Rakesh C. Patel, M.D. 1812 North Mills Avenue Orlando, FL 32803 Education: Division of Urology, Department of Surgery Current Position: June 2003-present University of Florida Urology Research Award, 2002 Licensure: Book Chapters: Endourological Management of Ureteral Strictures, Rakesh C. Patel, M.D. Professional Associations: American Ur
sydneyrx2014.com Online ED Drugstore is an 1st. pharmacy providing a personal service to the society in Australia. Over 50,000 extremely satisfied buyers! We're your prescription drug store cialis australia and have provided trusted service to families in Australia for over 15 years.
Chi20673 847.852Schuyler W. Henderson, M.D., Michael S. Jellinek, M.D.
Prelude to a School Shooting? Assessing Threatening On March 21, 2005, Jeffrey Weise, a 16-year-old student at Red Lake 16, 2007, the deadliest school shooting in U.S. history High School, Minnesota, killed his grandfather and his grandfather_s occurred at Virginia Tech when a student, Seung-Hui girlfriend. Next, he drove his grandfather_s squad car to the high schooland fatally shot a security guard. Before mortally wounding five students Cho, gunned down 32 students and teachers and and a teacher and injuring seven others, Jeffrey smiled and waved. He wounded another 25 before taking his own life.4 then committed suicide by shooting himself in the head.
As each school massacre unfolds, debate in the media recurs as to where blame can be laid. BExperts[ and Weise left many dark and depressive postings on Web sites such as pundits will make claims about the purported roles of Bnazi.org,[ calling himself BTodesengel[ (German for Bangel of death[) all aspects of the school shooters_ life, from violent and BNativenazi.[ He dressed in black and wrote stories about schoolshootings and zombies. Weise_s Internet animation, BTarget Practice,[ movies, video games, gun control, heavy metal music to depicted his blueprint for murder and suicide.1 Weise was reportedly parenting techniques and antidepressant medications.
taking Prozac and had been hospitalized for suicidal behavior.2 His There is, however, little evidence to draw on to explain father had committed suicide after a standoff with police and his motherwas in a nursing facility after sustaining head injuries in a car accident.3 this frightening phenomenon. This is also true aboutstudents who make threats. With few studies of these Columbine. Red Lake. Virginia Tech. Merely invoking students, the child and adolescent psychiatrist must the names of these schools is enough to introduce the extrapolate lessons from related studies of aggression in topic to be discussed. Since the 1999 Columbine High childhood and adolescence and a nonscientific literature School shooting, child and adolescent psychiatrists have based on reports in the press about school shooters.
been called on with ever-increasing frequency to A major symposium, partly prompted by the evaluate children and adolescents who have made Columbine High School shooting, took place in 1999 threats toward other students or school staff. On April when the National Center for the Analysis of ViolentCrime brought together 160 law enforcement person-nel, school personnel, and psychiatrists and other mental Accepted March 19, 2008.
Clinical Perspectives aims to provide a venue for exploring topics of health professionals. Eighteen cases of school shootings importance to child and adolescent psychiatry, fostering discussion about these or foiled shooting attempts from the 1990s were issues, educating child and adolescent psychiatrists and the broader medical studied.5 The FBI had exclusive access to the case community, and bridging clinical practice and research. Where applicable, files, and a number of the law enforcement and school appropriate permissions for publication were obtained from the patient(s).
Dr. Weisbrot is with Stony Brook University Medical Center.
personnel at the symposium were present during the The author expresses grateful appreciation to Alan Ettinger, M.D., Gabrielle A.
actual shooting incidents and had known the school Carlson, M.D., and Kathy Grzymala for their support of this work. The author shooters personally.6 A key finding of the symposium also thanks the Clinical Perspective Section editors Drs. Michael S. Jellinek andSchuyler W. Henderson for their invaluable suggestions in the preparation of this was that school shooters indicated their plans before the shootings occurred through direct threats or by The case vignettes described in this article are composites created by the author implication in drawings, diaries, or school essays.
and do not refer to any specific patient or family.
Correspondence to Dr. Deborah Weisbrot, Putnam Hall, South Campus, A similar study was performed by the Secret Service Stony Brook University Medical Center, Stony Brook, NY 11794-8790; e-mail: and the Department of Education, aiming to identify information available before a school attack that could 0890-8567/08/4708-0847Ó2008 by the American Academy of Child and be used to formulate policies and strategies to prevent school attacks.7 The study examined 37 incidents of J. AM . ACAD . CHILD ADOLESC. PSYCH IAT RY, 47:8, AUGUST 2008 Copyright @ 2008 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
school violence involving 41 students who attacked Threat assessment requires a thorough psychiatric someone at his or her school with lethal means (e.g., diagnostic evaluation, including fundamental assess- gun, knife) and where the student attacker purposefully ments of suicidality, homicidality, thought processes, chose his or her school as the location of the attack. The reality testing, mood, and behavior. As always, a detailed findings were similar. In more than three fourths of developmental and educational history should be incidents, at least one person had information indicating obtained with a specific focus on abuse, past trauma, that the attacker was thinking about or planning the school suspensions/expulsions, school performance, and school attack; in nearly two thirds of incidents, more peer relationships. One needs access to descriptions of than one person had information about the attack before the actual events leading to referral. In an office-based it occurred. However, the information known by other setting, the clinician should request collateral informa- students or friends was rarely communicated to adults.
tion in the form of past school records and previous Furthermore, most attackers did not threaten their psychological and psychiatric assessments. A detailed written or verbal description of the incident from school The assessment of a student associated with poten- administration is needed; description by the child or tially threatening behaviors presents diverse challenges parents is generally insufficient, although in an to teachers, school administrators, and mental health emergency department evaluation, it may be the only professionals. They may ask, BWill this student be the information available. In this case, the clinician should next school shooter?[ and BIf I miss something, will I be chart efforts to obtain this information and to ensure responsible for the next school shooting?[ These fears adequate follow-up if the child is to be discharged from often lead to the knee-jerk reaction of removing any the emergency department. Obtaining this information student with suspected threatening behavior. Although may also be difficult when a student has been suspended the actual school shooters were likely to have made for a long time or when legal implications promote threats, the number of completed school shootings is reluctance by school administration or parents to share extremely small compared to the number of threats occurring in school but never acted on. The exact Specific issues include whether a threat has indeed number of actual threats occurring each year is been made, its severity level and the child_s ongoing unknown. In 2003, an estimated 9.3% of all U.S.
intent, the focus of the threat, the intensity of threat students in grades 9 through 12 had been threatened or preoccupation, access to weapons, and degree of concern injured with a weapon in school,8 suggesting school- expressed in the child_s environment. A Bthreat[ can be related threats of violence are not a rare occurrence.
defined as an expression of intent to do harm or act out Remarkably, there is limited psychiatric literature on the assessment of child or adolescent threatening Threats can be categorized according to level of behaviors, and few of us received training in threat realism.5 In low-level threats, there are no strong assessment during our child and adolescent psychiatry indications that preparatory steps were taken and fellowships. This Clinical Perspectives section is based realism is lacking. There may be vague allusions to on my experience in evaluating 114 students during the violent books or movies. Medium-level threats are those course of 9 years running an outpatient child and that could be carried out; they may not appear realistic, adolescent psychiatry clinic receiving referrals from but they are more direct and concrete and may give more than 25 school districts in eastern Long Island, general indications of place and time. High-level threats represent an imminent and serious danger; they containdirect, specific, and plausible plans.
Direct threats have clear content indicating intent (e.g., BI know where to get a gun and I_m going to shoot A 15-year-old girl_s crumpled paper with a Bhit list[ to kill five students you and your buddies[). Indirect threats are vague, unclear, and ambiguous (e.g., BYou_re going to be sorryyou ever said that,[ BI could kill you if I wanted to[).
A 12-year-old boy announced, BI have a gun in my locker,[ and laterannounced he was going to shoot. After returning from 1 week of Veiled threats are more suggestive of intent (e.g., BThis suspension, he declared, BA bomb, here and now![ school would be a lot better off if you weren_t here)[, J. AM. AC AD. C HIL D AD OLESC. PSYCHIATRY, 47:8 , AUG UST 2008 Copyright @ 2008 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
whereas conditional threats include a demand (e.g., behaviors and/or paranoid ideation, an intensified BYou_d better not fail me. If you do, I_m going to bomb perception of dangerousness may occur.
the school[).5 Sometimes threatening statements blur Another red flag is a history of trauma or violence, these categories and cannot be easily classified.
either as victim or perpetrator. The clinician needs to With respect to access to weapons, numerous devote time in the interview(s) to explore and formulate epidemiological studies document a direct relation the meaning of the student_s threat behavior in the between accessible firearms and young people_s risk of context of his or her history. For example, a child_s homicide and suicide.9 All children and their parents experience of witnessing parental conflict and aggression need to be asked about a child_s potential access to may engender aggressive and antisocial behaviors.12 The weapons, both inside and outside the home. I routinely child_s earlier responses to fears of threat in his or her provide parents with the American Academy on Child environment may play a significant role in the later and Adolescent Psychiatry_s gun safety handout10 when development of threat behavior as traumatic memories the evaluation is completed. When the evaluation is are evoked. Complex identifications with a parent and/ initiated through a school and involves only an or subtle ways where a parent covertly encourages evaluation session(s), the psychiatrist should initiate threatening behaviors are likely to take more than one direct contact with a school mental health professional to ensure that appropriate follow-up on psychiatricconcerns is pursued. Child protective services may also need to be contacted if the child_s psychiatric care isbeing neglected. If an imminent danger to others is A 14-year-old boy was drawing violent pictures in school. At age 10, he thought to be present, then the issue of duty to warn sprinkled lighter fluid on another child and threatened to light a match.
becomes the responsibility of the psychiatrist, and Preoccupied with his drawings and stories about aliens and superior confidentiality will need to be breached to inform the violent characters; he considered himself one of the world_s greatestcartoonists.
target(s) of the threats, as well as the police.
A student_s preoccupation with violent themes can emerge in diverse contexts. Leakage is a term originallyused in an FBI monograph to describe potential Bclues The basis for a study of actual aggression must be a study of the roots of signaling a potentially violent act including, feelings, thoughts, fantasies, attitudes and intentions.[5 Exam- Any assessment of threats must to look beyond overt ples include direct threats, boasts, doodles, Internet sites symptomatology to probe the multiple levels of mean- (e.g., MySpace, YouTube), songs, tattoos, stories, and ings of behaviors and how aggression is integrated into yearbook comments with themes like death, dismem- one_s personality. In the following five sections, the berment, blood, or end-of-the-world philosophies. No focus is on thought processes, preoccupations, fantasies, conclusion can be drawn from these clues in isolation; and conflicts, all of which are needed in a threat violent drawings/themes can be developmentally appro- priate and are common in adolescence. Understandingthe context is critical. During an interview, students typically minimize such preoccupations with comments What makes some student_s threats more disturbing such as BThey_re just drawings, I would never hurt than others? Ultimately perhaps, the concern is clinched anyone[ or BIt was a stupid thing to say. I didn_t mean by the intuition of the astute clinician who senses signs of the student_s dark, inner rage, particularly in the The psychiatric evaluation must delve into the nature of context of social isolation from family and peers as well these materials to clarify the nature and degree of violent as the student_s emotional disconnection during the preoccupation. In a student who is obsessed with violence, interview. Furthermore, intense immersion into fantasy the theme is likely to emerge no matter what the nature of combined with less-than-secure reality testing should the discussion. Clearly, many adolescents are fascinated also arouse concerns. When an adolescent_s odd beliefs with violent and/or macabre themes; this can be a or magical thinking are combined with suspicious developmentally appropriate and common experience. I J. AM . ACAD . CHILD ADOLESC. PSYCH IAT RY, 47:8, AUGUST 2008 Copyright @ 2008 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
have found it helpful to include several projective measures (about 50% in my series of 114 students evaluated for as part of the psychiatric evaluation to potentially obtain threats). They are often socially isolated loners who these clues, including a sentence completion measure and conceal retaliatory thoughts. Such students have been asking the student to draw a picture of him- or herself.
described as Binjustice collectors[ who nurse resentment Sometimes, the traditional question of asking the child or about real or perceived injustices. No matter how much adolescent to provide his or her life story can also time has passed, the Binjustice collector[ will not forget illuminate underlying violent preoccupations.
or forgive those wrongs or the people he or she believesare responsible.5 In the Safe Schools Initiative Study, 29 of the attackers (71%) were reported to have feltpersecuted, bullied, threatened, attacked, or injured by An 11-year-old boy made multiple threats toward other children. He others before their attack.7 Although it has often been had severe attention-deficit/hyperactivity disorder. His parents were avidhunters who did not believe in standard safety precautions for guns. The assumed that threats result from intense teasing and boy stated he knew that guns were kept in the parents_ bedroom closet.
bullying, it is nevertheless unclear whether students who When this concern was raised, the father angrily exclaimed, BOur child threaten school violence are teased and bullied more than their peers. What is important to explore during a Denial refers here to the parent_s acceptance of the threat assessment is the student_s reaction to such child_s threatening behaviors and a limited reaction to behaviors that most others would find disturbing or Another hypothesis centers on the presence of covert abnormal.5 Parents who are in denial respond defen- power dynamics in schools with a high level of violent sively to real or perceived criticism of their child; the episodes. For example, in these situations, there may be parents appear unconcerned, minimize the problem, or Bconspiracies of silence[ in which students remain silent while their peers are being harassed.13,14 Parents may present as angry and defensive when Psychiatric assessments should query a student_s psychiatric evaluations are school mandated. Often the experiences of bullying and teasing, including their child has been suspended for indeterminate duration, reactions and responses and the student_s experiences with education disrupted; the child and parents attend of how his or her peers are responding to this bullying.
intimidating disciplinary hearings with school district Once the clinician discovers a history of teasing or officials. Some parents may not accept the notion of bullying, intensive inquiries should be made about their child threatening others and consider their child to retaliatory fantasies and whether these become diffuse, be a victim. I have found the most disturbed children with a desire to retaliate against not just perceived often had parents who demonstrated pathological levels perpetrators but also those who are perceived as of denial, a statement of the potential contribution of colluding in the bullying. Revenge fantasies may be parental psychopathology. Such attitudes may be associated with Bsoft[ psychotic symptoms, including associated with a chaotic home environment, highly vague paranoid ideation, ideas of reference, or vague conflicted parentYchild relationships, and inadequate limit setting.5 These problematic parental responses There is no evidence that proves that interest in leave the impression that if the child revealed threats at violent video or Internet games, BGoth[ culture, music home, then the parents would minimize such behaviors, with dark or morbid themes, and so forth directly leads potentially heightening the threat risk.
to threatening behaviors. Nevertheless, immersion intovarious cultures of violence, including involvement with a troubled peer group or identification with violentgroups, could promote antisocial and threatening A 12-year-old boy with severe anxiety and social skills deficits was behaviors; the psychiatrist should delve into these severely teased throughout elementary school. One boy kicked his potential issues during the interview. In some cases, backpack, and another teased him as having a nerdy backpack. Later in Bcontagion[ and Bcopycat[ dynamics can also occur, as the day, H. said, BI_m going to get a gun and kill those kids.[ in a recent episode involving two students planning to Children and adolescents who threaten others attack a school and creating a journal that frequently frequently have histories of being intensely teased J. AM. AC AD. C HIL D AD OLESC. PSYCHIATRY, 47:8 , AUG UST 2008 Copyright @ 2008 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
prolonged suspension or expulsions, it may be difficult As was the case for Jeffrey Weise, a number of the for the student catch up on course work. College school shooters committed suicide or attempted to do applications may be ruined by notations on a student_s so. In students referred for threats, depressive symptoms and suicidal ideation may also be present, and a careful School suspensions lasting many months may end up assessment of mood is essential. The close ties between serving no purpose beyond displaying administrative externalized aggression and aggression against the self enforcement of Bzero tolerance[ school policies and may were originally highlighted in an earlier psychoanalytic in fact be problematic. Such policies may discourage literature emphasizing disturbances of ego function in classmates from coming forward to make such dis- aggressive children. From this perspective, intense closures.5 For some students with academic and social emotions of self-hate become organized into highly difficulties, suspension and home tutoring may lead to resistant defenses against the world around them (i.e., improved scholastic functioning and reduced stress projection).16 These concepts were used to explain the levels. The mental health clinician may have a role in dynamics involved in anti-Semitism and genocide and facilitating return to school or appropriate treatment may also be valuable in understanding the mental and education during the course of a suspension, with functioning of children who develop intense fantasies of an eye on helping the child, family, and school return to hatred against fellow students or teachers. The complex a safe and developmentally appropriate relationship.
relation between homicide and suicide is beyond thescope of this article and is mostly concentrated in the forensic psychiatry literature. Notably, of the 37 attacks The child and adolescent psychiatrist plays a crucial analyzed in the Safe Schools initiative, Bmost attackers[ role in evaluating threats made in school settings, were reported to have some history of either suicidal including estimating the severity of danger level, as well attempts, thoughts, or a history of feeling extreme as clarification of unrecognized or inadequately treated depression or desperation. In contrast, only 17% (n = 7) psychiatric disorders. The school consultant must be had been diagnosed with Ba mental health or behavior prepared to interpret complex individual, family and group dynamics potentially leading to the expression ofthreats, such as retaliation for bullying and teasing. Such situations are compounded by potential access toweapons in the home. Effective educational and A 17-year-old honor student with no history of behavior problems has treatment recommendations for children and adoles- drawn doodles of a girl hanging from a rope. He revealed being upset cents who make threats depend on an in-depth about a girl gossiping about him. On psychiatric evaluation, he was not appreciation of their diverse psychiatric problems.
found to be a danger to others nor was a psychiatric diagnosis present.
Nonetheless, he was suspended for months, his college applications weredelayed, and he was ostracized by peers.
Disclosure: The author has received grant support from Cyberonics, Inc.,and Pfizer, Inc.
A 12-year-old girl left a message on her school_s voice mail threatening toblow up the school. The call was traced; she was suspended. The risk ofattack was assessed to be low. She subsequently became preoccupied byBthe terrible thing[ she did, calling herself a Bterrorist[ and resisted 1. A school killer_s animated terror: Minnesota teen posted bloody flash film warning last year. 2005. thesmokinggun.com Web site. http://www.thes- The consequences for students of making a threaten- mokinggun.com/archive/0323051weise1.html. Accessed October 14, ing statement can be devastating, with significant and 2. Gunman stole police pistol, vest. 2005. CNN.com Web site. http:// lasting effects on a student_s academic career and social www.cnn.com/2005/US/03/22/school.shooting/index.html. Accessed July relationships. The student may find peers and/or school faculty avoidant and distant, and the student_s reputa- 3. Bakken R. Teen seemed lost in life, 2005. http://seattletimes.nwsource.com/ html/nationworld/2002215413_kid22.html Accessed January 15, 2008.
tion as a potential Bschool shooter[ often persists.
4. Hauser C, O_Connor A. Virginia Tech shooting leaves 33 dead, 2007.
Behaviors that would have not evoked concern in the www.nytimes.com/2007/04/16/us/16cnd-shooting.html. Accessed October14, 2007.
past are now the focus of intense analysis. In cases of 5. O_Toole ME. The school shooter: a threat assessment perspective: J. AM . ACAD . CHILD ADOLESC. PSYCH IAT RY, 47:8, AUGUST 2008 Copyright @ 2008 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
Federal Bureau of Investigation. Quantico, VA, 1999. http://www.fbi.gov/ families: children and firearms. 2004. http://www.aacap.org. Accessed library/school/school12.pdf. Accessed January 16, 2008.
6. Kupersanin E. FBI expert says school shooters always give hints about 11. Winnicott DW. Aggression in relation to emotional development. In: Collected Papers: Through Paediatrics to Psychoanalysis. London: Tavi- 7. Vossekuil B, Fein RA, Reddy M, Borum R, Modzeleski W. The Final Report and Findings of the Safe School Initiative: Implications for the 12. Hetherington E, Stanley-Hagan M. The adjustment of children with Prevention of School Attacks in the United States. United States Secret divorced parents: a risk and resiliency perspective. J Child Psychol Service and the United States Department of Education. Washington, DC: U.S. Department of Education and U.S. Secret Service, National Threat 13. Twemlow SW, Fonagy P, Sacco FC. An innovative psychodynamically Assessment Center, Education Publications Center; 2002.
influenced approach to reduce school violence. J Am Acad Child Adolesc 8. Brener N, Lowry R, Barrios L, Simon T, Eaton D. Violence related behaviors among high school students. MMWR Morb Mortal Wkly Rep.
14. Twemlow SW, Fonagy P, Sacco FC, O_Toole ME, Verberg E.
2004;53:651Y655; http://www.cdc.gov/mmwr/preview/mmwrhtml/ Premeditated mass shootings in schools: threat assessment. J Am Acad mm5329a1.htm. Accessed January 16, 2008.
Child Adolesc Psychiatry. 2002;41:475Y477.
9. Connor DF. Prevalence of aggression, antisocial behaviors and suicide.
15. Sinco JK, Robertson T. Connetquot suspect_s confessions: in their own In: Aggression and Antisocial Behavior in Children and Adolescents: Research and Treatment. New York: Guilford Press; 2002:22Y45.
16. Redl F, Wineman D. Children Who Hate: The Disorganization and 10. American Academy of Child and Adolescent Psychiatry. Facts for Breakdown of Behavior Controls. Glencoe, IL: Free Press; 1951.
J. AM. AC AD. C HIL D AD OLESC. PSYCHIATRY, 47:8 , AUG UST 2008 Copyright @ 2008 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
Room Sale, 11am Thursday 13th June 2013 MICROSCOPES & CAMERAS Leitz No14 under Gallenkamp name. Monocular, twin head, brass tube, mechanical stage, mirror, condenser & diaphragm. Objective: x 10 Leitz x40 (No6), engraved 41 both brass. Eye piece: Leitz x12 Simple Microscope, early German. Brass & enamel Monocular course, focus only. Objective: "triple" power compound