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.

Pharmacological treatment
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).

Risperidone (Risperdal). When added to stimulants, risperidone has been shown to improve aggression in children with ADHD and aggression, and in children with CD for up to 1 year (Armenteros JL et al, J Am Acad Child Adolescent Psychiatry 2007;46:558–565). While improvements were noted from baseline, the groups did not differ significantly, suggesting that long-term treatment may not be more effective than stimulant/behavioral intervention alone (Gadow KD et al, J Am Acad Child Adolescent Psychiatry 2016;55(6):469–478).

Molindone (Moban). Molindone has been studied for impulsive aggression in ADHD with an eye toward an FDA indication (Brittain S et al, Neurology 2016;86(16 sup):6.214). It also has limited research supporting its use in impulsive aggression.

Quetiapine (Seroquel). In one small study, quetiapine was shown to improve behaviors associated with CD. However, while clinicians noted improvements, parents did not report similar results (Connor DF et al, J Child Adolesc Psychopharmacol 2008;18(2):140–156).

Lithium. Limited studies demonstrate the benefits of lithium for CD (Campbell M et al, J Am Acad Child Adolesc Psychiatry 1995;34(4):445–453). However, in a trial of lithium for severe mood dysregulation without ADHD or ODD/CD, lithium did not decrease irritability or aggression (Dickenstein DP et al, J Child Adolescent Psychopharmacology 2009;19(1):61–73).

Valproate. Valproate has also been studied for children with ADHD, ODD/CD, and aggression and has shown effectiveness in small trials.

For patients with autism spectrum disorder (ASD) who become aggressive, both aripiprazole and risperidone are FDA-approved for treating irritability. But youths with ASD have different and often slower processing, so check for sensory problems and whether people are giving your patient enough time to respond to requests.

For psychotic aggression in childhood schizophrenia or bipolar illness, treat the underlying illness. If the child fails to respond, monitor antipsychotic levels and consider long-acting injections. Consider clozapine for those who do not respond despite adequate adherence to treatment.

Working with families
Always ask whether there are firearms in the house and, if so, how they are secured. I strongly advise families to store guns off-site, locked away, unloaded, and separate from ammunition. Ask about exposure to violence at home or in the child’s community, including gangs, shootings, and bullying. Check how closely the child is supervised. Some kids have free rein to roam the city via subways; others have several unstructured hours after school. Even school lunch or recess can be an opportunity for trouble. Has the youth been exposed to violence in the community (eg, gang activity or domestic violence)? Organized activities may promote positive peer relationships and limit the youth’s access to corrupting activities (Eisman AB et al, J Youth Adolesc 2018;47(10):2231–2242). Supervise and limit screen time and access to violent media, and monitor the child’s social media use.

Since children model their behavior after what they experience, use non-physical forms of discipline such as loss of privileges. Some families use alarm systems to prevent teens from leaving at night. Talk with families about when to call 911 and what to expect when the police or paramedics arrive. This usually helps everyone calm down—an important lesson that the teen is not in charge and that the community will keep everyone safe. If things do not settle down following a 911 call, parents should understand that the child will be typically transported for psychiatric assessment or, rarely, taken into custody for violent behavior or evidence of planning such behavior.

Documentation
Documentation is critical when there are questions about potential violence. Malpractice companies look for statements within the clinical encounter that speak to the risk patients pose to themselves or others, such as, “The patient does not currently pose an acute risk to himself or to others.” The chart needs to support these statements by documenting such things as good impulse control, non-labile affect, and lack of suicidal or homicidal ideation. If we get in the habit of looking at these things, we will be in better shape to take action when the situation warrants it.

CCPR Verdict: Always screen for the risk of violence, and when a patient is at risk, prioritize safety first. Decide what level of care is appropriate and treat specific disorders with a focus on helping the patient be calm, regulated,  and less reactive. Medications may be helpful for aggression in ADHD, CD, and ODD, but hard evidence is sparse at best. Use of antipsychotics for aggression is more likely to work with diagnosed conditions for which they have more clear benefit, such as psychotic, bipolar, or autism spectrum disorders. Make a habit of documenting risk for violence during all clinical encounters so you do not overlook children who are at risk.