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Featured guests: Thomas Zimmer, M.D., and Lynetta Smith, Associate Director of Security at Michigan Medicine

Objectives:

• Define a threat assessment
• Identify who should be involved in a threat assessment
• Apply skills to discussing safety with the pediatric population

Resources:

• The concept of leakage in threat assessment (Behavioral Sciences and the Law)
• Enhancing school safety using a threat assessment model (U.S. Dept of Homeland Security)
• Protecting America’s Schools (U.S. Secret Service)
• The need to see and respond: The role of the child and adolescent psychiatrist in school threat assessment (Journal of the American Academy of Child & Adolescent Psychiatry)

CME:

Credits available: 0.75

Visit our CME course overview page for CME credit(link is external), or complete this survey for social work CEUs.

Transcript:

Syma Khan:

Hello and welcome to our podcast, Breaking Down Mental Health, with myself, social worker Syma Kahn, child and adolescent psychiatrist Dr. Heidi Burns, and nurse practitioner, Dr. Christina Cwynar. Unfortunately, Dr. Burns could not join us today, but we are very excited to have Dr. Thomas Zimmer and Lynetta Smith to discuss threat assessments and preparing our youth for violence. Dr. Zimmer received his bachelor's degree in biochemistry, biology, and psychology from the University of Nebraska Lincoln, and his MD at the University of Pittsburgh. He completed his psychiatry residency at the University of Michigan in Ann Arbor, and he is currently a second year fellow in the Child and Adolescent Psychiatry department. Dr. Zimmer's clinical interests include inpatient psychiatry, mood disorders, interventional psychiatry, clinical informatics, and medical education.

Dr. Christina Cwynar:

Lynetta Smith is an associate director for the Division of Public Safety and Security, and has spent much of her 25-year career focusing on threat assessments and workplace violence prevention strategies. None of the speakers here today have any conflicts of interest or financial disclosures. Thank you both for joining us today.

Dr. Thomas Zimmer:

Thank you for having us.

Lynetta Smith:

Thank you.

Dr. Christina Cwynar:

Lynetta, let's just start out with a definition. What is a threat assessment?

Lynetta Smith:

Well, that's a wonderful question. Threat assessment is most successful when it's part of an overall strategy that's rooted in prevention and not prediction. Fundamentally, a threat assessment should have three components in that you identify, assess, and then manage the risk or the potential for risk.

Dr. Thomas Zimmer:

I think it's helpful to take a moment and define what we mean about a threat, and that can either be a direct communication of an individual to do harm, could be a post to social media, something that one individual says to another, or it could be more diffuse, and somebody who just seems to be a risk to a person, a place, or organization.

Syma Khan:

Thank you so much for starting us off with those basic definitions. Lynetta, would you like to dive further into what are the components that you discussed? The identify, assess, and managing potential risks.

Lynetta Smith:

Yeah, thank you Syma. Yes, so identifying the risk or the potential for risk is that preventative stuff. It's a partnership with everyone in the community, and by community I mean wherever you live, you work, you thrive, you worship, and community safety should be an encouraged element within every community's culture. Again, whichever culture and community that is to you. And a community's awareness of how to identify those at risk behaviors or actions and then where to report them could be a step in preventing a potential escalation, and also an opportunity determine that there may be an individual that needs our resources and support. And that's on identifying.

Assessing then is more of a structured fact-based process, and it's the review of those behaviors that have been identified. Those behaviors are actions that have either posed or could pose a risk of harm to the individuals or to an organization. And the process usually includes ways to manage potential and then manage eminent risk. And a key goal should be for that process, kind of as Dr. Zimmer mentioned, is, distinguish between an individual who makes a threat versus an individual that poses a threat, and kind of managing that ongoing process.

Managing a threat is situational for the community as well as that individual that's posing the threat, and ensuring that there's a structure for that continuing of the monitoring of the risk behaviors is equally as important as ensuring that there's an intervention and then a response to that individual or to that risk of threat.

Syma Khan:

So there's a lot of things that we want to integrate within a threat assessment, and I really appreciate that community piece of recognizing that this should be occurring in multiple settings. One thing that's come up a lot recently is thinking about threat assessment within adolescent populations, and Dr. Zimmer, I'm wondering if you could elaborate a little bit about when we're working with youth and this kind of concern comes up.

Dr. Thomas Zimmer:

Yes, thank you Syma. I often think about this in the context of schools. Unfortunately this is a fairly common occurrence, and having a systematic way to do exactly what I described, of assessing the threat and then figuring out the best ways, usually in a school context, to support the individual. The identification element of school, you probably always heard the, "If you see something, say something," or honestly encouraging kids to disclose if one of their peers has made a threat or is concerning them. Part of that to me is having a response that is positive and supportive so that a student would be more comfortable disclosing that their friend might be struggling like this if they were confident that the system, the school district was going to have a more than punitive response.

Dr. Christina Cwynar:

I think in thinking about that, who should be the ones conducting these threat assessments?

Lynetta Smith:

Well, given the complexity of some organizations and the varying methods in which those behaviors can be identified, a lot of best practices will encourage that a multidisciplinary team review is the best at assessing and identifying the risk. Oftentimes a collaboration of people coming together, they have different pieces of information, and human resources can be at the table because they have one element that was reported through their structure, law enforcement and security partners, our mental health professionals, administrators, and it's that team participation that will need to be continuously evaluated and having representation of areas that would be value add to the overall strategies and mitigation strategies, goals for that team.

Dr. Thomas Zimmer:

So I can comment on what that looks like in a school setting. So every guideline I've encountered for how to do threat assessments in school talks about a multidisciplinary team. Partially, you can never have enough collateral. You want all the teachers who might know the individual's opposed a threat to give their input. Someone needs to interview the peers, someone needs to talk to the parents, people need to hopefully follow this individual longitudinally. School resource officers, law enforcement can be vital for this because they can go check out a home, see about access to weapons, maybe remove access to weapons. This is not something that one person can do alone.

Dr. Christina Cwynar:

Dr. Zimmer, I really appreciate you pointing out, and Lynetta, you alluded to this too, that this really is a big team of people that needs to be involved in these assessments and really can't be occurring in a single time point. It shouldn't be happening in our ERs or in a psychiatrist's office where they have limited access to that collateral information. And I think we've talked about this as ... a lot as a group and as mental health providers, and within our communities and our professional circles, that we don't have that crystal ball to look into and predict the future, but we can as a community and as a group doing these assessments, provide that support to these people and intervene. And that's why that team approach is so important. And in speaking a little bit more about these threat assessments, what needs to be in a threat assessment more specifically, and how do we document and communicate this information?

Dr. Thomas Zimmer:

One thing I want to address up front, because there's a lot of myths about how to do threat assessments. For starters, there isn't a profile. People imagine the Columbine shooters and they assume that all school shooters are going to fit that persona. They're going to wear black trench coats, they're going to absolutely fit that. But they can be high schoolers, they can be middle schoolers, they can be male, they can be female, they can be loaners, they can be popular kids, they can be kids who are struggling academically, they can be kids who are very successful academically. So trying to assume that we're just going to be able to make a profile for someone and then know what they're going to do is not the truth. You really want to focus on warning behaviors that you can observe. And again, to emphasize, we really can't do a perfect job of prediction and that shouldn't be what we're trying to do. We should identify people who are at risk and then do everything we can to mitigate that risk. Fortunately from my point of view, that's usually supporting the individual themselves, so win-win.

Lynetta Smith:

Yeah, very well said, Dr. Zimmer. And it's not necessarily about what we would miss being in a threat assessment, it's all encompassing, it's all of those behaviors. It's what community members have observed and seen posted on social media and within an organization or a structured workplace, there are a lot of different tools that are available. Threat assessment tools, some at no cost, some on the internet. Within DPSS, the division of Public Safety and Security, there are a couple of us that have been certified and trained on using a structured professional judgment guide, and we do that as a workplace assessment for violence risk. But no matter what tool is providing guidance with an assessment, it should just be that, it should be one tool in the overall assessment.

Dr. Thomas Zimmer:

If someone is looking for guidance on how to do this, there are fortunately some guidelines in the school setting. There's the Comprehensive School Threat Assessment. This used to be called the Virginia School Threat Assessment cause it came out of Dewey Cornell's group in the University of Virginia. But since they're trying to have it leave their state and be more broadly applicable, they changed the name. If you just want a turnkey operation, they have their documentation available, they have trainings.

The various government agencies have also released guidelines that are actually surprisingly easy to read and short. The Department of Education, the Department of Homeland Security, the FBI, and the Secret Service have participated in this, allying with school psychologists and other professionals to come up with how to do these guidelines.

Exactly as Lynetta was saying, you do want to have a holistic and longitudinal view of the person. That's why you need to hopefully figure out how things are going in school in different classrooms with their peers. You want to look at their social media, see if they're having threats there. With students and adolescents that can be even done ... the police can look at an adolescent's phone with a parent's permission or with a court order. That might require someone, again, going to the home potentially with a court order at a high risk individual to see if they have access to weapons. Remember, this needs to be not just their home. They need to be checking, would they have access at their friend's home, would they have access at their grandparents' home? So you really do want to have a broad, holistic approach.

Lynetta Smith:

It's very similar in an organization at looking at that broad assessment. And we talked about the collaboration of a team and part of another piece of a threat assessment, a component that should be in that broad reach and that net, is looking at positive ties that people have, mitigators to a risk of violence. I sometimes call them anchors. I've heard them called inhibitors in other spaces. But those would be those ties to their community and ties to their friends and ties to their family that would act as a preventative, a prevention that kind of holds them in place. It's an anchor to not being a risk for violence.

Dr. Thomas Zimmer:

You're probably, if you're familiar with doing suicide threat assessments, you're hearing a lot of similar language and that's for good reason. Anyone that you're concerned for doing a threat assessment of harmed others or homicide probably warrants that you do a thorough suicide threat assessment. School shooters and many other shooters typically don't expect to survive the activity, so this is directly just a risk factor for that itself. And the majority of people that are identified as risks would not go on to have that behavior, but a large amount of them would benefit from having some form of support or care. They might have depression, anxiety, many of them have suicidal ideation. So I've described that more as a good way to identify people who need additional support.

Another term that I think we're talking about here is in the literature called leakage. How do you identify these individuals in the first place? We're not reading people's minds, so they had to come to our attention somehow. And there's various ways that can be. It can be a direct message, it can be something they said to a peer, they can be in a group. In the case of the Oxford shooting, there were drawings on a math quiz that made people concerned. So if you encounter that leakage, and from what I've read they estimate 80 to 90% of these cases are going to have some kind of leakage before they progress onto violence, you would take that individual you've identified and then look for other concerning factors or factors that make you feel more confident this individual will be safe.

To talk about some of the ones you would be concerned about are pathways to violence, are they researching or really thinking about means? Are they researching old school shooters and idolizing them? Do they seem to be moving towards a warrior mentality or are they idolizing that kind of behavior? Are they doing anything that is kind of testing out the waters? Are they having small acts of violence and then kind of building up their nerve? These are all things that would make you more concerned and maybe have you have a more assertive strategy for trying to mitigate the risk.

Christina Cwynar:

We just covered a lot of information about who should be conducting threat assessments, what is included in these threat assessments, but let's talk a little bit about what happens if we identify something positive on a threat assessment that makes us really concerned that something's going to happen. What are next steps? What do we do with that information?

Dr. Thomas Zimmer:

So some examples of different kinds of threats. If there are a lot of specifics, if individual says they're going to use this gun that they're posing with in a social media photo to shoot up Mrs. Kraboppel's third period English class on Tuesday, September 9th. That has a lot of specifics. They've thought it out, they have the means to carry it out. That would be a very serious threat and you might actually proceed to having law enforcement pick up the individual before you even try to proceed with an assessment in them.

On the other side of it, somebody might make a joke in passing that they want to call in a bomb threat so they can avoid an algebra quiz. That would be the most transient threats. But I have seen kids be suspended from a semester of school for threats as transient as that.

Everything else is of course somewhere in between where you use your judgment, but there are a few things that you should uniformly do. The most important one, we've mentioned it a couple of times, is mitigation, and that might be called means mitigation, very similar to a suicide threat assessment. Someone that you're worried about hurting themselves or others probably shouldn't have access to easy means to kill people, and that is something we've seen fail in recent cases and that's another way that our law enforcement partners can be really helpful in trying to carry that out.

Lynetta Smith:

Yep, very great information. And our law enforcement partners and our community partners are wonderful advocates in those ... identifying and assessing as well. We've had cases where we've asked our family members of those that have been identified as a risk to let us know when guns have been secured or when they have been removed, and they also have a huge concern for that individual in their home and they want them to be connected with support and resources. It's all in looking for those signs. And Dr. Zimmer said it best, when you see something, say something, don't be afraid to come forward and connect with those that can help connect the person with resources, up to and including a law enforcement intervention as needed.

Dr. Thomas Zimmer:

I could mention some things that we probably shouldn't include in this. One example would be zero tolerance policies that are shown to not be protective. If somebody is willing to shoot up their school, they're probably not going to be deterred by being told they're not supposed to show up that day. It does tend to isolate individuals who are already struggling, already feeling alone, and removes all the supports in somebody that we probably need to be leaning in and support them more. Regarding zero tolerance policies, we have to think of the harm that we're doing to the large number of kids that are identified by leakages of some kind who aren't going to go on to do it and that those missed days of school, those suspensions are real harms.

One factor of having a systematic, standardized way of assessing this within a multidisciplinary team is it reduces how long those suspensions are, those days. And it also reduces the rather wide racial disparities we see in how these suspensions and expulsions are done. We mentioned that a psychiatric emergency room is probably not a great place to do this assessment because we can't get that kind of collateral or that kind of continuity for the long run. But when a psychiatrist does make sense is, maybe you've identified a concern for anxiety or depression or something else that they'd benefit from a therapist or a psychiatrist, then you would refer them to receive appropriate care.

If you were so worried about somebody that you didn't feel safe having them at the school, the threshold for that should be the same threshold as they would need immediate hospitalization or incarceration. If it's less than that, we should be figuring out how to support them in place in a school.

Syma Khan:

I think that reflection is really important, that school is a really important setting for our youth and an important part of their development. And so potentially we need to identify digital supports in that setting and the community to help that child be successful. I think as Dr. Zimmer mentioned, oftentimes there can be comorbid, depression, anxiety, suicidal thoughts, ensuring we're kind of targeting those things as well, though that's not always the case, so we don't want to kind of conflate those two things. And Dr. Zimmer, I don't know if you have any other reflections about how mental illness and threat assessment go along and kind of things we want to be mindful about with working with that population?

Dr. Thomas Zimmer:

Thank you. That's an excellent question. There's often a thought that if anyone would do something this transgressive, it must be mental illness. But I'll say homicidality is not really part of the DSM five. That's not directly what's causing, these are often individuals who are struggling broadly, but that tends to be something else that's going on rather than the direct cause.

Additionally, sometimes people have concerns, getting back to the profile that kids with autism are at higher risk of being school shooters, and the evidence has not borne that out. Regarding documentation, document like it's going to be read in court. You should be getting a lot of collateral information, holistic approach. You should be coming up with your idea of why this individual might have risk factors, that are more likely, things that are protective factors. Be very clear and thorough in the documentation. And again, the guidelines can be helpful if you need a structure for how to do that.

Syma Khan:

So I think we've spoken broadly about threat assessments, what they entail, how we should document them, but one thing we know is that this really does impact our children and our youth as well as they're exposed to this in different settings. It also does impact people in workplace settings as there has been an increase in workplace violence, in particular in healthcare settings. I know that's a concern as well. So one question is how do we talk with children about gun violence?

Lynetta Smith:

I think that's a really wonderful question and it can be really challenging to have that discussion with children. A lot depends on that contributing factor such as the child's age and how they process information, the timing of the discussion. Have there been recent events in the media that may have caused anxiety for the children that you're getting ready to have those discussions with? With some younger children, preschool, kindergarten ages, and you may be answering questions that they may have. And one approach could be to align with your own parental morals, and you could say that that person made a bad choice, that person made a bad choice that hurt a lot of people. And aligning with your own parental guidelines and morals that you want your children to learn from. Younger ages, probably less is more. And as they start to get older, ultimately I think all children want to feel safe.

And if you're having those discussions that are with children that are a little bit older than preschool or kindergarten ages, one approach could be in having discussions about how you're keeping your children safe. With my own children, whose ages are eight and 10, I talked about it from an overall safety measure. When we get in the car, we buckle our seat belts and when we go for a bike ride, we wear helmets. And I speak specifically about safety features at their school that are there to help keep them safe, such as, they have locked exterior doors and they have a video system when you have to call in, the doors aren't just unlocked for everybody. We have a system where you have to show identification to pick up the students at the school. So just reassuring our children the safety measures that are already in place.

And if we're having those discussion and we don't know what those safety measures are, maybe going into conversations at parent teacher conferences and meeting with the school administrators and finding out what those plans are for the school, and talking a bit more about that with your children to reassure what those measures are to support them.

Christina Cwynar:

Lynetta, I really appreciate you pointing out that there is a way to frame this message, especially talking to different developmental ages and individuals with different cognitive abilities, and really focusing on what information needs to be known for that individual. So you reference preschoolers and kindergartners, and really thinking, what do they need to know in this moment? And oftentimes these young children are being exposed to lockdown drills for the very first time in school and maybe don't have a context of what that is. And that can be really scary.

And our teachers and law enforcement who come in and do some of these things do an excellent job in preparing our kids, but they often come home with questions for our parents or maybe even it's brought up in a pediatrician's visit or something like that. And remembering to keep that message really simple, reflecting back on them, what are your questions? How can I explain this? But also relating it to something they may understand a little bit better and is a little bit more tangible, like a fire drill. They've all seen fires, they see the fire trucks and all of that. And fires rarely happen at school, and they rarely happen at houses, but we still practice them. And we practice lockdown drills to keep us safe. And sometimes we don't know in the moment if something is dangerous or not, and that's why we go into lockdown mode. And then being able to direct the kids, like you said, through different safety measures that we have in place, and kind of moving on and just answering those direct questions but not giving enough information to scare them or overwhelm them in that moment.

Dr. Thomas Zimmer:

I agree with everything both of you are saying. I wanted to just emphasize some of the points of thinking what is developmentally appropriate for the child. For young enough children, they're probably not going to appreciate everything that's going on and trying to explain it like you'd explain it to an adult is just going to cause distress with no value add.

I like the fire drill analogy. I always go to a tornado drill myself of, they don't happen all that often but everybody knows they're supposed to go to an interior room without windows. Third grade and earlier, you should really just be focusing on are the kids following the directions, they don't really need to understand why. And trying to get them to understand why is not the most productive part. Fourth grade to sixth grade, the kids probably have some appreciation of what a school shooter is and they're going to have a few more questions.

But again, getting to the point where they appreciate that they need to get out of sight and hide, but not trying to unload all of your anxieties on the child when you're describing it. Older than sixth grade, you can probably have a fairly straightforward, frank conversation with them, appreciating that they've unfortunately acclimated to hearing this in the news at that point. And they've probably done a number of school shooter drills at that point, and often they're uncomfortably for us comfortable with it.

I will say there is an exception of a number of kids with anxiety after these. [inaudible 00:24:14] will come into my office and their anxiety will have shot through the roof and they're really perseverating on it. And if you do have a child whose anxiety is getting out of control like that, it is very reasonable to bring them in to talk to a therapist or psychiatrist to see if this is getting to the point we may need to intervene clinically.

Lynetta Smith:

I think it's a great point, Dr. Zimmer, talking about our own anxieties as parents and caregivers. And I think we oftentimes view the world and ... I mean honestly, we have a lot of access to media and social media postings and all of the news and everything that is out there, but often it's brought to us whether we want the access or not. And I think that serves to increase our anxiety sometimes as parents and caregivers, and as you mentioned, we want to make sure that we have a healthy balance for ourselves and working through those anxieties before we're having those conversations with our kiddos, and trying not to transfer some of our own anxiety into those conversations.

Christina Cwynar:

So we talked a little bit more broadly about how to prepare younger children or children being first exposed to lockdown drills, active shooter drills. Let's talk a little bit more specifically, how do we as healthcare providers, but also parents, talk to children about these lockdown drills that are occurring?

Lynetta Smith:

I think that's such a thoughtful question, and I mentioned before as a parent myself, I think we often have anxieties that we may cause further distress or harm to our children by talking about lockdown drills, or we worry that we could do more harm than good. But coming from a place of curiosity and when you're having that conversation with your children and your kiddos and asking them, what does their lockdown drill look like? I mean, have them walk through the practice of it. Is their teacher turning out the lights? Is their teacher asking them to be more silent, and ask them if their classmates are able to do that? Are you able to keep silent for two minutes? Asking if there's a lock on the classroom doors, or if there's a way that they're shielding visibility from an outside space. If they are locking the door, have they practiced locking the door? And if they're opening windows, have they practiced how heavy it is to open a window? And if they themselves would find it challenging to open a window, maybe they can have two of their friends practice with them on opening that window.

Having those questions and the tangible results and behaviors, repetitive behaviors like we're talking about, drills, just encouraging those practices at home, and offering praise and encouragement when your child is showing you what they can accomplish during a lockdown drill can go a long way. And helping them remember those skills, lifelong skills, whether they're in elementary school, high school, growing up in an organization. And we of course teach active attacker response here within Michigan medicine and those same principles apply, and it's a lifelong learning process of practicality.

Dr. Thomas Zimmer:

I think Lynetta is demonstrating the value of having a law enforcement individual or a school resource officer be involved in this conversation. I think they can be really great for having these in a very informative, calm way. And I'm just going to say they're going to be probably more practiced at it than most of us. And to lean into those resources.

Syma Khan:

We've had such a rich discussion of an overview of threat assessment, why it's important to conduct threat assessments, who should be connecting those assessments, and then also just some resources and tips for parents and families and caregivers and healthcare providers as well. Is there anything else that either of you would like to share with our audience today?

Dr. Thomas Zimmer:

When I think about this, I often think about that math quiz with the Oxford shooting and what was written on it. And there were definitely some scary things, like a frighteningly accurate drawing of a pistol, person seemingly dead on the ground, two gunshot wounds, some scary phrases like "blood everywhere," "the world is dead." But I think it's important to remember what else was written on that. "My life is useless, the thoughts won't stop, help me." And remembering that that is such an important part of taking care of these individuals.

Lynetta Smith:

My only parting thought is something that Dr. Zimmer touched on earlier in our discussions, on leakage itself. And we know that research has shown us that there's so many ways that people are communicating and they're asking for help. They're asking for an intervention, they're posting on social media, their behaviors, and just wanting to make sure that people have the right resources beforehand to know where to reach out and report those. Always calling 9-1-1, of course, if it's an eminent danger and it's an emergency, but there's of course a multitude of other resources. Going to your organization or your school's threat assessment team and administrators and not letting that voice go unheard. And when you see something, say something, and bring those concerns forward.

I think oftentimes people have a fear, maybe, of calling the police or bringing something forward because we want to be right. People want to make sure that if they're reporting something, that they have the accurate information and they're not subjecting somebody to an allegation that's untrue. But it's okay to call, it's okay to call law enforcement and have those conversations. It's going to be a respectful and curious approach. It's not going to be one of being punitive or a biased approach, and there's no consequence to being wrong even if we are. But there's millions of people and kids out there that will benefit when we're right.

Dr. Thomas Zimmer:

I agree entirely, especially getting back to the point of, even if the individual is unlikely to commit violence, they are fairly likely to be an individual who could really use some support and some help. So see something, say something.

Syma Khan:

I think one other reflection about a team approach and kind of bringing in people from different perspectives that really helps address any bias that may be occurring in these situations, as Dr. Zimmer indicated, sometimes there are more frequent suspensions or expulsions with certain populations, minority groups, those kinds of things. And so for bringing people from different perspectives, hopefully we're able to work through that bias and recognize that we're looking at the threat without any personal or implicit bias, and we're really being thoughtful about the behaviors.

Christina Cwynar:

Well, thank you both for joining us today. We truly appreciate your time and your expertise. And thank you to our audience for tuning in this week. Nurses, social workers, and physicians can claim CMEs and CEs at uofmhealth.org/breaking down Mental health. You are able to do this anytime within three years of the initial air date. We hope that you'll tune in with us next week.