To the Editor: In their Treatment in Psychiatry article, published in the February 2008 issue of the Journal, Nora K. McNamara, M.D. and Robert L. Findling, M.D. (1) reported on the management of an adolescent patient with psychosis who was found with a loaded gun at school. Drs. McNamara and Findling noted that after the patient was released from a brief psychiatric hospitalization, he was “no longer agitated” and even “return[ed] to his high school for two classes per day” (1, p. 191). Their article does, however, raise some unanswered questions.
The authors’ clinical description did not address several important aspects of managing aggressive students, as documented in relevant literature (2). For example, were there no charges pressed against the patient for bringing a loaded gun to school? It seems implausible that no charges were filed, given that even milder transgressions have resulted in severe consequences. If the patient avoided expulsion, was there knowledge of how his support system was mobilized upon his return to school in order to address safety concerns?
Cornell and Sheras (3) developed detailed school practice guidelines for conducting threat assessments. Such assessments, which have been field tested in 35 schools, consider the context and meaning of a student’s behavior and make key distinctions between transient threats (ones that are easily resolved) and serious substantive threats (ones that pose continuing risk or danger). Even if the threat of violence was a symptom of the patient’s emotional disturbance, the school and treating clinician would have a responsibility to balance the patient’s rights with school safety. Drs. McNamara and Findling advised the treating physician to “communicate effectively with school personnel to help educators develop appropriate accommodations for the youth in the least restrictive teaching environment” (1, p. 193).
Most notably absent in the hypothetical case report presented by Drs. McNamara and Findling was any emphasis on the urgency of seamless communication between school personnel and the student’s psychiatrist in order to enhance 1) the evaluation of any potential threat and 2) monitoring of this vulnerable student. School mental health clinicians can provide critical collateral information about a patient’s functioning, and for the type of patient presented in the authors’ hypothetical case report, with proven access to weapons, school personnel may be the first to identify any change in function if the patient does not take his or her medication. There is a critical need for clinicians to maintain the patient’s confidentiality while also increasing school safety by establishing a coordinated effort of sharing relevant information with school personnel. Such an effort may, consequently, detect and address the reasons why a student has deteriorated.
Assessments of student safety are time-limited, and psychiatrists need to partner with schools and parents in order to advocate for a rapid response if disturbing changes, which might warrant an intensification of services (e.g., therapeutic school), are prevalent in the student. The treating clinician is in the challenging position of assessing a patient’s risk for violence and making decisions regarding the management of any potentially violent behavior. The sobering reality is that we cannot accomplish such challenging assessments alone.
1.McNamara NK, Findling RL: Guns, adolescents, and mental illness. Am J Psychiatry 2008; 165:190–1942.Rappaport N: Survival 101: assessing children and adolescents’ dangerousness in school settings. Adolesc Psychiatry 2004; 28:157–1813.Cornell DG, Sheras PL: Guidelines for Responding to Student Threats of Violence. Longmont, CO, Sopris West Educational Services, 2006
Dr. Rappaport reports no competing interests.
This letter (doi: 10.1176/appi.ajp.2008.08030327) was accepted for publication in April 2008.