Chapters Transcript School Safety Daphne Branham, MD, discusses the impact of active shooter drills on the mental health of children. Well, good morning, everyone and welcome back to the early bird rounds this morning. We have Doctor Daphne Branham who specializes in pediatric emergency medicine and today she'll be speaking on school safety. As always, please type any of your questions in the chat um during the presentation and she'll have time later on to answer those questions. Um And also if you are having trouble finding the chat, you can unmute yourself at the end as well. Um And doctor Brennan, if you need any help, pulling up your presentation, let me know. Um, we'll get started here soon. Mm Give me one second. All right. Thank you guys for having me here. Um Again, so I'm doctor, I'm Daphne Branham. I am part of the division of emergency medicine um at Saint Louis Children's Hospital. Um And today I'm talking to you guys about active shooter drills, um and their impact on student preparedness and anxiety. And the question is, are they useful? I have no conflicts of interest to disclose. So this talk is meant to be informative. It will probably not change how you practice medicine, but it will hopefully inform and empower you to ask questions about active shooter drills that your patients experience in school. The main objective of this talk is to provide you the community pediatrician, an understanding of the potential impact of active shooter drills on the mental health of your patients. So here's a brief outline of our talk. Um We're first gonna go through a brief history of school shootings and lay out how we as a society have accepted, needing to perform active shooter drills in schools. Then we will review some of the current literature on active shooter drills and its emotional and psychological effects on students. And then finally, we will discuss next steps and how to address this in your practice. So to start us off, here is a brief history of school shootings just to start us off in an uplifting note. This graphic came from an article written in the New York Times on May 24th, 2022 after the Uvalde Texas school shooting. The source of this data is the K 12 school shooting database, which is an inclusive open source research project that was initially run by the Center for Homeland Security and Defense. That documents when a gun is fired or brandished or when a bullet hit school property regardless of the number of victims time day or reason. The data in this database ranges from 1970 to today. So we're gonna start off over here in um California. So the first large US non college school shooting occurred at Cleveland Elementary School in Stockton, California on January 17th, 1989 a 24 year old shot and killed five students and wounded 32 others. The next kind of big one was the Columbine High school massacre and this occurred on April 20th, 1999 in Columbine, Colorado. This supplanted the shooting in Stockton as the deadliest mass shooting at a high school where 12 students and one teacher were murdered. The shooting has inspired many quote copycat killings and that's been dubbed at the Columbine effect. And then fast forward about 13 years over here to Connecticut. The deadliest mass shooting at an elementary school occurred on December 14th, 2012 at Sandy Hook Elementary School in Newtown, Connecticut where 20 Children and six staff were killed. Then down here six years later in Parkland, Florida. Um This was the deadliest. This is now the deadliest mass shooting at a high school to date. This occurred on February 14th, 2018 at Marjorie Stoneman Douglas High School in Parkland, Florida where 14 students and three staff members were killed. And the most recent mass shooting at a school occurred on May 24th, 2022 at Rob Elementary School in Uvalde, Texas where 19 students and two staff members were murdered. This is another way to view kind of the same data. Um This is still from the K 12 school shooting database and this graphic again was published in the New York Times. Um And it was published on May 24th, which was right after the Uvalde shooting. So on this, the X axis includes the year and the Y axis includes the number of people killed. And as you can see, the number killed per year at a primary or secondary school has typically been below 10, typically below five. except for those mass shooting incidences that I described on the previous slide, which seems if you look at this that it has become more frequent since the 20 teens hearing about these school shootings are shocking, anxiety provoking and moralizing. However, it's good to keep in mind that school shootings are rare. So the education department reports that roughly 50 million Children attend public schools for roughly 100 80 days per year. Since Columbine, there's been approximately 200 public school students that have been shot to death while school is in session. That means the statistical likelihood of any given public school student being killed by a gun in school on any given day since 1999 has roughly one in 614 million. For comparison. The odds of winning the powerball jackpot is one in 292 million. So this risk is extraordinarily low. It's lower than almost any other mortality risk a child faces such as traveling to and from school or suffering a life threatening injury while playing interscholastic sports. Despite knowing that a pew research study conducted in 2022 notes that approximately one third or 32% of parents of Children in K 12 schools are either very or extremely worried about a shooting ever happening in their child school. And the graphic here on the right um is a representation of that research that was done by the PEW Research um Pew Research Center. There's only about one third of pay of parents who seem like they are not worried at all about their um students or about their child experiencing a school shooting at their school. There's another PEW research survey that was conducted in 2018 that showed the majority of American teens aged 13 to 17 are also worried or either very or somewhat worried about the possibility of a shooting happening in their school as well. So in response to the increasing incidents of school shooting and the perception that there are, these are becoming more frequent, um, school districts around the country have put into place school safety curriculums and active shooter drills to prevent or mitigate the effects of a similar incident taking place on their grounds. There's a study performed by the National Center for Education statistics in 2018 that revealed almost 95% of students attending public schools participate or practice a form of an active shooter drill. States have also recognized the increase in school related shootings and they've passed legislation mandating active shooter drills. Several of these laws were passed following the Parkland shooting in 2018. And as of now, there's at least 40 states that have laws mandating active shooter drills in school. In Missouri. Legislation was passed in 2013 that mandated starting 20 July 1st 2014, all school districts and charter schools must conduct active shooter and intruder response training and participate in a simulated active shooter and intruder response drill at least once per year. So we're going on here at almost 10 years. Um or this is the 10th year that this legislation since this legislation was enacted. The most well known active shooter drug protocol includes Alice training which was created by a company called Navigate 360 Run Hide Fight, which is something developed by the Department of Homeland Security. In case you're wondering emergency management at wash U utilizes run hide fight training. What constitutes an active shooter drill in school is unclear and it is all up to the discretion of school districts and the protocols or companies that they employ the manage the manner that these activities are conducted. Run the gamut from tabletop exercises to full scale simulations. Some school districts have even used tactics such as shooting teachers with plastic pellets simulating gunfire and using fake blood. So here's an example of an active shooter training and drill that was conducted at a preschool in Arizona. This was aired by CBS Ion America on May 29th, 2018. This first part shows the training that the teachers undergo. And the second part includes the preschoolers that participate in this active shooter drill. And I include this because it's a little bit eye opening because the Children in this video are four and five years old in schools across America. The job description for teachers has changed. This is only a drill. He is holding a cake gun today, thousands of teachers are now required to participate in active shooter drills like this 10 goodness gracious. Sorry about that. Let me try this one more time in schools across America. The job description for teachers has changed. This is only a drill. He is holding a cake gun today. Thousands of teachers are now required to participate in active shooter drills like this one. I know it's a drill but it doesn't feel real. It does because you can't be with the mentality. It's just a training, nothing's gonna happen because if not, you're not gonna put your effort in it. I'm not teaching you something out textbook. I'm teaching something to actually live through former deputy sheriff, Eric Frost runs a company that conducts safety trainings for mass shootings. He says he's busier than ever. An active shooter situation is scary generally because in this scenario, you did fight back in what happened, he was able to shoot you guys and that's it. In a scenario where you fight back, you have a chance to go home at the end of the day. Hey, open the door, open the door. I'm gonna get this kid every month at Casa De Ninos in Yuma, Arizona. After the students go home, the teachers go through active t training. But this is a preschool with kids as young as one year old. Since Columbine, 16% of school shootings took place where preschoolers and kindergarteners were present. This is Jessica Aga's 10th active shooter drill since August. She's been a teacher for 12 years, years ago. When you started doing this. Did you ever think you'd be locking kids down and, and taking precautions for a potential shooter? No, because um back in the days when I grew up, I was in school schools. That's the safest place ever. So, and then all this happening, it's like, am I really safe in school in the next drill? There's a twist, a student gunman. No stop. There's always that moment where even though it's just a practice, it gets to each drill cost the school $1000. A 2016 us government accountability report found two thirds of school districts across the country conduct active shooter drills. The training is required by Sabrina seal the preschool zone. I'm very protective. Very, very, very, very protective and we wear so many hats. We're a nurse, we're, we're a teacher, we're a mom. Super cool. I like it. And now your security and, and that is totally put us in a different element that we were not prepared for. We came back the next morning, there are four and five year olds in that classroom and they don't know it yet. But at any moment there's gonna be a lockdown drill where the teachers have to apply what they learned and keep these kids safe. But there won't be any guns and the kids are told it's a game. Miss. Are you ready? 123. Ok. Over there. Let's go. Hello? Ok. Or at least? Ok, guys, it's over. So why do you have to be so quiet? I might take you a stranger might take you. We call a stranger. We're not gonna tell them, you know, it can be, you know, have a weapon and go to an extreme. We just put a name on it so they know and quiet and you were crouched down with the kids. What was going through your mind? My mind was blank. It was just to keep them safe. Keep us quiet. Are we teaching them at such a young age to be scared? It's not quite teaching them. We're just keeping them safe because I don't want them to be afraid. I'm not gonna lie. It can be, you know, to the point that they question like why are we doing this or why do I need to be safe if this should be all safe? Ok. You guys did a fabulous job. Good job. 55, you guys were very quiet. You wanna, I so join and see if it's Adrianna. Uh how widespread have these drills become? All right, it's quite sobering. All right. Now, this is a, another example. This is a very brief one. This was an active shooter drill that occurred in a mi at a middle school in Florida. This was aired on ABC news um, on November 15th 2014. I'm gonna kill everybody. Nobody getting out here. It's every parent's worst nightmare, an active shooter on campus threatening to kill innocent kids in this case, just a drill but a terrifyingly realistic drill. That's now an issue. How do you strike a balance between preparing kids and scaring the pants off? It may be just a drill but the trauma is real outside Tampa Florida yesterday. Parents and students say Jewitt middle school got it wrong. The school there held a drill without warning in which police officers showed up on campus weapons drawn had announced that we were going to have a lockdown. Seventh grader Lauren Marino and her siblings frantically texted their mom. Police came in with guns and I'm kind of scared. We actually thought someone was gonna come in here and kill us. Their mom was scared too. Well, I'm panicking because I'm thinking that it's, you know, a legitimate shooter coming. Xavier Tate was scared too. His dad raced to the school unaware it was only a drill. My husband almost got a ticket coming over here yesterday. He was doing 130 the school has now apologized to the parents and the local police chief now says officers won't use weapons in future drills but the school will continue to hold unannounced lockdowns. The fact is ever since Columbine 15 years ago, the US has had more than 160 active shooter incidents. That's about one a month. And as we saw in Sandy Hook, even the youngest kids aren't safe. So in school districts across the country, lockdown drills are now as common as fire drills. Some go as far as covering students in fake blood and recruiting volunteers to play dead in the hallways all in an effort to make the drills more realistic. We need to lock down the modern version of duck and cover. Please go behind my desk. The teacher locks the door, pulls down the shade, everyone's told to keep quiet. It's kind of scary. Huh? The kids huddle quietly under the teacher's desk. Do you know why they do this drama? I, do you worry that this scares students. We do, but we practice enough that we hope that students are, are as staff as you know, getting used to the idea. We have to. How long did this go on for five minutes I think is maybe the longest we've ever had the teacher in one classroom we visited in Colorado fully supports these drills. Holly Carpenter is a graduate of Columbine High School. When you look at those kids. So one thing to keep in mind about these active shooter drills um and protocols is that they're typically developed by law enforcement psychologists and educators are not typically involved in the development of these protocols, which is why sometimes they um can be taken to a little bit more of an extreme. And so, despite the prevalence of these active shooter drills, there is very limited evidence to suggest what impact these drills have on those who participate. So this study was published in 2020 in the journal of school violence. Um and that evaluated the impact of students perception of emergency preparedness was conducted at an in an urban school district in central New York where a school district forming an active shooter drill um with no training in the fall. But in the spring, they included a training session two months prior to the performance of a second drill. And they found that while students perception of emergency preparedness improved with the additional training, their perceptions of safety in the schools did not. The second article was published in 2021 in humanities and social sciences. Communications. The authors here used machine learning to search and analyze 54 million social media posts on Twitter and reddit to extrapolate stress, anxiety and depression via language analysis and correlated it with school active shooter drills in 100 and 14 schools spanning 33 states. And based on the language analysis, they extrapolated that anxiety, stress and depression increased following the drills. That being said, those who would go on to social media to post is a little bit of a self selecting group. Um And so that was something that is meant to, you have to keep in mind for a study that looks at social media. So there have been no studies that have directly evaluated the effect of active shooter drills on student psychosocial health or whether they make students feel prepared to respond to school shootings. And so in an attempt to bridge this gap in knowledge, I put a study together in fellowship to try and address this. These are our methods. This we set up the study as a prospective observational cohort study of students enrolled in grades 3 to 12 at a suburban public school district. This is up in Wisconsin. Data was collected between October and December 2019. Um The students received active shooter training training using a curriculum provided by the I I love you guys foundation early in the school year. This training um is less hands on, pick up things to attack the shooter, more knowledge based in giving students and empowering them to know what to do in certain situations. Whether it's an intruder, whether it's an active shooter, whether it's a fire drill. Shortly after they completed the training, the students completed the state trade anxiety inventory for Children. This is a validated 40 question anxiety scale. Um The these scales. So there's two parts of it. The trait anxiety scale is comprised of 20 questions that assess generalized anxiety scores on this range from 20 to 60 higher scores indicate higher levels of anxiety. There's also the state part of the scale. Um and that assesses anxiety at a point in time. Scores on that also range from 20 to 60 higher scores indicate higher levels of anxiety. So approximately 3 to 4 weeks after they received training, the students participated in an active shooter drill. And immediately afterwards, students completed again, the state trade anxiety inventory. Um as well as a few additional questions, we had two questions regarding preparedness and usefulness. Um after the active shooter drill this, so the preparedness question that was asked was how prepared do you feel to respond to a school safety announcement? We assess this using a five point liard scale. But for analysis, we grouped these responses into three categories, either prepared unprepared or neither. We also asked the question, how useful do you think school safety drills are? This was also assessed using a five point scale. And again, for analysis, these responses were grouped into three categories either very or somewhat useful um were grouped into useful um useless. And then neither and these responses were compared to the anxiety scores using anova so analysis of variants. So hypothesis for this study was that active and after an active shooter drill, students with um students in general their anxiety levels would increase immediately after participating. That just seems like the logical um logical thought. We also um hypothesize that active after an active shooter drill, students with high baseline anxiety levels will feel less prepared and will have higher post drill anxiety compared to those with low levels of baseline anxiety. And in addition, students who find active shooter drills useful will have lower baseline anxiety levels than those who do not. So in other words, those students with high baseline levels of anxiety will find active shooter drills more useless. Um So here are some of our results. These are the overall demographics of those who are enrolled. There was a total of um about 5700 students enrolled in this study. Um Approximately half of them were male and half of them were female. A little over one quarter were elementary school students, one quarter were middle school students and a little less than half were high school students. The school district this was conducted in comprised, was comprised of five elementary schools, two middle schools and two high schools. Um And the de of the demographics here, approximately 70% of these students were white, 16% were Asian. Um 6.5% were Hispanic. 5% were multi racial and 3% were black. And I'm not totally certain what happened with my labels, but apologies. There, 982 students completed both the baseline and post drill. Um anxiety skills of the state trait scores were compared using paired T tests. So on this chart, gender is on the X axis and the state score, their anxiety score is on the Y axis. State. Anxiety is again a measure of anxiety at a specific point of time. And the higher the score, the greater the anxiety we found that in the anxiety levels were reduced actually after an active shooter drill in both males and females and these were found to be statistically significant. However, a reduction of less than a point on the state is very small and in many ways shows that state anxiety was unchanged pre and post drill. The more notable piece of this part of the data is that anxiety levels, at least using this protocol did not increase after an active shooter drill, we broke this down also looking at school type and when we did this, we saw that there was a decrease of approximately two points in their anxiety score that was only present in high school students. And that was, that was statistically significant. There was no difference in pre and post drill anxiety in elementary and middle school students. Um again, a drop in two points might be small and while it's statistically significant may not be clinically significant. But across the board, um it doesn't seem like anxiety levels increase. After an active shooter drill, we then looked at the preparedness question. So a total of 1600 students responded to the question. How prepared do you feel to respond to a school safety announcement? And there is of these responses, there was a slight predominance of female students compared to male students. Approximately half of those who responded to this question were in elementary school. About one quarter were in middle school and approximately one quarter were in high school. Um From our responses, the majority or 88% felt like they were prepared to respond to an active shooter drill. 4% felt unprepared and 8% felt neither prepared or unprepared. When we differentiated these by school type, the middle schoolers felt the most prepared followed by high schoolers and then grade schoolers. And in addition, the high, the highest percentage of students who felt unprepared were grade schoolers followed by high schoolers and then middle schoolers. While these differences are very small, they were all statistically significant. When we tried to differentiate these responses by gender, they were not found to be statistically significant in regards to usefulness. There was a total of 1600 students who responded to this question. How useful do you think school safety drills are? And again, there was a slight predominance of female students compared to male students who responded this one again was about half grade schoolers, a quarter, middle schoolers and a quarter high schoolers from our responses. Again, the majority, 91% felt that active shooter drills were useful. 4% felt that they were useless, but 5% felt like they were neither useful or useless. When we were differentiated, these responses by school type, we found that the middle schoolers felt that active shooter drills were the most useful followed by elementary school students. And then high schoolers. Conversely, high schoolers were more likely to find active shooter drills useless, followed by grade schoolers and the middle schoolers again. While these differences are small, they were all statistically significant. In addition, when we broke this down by gender, females were more likely to find active shooter drills useful compared to males, females felt. Um there were 94% who felt that they were useful compared to 87%. And this finding was also statistically significant. Next, we compared these preparedness responses to anxiety scores. So this chart shows preparedness responses on the X axis and their anxiety scores on the Y axis. And again, higher scores are associated with higher levels of anxiety. So as a reminder, these trait scores or the blue bars on this chart are a measure of generalized anxiety. So those who felt unprepared for active shooter drills, which would be the ones on the left had higher were found to have higher levels of generalized anxiety compared to those who felt prepared just a little which are the bars on the left. These values, the comparison is about 35 to 40 on their scores. And these values are found to be statistically significant, the state scores or the orange bars are a measure of anxiety at a point in time. And in our case, that point in time was immediately after participating in an active shooter drill. Those who felt prepared were found to have lower levels of anxiety compared to those who felt unprepared or neither prepared or unprepared. You can see on the left, um those who felt prepared, their scores were about 32. Um and those neither and somewhat unprepared or at 35 and 34 these differences while less pronounced than the generalized anxiety score differences were also statistically significant. Finally, we compared usefulness responses to anxiety scores and the chart shows usefulness responses on the X axis and anxiety scores on the Y axis. The trait scores or the blue bars, which are the measures of generalized anxiety. Um We found that those who felt active shooter drills that were useless had higher levels of generalized anxiety compared to those who felt active shooter drills were useful. This is the difference between 35 to about 40. These values were found to also be statistically significant. The state scores um which are the anxiety measures of the anxiety levels. Immediately after participating in an active shooter drill, we found that the state scores, those who felt that active shooter drills were useless, had higher levels of anxiety immediately after participating in the drill compared to those who found active shooter drills to be useful. So those who found it to be useless was about 37 and those who found it useful were at 32 these differences were found to be statistically significant. Here are some of the conclusions from our study. Interestingly, school safety drills, at least the one that was conducted in this school district um at this particular and the version that they had um in at that fall, they were not associated with general like increased levels of anxiety, especially immediately after the drill. However, we did find that students with higher anxiety levels at baseline were more likely to feel that active shooter drills were useless. They were also more likely to feel unprepared to know how to respond to an active shooter. So this cohort of students, they might benefit from an alternative version of active shooter drills that would account for their elevated baseline anxiety levels. So what's next for this work? Um There's a few ways that I'm hoping to try and take this research one way is to expand the study to different populations. So I conducted this at a suburban school district and it would be interesting to me to see how active shooter drills that affects those in urban school districts and rural school districts. Um compared to those in suburban school districts, because the issues that these students deal with in these different communities obviously vary. I'm also interested in learning how these active shooter drills um in school districts with different socio-economic or racial compositions um could change um students perceptions as well. Um This district that I conducted this in was majority white. Um and majority, the second most populous population, there were Asian and obviously different school districts around the country have different compositions. Finally, I'm interested in evaluating how different curriculums of active shooter drills would affect anxiety. The curriculum that was used at the school was the Standard Response Protocol and it is one of the most benign versions um of active shooter drills that I had seen in my research, this doesn't involve promoting any physical harm. It just wants to set out a plan for students and what they can do. But like I stated before, how these drills are conducted, run the gamut. And it would be interesting to see anxiety responses in situations where a district uses more intense tactics. And this knowledge could aid in learning, you know, what form of active shooter drill resonates best and is most effective in students with elevated anxiety levels and potentially dictate and help advise school districts as to what kind of curriculum to um to implement. So what does this mean for you as a community pediatrician? Well, I guess um some of it is just awareness. Um One thing um that I was thinking about was, you know, as a community ped pediatrician, it would be good to be in touch with your local school district, just contact your local school district to learn what about the kind of active shooter drills that are conducted in school? And if drill intensity seems to be causing more harm than good advocate for modifications in the drills or training and be aware of when active shooter drills occur in your school district. So state law mandates that schools participate in at least one uh drill and training per year. But some school districts perform 21 in the fall and one in the spring and know that there might be an increase in mental health visits after an active shooter drill and then be aware of the mental health resources in the community so that if needed, you can refer patients and families after these active shooter drills occur. Um So doctor Joseph Simonetti at the University of Colorado had written a nice opinion article in Jama Pediatrics about this topic a few years back and he closed his article with the following quote that I'm going to paraphrase schools have a responsibility to educate and protect the physical and mental well being of students and having a plan in place in case of a school shooting is part of that, but it is imperative that we are making sure we are being thoughtful and deliberate about the potential harms. We are willing to inflict to justify the benefit of a rare event. All right. And that's all I have any questions or comments that I can answer right now if anyone wants to unmute for any questions, please feel free. Um, while we wait for it to roll in in the chat, I was gonna go ahead and let you all know that this was our last early bird round for 2023. So, um, the next one will be January 12th. Um, so we'll look forward to seeing you all there and it looks like we do have a question in the chat. So someone asked, um, is there evidence to support that the drills improve survival in an active event? Um So I don't believe that many of these studies have been conducted yet. Um There is anecdotal res um reports at least of the one that had happened last year here in Saint Louis that people, people did feel like the response was improved um because of the drills. Um But in terms of actual survival, because these events, the actual shootings are rare, which is good. Um It is hard, really also hard to measure if that improves your survival. Hi doctor. Um Thanks for the information that the videos were scary. I'll tell you it was anxiety provoking for me to watch some of those uh training uh sessions. But um do you know, was there any debriefing after these drills? And do you, do you see any changes if there's a debriefing after the drills for the Children and teachers? Yeah, that's a great question. Um So at least in the district that we conducted this in they do probably like a one minute debrief of what happens and depending on the age of like what type of school they're in. Um there are like more or less questions but because kids have been doing this for so long, the number of questions usually are very minimal. So, um so I don't know if this, if debriefing happens in every um school district. Um but at least in this one that we conducted this and they do a very brief one and then they move on with their school day. Well, I'll ask another question then. Thank you. Um, do they really see if these drills are effective as opposed to the student's opinion about whether they're prepared or not? Do they do a, like a post test three months later to see if the Children have learned anything or teenagers? Because it, it's frustrating when you say it's like lightning striking. I'd be more concerned about tornadoes here than school shootings. Yeah. So part of our plan with this study was to conduct a post drill to see if knowledge retention occurred and, you know, feelings of preparedness and we put out a survey about a month later. Um And what's actually really kind of demoralizing about this is when you ask questions about knowledge retention, it was like we put in three questions that were very basic based off of the curriculum that they learned and they, um, the percentage of students who just were able to answer one of those three questions was much lower than um we expected. So only about like 40% answered one question correct about, you know, what you're supposed to do in this active shooter drill. Um And so, and anxiety levels, I didn't include this in this um in the data on here, but um anxiety levels did not like creep up a month later and the feelings of usefulness and um preparedness were about the same. So, um we're, we were planning on running this a second time to see if you know, going through a drill twice um would change some of that knowledge retention. Um But 2020 was the year after and then kids were not in school for a bit. So, um that is part of the plan to try and uh re reboot the study um in districts here and hopefully that will be part of it. Thank you. Yeah. Well, thank you for speaking for us. This mor this morning, Doctor Brandon, we really appreciate your time and everyone's time to log on. Um It seems like that might be all the questions. So um we'll go ahead and let you go, but we appreciate it. I hope. Thank you so much. Appreciate it. Yeah, you as well. Thank you. Created by Presenters Daphne Branham, MD Pediatric Emergency Medicine View full profile
