pointed out over a decade ago, "The knowledge base of empirically researched risk factors for targeted school violence has not yet been developed, nor has any relationship been established between general youth violence risk factors or standard psychological tests/instruments and the occurrence of targeted violence." [Italics added]
Unfortunately, this caveat still applies over a decade later. Indeed, there is no substitute for careful observation, history-taking, and informed clinical judgment. As for structured assessment tools, Dr. Knoll notes that "...the standard of care does not require their use in clinical treatment settings."
Perhaps the most useful synopsis comes from the Interdisciplinary Group on Preventing School and Community Violence, writing in the aftermath of the Newtown shootings:
"Comprehensive analyses by the U. S. Secret Service, the FBI, and numerous researchers have concluded that the most effective way to prevent many acts of violence targeted at schools is by maintaining close communication and trust with students and others in the community, so that threats will be reported and can be investigated by responsible authorities. Attempts to detect imminently violent individuals based on profiles or checklists of characteristics are ineffective and are most likely to result in false identification of innocent students or other individuals as being dangerous when they actually pose little or no threat. Instead, school authorities should concentrate their efforts on improving communication and training a team of staff members to use principles of threat assessment to take reasonable steps to resolve the problems and conflicts revealed through a threat investigation."
Risk Factors for Violence in Adolescence
After the Columbine High School massacre in 1999, the National Threat Assessment Center completed a comprehensive study of targeted (well-planned, premeditated) school violence. Their report concluded that "Almost three-quarters of the attackers felt persecuted, bullied, threatened, attacked or injured by others, prior to the incident." In the decade since Columbine, a more comprehensive, general profile has emerged that may help identify adolescents at high risk for violence -- though not necessarily targeted violence. It must also be emphasized that placing adolescents in a high risk category is far from being able to "predict" who will carry out a violent act. This is especially true of relatively rare events, such as mass shootings. As my colleague, Dr. James Knoll, notes in a companion piece, "The reality is that mass murder cannot be 'predicted' as such, particularly by persons outside the perpetrator's social circle. Any hopes of prevention must rely on various approaches acting together to provide a widely cast safety net."
Nevertheless, psychiatrists and primary care physicians should become familiar with the risk factors for adolescent violence and carefully assess these risks in their practice. In a recent book chapter on violent children and adolescents, psychiatrist Dr. Peter Ash lists a number of sociodemographic, familial, and neuropsychological factors that increase the risk for violence in younger populations. Some of the salient risk factors are summarized in the following Table.
Table. Selected Risk Factors for Violence in Adolescents
| History of previous criminal acts, including nonviolent offenses |
| Poor parenting, including abuse and neglect; antisocial biological parent |
| Delinquent peers or gang membership |
| Poor social skills |
| Poor school performance, learning disabilities, frontal lobe dysfunction |
| Psychopathology, including conduct disorder, substance abuse, mood disorder |
| School's tolerance of bullying |
| Student lives in high-crime or severely disadvantaged neighborhood |
Modified from Ash P.
A detailed history of the adolescent's violent acts is critical. In addition, the physician's assessment ought to consider protective factors (such as a closely involved school or family); the intent and pattern of the adolescent's violent acts (are they mainly impulsive or predatory?); and the adolescent's potential for carrying out lethal violence (eg, possession of or easy access to firearms).
As Dr. Ash notes, "The assessment should take place in an environment where both the clinician and patient can feel safe. For high-risk youth, this requires a setting where the youth can be screened for weapons, is free of objects which can be used as weapons, and where others are rapidly available in the case of an impending assault from the patient."
Furthermore, "In discussing past violence with a youth, the interviewer may be hearing about criminal acts, and since such information could potentially be utilized to further criminal prosecution, issues regarding informed consent and confidentiality need to be thought through carefully."
Legal consultation may be advisable if the clinician is not familiar with appropriate safeguards and procedures in such cases. For mental health professionals, more detailed guidelines for assessing risk for violence are provided in Dr. Knoll's chapter on this subject.
With respect to structured assessment scales for determining violence risk in adolescents, Ash believes that the best-validated tools are the PCL:YV (Psychopathy Checklist: Youth Version) and the SAVRY (Structured Assessment of Violence Risk in Youth). Recently, Andershed and Andershed introduced ESTER, a research-based and computerized risk-need assessment system for youths (0-18 years) with or at risk for conduct problems. The ESTER system includes a useful screening tool/questionnaire, but more research is needed to establish the clinical utility of the ESTER system.
It is important to note that most of the research and assessment tools discussed have application to the "ordinary" violent behavior seen among school-age adolescents -- for example, impulsive or unplanned aggressive acts. We are still some distance from having reliable screening tools for planned or targeted violence, such as what occurred in Newtown. As a study by the National Threat Assessment Center and the US Secret Service pointed out over a decade ago, "The knowledge base of empirically researched risk factors for targeted school violence has not yet been developed, nor has any relationship been established between general youth violence risk factors or standard psychological tests/instruments and the occurrence of targeted violence." [Italics added]
Unfortunately, this caveat still applies over a decade later. Indeed, there is no substitute for careful observation, history-taking, and informed clinical judgment. As for structured assessment tools, Dr. Knoll notes that "...the standard of care does not require their use in clinical treatment settings."
Perhaps the most useful synopsis comes from the Interdisciplinary Group on Preventing School and Community Violence, writing in the aftermath of the Newtown shootings:
"Comprehensive analyses by the U. S. Secret Service, the FBI, and numerous researchers have concluded that the most effective way to prevent many acts of violence targeted at schools is by maintaining close communication and trust with students and others in the community, so that threats will be reported and can be investigated by responsible authorities. Attempts to detect imminently violent individuals based on profiles or checklists of characteristics are ineffective and are most likely to result in false identification of innocent students or other individuals as being dangerous when they actually pose little or no threat. Instead, school authorities should concentrate their efforts on improving communication and training a team of staff members to use principles of threat assessment to take reasonable steps to resolve the problems and conflicts revealed through a threat investigation."
