Recognizing Concerning Behaviors in Children to Prevent School Shootings

TMA Testimony by Clifford Moy, MD

Senate Select Committee on Violence in Schools and School Security

July 18, 2018  

Chairman Taylor and members of the Select Committee, thank you for the opportunity to offer testimony from the Texas Medical Association (TMA) on this important topic. My name is Dr. Clifford Moy; I’m a psychiatrist from Houston, a member of the Dallas County Medical Society, and the former speaker of TMA’s House of Delegates. 

Personally, I am a gun owner and an avid hunter and target shooter.

Our 51,000-plus members share your concerns with school violence and the threats to safety for the more than five million children attending Texas schools. Last year the U.S. had the highest number of separate active shootings ever recorded in a single year.  Six of the 50 “mass killings” in 2016 and 2017 occurred in Texas — more than in every other state.  Seven of the recent mass shooting incidents occurred in an educational setting. The Federal Bureau of Investigation’s studies indicate most of those involved in mass shootings had not been diagnosed with a mental illness but were reported to have experienced multiple stressors and/or have demonstrated “concerning behaviors.”

My testimony today will focus on those “concerning behaviors” — what causes them, how we can detect them, and what we can do about them.

Youth Risks in Texas High Schools
The national Youth Risk Behavior Survey (YRBS) monitors health behaviors of high school students. The most recent Texas data from 2017 notes that almost 19 percent of public and private school students surveyed were bullied on school property, and 7.4 percent were threatened or injured with a weapon on school property. 

Over 26.7 percent of Texas students were offered, sold, or given an illegal drug on school property by someone during the past 12 months, 26.8 percent had at least one drink of alcohol on one or more of the previous 30 days; and 14.9 percent had used prescription pain medicine without a prescription. Many Texas students (16.4 percent) reported that in the previous year they had been forced to perform sexual acts by someone they were dating, over 22 percent of the females and over 9 percent of males; and more than 10 percent were forced to have sexual intercourse against their will. 

More than a third (34 percent) of Texas high school students reported they had stopped usual activities because they felt so sad or hopeless almost every day for at least two weeks. Over the past 10 years, the percentage of students attempting suicide has increased from 8.4 to 12.3 percent, and suicide attempts requiring medical treatment increased from 2.6 to 4.5 percent.

The relationship among a student and adults during a child’s time in the school setting is a critical component in child and adolescent development. Over those 12 years, a child will likely be exposed to hundreds of adults and other students in the school who will either challenge or support them in recognizing their potential. The Centers for Disease Control and Prevention (CDC) identifies school connectedness, or students’ beliefs that their peers and adults in their school care about them, as an important protective factor that reduces risk behaviors and improves academic achievement. Children and youth will experience challenges in the home and school setting that can be overwhelming without guidance or support from trusted adults, friends, and professionals. Increased exposure to these adverse events over a prolonged period of time can have a devastating effect on a child’s physical and mental health. Physicians recognize these as adverse childhood experiences (ACES). Over time, prolonged exposure to stressors can lead to toxic stress and contribute to troubling or violent behavior that harms them or others.  

Certainly, not all stress is bad. Most children will recognize a challenge as positive stress, and they learn to seek support and develop skills to address it. Most will learn to build healthy relationships and skills to deal with stressors and adversity, i.e. they develop resiliency. As physicians we know that parent engagement, school connectedness, and access to a comprehensive medical home are protective factors that offer the best promise to children and teens. Research indicates continuous access to a trusted adult in childhood may dramatically reduce the impact of childhood adversity on mental well-being and adoption of unhealthy behaviors, but many children lack the support provided by predictable and nurturing relationships.

Mental Health Screening and Care for Children
It is estimated that up to half of lifetime cases of mental illness develop by the age of 14. Approximately one in every four to five youth in the U.S. meets criteria for a mental disorder that will result in severe impairment across their lifetime. While mental health screening is recommended for adolescent children, there is limited information on whether children are receiving it. In 2016, 25 percent of Texas adolescents age 12-17 did not receive any preventive care; these are missed opportunities for children to have a mental health screening. Effective this month, Texas Health Steps now covers annual mental health screening of adolescents age 12-18 years using a standardized screening tool. There are multiple validated screening tools for children, and we support the routine screening of children for other risk factors such as substance use. 

Students who are experiencing stressors at home and/or at school are less able to function at school and can soon be unable to complete school assignments and maintain relationships with classmates. Students will often turn to a trusted teacher or a school counselor for support. A survey of school counselors  noted this is most likely to occur with children from families with a low income, who are minority, or who reside in a rural area. These school educators are an essential resource for many and in some communities have helped to establish school-based mental health resources. 

Students that get involved in illegal activities will be removed from school and enter the juvenile justice system. A large proportion of U.S. adolescents in the juvenile justice system have a mental health condition including substance use disorders. More than 800 children age 10-17 are admitted to the Texas Juvenile Justice System each year. In 2016, almost a third (32.9 percent) of the new admissions had a suspected history of abuse or neglect. State support for these children includes residential treatment, but these resources appear insufficient meet the current need.

The early identification and treatment of child behavioral disorders can prevent and reduce further impairment of the child’s psychological and social functioning. It is critical that once a disorder is identified, that children in all parts of the state have access to treatment and support. 

Recommendations 
We can all do more to help children manage the stressors to their physical and social well-being. There are evidence-based methods that we know will help children develop resiliency. We believe the suggestions below offer opportunities to engage current Texas resources to directly address our mutual concerns about school safety: 

  • We must work with our medical schools and residency programs to ensure physicians are trained to identify children’s stressors than can contribute to behavioral concerns and to mental illness. And we must ensure active screening of our children. We support the current mental health screening of children as part of the Texas Health Steps program and encourage you to ensure the state’s guidance on this benefit addresses not only depression but also screening for other factors such as substance use and adverse childhood experiences;
  • We recognize and will continue to support your efforts to increase the number of state psychiatric and residential beds;
  • We encourage you to work with the Texas Juvenile Justice Department to increase the behavioral health assessments of youth in the juvenile justice system;
  • We encourage you to promote the engagement of the School Health Advisory Committees at the district and the school campus level to work with educators and heath care professionals to monitor and assess challenges and stressors in the community and among their students. The members of these committees are in unique positions to identify leaders and resources in the community that can aid school children at risk and in need of additional support;
  • We encourage you to continue to expand public school mental health training programs and in particular, to improve access to school counselors who are trained in assessing the mental health of at-risk students;
  • We ask you to encourage school districts and campuses to develop relationships with local mental health authorities and local public health; and
  • We must begin to capture accurate data on the stressors that children face, and the school setting is a unique environment for this to happen. We must consider the feasibility of having a reporting system so that we can detect and study the stressors that children face amid the school setting. This could include an addition to the Youth Risk Behavioral Survey that is already routinely conducted in Texas.

Conclusion
With an increased awareness of the impact of adverse childhood events to health, we recognize that all physicians must be informed on the evidence of their health and social impact and on the need for routine screening of patients. TMA has already presented a continuing medical education program to our members, and we are organizing a panel presentation for legislative staff later this year. We are also developing educational materials on screening pregnant women for ACES to identify risks for maternal morbidity. 

While youth violence appears to be declining in the U.S., in 2017, minors represented about 13 percent of those who were identified as mass shooters. It is clear that now is the time for physicians to join you, educators, and community leaders to support and improve child safety in schools. We offer our commitment to work with you in this important work ahead for Texas.

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Last Updated On

July 30, 2018