Risk Assessment: Actuarial Prediction and Clinical Judgement of Offending Incidents and Behaviour for Intellectual Disability Services

Background Research on prediction of violent and sexual offending behaviour has developed considerably in the mainstream criminological literature. Apart from one publication [ Quinsey (2004) Offenfers with Developmental Disabilities, pp. 131–142] this has not been extended to the field of intellectual disabilities. Methods Work on actuarial instruments, dynamic variables, clinical judgement and structured clinical judgement is reviewed. Results A number of studies comparing actuarial instruments in terms of their predictive validity are reviewed. Relative effectiveness and applicability to intellectual disability is considered. A framework for dynamic variables is outlined and the importance of dynamic variables for inclusion in risk prediction is established. Strengths and limitations of clinical judgement are reported and the importance of reliability is noted. Finally, structured clinical judgement is reviewed in terms of the way in which it combines the other three groups of variables. Conclusions The information regarding different methods of risk assessment is integrated with research and opinion contained in the Special Issue. Risk prediction will always be a judgement and as such there will always be errors in judgement. As clinicians, researchers and policy makers it is our duty to employ the latest research information to make predictions that are as accurate as possible. However, we must also help to promote a culture that can be tolerant of inevitable errors.     

Violence and aggression: a literature review

This paper reports the results of a literature review that was undertaken to provide background for a small pilot study that introduced violence measurement instruments that was to assist the development of nursing practice on an acute psychiatric unit. Multiple databases were searched, focusing on publications since 1994: CINAHL, Ovid Healthstar, Ovid MEDLINE (R), EMBASE, and PsycINFO. The search used the following four groups of key word alternatives (used in truncated form to allow for ending permutations) in combination with each other: violence, aggression, dangerous; prediction, assessment, factor, risk, issue, cause, reason; mental, psychiatric; inpatient, short-term, acute, admission. Searching was supplemented with footnote chasing of those papers retrieved and existing resources of the first author. Consequently, the synthesis of the results discussed cannot be considered a systematic review of the literature and is a reflection of some of the key issues found in the literature.     

The Factor Structure of Static Actuarial Items: Its Relation to Prediction

Principal components analysis was conducted on items contained in actuarial instruments used with adult sex offenders, including: the Rapid Assessment of Sex Offender Risk for Recidivism (RASORR), the Static-99, the Violence Risk Appraisal Guide (VRAG), the Sex Offender Risk Appraisal Guide (SORAG), and the Minnesota Sex Offender Screening Tool-Revised (MnSOST-R). In a data set that included child molesters and rapists (N = 311), six interpretable components were identified: Antisocial Behavior, Child Sexual Abuse, Persistence, Detached Predatory Behavior, Young and Single, and Male Victim(s). The RRASOR was highly correlated with Persistence, and the VRAG and SORAG were highly correlated with Antisocial Behavior. Antisocial Behavior was a significant predictor of violent recidivism, while Persistence and Child Sexual Abuse were significant predictors of sexual recidivism.     

A Follow‐up of Deinstitutionalized Men with Intellectual Disabilities and Histories of Antisocial Behaviour

Background There is frequently great concern about the dangerousness of deinstitutionalized men with intellectual disabilities who have been institutionalized because they are considered to be at high risk for the commission of serious antisocial acts or sexual offending. Unfortunately, there is little information on whether changes in the behaviour of these men can be used to adjust supervision so as to manage risk. Methods An appraisal of men with intellectual disabilities and histories of serious antisocial behaviours who were residing in institutions about to be closed led to a 16 month follow‐up of 58 of these clients who had been transferred to community settings. Results A total of 67% exhibited antisocial behaviour of some kind and 47% exhibited ‘hands‐on’ violent or sexual misbehaviours directed toward other clients or staff. The Violent Risk Appraisal Guide was the best predictor of new violent or sexual incidents and a variety of other pre‐release predictors were related to the likelihood of antisocial incidents of any kind. Overall predictive accuracy was moderate. A field trial showed that monthly staff ratings of client characteristics were related to antisocial incidents. Conclusions These preliminary data indicate that measures of dynamic risk involving staff ratings are worth developing and evaluating.     

智残评定量表在司法精神鉴定案例中的应用研究

目的 :比较和分析司法鉴定中应用成人智残评定量表和成人智力测验对智力残疾进行等级评定的差异和一致性。案例和方法 :案例 6 0例 ,均来自 2 0 0 2～ 2 0 0 3年 3月在本鉴定中心鉴定的案例 ,分别应用成人智残评定量表和成人智力测验对智力水平进行评定 ,测定结果按照《中国实用残疾人评定标准 (试用 )》进行残疾等级分级 ,统计结果用spss11 0进行统计。结果 :分别应用成人智残评定量表和成人智力测验进行智残等级分级不存在统计学差异 (P >0 0 5 ) ,两者的相关系数为 0 75 1(P <0 0 0 1) ,说明智商分级结果与量表评定结果是一致的 ,但不是量表评定的每个等级与IQ等级都一致。两者符合率最高的为中度智力残疾等级 ,符合率为 76 9%。极重度符合率最低。讨论 :在司法鉴定中的智残等级评定 ,智力测验是很重要的指标 ,但影响智力测验结果的因素很多 ,测得的IQ值应作为参考 ,成人智残评定量表更接近实际。     

Validation of the Violence Risk Screening‐10 instrument among clients discharged from a psychiatric hospital in Beijing

The Violence Risk Screening‐10 is one of the few instruments available for evaluating violence risk in mental health clients during and after hospitalization. This prospective study examined the applicability of this brief instrument with a sample of 289 clients in the 6 months after discharge from a general psychiatric hospital in Beijing. During the research period, 24 of the 289 clients demonstrated aggression. The receiver–operator characteristic curve yielded an area under the curve of 0.62. At the cut‐off point of 4.5, its sensitivity/specificity was 79.2%/33.3%, and the corresponding positive/negative predictive value was 9.9%/94.5%. The predictive accuracy of this instrument was lower compared with the results of the original study, and was also less accurate than when it was administered while the clients were in the hospital. While promising in its utility for use beyond the hospital, it deserves further modification prior to its wide use across culturally‐diverse China.     

Violence risk assessment: combining actuarial and clinical information to structure clinical judgements for the formulation and management of risk

Throughout history most societies have assumed a link between mental disorder and violence to others. In recent times there has been increasing concern in the United Kingdom over law and order, specifically the risk of violence, and these issues are now high on the political and mental health agenda. Nurses and staff working in National Health Service Mental Health Service Trusts are the groups most at risk of violence. Many clinical decisions are based on risk. Mental health nurses play a pivotal role in the assessment and management of risk and it is argued that they need to adopt a clear structured approach to violence risk assessment and management, which is evidence-based. The advantages of clinical and actuarial approaches to risk assessment are briefly reviewed and a structured clinical judgement approach is proposed that combines these approaches. A method of linking the assessment process with the management plan via a risk formulation is discussed.     

Forensic Learning Disability Nursing Skills and Competencies: A Study of Forensic and Non-Forensic Nurses

This paper reports on an investigation into the skills and competencies of forensic learning disability nurses in the United Kingdom. The two sample populations were forensic learning disability nurses from the high, medium, and low secure psychiatric services and non-forensic learning disability nurses from generic services. An information gathering schedule was used to collect the data; of 1200 schedules, 643 were returned for a response rate of 53.5%. The data identified the “top ten” problems that forensic learning disability nurses may encounter, the skills and competencies necessary to overcome them, and the areas that need to be developed in the future. The results indicated that the forensic learning disability nurses tended to focus on the physical aspects to the role whilst the non-forensic learning disability nurses tended to perceive the forensic role in relational terms. This has implications for practice, policy, and procedures.     

A Systematic Review of Violence Risk Assessment Tools Currently Used in Emergency Care Settings

IntroductionViolence risk assessment is commonplace in mental health settings and is gradually being used in emergency care. The aim of this review was to explore the efficacy of undertaking violence risk assessment in reducing patient violence and to identify which tool(s), if any, are best placed to do so.MethodsCINAHL, Embase, Medline, and Web of Science database searches were supplemented with a search of Google Scholar. Risk of bias assessments were made for intervention studies, and the quality of tool development/testing studies was assessed against scale development criteria. Narrative synthesis was undertaken.ResultsEight studies were included. Three existing violence risk assessment tools featured across the studies, all of which were developed for use with mental health patients. Three newly developed tools were developed for emergency care, and 1 additional tool was an adaptation of an extant tool. Where tested, the tools demonstrated that they were able to predict patient violence, but did not reduce restraint use. The quality issues of the studies are a significant limitation and highlight the need for additional research in this area.DiscussionThere is a paucity of high-quality evidence evaluating the psychometric properties of violence risk assessment tools currently used along the emergency care pathway. Multiple tools exist, and they could have a role in reducing violence in emergency care. However, the limited testing of their psychometric properties, acceptability, feasibility, and usability in emergency care means that it is not possible to favor one tool over another until further research is conducted.     

The Assessment of Basic Learning Abilities Test for Persons with Intellectual Disability: A Valuable Clinical Tool

The Assessment of Basic Learning Abilities (ABLA) test requires a tester to attempt to teach to a person, using standard prompting and reinforcement procedures, six tasks that are hierarchically ordered in difficulty. Performance on the test provides valuable information for teachers and rehabilitation workers to match the difficulty of training tasks with the learning ability of persons with profound, severe and moderate intellectual disabilities. This paper summarizes the characteristics of the test, outlines the testing procedures, and reviews supporting data and practical guidelines for clinicians.     

The Impact of Physical,Intellectual and Social Impairments on Survival in Adults with Intellectual Disability: A Population‐Based Register Study

Background Research into factors associated with survival in adults with intellectual disability is limited and no studies have controlled for changes in these factors over time. Material and Methods All adults aged ≥20 years with moderate to profound intellectual disability (approximate IQ < 50) using specialist services in Leicestershire and Rutland, UK, were identified. The relationship between survival and physical, intellectual and social impairments was investigated, also adjusting for age, sex, ethnicity and exact year of birth. Results Of 2453 adults studied, 402 (16%) died over a maximum follow‐up period of 19 years. While physical, intellectual and social impairments were all associated with survival individually, physical impairment was the only impairment to significantly predict survival in the multi‐variable analysis. Being non‐mobile was associated with a sevenfold increased risk of death and being partially mobile with a twofold increased risk of death compared with being fully mobile [adjusted hazards ratios (HR) = 7.14; 95% confidence interval (CI) 4.99–10.21 and HR = 2.33; 95% CI 1.84–2.95]. Being male and earlier year of birth were also associated with shorter survival. Conclusions The implications of these findings are discussed.     

Physical Training and Well‐being in Older Adults with Mild Intellectual Disability: A Residential Care Study

Background Exercise is important for health and well‐being. The aim of this study was to investigate the effect of physical training on general well‐being and self‐image in older people with intellectual disability. Methods This study evaluated older adults with intellectual disability in residential care in Israel. The concept of well‐being perceived by the participants was measured by direct interview with a questionnaire consisting of 37 structural statements. The physical training programme was conducted three times a week for 10 consecutive months. Results Statistical analyses suggested a positive relationship between perceived well‐being and physical training between the experimental and control group. Conclusions This positive relation supports the important role of physical training to improve perceived well‐being among older adults with intellectual disability.     

Introducing a Digital Occupational Violence Risk Assessment Tool Into an Emergency Department: A Pilot Implementation Study

IntroductionOccupational violence in emergency departments is prevalent and detrimental to staff and health services. There is an urgent call for solutions; accordingly, this study describes the implementation and early impacts of the digital Queensland Occupational Violence Patient Risk Assessment Tool (kwov-pro).MethodsSince December 7, 2021, emergency nurses have been using the Queensland Occupational Violence Patient Risk Assessment Tool to assess 3 occupational violence risk factors in patients: aggression history, behaviors, and clinical presentation. Violence risk then is categorized as low (0 risk factors), moderate (1 risk factor), or high (2-3 risk factors). An important feature of this digital innovation is the alert and flagging system for high-risk patients. Underpinned by the Implementation Strategies for Evidence-Based Practice Guide, from November 2021 to March 2022 we progressively mobilized a range of strategies, including e-learning, implementation drivers, and regular communications. Early impacts measured were the percentage of nurses who completed their e-learning, the proportion of patients assessed using the Queensland Occupational Violence Patient Risk Assessment Tool, and the number of reported violent incidents in the emergency department.ResultsOverall, 149 of 195 (76%) of emergency nurses completed their e-learning. Further, adherence to Queensland Occupational Violence Patient Risk Assessment Tool was good, with 65% of patients assessed for risk of violence at least once. Since implementing the Queensland Occupational Violence Patient Risk Assessment Tool, there has been a progressive decrease in violent incidents reported in the emergency department.DiscussionUsing a combination of strategies, the Queensland Occupational Violence Patient Risk Assessment Tool was successfully implemented in the emergency department with the indication that it could reduce the number of incidents of occupational violence. The work herein provides a foundation for future translation and robust evaluation of the Queensland Occupational Violence Patient Risk Assessment Tool in emergency departments.     

The application of a violence risk assessment tool among Chinese psychiatric service users: a preliminary study

The Violence Risk Screening-10 (V-RISK-10) is one of the few instruments available for evaluating violence risk among general psychiatric service users. This naturalistic prospective study involved 376 inpatients in a general psychiatric hospital in Beijing and intended to determine whether this brief instrument could be applied to a sample of Chinese consumers and whether its predictive properties could be retained. Risk assessment at admission was compared to the record of aggression and violence during the first month of hospitalization. During the research period, 108 of the 376 consumers caused 265 incidences of aggression. Receiver operating characteristics for the V-RISK-10 Chinese version yielded an area under the curve of 0.63. Its sensitivity/specificity was 0.80/0.38 and the corresponding positive/negative predictive value was 0.34/0.82. Intraclass correlation coefficient for the whole instrument was 0.89. Compared to the results of the original V-RISK-10, its predictive accuracy was lower. However, with some modification, the V-RISK-10 still shows promise as an instrument for use in daily practice in Chinese clinical settings.     

A Comparison of Anxiety and Depression in Sex Offenders with Intellectual Disability and a Control Group with Intellectual Disability

The aims of this study were to employ modified versions of the 21-item Beck Anxiety and Depression Inventories with a group of 16 sex offenders with mild intellectual disability and borderline intelligence and 16 control participants with similar levels of intellectual disability. Test-retest correlations found high reliability for both assessments across all participants. There was a significant difference between the scores of the 2 groups with the sex offenders reporting significantly lower levels of anxiety and depression than the control participants. The results are discussed by presenting hypotheses on the emotional stability in each group.