In hindsight, the warning signs were abundant that Seung-Hui Cho was mentally troubled and potentially dangerous. But authorities at Virginia Tech didn't put together all the pieces until after the 23-year-old student opened fire on the Blacksburg campus on April 16, 2007, and killed 32 people before taking his own life.

In the aftermath of last year's tragedy, administrators at Virginia Tech and countless other schools and universities began to examine the lessons to be learned so they could respond more quickly and effectively to the next crisis on campus. Many campuses have worked to notify students and staff members more quickly and comprehensively when a threatening situation is underway.

But another key aspect of schools' self-examinations should focus not on how to react to a crisis, but how to prevent one. Numerous task forces and study groups formed after the Virginia Tech tragedy have concluded that schools and universities can do a better job identifying and providing services for students like Cho who are experiencing mental-health problems.

When a massacre on the scale of what happened at Virginia Tech occurs, it's clear that the person who carries out such horrific crimes is mentally troubled. But every day in thousands of schools and campuses across the nation, students are wrestling with problems and stress in their lives, and may not know how to cope or where to turn for help. Schools cannot afford to let students' problems go ignored or untreated.

Proactive measures

Education institutions are being encouraged to bolster their mental-health services, to train faculty and staff to recognize potentially troublesome behavior, and to make sure staff members know when it is proper and legal to disclose information about a student so that potentially dangerous situations can be prevented or defused.

“A well-funded, robust, comprehensive and interconnected network of specifically student-mental-health-related services is the best line of defense in facilitating the early identification and treatment of students presenting mental-health-related behavioral issues,” the University of California Security Task Force says in its January 2008 report.

It's not surprising that many schools and universities are less than comfortable addressing issues of mental health. Society as a whole is uneasy about dealing with psychological and emotional troubles.

At the same time, institutions are finding that more students are manifesting problems that go beyond what might be considered “typical” troubles such as homesickness or grade anxiety.

“More and more students of all ages and backgrounds are experiencing mental health problems that are qualitatively different and significantly more complex,” says a 2006 report from the Student Mental Health Committee at the University of California.

Those include depression, eating disorders and substance abuse. “Crises, tragedies and darker issues now involve university students with a regularity that is deeply troubling,” the report says.

If students are likely to feel ashamed to seek out treatment, they won't do it (see sidebar at right), and their problems will only fester.

The Wisconsin Governor's Task Force on Campus Safety issued a report last year that urges schools and universities to work to lessen the negative connotations associated with mental-health services.

“Active campaigns are needed to convince students that seeking treatment is a sign of strength and maturity, and that they should support friends or classmates seeking counseling to cope with their stress,” the task force says. “Another way to reduce stigma is to make the mental health services readily available or part of a standard procedure.”

In addition, education institutions need to make sure they have adequate resources to provide help to the growing number of students who could benefit from treatment.

“Colleges and universities should reach out to the surrounding communities to catalog additional counseling personnel,” the Wisconsin task force says. “Pre-arranged agreements will also expedite the process of bringing these resources onto campus should the need present itself.”

Keeping track

To be able to identify when a student's mental health is becoming a cause for concern, school officials have to know the student well enough to make an assessment. It helps to have some history about the student's past behavior.

But when students enroll in a new school, administrators and teachers often have no information. The new surroundings may enable students to conceal past behaviors that, if disclosed, would give administrators at a new school a more complete picture to determine whether counseling or some other intervention would be beneficial.

In the bureaucratic setting of a school district, information about a student might not find its way from one elementary school to the next, or to middle and high school, let alone to a college that has no official connection to the K-12 schools a student attended.

Some school systems have begun to use technology to help them maintain more complete student records. Dan Datkuliak, assistant principal at Canton High School in Canton, Ohio, says his school is using a web-based computer system that collects and stores data about student conduct and behavior.

“It gives us a history and enables us to see trends,” says Datkuliak. “It's definitely opened my eyes to some data. Say a kid skips class several times at the same time every time. If that coincides with break-ins in the parking lot … I'm going to look at that kid first.”

The ease of adding information to the system online means that incidents that might have gone unreported now provide a more complete picture of a student's conduct.

“Things that might not seem to be a big deal are being added in case they have some relevance,” says Datkuliak. “We need to know everything to have a proper intervention.”

The collection of information in and of itself will not help students, Datkuliak emphasizes, unless a teacher or administrator can develop a relationship with a student and form a bond of trust. That can be helpful if a student develops problems after moving on to college.

“If Johnny doesn't know me, and I ask the parents, ‘I want to go to Mr. Smith at Ohio State and talk to him about Johnny,’ they're going to look at me and say, ‘Are you kidding me?’” Datkuliak says. “You can't do it without the relationship piece.”

New rules

Another hurdle that schools have to overcome when addressing mental-health issues is a legal one. Privacy laws determine whether a school can release data about students, and many administrators, not wanting to violate the law, have been reluctant to disclose mental-health information about a student, even if a student is exhibiting behavior that could be considered dangerous.

A 2007 report to the president by the Departments of Education, Justice, and Health and Human Services concluded that education administrators were unclear what information they were allowed to disclose under the Federal Education Rights and Privacy Act (FERPA).

“A consistent theme … was that this confusion and differing interpretations about state and federal privacy laws and regulations impede appropriate information sharing,” the report said.

The report recommended that the Education Department revise the guidelines related to FERPA to clarify to what extent schools could share information.

In March, the department followed through on the report's recommendation. The proposed new regulations for FERPA specifically address the potential release of student information in an emergency.

“An education agency or institution may take into account the totality of the circumstances pertaining to a threat to the safety or health of a student or other individuals,” the proposed regulations state. “If the educational agency or institution determines that there is an articulable and significant threat to the health or safety of a student or other individuals, it may disclose information from education records to any person whose knowledge of the information is necessary to protect the health and safety of the student or other individuals.”

As long as the school or university in question has a rational basis for determining that a legitimate threat exists, the Department of Education “will not substitute its judgment for that of the educational agency or institution.”

“In balancing the interests of safety, privacy and treatment, the Secretary (of Education) proposes to revise the regulation to specify legal standards, but to couple those standards with greater flexibility and deference to administrators so they can bring appropriate resources to bear on a circumstance that threatens the health or safety of individuals,” the proposal states.

Comments solicited

Before deciding whether the proposed changes will be adopted, the education department accepted comments on the proposal from interested parties.

The National School Boards Association (NSBA) has raised several concerns in its comments.

“School districts, particularly those that are small and rural districts, may not feel they have the expertise on staff (law enforcement officer or school resource officer, psychologists, and other mental health professionals) to determine whether a threat is ‘articulable and significant,’” NSBA states. “NSBA recommends that the Department change the proposed regulations to allow school districts to involve outside experts in determining whether a health and safety emergency exists.”

NSBA also says setting “articulable and significant” as the standard for a threat is too stringent.

“The standard created by the language is so high that school districts will not be able to act until a crisis is already happening,” NSBA contends. “Often student behavior that raises concerns … is chronic or escalating and does not necessarily pose a clear and immediate threat.”

NSBA, noting that some of the changes to FERPA rules have been prompted by the Virginia Tech shootings, suggests that the regulations also address less catastrophic safety threats.

“School districts face threats daily from students who are at risk of engaging in behaviors less dramatic than school shootings (sexual abuse, physical assaults, gang activity, etc.) that can have equally devastating consequences on individual victims,” NSBA states. “Guidance from the department in determining when these behaviors meet the threat threshold would help schools cope with the full range of threats to the safety of its students, and facilitate the provision of services to students engaged in threatening or unsafe behavior.”

The association offered to work with the education department after the new regulations are in place to look at how they work in real-life situations.

“Such guidance might include scenarios … would describe when and how school districts could evaluate the threat; when and whom school districts could share information with; and what information could be shared,” says NSBA.

Appropriate protection

In its comments, the National Alliance on Mental Illness (NAMI) stated that it supports the proposal.

“This provides appropriate protection for sensitive and otherwise protected information, while ensuring that parents and other appropriate individuals are apprised of an emergency and have the opportunity to intervene to protect the health and safety of those involved,” says Michael J. Fitzpatrick, executive director of NAMI.

However, the New Mexico Protection and Advocacy System, a nonprofit group that supports the rights of people with disabilities, says the “rational basis” standard for disclosing private student information is not stringent enough and could “destroy the department's enforcement capabilities.”

“Schools may take broad leeway in making disclosures, which could include private and sensitive mental health information,” says Tim Gardner, a staff attorney for the organization. “With only a ‘rational basis’ review, student confidentiality would be in serious danger.”

Gardner suggests that the standard should be that school administrators have a “legitimate belief” that a health or safety risk exists.

The proposed regulations also clarify that even after a student reaches the age of 18, a school in certain circumstances may disclose education records to parents without the student's permission. Among those circumstances: if the student is a dependent for federal income tax purposes; if there is a health or safety emergency; or “if the student is younger than 21 and has violated an institutional rule or policy governing the use or possession of alcohol or a controlled substance.”

Fitzpatrick's comments on the proposal emphasized the benefits of colleges providing parents with information about mental-health issues involving their children.

“There are certainly exceptions in which students would not want their families notified,” says Fitzpatrick, “but in most cases, college students with mental illnesses rely on their families for support, especially in cases involving a psychiatric crisis.”

Kennedy, staff writer, can be reached at mkennedy@asumag.com.

Reluctant patients

Even when services are free and readily available, the stigma that is attached to seeking mental-health services may prevent students from seeking counseling or medication to help them cope with their circumstances.

A study published in June 2007 that surveyed 2,785 students at the University of Michigan indicates that more than half of students with significant symptoms of anxiety or depression do not seek help, according to the university news service. The reluctance to seek mental-health services is prevalent even though resources are available at no cost on the Ann Arbor campus.

The study, “Help-Seeking and Access to Mental Health Care in a University Student Population,” by Daniel Eisenberg, assistant professor at the University of Michigan, and doctoral students Sarah Gollust and Ezra Golberstein, appeared in the journal, Medical Care.

Depending on the disorder, anywhere from 37 percent to 84 percent of students did not seek treatment for significant symptoms of depression or anxiety. The study found that students who reported growing up in poor families were almost twice as likely not to seek help. Poor students also were much more likely to exhibit symptoms of depression and anxiety disorders.

The study also found that women were more likely than men to acknowledge the need for treatment and seek it. Other factors associated with not seeking treatment included lack of perceived need, being unaware of services or insurance coverage, skepticism about effectiveness, or being Asian or Pacific Islander.

Signs of trouble

A student exhibits odd or troubling behavior. Is he or she just having a bad day, or is it an indication of more serious and dangerous problems bubbling under the surface?

That is the kind of judgment call that school and university faculty and administrators have to make. To help teachers and staff determine how to assess such situations, The Massachusetts Institute of Technology has put together a pamphlet, “How to Help Students in Distress.” It spells out academic, psychological, physical and social indicators that could be warning signs.

“Taken alone, any one … indicator is not necessarily a sign that the student is experiencing severe distress,” the pamphlet states. “However, a student may need, or may be asking for help if he or she exhibits several of these warning signs.”

Academic:

  • Frequent absences from class or work, especially when this is a change.

  • Marked decline in academic work or work performance.

  • Repeated need for accommodations (such as extensions).

  • Marked changes in concentration, motivation and investment in academic work.

  • Papers or essays with themes of depression, hopelessness, helplessness, anger, social isolation and/or despair.

Psychological or physical:

  • Marked changes in personal hygiene, noticeable weight gain or loss, or reported changes in sleeping or eating habits.

  • Depressed demeanor, isolation or withdrawal.

  • Apathy, lack of energy or noticeable changes in social behavior or work habits.

  • Noticeable anxiety or panic.

  • Marked changes in personality traits or interpersonal style.

  • Anger, irritability and increased interpersonal difficulties.

Social:

  • Reported family issues, parent-child conflicts, personal losses, romantic breakups or friction in friendships, relationships with advisers or other interpersonal relationships.

  • Concerns expressed by peers, housemasters, resident assistants, advisers or anyone else with immediate and personal knowledge of the student.

To read the entire pamphlet, go to http://web.mit.edu/medical/pdf/faculty_brochure.pdf.