Biological and Neurological Considerations in Behavioral Threat Assessment

How might underlying biological factors such as brain injury, medical conditions, sleep disruption, substance use, or chronic stress influence an individual’s behavior, emotional regulation, and decision-making in ways that could be misinterpreted as purely behavioral or disciplinary issues? I’m glad you asked! 

To ensure Behavioral Threat Assessment and Management (BTAM) teams conduct comprehensive, multidisciplinary assessments that account for biological, medical, and neurological factors that may influence behavior, risk presentation, and appropriate intervention, the process begins by asking the right questions.

Biological factors that can contribute to internalized and externalized thoughts of violence or aggressive behavior include:

1. Traumatic brain injury (TBI) and/or brain damage

Especially injuries involving the frontal and temporal lobes, which affect:

• impulse control

• emotional regulation

• judgment

• threat perception

  
  

2. Neurological conditions

• epilepsy (particularly temporal lobe involvement)

• brain tumors

• neurodegenerative disease

• stroke or hypoxic injury

  
  

These can alter personality, irritability, and behavioral inhibition.

3. Neurodevelopmental differences

• ADHD

• autism spectrum conditions

• intellectual and developmental disabilities

Primarily through difficulties with:

• emotional regulation

• social interpretation

• executive functioning

  
  

4. Sleep disorders and chronic sleep deprivation

• insomnia

• sleep apnea

• circadian rhythm disruption

  
  

Sleep loss significantly impairs:

• emotional control

• frustration tolerance

• threat appraisal

  
  

5. Hormonal and endocrine dysregulation

• thyroid disorders

• cortisol dysregulation from chronic stress

• pubertal or perimenopausal hormonal changes

  
  

These can influence mood instability, irritability, and reactivity.

6. Substance use and withdrawal

• alcohol

• stimulants

• cannabis (especially high-potency or early-onset use)

• sedatives and opioids

  
  

Both intoxication and withdrawal states can increase:

• impulsivity

• paranoia

• aggression

  
  

7. Medication side effects and interactions

Certain medications may contribute to:

• agitation

• disinhibition

• akathisia

• emotional blunting or irritability

  
  

Examples include:

• some antidepressants

• stimulants

• corticosteroids

• dopaminergic agents

  
  

8. Chronic pain and inflammatory conditions

Persistent pain and systemic inflammation are associated with:

• irritability

• emotional exhaustion

• reduced coping capacity

  
  

9. Nutritional and metabolic factors

• hypoglycemia

• micronutrient deficiencies (e.g., iron, B12, vitamin D)

• metabolic disorders

  
  

These can affect:

• cognition

• mood stability

• fatigue and frustration tolerance

  
  

10. Autonomic nervous system dysregulation

Including prolonged sympathetic activation (“always on edge” physiology), which can present as:

• hypervigilance

• exaggerated threat perception

• rapid escalation under stress

It’s important to note that biological factors are risk factors and do not predict violence. They can significantly influence an individual’s capacity for emotional regulation, impulse control, threat perception, and decision-making, making them essential considerations in accurate risk formulation and effective intervention planning.

Guiding Principles

• Threat assessment focuses on prevention, early identification, and management of risk, not prediction or punishment.

• Concerning behaviors may arise from biological, neurological, and environmental factors and may resemble pathway behaviors without indicating intent.

• Consistent with U.S. Secret Service, NASP, and Calhoun & Weston, BTAM decisions must be based on behavioral evidence, context, and trajectory, not assumptions.

Response

• The BTAM team should recommend medical and/or psychiatric evaluation when medically driven behavior is suspected.

• Intervention plans should prioritize treatment and stabilization, not solely disciplinary or punitive responses.

• Ongoing monitoring and collaboration with caregivers and healthcare providers should be incorporated into the management plan.

School Response Guideline Language

Behavioral Change Response

Schools should respond promptly when a student exhibits sudden, severe, or uncharacteristic changes in behavior, particularly when those changes involve aggression, violent imagery, or self-harm.

Guidelines

• Graphic drawings, writings, or statements depicting harm to self or others should be treated as signals for assessment, not automatic indicators of intent.

• Staff should document observations factually and refer concerns to the school’s threat assessment or behavioral intervention team.

• Schools should engage parents or guardians early and recommend appropriate medical or mental health evaluation when warranted.

  
  

Discipline & Support

• Disciplinary action alone is not an appropriate response when behavior may be linked to medical or neurological conditions.

• Supportive interventions, accommodations, and referrals should be implemented alongside safety planning.

BTAM Clarifying Statement (Recommended Inclusion)

The presence of violent thoughts, imagery, or dysregulated behavior does not, by itself, confirm intent to harm others. Comprehensive threat assessment requires evaluation of behavioral trajectory, intent, capacity, stressors, access to means, and potential biological and medical contributors. 

Training Note for BTAM Teams

Risk does not equal intent. 

Medical and neurological conditions can amplify behaviors that resemble pathway behaviors. Early identification and treatment can interrupt escalation and prevent harm.

Case Study

This is a case many in the BTAM community will recognize. However, a critical element continues to go unnoticed.

In 1998, 15-year-old Kinkel murdered his parents before using a semi-automatic rifle to target and kill his classmates at Thurston High School in a mass shooting. Kinkel, who had been diagnosed with attention-deficit hyperactivity disorder killed two students and wounded 25 more.

A brain scan of Kinkel’s brain was displayed at his trial and revealed marked overall decreased blood flow, primarily in two regions:

• Left medial temporal lobe

• Inferior orbital prefrontal cortex

In multiple case summaries and court-related documents, it is noted that Kinkel had fallen off a bicycle and struck his head, resulting in a head injury. Following that period, people close to him reported noticeable changes in mood, behavior, and functioning.

The Takeaway

During the threat assessment process, evaluating an individual’s history of head or brain injury, medical conditions, substance use, and environmental stressors should carry the same weight as assessing criminal history. When these factors are overlooked, BTAM teams risk missing critical opportunities for early identification and intervention, ultimately failing both the individual in need of support and the chance to prevent further escalation.

To better understand the biological, medical, and neurological factors that should be considered in BTAM, review my previous posts (hint, they all have an image of a brain in the title of the post). If you would like additional case studies, published research or a customized Threat Assessment Worksheet that includes biological considerations, contact me directly for more information.

-Author: Jordan Garza, Founder of Lifeline Strategies, LLC

Lifeline Strategies specializes in community health, resilience, and evidence-based approaches to improving public safety and well-being.