How to Best Assess Violence Risk of Youth in Emergency Department

Violent acts, like the shooting in Munich last summer in which a teen killed nine people, inevitably spur anxiety about potentially violent youth in schools and communities. While individuals with mental illness are much more likely to be victims of violence than perpetrators, the stigma and lack of understanding around mental illness are such that many fear that youth with psychiatric disorders may become violent.

Youth who stand out at school as odd, withdrawn, or socially isolated may be brought to the outpatient psychiatrist or emergency department (ED) by concerned school staff. Other youth, with poor frustration tolerance and impulse control due to attention-deficit/hyperactivity disorder, learning disabilities, disruptive behavior disorders, or trauma may make a verbal threat or become physically aggressive when upset. Still other youth may manifest interest in violent acts in video games, news media, or online searches and discussions. These youth require careful risk assessment.

When youth are brought to the ED for “psychiatric clearance,” the ED psychiatrist faces multiple challenges: to complete a meaningful assessment with little time and often minimal collateral information, to build rapport with an adolescent who inevitably does not want to be there, and to balance the societal demands for prescience with the reality that even the best risk assessment cannot predict the future.

Risk assessment in the ED is limited by the short time available for an assessment, by the lack of accessible collateral, and most of all by a young person who is generally either skeptical of the ED psychiatrist or overtly guarded or afraid to open up. The ED psychiatrist must build a quick rapport with the patient to have any chance at effective assessment. Taking a nonjudgmental, curious stance and trying to truly understand the child’s perspective will be key to ascertaining the why behind the concerning behaviors that brought the child to the ED.

The ED psychiatrist should ask carefully about thoughts of violence, any plans or steps taken toward a violent act, interest in and attitudes toward violent acts perpetrated by others (such as the Munich shooter and other high-profile cases), as well as thoughts of suicide or violence to self (as those who are violent to others are also at increased risk for self-harm). The psychiatrist should assess not only immediate safety for discharge versus need for admission, but the broader diagnostic differential and psychosocial context. An involved and stable family, positive connections to peers or teachers at school, future orientation, and reassuring mental status can all be protective, while recent stressors, interpersonal conflicts, feelings of hopelessness or helplessness, family changes or losses, or triggers for shame or alienation can increase risk. Access to weapons or potentially dangerous objects must be assessed as well.

A thorough assessment can never be based only on a patient’s self-report, however. The ED psychiatrist must also take into account the subtle cues from the patient interview, such as observations regarding engagement with the ED staff and family members, any incongruous or unusual affect, capacity for reality testing, remorse versus paranoia and retaliatory fantasies, and the psychiatrist’s countertransferential reaction to the patient.

Collateral from school is critical and should include detailed reports of any incidents or threats, copies of any writings or drawings with concerning or violent content, information about social connections and social behaviors at school and in social media, and any prior testing or treatment history.

In reality, however, such records are rarely available to the ED psychiatrist. Collateral from family is also important, though family members may be unaware of a child’s—and especially an adolescent’s—internal state. Parents’ denial that there is anything wrong is often more concerning than if the parents are very worried. The ED psychiatrist is often in the difficult position of feeling concerned about a child who needs treatment but does not meet the threshold for involuntary admission, and the parents are adamant that nothing is wrong or insistent on discharge.

Even when all necessary information is available to the ED psychiatrist and parents are open to recommended treatment, it is important to remember that a risk assessment is just a risk assessment, not a prediction. It is a reflection of the child’s current mental state and social context, which can change quickly. Connection to ongoing care is thus incredibly important, and the outpatient psychiatrist should engage risky youth in ongoing risk assessment, getting information from school staff and even law enforcement if necessary. Educating school staff and other adults to understand—and not fear—mental illness will help them to connect with an at-risk teen and help him or her feel cared for and connected to others, potentially reducing the risk of violence and perceived stigma and increasing the chances of adhering to psychiatric treatment. ■