I_SchSafety_2016A 01/22/2016 01:36:12 PM Committee Summary

01:37 PM -- Davis Family



Majority Leader Scheffel, chair, welcomed the audience and went over the agenda. He spoke about the Davis' family's loss and their response to tragedy. He spoke about the benefits to the state of Colorado of having this information available to make good policy. He thanked the Davises for their contribution.































01:41 PM -- Michael Davis, father of Claire Davis, introduced himself and distributed a written statement to the committee (Attachment A). He thanked the committee for waiting until the completion of the arbitration between the family and Littleton Public Schools (LPS). He thanked legislative leadership and Governor Hickenlooper for studying the reports, the three independent groups of experts for providing their analyses and writing the reports, Michael Roche for his role in handling the depositions, the Arapahoe County Sheriff for thinking of the idea of expert reports, the teachers and administration of LPS and Arapahoe High School (AHS) for their contributions of honest information, Natalie Pramenko, principal of AHS for her willingness to make changes to prevent future tragedies, Brian Ewart, Superintendent of LPS, who publicly acknowledged that LPS and AHS missed opportunities to prevent the tragic deaths of two students and publicly apologized for those mistakes. Mr. Davis spoke about the goals of the arbitration, and about the changes recommended in the three reports.



16SchoolSafety0122AttachA.pdf



He continued discussing the role schools play in identifying troubled students and identifying resources to help. He said that schools must be held accountable for carrying out this responsibility. Mr. Davis said that there is no role for finger-pointing or blame, and that schools should not become less tolerant or more punitive. He urged schools to embrace the reports' recommendations in a mindful, professional, caring manner. He said that this study is no longer about his daughter Claire, or Karl Pierson, who he described as a teenager in crisis who may have made different choices if a helping hand had reached out to him. Mr. Davis said that this process is now about the next student in crisis who needs a helping hand, and about making sure interventions occur to prevent tragedy. He introduced Susan Payne, director of Safe2Tell, and Beverly Kingston, board member of Safe2Tell, and a student at Kent Denver who gave $1200 she raised on Colorado Gives Day to Safe2Tell.



01:54 PM -- Michael Roche, attorney for Mr. and Mrs. Davis, spoke about his part in the arbitration process and the uniqueness of the process. He discussed the Davis family's commitment to finding answers, not blame, and solutions, not problems. He thanked the legislative leaders who showed bipartisanship in passing the Claire Davis School Safety Act in 2015 and described that law's role in finding answers to the causes of the shooting at AHS. Mr. Roche introduced the first report, conducted by the University of Colorado's Center for the Prevention and Study of Violence.















































01:57 PM -- Center for Prevention and Study of Violence Report



Dale Elliott, representing the University of Colorado's Center for the Study and Prevention of Violence (CSPV), spoke about the opportunity to create the report, and described it as a gift to the state of Colorado. He spoke about his experience, and how the problems described in the report are widespread among American schools. He described his experience studying this issue, and spoke about what happened after the shooting at Columbine High School. He distributed a slide show to the committee (Attachment B). He said that recommendations made after the shooting at Columbine High School have never been addressed, and that the root causes of violence, primarily school climate, are not being well addressed. He said that 50 percent of middle schools nationally have a drug prevention program but only 1 in 4 of those programs is evidence-based. He spoke about the Scared Straight program and said that evaluations show it does more harm than good by increasing the probability of violence and criminal involvement. He described the 21st Century Learning Center, which has also been shown to be harmful. He spoke about the DARE program, which has also been shown not to work. He said schools should be diligent when selecting and implementing programs because there are programs that have been shown to work and that are hugely successful, but that those programs are not being implemented widely. He spoke about the need for school climate surveys so officials can identify students that are in need, schools with issues, and students with serious problems. He said that a positive school climate is the primary prevention strategy. He spoke about the need to end the code of silence within schools and about evidence-based bullying and drug prevention programs. He said that every student should have trusting relationship with at least one adult.



16SchoolSafety0122AttachB.pdf



02:10 PM -- Bill Woodward, representing CSPV, spoke about process of researching and writing the report, and about the team's efforts to remain independent. He stated that the team had received no guidance or feedback from the Davis family or LPS. He described the recent rise in shootings, and the contributing factors to that rise. He described the need to address the root causes of youth violence and said that 20 to 25 percent of students report being bullied or being a bully. He said that 33 percent of high school students have been involved in a physical fight at school in the past year. He described the documents the team had consulted in researching and writing their report: 12 depositions, 58 exhibits, 4,215 pages of documents, and the Arapahoe County Sheriff's Office (ACSO) report. Mr. Woodward said there were 27 decisions made or not made that were part of the process of failure leading up to the AHA shooting. He divided the team's findings into three areas: information sharing, threat assessment, and systems thinking.









































02:15 PM -- Sarah Goodrum, representing CSPV, spoke about the lack of information sharing leading up to the AHS shooting. She said that a lot of information about Karl Pierson was available, but that it was scattered and there were missed opportunities to gather the information together. She spoke about the timeline of events (Attachment C). She discussed the CSPV team's first major finding: that there was a failure of information sharing at AHS and within LPS. She said that according to the Secret Service, information sharing is critical to the prevention of violence. Ms. Goodrum described how AHS staff failed to share information because of inconsistencies in the use of Infinite Campus, AHS' student data information system. She described restrictions to teachers' access to that system, and widespread misunderstandings of FERPA guidelines. Ms. Goodrum stated that at the time of the shooting, there was no formal policy of training students or staff about Safe2Tell, that there was no interagency information sharing agreement, and that those agreements, supported by state law and suggested by CSSRC, allow for agencies including social services, law enforcement, the criminal justice system, and schools to share information about an adolescent exhibiting concerning behavior.



16SchoolSafety0122AttachC.pdf



02:19 PM -- Mr.Woodward spoke about LPS' threat assessment policy. He said there were many missed pieces of information that did not make their way into the threat assessment. He said that of 21 total risk factors, there were seven to nine that were not checked but that should have been checked. He stated that checking those risk factors would have raised Karl Pierson to a higher level of threat, and that if that had happened, perhaps management of Pierson's case would have been different. He described the FBI and Secret Service's threat assessment instructions, which include requirements that the process be investigative and inquisitive, and requires a skeptical mindset. Mr. Woodward said that threat assessment training in LPS consisted primarily of audio visual materials, independent reading, or lectures and that these are not training mechanisms that lend themselves to a high rate of information retention. He stated that the threat assessment process used in Colorado school districts should be validated, or proven to work. He described the threat assessment system used in Virginia (V-STAG), which has been proven and validated (Attachment D). Mr. Woodward spoke about the results of the system used in Virginia and the benefits of that system. He said that there are no research-based proven results for any threat assessment system in use in Colorado schools.



16SchoolSafety0122AttachD.pdf



02:26 PM -- Ms. Goodrum spoke about systems thinking. She said that without better systems thinking, good threat assessment can do no good. She described the importance of acknowledging mistakes, and reflecting upon error. She said that the first symptom of a systemic problem relates to an organization's willingness to allow for imperfections. She said organizations must acknowledge imperfections in order to fix them and that the school culture at AHS did not allow for failure or reflection, and that it discouraged questioning. She stated that systems should adopt continuous improvement models of error review.



























Mr. Woodward and Ms. Goodrum described the CSPV team's recommendations:

Information sharing:

1. Use student information system, consistently use that system to document concerns relating to public safety. Should be shared with teachers, and teachers should share what they know

2. Promote Safe2Tell in formal trainings

3. Adopt interagency information sharing agreements



Threat/Risk Assessment

4. Install validated threat assessment process (V-STAG)

5. Install validated risk assessment process (SAVRY)

6. Use Secret Service's 6 principles and 11 questions

7. Cognitive behavioral training for assessors

8. Assign information vortex coordinator during threat assessment process, gatherer of all information relating to the assessed student

9. Authorize CSSRC to audit school or district requesting it to determine level of completeness/validity of threat assessment process

10. Threat assessment safety and support plan (IEPs and SITs as models)

11. Ensure that each threat assessed student has a trusted adult in the school



Systems Thinking

12. AG annually update CO School Violence Prevention and School Discipline Manual on both school safety and FERPA

13. Conduct school climate surveys of students/staff every 1-2 years, and use data to build a plan

14. Develop continuous improvement model of error review, to promote culture of safety

Mr. Woodward spoke about a grand program available to schools and districts that would implement these recommendations.





02:41 PM



The presenters responded to questions from the committee.





03:16 PM



The committee recessed.



































03:30 PM -- Safe Havens International Report



Majority Leader Scheffel called the committee back to order. Michael Dorn and Phuong Nguyen of Safe Havens International presented their report. Mr. Dorn spoke about the personnel who helped produce the report and about Claire Davis. He described his team's conclusions that there were opportunities to take actions that may have prevented the death of Claire Davis. He spoke about the limitations of their study, including limited documents to review; inconsistencies in witness statements, both in the criminal investigation and the deposition process; and time constraints. He spoke about the larger context of school violence and other types of incidents that cause deaths on school property.



Mr. Dorn spoke about key findings and lessons learned. He said that LPS and its public safety partners had preventive security measures in place at the time of the incident, and that there may have been too much information given to staff. He said the district did have a structured threat assessment process, but that the shooting still occurred. He spoke about problems with the school's camera system, which caused difficulty for investigators from the ACSO. He said that LPS' threat assessment process has significant opportunities for improvement and that because there was no systematic approach to guide the process, the focus was more on establishing evidence that the student had made a threat rather than on whether or not he posed a threat. Mr. Dorn stated that LPS' threat assessment process was not thorough, and lacked attention to detail. Mr. Dorn spoke about LPS' approach to student discipline, which lacked no formal consequences for Karl Pierson after he threatened to kill school librarian Tracy Murphy. Mr. Dorn spoke about a number of violent incidents after aggressors were not arrested, suspended, and/or expelled for aggressive behaviors prior to the attacks. Mr. Dorn spoke about opportunities for improvement in law enforcement partners' investigations of the threat by Karl Pierson, and described how the mother of Karl Pierson reported that her son had threatened life of girl at West Middle School. Mr. Dorn stated that no information about the actions of the SRO at West was available. He said that there were two possible opportunities to interrupt the pathway to violence that were not taken. Mr. Dorn spoke about opportunities for improvement in site-based management approach to security personnel at AHS. Mr. Dorn spoke about how nobody at the school called Safe2Tell to report any of Karl Pierson's concerning behaviors. He described the benefits of interlocking approaches, with an array of protective programs in place at each school. He said the focus should not be only on threat assessment, but that it should be one of a number of key school safety strategies.



Mr. Dorn spoke about Colorado's limited data on school fatalities, and about the difficulty he had in obtaining access to what data there is. He said there were a total of 16 fatalities due to violence occurring in Colorado schools and colleges from 2004 to 2015 and that of those, 12 were suicide, 3 were homicide, and the other was from an undetermined cause.



Mr. Dorn concluded that there were multiple opportunities to prevent this attack, and spoke about the actions of custodian Fabian Vldrio Llerenas, librarian Tracy Murphy and other staff and students to prevent additional casualties.





04:07 PM



Mr. Dorn responded to questions from the committee.





04:36 PM



Mr. Dorn offered a final comment, and thanked the Davis family for the thoroughness of the arbitration reports.













04:37 PM -- Kanan-Nicoletti Report



Linda Kanan, John Nicoletti, and Sarah Garrido came to the table to present their report and its findings. They introduced themselves and distributed two handouts to the committee (Attachments E and F). Dr. Kanan thanked the committee for the opportunity to present the team's findings and offered condolences to the Davis family. She clarified their independence from LPS and spoke about her focus on psychological safety in schools. She said that safety is not just physical and that it also includes school climate and perceptions of safety. She described her team's work researching psychological safety and threat assessment in LPS and spoke about her gap analysis. She described how the team's report reviews practices and procedures in place in 2013, efforts to improve, and practices and procedures in place now. She said the team had provided to the LPS school board a series of 21 recommendations, and clarified that her presentation would focus more broadly on lessons learned for all Colorado schools.



16SchoolSafety0122AttachE.pdf 16SchoolSafety0122AttachF.pdf



Dr. Kanan described prevention efforts as including planning, awareness training, and the impact on both mental health personnel and disciplinary personnel. She stated that gaps in 2013 included awareness of behavior concerns and reporting of concerns, and that the use of reporting mechanisms was informal and not systematic. She said that there were also misunderstandings of the Family Educational Rights and Privacy Act (FERPA), mental health and discipline teaming, reasonable suspicion searches, and searches of electronic media. She said that since 2013, the use of Safe2Tell has increased, and an teacher tab in the LPS student data system (Infinite Campus) is now being piloted.



Dr. Kanan listed her recommendations:

• district level safe schools planning team

• use of objective and student reports or climate survey data

• awareness training that is explicit, repeated yearly across employee groups, students, parents, and community (what to watch for, what to report, importance of timely reporting

• mental health and discipline need to work together and have ongoing training

• FERPA should not be a barrier

She stated that one in five children have mental health problems, that many do not get help, and that Colorado lags in ratios of mental health professionals to students. She said that LPS has increased mental health staff 22 percent over the last two years, but that sustaining that increase will be difficult because of the financial impact to the district. She explained that disciplinary staff need more training in how to deal with students who exhibit concerning behaviors.



Dr. Kanan described the threat assessment process, training of personnel, and documentation. She said that the gaps were in the implementation of the process because there was no use of an information vortex, the composition of team was problematic, and so was the evaluation of information, follow-up, and monitoring plan. She spoke about disparities in who gets trained, what training they get, and how that varies from district to district. She advocated for the addition of district-level threat assessment teams, for consultation and to review cases.



















05:01 PM -- Dr. Nicoletti described his work with Dr. Garrido to review the threat assessment conducted on Karl Pierson, and how they looked at other threat assessments as well. He described what a threat assessment is, and talked about the differences between profiling and threat assessment. He also spoke about trend analysis and the relative risk for varying types of attacks. He talked about AHS' threat assessment and stated that his came out differently than the one done by LPS. He described two categories of responsibility: detectors and disruptors. He said that detectors are those who see events leading up to an event, and that disruptors are those who take action to prevent an event. He said that both need to function, but that at AHS, there was a breakdown among the detectors. He described students observing behaviors and not reporting those behaviors, and he explored the causes of that failure to report. He spoke about threat management, as opposed to stand-alone threat assessments. He described the need for countermeasures to concerning behaviors and explained that countermeasures need contingency plans in case they fail.



05:09 PM -- Ms. Garrido spoke about helping schools identify overreporting and underreporting. She defined those terms and spoke about countermeasures, and said that schools do not necessarily know what their options are if they perceive a threat, particularly if an intervention does not work.



05:11 PM -- Dr. Nicoletti spoke about mental health professionals missing Karl Pierson's risk. He said that the data source for a community mental health evaluation is usually just a conversation with the patient. He explained that one major variable in violent incidents is mental health, but that focusing solely on mental health diagnoses causes both over- and under-reactions. He said that there is no statistically significant category of diagnosis for attackers, and explained that many have no diagnosis. He said that mental health is a causative factor, but not a predictor of violent incidents. He spoke about the importance of a centralized data collection point, or information vortex.



05:14 PM -- Dr. Kanan spoke about the need for better training for faculty, staff, and students. She explained the risk of unilateral decision making on what is supposed to be a threat assessment team. She described the forms schools are using and how to improve them. She explained that diagnosis should not be a category on these forms, and talked about crisis recovery efforts.





05:18 PM



The panelists responded to questions from the committee.













































05:23 PM -- Comments by Michael Roche



Mr. Roche introduced himself and distributed a written statement to the committee (Attachment G). He spoke about his role in the arbitration process, and about the desires of the Davis family and their work with the CSPV. He spoke about his daughter's friendship with Claire Davis, and about the unique nature of the arbitration. He described his gratitude to the officials at LPS who were willing to look at what needs to change. He spoke about the three reports' common ground, and about the need for change in public schools. He said that first, a culture of openness and critical self-evaluation in schools and districts is key. He described the importance of a continuous improvement model that permits schools and districts to examine problems and said that is one of only things that will actually help school violence prevention efforts. He described systemic failings that exist in every school in Colorado, and said that every superintendent in Colorado has received these reports. He said that a statewide problem requires a statewide solution, that LPS has acknowledged for the first time that there were missed opportunities to prevent Claire's death, and that a steady stream of small failures led to a catastrophic result. He said that first, people didn't receive training they needed, or training was flawed, that there was a lack of accountability. He said that nobody was responsible to gather information, put it together, and see the big picture, that the threat assessment was an ad-hoc process, of which no single person had ownership. He said that teachers were not informed about safety concerns with a student in their own classrooms, and that law enforcement, including SROs, did not have access to required information. He explained that when everyone is responsible for safety, no one is. He advocated for the passage of legislation implementing the recommendations listed in these reports.



16SchoolSafety0122AttachG.pdf





05:33 PM -- Public Comment



No witnesses having signed up, Majority Leader Scheffel closed public testimony.





05:33 PM -- Committee Discussion



Senator Scheffel spoke about the interim committee process and about the process of introducing late bills. He assured everyone that leadership in both chambers is working to digest the reports and figure out next steps. He said the next meeting date for this committee is not planned, and that he will be in contact with committee members. Committee discussion ensued.





05:40 PM



The committee adjourned.