School shootings keep happening in the US, and most of us have wondered at times whether one of our patients might carry out a violent act, shooting or otherwise. This article will help you assess and treat violent youth and advise families who are grappling with these issues.
Most people with mental health conditions do not hurt others—our patients are more likely to be victimized. About a fifth of adult psychiatric patients (19%) report having been assaulted, while rates of patients committing violent acts are comparable to the general population: about 4% (Rueve ME and Welton RS, Psychiatry (Edgmont) 2008;5(5):34–48). Still, some teens and kids do hurt others, particularly those who have had adverse childhood experiences, are doing poorly in school, and have access to weapons.
Some specific questions to ask in the interview and to pose with family and other collateral sources include:
1. How has the child/teen been getting along with peers? Have there been any violent incidents in the past?
2. Is the child/teen hanging around with other kids who are in trouble?
3. How far has the child/teen progressed in the hierarchy of aggression (oppositionality, threats, breaking things, hurting others)?
4. Why is the child/teen doing this? Are there specific triggers or circumstances, such as bullying or learning problems? Is there a specific syndrome, such as ADHD, bipolar disorder, or a psychosis, that can be targeted for treatment?
Level of care
Based on the answers to these questions, you must decide what level of care your patient needs to maintain safety and receive effective intervention. Outpatient care can be relatively safe if the youth is in good control, under supervision, and can’t access firearms. Intensive outpatient treatment is needed for more assertive medication changes or if patients require frequent therapy. Partial hospitalization helps if a youth needs to be out of school to stabilize symptoms. Hospitalization is appropriate when there is an acute risk for violence. Some teens require new school placement with increased supervision. Lastly, residential placement may be necessary for teens not responding to treatment.
For high-risk individuals, communities may integrate youth services and criminal justice systems to reduce violence. Typically, programs work with teenagers/young adults to ensure engagement with supports/services (schooling, jobs) while steering them away from violence through supervision by social services and probation officers.
Many psychiatric disorders are associated with impulsive aggression. When in distress, the ability to read the intent of others can be narrowed to self-preservation, causing the person to misread even neutral communications as threats and react accordingly. Beyond helping the person to be calmer and more regulated, research on treating aggression in children and teens has focused on the disruptive behavior disorders: ADHD, oppositional defiant disorder (ODD), and conduct disorder (CD).
Stimulants are first-line treatment for ADHD. Multiple studies show improved aggression in children with ADHD and comorbid ODD/CD:
Clonidine (Catapres). For youth with ADHD and ODD/CD, clonidine has demonstrated efficacy in decreasing aggression, and guanfacine improves frustration tolerance and irritability (Connor DF et al, CNS Drugs 2010;924(9):755–768).