1. This analysis found that online exposure, proximity, attrac-
tiveness, and deviance were weakly but positively correlated
with the dependent variable of cyberstalking. For example,
the amount of time a student spent online was positively
associated with and increased the likelihood of unwanted
contact and threats of violence. A “moderately positive”
relation with cyberstalking was found for the number of
operating online social networks belonging to the respon-
dent. An unanticipated positive but weak relation emerged
between cyberstalking victimization and online guardian-
ship. The author speculates that the guardianship behavior
was probably a subsequent consequence of victims’
responses to prior victimization. In summary, essentially all
the relations between the measured variables were found to
be “weakly positive.” In turn, these results might be
considered to weakly support the hypothesis that the LRAT
construct might positively dispose toward limited utility in
the understanding of the phenomenon of cyberstalking
victimization.
The final chapter presents the study’s conclusions, limi-
tations, and unanswered questions. One such question is,
can the results of this study, which was performed on a
limited sample of college students at 1 university, be
generalized to college students nationwide? The author also
posited the possibility of study replication with larger
numbers of students at multiple college and university sites.
Unfortunately, he did not address the study’s glaring pri-
mary limitations, namely the factor of selection bias in a
self-selected sample of respondents and the absence of
control groups. Compared with the large cohort, whose
participation in the study was initially requested, it is
reasonable to speculate that cyberstalking victims would be
more likely to respond to such a randomly presented
questionnaire and are therefore overrepresented in the
respondent sample. Thus, the finding of 40% lifetime inci-
dence of cyberstalking victimization likely overestimates
that experience for the larger college student population.
Moreover, any such replication of the study at multiple sites
would definitely want to avoid this study’s conspicuous
deficiencies.
If readers are looking for an appealing book about
cyberstalking and college students, with interesting anec-
dotes and engaging narratives, this book is not for them.
Rather, the volume focuses mainly on quantitative group
data presented primarily as tables and statistical analyses,
as one would expect of a dissertation study. However, if
this review generates nagging questions that promote a
desire in the reader to pursue further systematic examina-
tion of the book’s focus, then the reader is urged to view
this work as an initial effort that could serve as an impor-
tant contribution toward continued and more elaborate
investigation of the phenomenon of cyberstalking in the
college setting.
Mirela Loftus, MD, PhD
Hartford Hospital – Institute of Living
Hartford, CT
Mirela.Loftus@hhchealth.org
http://dx.doi.org/10.1016/j.jaac.2016.02.005
REFERENCES
1. Hindelang M, Gottfredson M, Garofalo J. Victims of Personal Crime—An
Empirical Foundation for a Theory of Personal Victimization. Cambridge,
MA: Ballinger; 1978.
2. Cohen L, Felson M. Social change and crime rate trends: a routine activity
approach. Am Sociol Rev. 1979;44:588-608.
3. Fisher B, Daigle L, Cullen F. What distinguishes single from recurrent
sexual victims? The role of lifestyle-routine activities and first-incident
characteristics. Justice Q. 2010;27:102-129.
4. Fox J, Levin J, Forde D. Elementary Statistics in Criminal Justice Research.
3rd ed. Upper Saddle River, NJ: Allyn and Bacon; 2009.
The Virginia Tech Massacre:
Strategies and Challenges for
Improving Mental Health
Policy on Campus and
Beyond. Edited by Aradhana Bela
Sood and Robert Cohen. New York:
Oxford University Press; 2015.
Since the tragic events at Virginia Tech in 2007, in
which 1 student gunned down 27 fellow students, 5
faculty members, and injured a score of others before
taking his own life, many more such shootings have
occurred on campuses. Most have taken place in the United
States. Columbine (whose episode preceded that of Virginia
Tech), Fort Hood, Gabby Giffords, Aurora, and Sandy Hook
are emblazoned on our collective American consciousness.
Students, faculty, and staff at college and university settings
have since become all too familiar with the email/text/
phone drills of “ACTIVE SHOOTER ON CAMPUS,” while
dreading the time the alert will not end with “THIS IS ONLY
A TEST.”
The excellent multi-authored volume The Virginia Tech
Massacre focuses in part on efforts aimed at the prevention of
such catastrophes. The contributors strongly recommend
and describe in detail the need for consultation with experts
in crisis management, review of best practices in mental
health treatment for young people, and addressing systemic
problems stemming from an explosion of mental health
demands in the college setting during the past 20 years.
Also, in the interests of combatting stigma and increasing
ease of access to mental health services, the book promotes
the integration of mental health and primary care services on
campus.
Aradhana Bela Sood, MD, the book’s chief author
and coeditor, a recent chair of Child and Adolescent
Psychiatry at Virginia Commonwealth University and
former secretary of the American Academy of Child and
Adolescent Psychiatry, served on the 2007 commission,
empaneled by Virginia’s governor, that was asked to re-
view all aspects of the incident at Virginia Tech and make
policy recommendations. Her first-person account of the
commission’s discoveries, detailing the shooter’s develop-
mental and psychiatric history, is coauthored by a security
analyst, Hollis Stanbaugh. Their narrative is gripping and
JOURNAL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATRY
VOLUME 55 NUMBER 4 APRIL 2016 www.jaacap.org 341
BOOK FORUM

2. disturbing as it recounts the multiple missed opportunities
for connection by mental health professionals with a young
man desperate for emotional, social, and educational sup-
ports. These missed opportunities took place during the
critical and vulnerable years of the young man’s transition
from high school to college and continued through his
college education. The authors’ “psychological autopsy”
lays bare Seung-Hui Cho’s profound and longstanding
social and emotional deficits, evident in early childhood
and continuing through grade school, high school, and into
his college years. Dr. Sood describes the considerable
efforts made by his Asian immigrant family, during Cho’s
middle school and adolescent years, to obtain mental health
help for their son. He initially received psychotherapy and
later antidepressant medication during middle school, the
latter after he verbalized his desire to commit acts similar to
those that took place at Columbine shortly after that attack.
Later, he was identified as eligible for special education
services after determinations of emotional disturbance and
speech and language impairments. At that time he was
diagnosed with major depressive disorder and selective
mutism by his local treating psychiatrist, and these condi-
tions were seen as having a negative impact on his educa-
tional functioning. However, he did not receive an
evaluation to determine whether he was affected by autism
spectrum disorder, which school personnel suspected was
the underlying cause of his difficulties. A recommendation
for such an evaluation, based on observations of very sig-
nificant and pervasive communication and social deficits,
was made by the personnel but not obtained by the boy’s
parents. As he went off to college, the young man appears
to have been cut adrift from all the supports from which he
had benefitted during middle and high school. Cho chose
to attend Virginia Tech despite disapproval of this choice
by his high school advisors and parents, who believed a
smaller school, located closer to home, would better meet
his needs. It is not clear why or how Cho nevertheless
attended Virginia Tech. Importantly, once he matriculated,
neither the Virginia Tech admissions office nor the office of
student affairs had knowledge of the considerable supports
he had previously received during his elementary through
high school years. This striking state of affairs results from
the stipulation that college students with disabilities must
themselves disclose their needs to receive accommodations
on campus.
After the exploration of many diagnostic possibilities, no
diagnosis is revealed at the end of the psychological autopsy.
Rather than focusing on the perpetrator’s significant psy-
chopathology, the volume focuses on his history, using it to
expose the current gaping systemic deficiencies in our
nation’s mental health system. These include the lacunae in
the clinical evaluation, treatment, and intervention systems,
established by colleges and universities, which were
designed with the specific intention of aiding students who
are in the process of passing through the transitional periods
of young adulthood and the college years.
The commission identified Virginia Tech’s major institu-
tional pathology as the lack of communication and coordi-
nation between campus entities and the many people who
had serious concerns about Cho, namely roommates, young
women he stalked, one of the women’s parents, a dedicated
and scared English professor, a department chair, counseling
center staff, university police, a mental health commitment
judge, an off-campus mental health inpatient unit, and the
campus-based deans and student affairs personnel. This
absence of communication resulted from a lack of vision for
the need and purpose to create organizational structures
designed to enable communication about students of
concern. Also, the absence of a campus-wide culture
of caring and encouragement of assistance for troubled
students was identified as another key factor. Widespread
overinterpretation of the strictures contained within the
Federal Educational Records Protection Act prevented the
university from assertively reaching out to, and communi-
cating about, students of concern. In sum, the combination of
these factors prevented otherwise reasonable people from
doing the reasonable thing, namely calling Cho’s parents to
express the institution’s concerns about their son.1
The au-
thors’ discussion of this state of affairs led to their strong
recommendation for an integration of on-campus mental
health with primary or student health care systems. They
believe integrated care would result in decreased stigma and
encourage student help-seeking behaviors. They also note a
fortunate outcome stemming from the Virginia Tech
massacre. That event led to the US Department of Educa-
tion’s subsequent clarification of the scope of the Federal
Educational Records Protection Act, clearly permitting
communication among relevant parties when safety con-
cerns arise.
Adele Martel, MD, in the course of 2 chapters coau-
thored with Dr. Sood, uses the Virginia Tech incident as a
stepping stone for a broad discussion of college student-
related issues. The authors ably address the devel-
opmental, emotional, and psychiatric strengths and
challenges common to the students and, separately, vari-
ability among college mental health systems. They provide
a summary of epidemiologic studies indicating that the
most common and important mental disorders experienced
by adults have their onset by 25 years of age and, therefore,
that college mental health systems might well consider the
development of a broad array of treatment services for their
students with pre-existing and emerging psychiatric con-
ditions. Drs. Martel and Sood further assert that compre-
hensive systems of care ideally should be developed in
collaboration with partners in the community, because
college mental health centers are inherently unable to pro-
vide full-spectrum treatments. In addition, they note that it
is in the colleges’ and students’ interests to create cultures
of wellness that emphasize social connections, adult coping
skill development, and self-care–seeking behaviors because
strong evidence indicates that student happiness, retention,
and graduation rates are directly related to student
wellness.2
What should college mental health services focus on? Drs.
Martel and Sood recommend a concentration on treatments
of the most prevalent disorders, namely mood, anxiety, and
substance abuse disorders, in addition to nonsyndromal
issues such as stress, sleep, and relationship problems. They
JOURNAL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATRY
342 www.jaacap.org VOLUME 55 NUMBER 4 APRIL 2016
BOOK FORUM

3. also urge a population-based, preventive health approach,
namely the promotion of mental health awareness in the
student body and faculty, lessening of stigma, creation
of peer-based suicide prevention, and implementation of
wellness programs. Education, outreach, and consultation to
faculty, student services, and resident life are similarly
endorsed as critical interventions in the provision of care to
the college campus. Importantly, the authors highlight the
significance of careful and planned transitioning of students
with psychiatric conditions from high school to college as a
key to maximizing student success during this vulnerable
period.
Drs. Martel and Sood point out that, 7 years after the
Virginia Tech atrocity, many universities have followed
through on some of these recommendations, but much work
remains to be done. Behavioral intervention or students-of-
concern teams, comprised of representatives from student
affairs, deans, campus law enforcement, university legal
staff, mental health, student health, and resident life staff,
have been established on many campuses to deal with
known “students of concern” in the effort to prevent
violence on campus. Drs. Martel and Sood further advocate
for mental health needs to be represented by on-campus
experts at campus administrative leadership levels to
create policies and promote allocation of resources
enhancing wellness and mental health.
Drs. Cheryl Al-Mateen, Sala Webb, and Sood, in a
related chapter, present a summary of violence prediction
for public venues and then outline approaches to threat
assessment. Clinical threat assessment and methods of
preventing mass violence certainly must be addressed.
However, a stronger emphasis regarding campus policies
concerning access to lethal weapons in general, and access
to lethal weapons by individuals with mental illness in
particular, would have been highly relevant and welcome.3
Because mental health clinicians cannot reliably identify
people at risk for violence, highlighting this point also is
very important.4
The book could benefit from a greater
exploration of these factors as they relate to externally and
internally directed violence.
The volume closes with chapters by Drs. Sood and
Cohen, the coeditor and a policy and program analyst
involved in children’s mental health and violence preven-
tion. The authors focus on systems of care and models of
service delivery across the United States and globally.
Although the events at Virginia Tech unfolded within a
context of inadequate access to mental health care, stigma,
and poor coordination of systems, it is important to note that
the college peer culture of “live and let live,” based on
respect for individual student autonomy, can be expected to
continue to contribute to the widespread lack of awareness
of the dangers posed by and to college students. That this
impaired young man, harboring destructive urges, managed
to get by in college without students, faculty, and health care
professionals connecting the dots continues to remain a
provocative issue. This book addresses and advocates for
establishing well-designed and comprehensive on-campus
mental health services to help create a college culture of
increased caring and compassion, improved student well-
ness, and decreased stigma that would benefit all students
and simultaneously create systems less likely to miss criti-
cally impaired students at risk to themselves and others.
In sum, apart from a few missing elements, I enthusias-
tically recommend this volume, especially to mental health
professionals involved in treating adolescents and young
adults and particularly those working in university settings.
University administrators and policy experts also would be
well served by this comprehensive review. Given the sub-
sequent events at Aurora and Sandy Hook, the book serves
as a timely, grim, but necessary reminder of the vulnera-
bilities of this age group of emerging adults and the work we
as professionals must do to meet their considerable needs.
Preston Wiles, MD
University of Texas Southwestern Medical Center
Dallas
preston.wiles@utsouthwestern.edu
http://dx.doi.org/10.1016/j.jaac.2016.02.006
REFERENCES
1. Shuchman M. Falling through the cracks—Virginia Tech and the
restructuring of college mental health services. N Engl J Med. 2007;357:
105-110.
2. Eisenberg D, Golberstein E, Hunt J. Mental health and academic success in
college. Berkeley Electron J Econ Anal Pol. 2009;9:1-35.
3. Pinals D, Appelbaum P, Bonnie R, Fisher J, Gold L, Lee L. Resource
document on access to firearms by people with mental disorders.
American Psychiatric Association Web site. http://www.psychiatry.org/.../
resource-2014-firearms-mental-illness.pdf. Published 2014. Accessed March
25, 2015.
4. Friedman RA. Why can’t doctors identify killers? New York Times. May
28, 2014:A21.
Disclosure: Dr. Sondheimer reports no biomedical financial interests or
potential conflicts of interest.
Dr. Malik has received research support from Pfizer, Sunovion, Syneurx, and
Forest.
Dr. Loftus has received research support from Pfizer, Sunovion, Syneurx, and
Forest.
Dr. Wiles reports no biomedical financial interests or potential conflicts of
interest.
Note to publishers: Books for review should be sent to Schuyler W. Henderson,
MD, MPH, NYU Child Study Center, One Park Avenue, 7th Floor, New York,
NY 10016 (email: schuyler.henderson@bellevue.nychhc.org).
JOURNAL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATRY
VOLUME 55 NUMBER 4 APRIL 2016 www.jaacap.org 343
BOOK FORUM