Schools Districts review Arapahoe High shooting report that outlines three ‘major failures’
The head of security for School District 11 said he will be reviewing a report on the 2013 shooting at Arapahoe High School in Centennial to make sure D-11’s procedures are up to date.
The reports said the school district missed opportunities to prevent the tragedy.
Senior Karl Pierson shot and killed classmate Claire Davis at the Denver-area school on Dec. 13, 2013. Pierson then took his own life.
A report done by the University of Colorado Center for the Study and Prevention of Violence concludes that the shooting might not have happened were it not for three major failures on the part of Arapahoe High School and Littleton Public Schools.
“Every time we have an incident happen, we all go back and re-look at what happen and are we still doing what we should be doing inside the district,” said Jim Hastings with District 11.
The report says the school district did a poor job documenting Pierson’s behavior and sharing that information. Hastings said that is one aspect of threat assessment that District 11 will now be reviewing.
“We are looking at that to make sure we are in line with where we should be,” said Hastings.
Hastings said the report is a tool that all school districts can now review to improve their own policies and procedures.
FAILURE OF INFORMATION SHARING
The report says there were many missed opportunities to share information about Pierson’s behavior and intervene before the shooting. It says that in his three years at the school, not one teacher or administrator documented concerning behaviors exhibited by Pierson.
According to the report, at least 10 students had concerns about Pierson’s anger problems and gun ownership before the shooting, but only one reported their concern to a counselor and none of them contacted Safe2Tell. The report suggests that if the school had more aggressively trained students to report their concerns, the shooting may have been avoided.
Also on the topic of information sharing, the report finds that Arapahoe High School and Littleton Public Schools failed to implement an interagency information sharing agreement to share safety concerns with law enforcement and social services.
FAILURE OF THREAT ASSESSMENT
Threat assessment failures are also noted in the document.
The report says that the school failed to properly implement the district’s threat assessment policy. As a result, staff were not adequately trained on threat assessment procedures, Pierson’s threat assessment was not thorough which resulted in his being listed as a “low level” of concern and there was not adequate follow up in Pierson’s case.
The report also says that the district’s threat assessment tool had not been previously proven effective, and the district had no plan to validate it. The report suggests that the plan should not have been implemented as there was no proof that it would work.
FAILURE OF SYSTEMS THINKING
The third major failure noted in the report suggests a series of system failures to recognize that Pierson was in trouble and to address his problems before they spiraled out of control.
The report lists the following decisions made prior to the shooting that it says by themselves did not cause the shooting, but that taken together paint a picture of a bigger systemic problem:
Decision to not build a safety and support action plan for KP after incidents of violence in elementary school, when early violence is clearly a strong risk factor for later violence (see Appendices 1 and 5)
Decision to ignore the possible impact of his parent’s divorce
Decision to not enlist the help of one adult at AHS that KP trusted in his safety and support action plan
Decision to not have a safety and support action plan (e.g., mental health referrals, follow-up meetings) when KP yelled (obscenity) in class and was suspended
Decision to not follow-up on KP’s use of inappropriate “penis” line in debate competition
Decision to not follow up on KP’s claims of being bullied by others and being a bully to others
Decision to not empirically validate LPS’s threat and risk assessment tool
Decision to not treat KP’s violation of the Assistant Principal’s request that he not attend speech and debate team practices as evidence of “boundary probing”
Decision to only use two threat assessment team members in the threat assessment process, despite
state and federal guidelines
Decision to leave the School Resource Officer out of the threat assessment process
Decision to not assign a staff member to serve as the “information vortex” for KP during the threat assessment
Decision to not have a district-level Safe2Tell training policy for high schools
Decision to not forward KP’s threat assessment to the district for review
Decision to not thoroughly check the facts and collect collateral information on KP in the threat assessment process
Decision to not tell a student’s teachers the reason for a threat assessment, detention, or suspension
Decision to train threat assessment using only didactic and audio visual resources (see Appendix 6)
Decision to not formally suspend KP for his threat to “kill” Mr. Murphy
Decision to not formally suspend KP for his outburst in Ms. Lombardi’s Spanish class
Decision to not obtain video surveillance footage of KP making a threat about Mr. Murphy in parking lot
Decision to allow KP to return to school without the threat assessment team obtaining release of records from KP’s private therapist
Decision to allow KP to stay in school, when requested release of mental health records was not provided, as requested
Decision to only have one follow-up meeting to discuss KP’s progress with the safety and support action plan
Decision to not recommend a Student Intervention Team (SIT) to support KP when his grades began to decline
Decision to not inform the threat assessment team about KP’s viewing of guns and mass shootings on his laptop
Decision to not search KP’s computer, locker, or possessions for confirmation of his viewing of guns and mass shootings
Decision to not report KP’s purchase of a gun or interests in guns, as well as his anger problems, to Safe2Tell
Decision to not re-open KP’s threat assessment case after being told he had an angry outburst in class and had a gun
The report goes on to say that “the evidence of faulty systems thinking within AHS and LPS included a tendency for groupthink, a reluctance to reflect on and admit failure, and the minimization of sincere concern.”
Finally, the report offers 14 recommendations that it says the school and the district should implement in order to correct the above mentioned failures.
1. Recommend that principals, assistant principals, teachers, counselors, psychologists, coaches, and School Resource Officers (SROs) consistently use a student information system (e.g., Infinite Campus) to document matters of a “public safety concern,”3 including student behavior concerns, conduct violations, interventions, academic concerns, threat assessment results, and safety and support action plans.
2. Recommend that schools and districts promote Safe2Tell in formal training to students and staff each year, using skills practice, one-on-one feedback, and coaching (see www.Safe2Tell.org and Appendix 6: Skills Training with Guided Practice) and emphasizing the three core principles: a. No one will know; Safe2Tell is an anonymous reporting system. b. When someone could be hurt or injured, you have a duty to report the concern to authorities and break the code of silence. c. Safe2Tell is not limited to student reporting; the system is available to all students, teachers, parents, staff, and community members, and they also have a duty to report any safety concern to either authorities or Safe2Tell.
3. Recommend that school districts complete an Interagency Information Sharing Agreement with community agencies, including law enforcement agencies, mental health service providers, social services agencies, and the criminal justice system, as recommended by the Columbine Review Commission, stated in C.R.S. 22-32-109.1(3), and outlined by the Colorado Attorney General’s Office. To facilitate this reform, it is recommended that the words “if possible” be removed from C.R.S. 22-32-109.1(3).
4. Recommend that schools and districts install a validated threat assessment process, by either using the Virginia Student Threat Assessment Guidelines (V-STAG), by using a different validated threat assessment process, or by validating the current threat assessment process with similar outcome measures to V-STAG (see Appendix 8).
5. Recommend that schools and districts install a validated risk assessment process, such as the Structured Assessment of Violence Risk in Youth (SAVRYTM) or the Risk and Resiliency Check Up (RRCU). Use the results from the risk assessment to build a safety and support plan for any student who has a threat assessment. Risk assessments incorporate both risk and protective factors in the plan for the student.
6. Recommend that, during a threat assessment, the Secret Service’s six principles and 11 questions be used to gather and evaluate the early warning signs, threat factors, risk factors, and protective factors. The process should emphasize an “investigative, skeptical, inquisitive mindset” for each factor until a clear yes or no is found (Fein, et al., 2002, p. 29). All threat assessment team members, and if needed the ISST members and peers, should be included in the process (see Appendix 3).
7. Recommend that schools and districts train in a validated threat and risk assessment process using a one-on-one cognitive behavioral training standard (see Appendix 6). Adopt a formal training curriculum for threat and risk assessment. Train all teachers and staff in the overall process, and train principals, assistant principals, counselors, and SROs in a minimum of one-day hands-on scenario driven training curriculum.
8. Recommend that an information vortex coordinator (from the threat assessment team) be assigned to every threat assessed student; the information vortex coordinator should be noted in the student’s profile within the student information system so that when a concern arises, all teachers and other staff can easily identify and communicate with the coordinator. In addition, it should be the proactive duty of the information vortex coordinator to continue to seek out and evaluate information about a threat assessed student and recall the threat assessment team if new risk or threat factors are revealed.
9. Recommend that the Colorado School Safety Resource Center (CSSRC) audit any school or district requesting an audit for proper use of V-STAG (or other validated threat and risk assessment process). Any school or district that has implemented a validated process and receives a “high pass” in an audit of that process could use the results as an affirmative defense in any proceeding under SB 15-213. The audit process and implementation guidelines should be reviewed by CSPV.4
10. Recommend that the threat assessment and support teams produce a formal safety and support plan for every threat assessed student, relying on Individual Educational Plans (IEP) and Student Intervention Teams (SIT) as models. ISSTs build and monitor the plan for threat assessed students and revise the assessment and plan whenever a new threat or risk factor appears (see Appendix 3: Child in Crisis Assessment Recommendation).
11. Recommend that each threat assessed (or red flag) student be paired with an adult in authority, ideally within the school, who can build a trusting and positive relationship with that student.
12. Recommend that the Attorney General annually update the Colorado School Violence Prevention and School Discipline Manual on school safety statutes, FERPA, and their application to school districts. Additionally, recommend that school districts conduct an annual training on all statutes related to school safety and violence prevention and produce an annual compliance report.
13. Recommend that schools and districts conduct an established school climate survey of students and staff every one to two years and when the findings exceed established norms, select and implement experimentally proven interventions, programs, and practices.
14. Recommend that schools and districts create a continuous improvement model of error review committee to promote a culture of safety (and minimize groupthink), whereby staff can report concerns about organizational errors and near misses and staff can openly discuss, reflect upon, and address concerns and mistakes without formal or informal penalty. This committee should help develop short and long term plans for school safety reform. Drner’s (1996) five steps can help with long term planning.
