The VRAG: A Decade of Use With Special Needs Offenders

1. The VRAG: A Decade of Use With Special Needs Offenders Marnie E. Rice, Ph.D. Scientific Director McMaster/Penetanguishene Centre for the Study of Aggression and Mental Disorder www.mhcp-research.com/present.htm riceme@mcmaster.ca July 14, 2003 International Conference on Special Needs Offenders

2. The VRAG: A Decade of Use With Special Needs Offenders Development and validation of the VRAG Application to Special Needs Populations Developmentally handicapped offenders Women Young offenders Mentally disordered offenders Sex offenders Other VRAG/SORAG studies Prospects for dynamic predictors Conclusions

3. Harris, Rice, & Quinsey, Criminal Justice & Behavior, 1993 3 Development of the VRAG 618 “mentally disordered offenders” Predictor Variables Demographic Criminal Psychiatric Childhood -sample of 618 men. Mentally disordered is in italics because although all came to Oak Ridge for an asessment prior to trial, only half came to OR for Rx, other half went to prison -approx 50 different predictor variables in these 4 categories -sample of 618 men. Mentally disordered is in italics because although all came to Oak Ridge for an asessment prior to trial, only half came to OR for Rx, other half went to prison -approx 50 different predictor variables in these 4 categories

4. Harris, Rice, & Quinsey, Criminal Justice & Behavior, 1993 4 Development of the VRAG 7 years average time at risk 31% committed a new violent offense Definition of violent offense -So, in late 80’s we embarked upon a project to try to improve accuracy in the prediction of violence -We thought we had the solution to 2 problems that had plagued the field to that point-- We had a population that was higher risk than most others that had been studied inasmuch as they were all men and virtually all had already committed at least one violent criminal act. And, we were able to follow their criminal careers for a long time after they left Oak Ridge- (Explain OR?) Most previous studies had used only very short follow-up times. -Original sample had over 600 men, all of whom had been admitted to OR at least for a very short time on a remand before going to court, but… -So was actually a quite diverse group of serious offenders, some with major mental disorders, and some with no mental disorder, or only a personality disorder -Used the information available on their clinical records before their release from OR (actually, used only info. available very soon after their admission to OR) and then, after we had coded all the information (about 50 variables ) from their files, we obtained information from the RCMP about their criminal careers after they left OR. We also checked to see if they were readmitted to OR. Anyone who committed a new violent offence (DEFINE) was counted a a violent recidivist -On average, men were at risk to fail for 7 years (DEFINE) - -So, in late 80’s we embarked upon a project to try to improve accuracy in the prediction of violence -We thought we had the solution to 2 problems that had plagued the field to that point-- We had a population that was higher risk than most others that had been studied inasmuch as they were all men and virtually all had already committed at least one violent criminal act. And, we were able to follow their criminal careers for a long time after they left Oak Ridge- (Explain OR?) Most previous studies had used only very short follow-up times. -Original sample had over 600 men, all of whom had been admitted to OR at least for a very short time on a remand before going to court, but… -So was actually a quite diverse group of serious offenders, some with major mental disorders, and some with no mental disorder, or only a personality disorder -Used the information available on their clinical records before their release from OR (actually, used only info. available very soon after their admission to OR) and then, after we had coded all the information (about 50 variables ) from their files, we obtained information from the RCMP about their criminal careers after they left OR. We also checked to see if they were readmitted to OR. Anyone who committed a new violent offence (DEFINE) was counted a a violent recidivist -On average, men were at risk to fail for 7 years (DEFINE) -

5. Harris, Rice, & Quinsey, Criminal Justice & Behavior, 1993 5 Development of the VRAG Analyses Multiple regression Divided sample into halves Univariate analyses Nuffield weighting system - 7 yrs of opportunity to commit a violent offence - used multiple regression to choose variables for the final model, but didn’t use weights given by multiple regression equation -to choose which of the 50 variables to include as possiblities in the multiple regression, divided sample into halves -only considered variables that had a univariate relationship to violent recidivism in each subsample- So, variables considered were quite robust -then did multiple regression to choose best set of variables including some from each category -then used system developed by Joan Nuffield to decide how to weight items - 7 yrs of opportunity to commit a violent offence - used multiple regression to choose variables for the final model, but didn’t use weights given by multiple regression equation -to choose which of the 50 variables to include as possiblities in the multiple regression, divided sample into halves -only considered variables that had a univariate relationship to violent recidivism in each subsample- So, variables considered were quite robust -then did multiple regression to choose best set of variables including some from each category -then used system developed by Joan Nuffield to decide how to weight items

6. Harris, Rice, & Quinsey, Criminal Justice & Behavior, 1993 6 Violence Risk Appraisal Guide Psychopathy Checklist Score Elementary school maladjustment Age at index offense* DSM III personality disorder Separation from parents before age 16 Failure on prior conditional release History of nonviolent offenses

7. Harris, Rice, & Quinsey, Criminal Justice & Behavior, 1993 7 Violence Risk Appraisal Guide Never married DSM III schizophrenia* Victim injury in index offense* History of alcohol abuse Male victim in index offense

8. VRAG- Psychometric Properties Range of possible scores: -26 to +38 Mean score in construction sample= .91 (SD=12.9) IRR= .90 SEM = 4.1 (Means that 95% confidence interval is approx. +/- 8 or 1 “bin”) SEM: This means, for example, that a person with a score of 18 (I.e. a deviation score of 17.09) has an estimated true deviation score of 17.09 * .9 = 15.38. Then add on the .91 to get 16.29. Then16.29+/- 1.96*4.1 is the 955 confidence interval= 8.23- 24.35. (For ease, just forget the .91 and use 0 as the mean- Get 16.2 as the true score and 8.14-26 as the range). Range of score: VRAG -26- +38 SORAG -26- +48SEM: This means, for example, that a person with a score of 18 (I.e. a deviation score of 17.09) has an estimated true deviation score of 17.09 * .9 = 15.38. Then add on the .91 to get 16.29. Then16.29+/- 1.96*4.1 is the 955 confidence interval= 8.23- 24.35. (For ease, just forget the .91 and use 0 as the mean- Get 16.2 as the true score and 8.14-26 as the range). Range of score: VRAG -26- +38 SORAG -26- +48

9. -Looks good here. Note that on a 7 yr. Followup, none of those in the lowest category, and all of those in the highest category, committed a new violent offense-Looks good here. Note that on a 7 yr. Followup, none of those in the lowest category, and all of those in the highest category, committed a new violent offense

10. Measuring Predictive Accuracy How can it best be measured? % Correct? Sensitivity & Specificity? Correlation? Area under the Receiver Operator Characteristic (AUC)? Effect size AUC d r* Zero .50 0 0 Small .55 .20 .10 Medium .64 .50 .30 Large .71 .80 .50 *(for a baserate of .50)

11. Receiver Operator Characteristic

12. Violent recidivism: Assessing predictive validity Rice, M.E., & Harris, G.T. (1995).. Journal of Consulting and Clinical Psychology, 63, 737-748. Further followup of original sample to a 10 yr. followup Sample was expanded to 799 men because it included men who had not had a chance to reoffend at the time of the original study ROC area of .73 for 3.5 and 10 yr. follow-ups Baserate was .15 for 3.5 yrs., 43% for 10 ROC area of .73 for serious violent recidivism Baserate was .29

13. Using the VRAG with developmentally handicapped offenders In original VRAG sample (N= 799): IQ< 85 N=128, ROC area =.79 45% violent recidivism in 10 years

14. A follow-up of deinstitutionalized developmentally handicapped men with histories of antisocial behavior. Quinsey, V.L., Book, A., & Skilling, T.A. (in preparation). 58 developmentally handicapped men with serious histories of antisocial behavior released from institutions for the developmentally handicapped when decision was made to close institutions 70% had histories of sex offenses Men were released under supervision & all but 1 to group home Average followup time was 15.6 months (sd= 5.6) Average age 41 yrs (sd=10.6) Diagnosis: All had diagnosis of mental retardation 80% had at least one additional diagnosis: 56% p.d, 36% paraphilia, 11% psychosis, 9% affective disorder, 2% substance abuse disorder

15. Quinsey, V.L., Book, A., & Skilling, T.A. (continued). VRAG scoring: PCL-R scores were not available Child and Adolescent Taxon Scale (CATS*) was used instead Frequent missing data Correlation between number of missing items and VRAG score was -.22 Also looked at potentially dynamic variables: Problem Checklist E.g. Inappropriate & Antisocial Behaviors, Psychotic Behaviors, Mood Problems, Social Withdrawal Proximal Risk Factor Scale E.g., Dynamic Antisociality, Medication Compliance, Compliance All were rated each month for each client Outcome measures Incident reports- Violent &/or sexual (hands-on) incident High inter-rater reliability

16. Quinsey, V.L., Book, A., & Skilling, T.A. (continued).Results Base rate of violent/sexual incident was high (47%), but most were minor All victims were staff or co-residents of the group homes ROC area for VRAG was .69

17. Quinsey, V.L., Book, A., & Skilling, T.A. (continued)Conclusions VRAG predicted subsequent violent or sexual incident with moderate accuracy Staff knew the VRAG score and provided extra security precautions on those of highest risk There were many missing data and definition of outcome was much more liberal than in studies on which the VRAG was constructed Followup was shorter than in other VRAG studies There was very little evidence that dynamic predictors added to VRAG even though several were related

18. Using the VRAG with women: Prospective replication of the Violence Risk Appraisal Guide in predicting violent recidivism among forensic patients. Harris, G.T., Rice, M.E., & Cormier, C.A. (2002). Law and Human Behavior, 26, 377-394 Background: All forensic patients in Ontario forensic system in June, 1990 347 mentally disordered male offenders not previously reported, whose data were not used in the construction of the VRAG two items were approximated scores significantly predicted violent recidivism. The ROC area was .76

19. Prospective replication of the Violence Risk Appraisal Guide in predicting violent recidivism among forensic patients. (cont.) Psychotic symptoms and other indicators of psychological distress assessed while still hospitalized were unrelated to violent outcome. Only in-hospital behaviors significantly related to violent recidivism were those pertaining to selfishness, rule-breaking, dishonesty, aggressive conduct, and antisocial attitudes.

20. Harris, G.T., Rice, M.E., & Cormier, C.A. (2002). Law and Human Behavior, 26, 377-394(continued) Results for Women 59 female patients had an opportunity to reoffend 8 (14%) reoffended violently vs 29% of men Scores on VRAG were low: Mean –8.71 vs -3.53 for men VRAG scores did not predict for women Clinical judgements of risk for women were also unrelated to recidivism

21. Applying the VRAG to the MacArthur Risk Assessment Study Data MacArthur Risk Assessment Study (Monahan et al., 2001) Participants 1136 nonforensic psychiatric patients at 3 public hospitals in U.S. 58% were voluntary admissions 40% were women Outcome measures Minor & severe violence on the Conflict Tactics Scale (primarily self-report) measured every 10 weeks after discharge for 1 year Arrests and rehospitalizations for violence in 1 yr. followup

22. Harris, Rice, & Camilleri , submitted (continued) MacArthur Risk Assessment Study Participants 1136 nonforensic psychiatric patients at 3 public hospitals in U.S. 58% were voluntary admissions 40% were women Outcome measures Minor & severe violence on the Conflict Tactics Scale (primarily self-report) measured every 10 weeks after discharge for 1 year Arrests for violence (<2% in 1st 20 weeks) Published studies from MacArthur Risk Project mostly report 20 week followup

23. Harris, Rice, & Camilleri , submitted (continued) VRAG had to be considerably modified to utilize MacArthur variables Only 10 items could be scored Modifications were made prior to any analyses of outcome data We used only those 741 participants who had both 10 and 20-week followup Primary outcome measure was severe violence in 20-week followup

24. Harris, Rice, & Camilleri , submitted (continued)Results Mean score= -.92 (SD=7.43) vs .91 (SD=12.9) Range –23 to + 24 vs –26 to +35 ROC area= .72 Baserate= 26% in 20 weeks

25. Harris, Rice, & Camilleri , submitted (continued)Results for women N= 318 ROC area= .73 Baserate= 23%

26. Harris, Rice & Camilleri (cont.) VRAG score predicted: (all p’s<.0001) # of seriously violent incidents r= .33 Total # of violent incidents r=.34, p<.0001 Most serious injury in a violent incident r= .25, p<.0001 Total amount of injury in all violent incidents r= .24, p<.0001 Violence in the entire 50 week followup ROC area= .70 Arrests for violence in the 50 week followup, r= .13 Most serious injury in 50 week followup, r= .23 VRAG predicted arrests in 1st 20 weeks r=.06, p<.05

27. Harris, Rice, & Camilleri , submitted (continued)Conclusions Modified VRAG worked with equal accuracy in both male and female patients Findings support robustness of VRAG across followup times, outcome definitions, populations

28. Accuracy for youthful and other subgroups of offenders -Teenager = under 20, but same results (smaller n) if under 18 - IQ< 85 N=128, Area =.79, obr=.45-Teenager = under 20, but same results (smaller n) if under 18 - IQ< 85 N=128, Area =.79, obr=.45

29. The VRAG for mentally disordered offenders: Proximal antecedents of eloping and reoffending among mentally disordered offenders. Quinsey, V.L., Coleman, G., Jones, B. & Altrows (1997). Journal of Interpersonal Violence, 12, 794-813. VRAG significantly differentiated serious violent recidivists from other mentally disordered offenders.

30. Actuarial assessment of risk for violence: Predictive validity of the VRAG and historical part of the HCR-20. Grann, M., Belfrage, H., & Tengstrom, A. (2000). Criminal Justice and Behavior, 27, 97-114. Also Tengstrom, A. (2001). Long-term predictive validity of historical factors in two risk assessment instruments in a group of violent offenders with schizophrenia. Nordic Journal of Psychiatry, 55, 243-249. 404 Swedish forensic patients. ROC area = .68 for VRAG prediction of violent recidivism Some VRAG items were unavailable or approximated. Counted only subsequent convictions; attempted homicide was not counted; for some subjects, trespassing and arson were counted as violent; for other subjects, sex offenses and kidnapping were not counted as violent; robbery was counted as violent for some subjects and not others.

31. Long-term predictive validity of historical factors in two risk assessment instruments in a group of violent offenders with schizophrenia.  Tested VRAG and H10 in 106 male insanity acquittees. Two VRAG items were not used; three were estimated or modified; one was reverse scored; and one new item was added to the VRAG. No reliability data provided. ROC area for VRAG predicting violent reconvictions =.68 (not significantly different from H10) Excellent goodness-of-fit for VRAG categories compared with calibration, chi-square (df=6) = 2.02.

32. The relative efficacy of statistical versus clinical predictions of dangerousness. Polvi, N.H. (2001, February). Dissertation Abstracts International: Section B: Sciences and Engineering, 61 (7-B), Simon Fraser University, Department of Psychology. Six-year followup of 215 Ontario mentally disordered offenders VRAG predicted violent recidivism much better than HCR-20 and clinical judgment

33. Assessing risk of inpatient violence in a sample of forensic psychiatric patients: Comparing the PCL:SV, HCR-20, and VRAG. Nichols, T.L., Vincent, G.M., Whittemore, K.E., & Ogloff, J.R.P. (1999, November). Paper presented at the conference on Risk assessment and risk management: Implications for the prevention of violence, Vancouver, B.C. VRAG significantly correlated with inpatient aggression within the first three months of hospitalization

34. Violence Risk Appraisal Guide (VRAG): Attempt at validation in a maximum-security forensic psychiatric sample. Douglas, K.S., Hart, S.D., Dempster, R.J., & Lyon, D.R. (1999, July). Paper presented at the joint meeting of the American Psychology-Law Society and the European Association of Psychology and Law, Dublin, Eire. 80 forensic patients AUC for VRAG of .60 Not significantly different than PCL-R Used approximations for most VRAG items

35. Actuarial and clinical risk assessment in decisions to release mentally disordered offenders from maximum security. Hilton, N.Z. & Simmons, J.L. (2001). Law and Human Behavior, 25, 393-408. Examined decisions made by clinicians and an autonomous review tribunal for maximum security forensic patients. Detained and released patients did not differ in their VRAG scores

36. Actuarial and clinical risk assessment in decisions to release mentally disordered offenders from maximum security (cont.) The best predictor of tribunal release decisions was the senior clinician's testimony, but there was also no significant association between the actuarial risk score and clinicians' opinions. Actuarial risk score, however, was significantly associated with criminal recidivism (r = .42), whereas clinical opinion was not.

37. The VRAG for sex offenders: Cross validation and extension of the Violence Risk Appraisal Guide for child molesters and rapists. Rice, M.E., & Harris, G.T. (1997). Law and Human Behavior, 21, 231-241. Studied 158 sex offenders not used in the construction of VRAG ROC area of .78 for the VRAG for violent recidivism VRAG and SORAG both worked in predicting violent and sexual recidivism with about the same level of accuracy These subjects plus 130 other sex offenders formed the construction sample for the SORAG and were the basis of the normative data presented in Quinsey et al., 1998.

38. Where Should We Intervene? Dynamic Predictors of Sex Offense Recidivism. Hanson, R.K. & Harris, A. (2000). Criminal Justice and Behavior, 27, 6-35. Federally sentenced sex offenders Recidivists and non-recidivists matched on age and sex and relationship of victim VRAG yielded largest differentiation between them

39. A multi-site followup study of sex offenders: The predictive accuracy of risk prediction instruments. 396 sex offenders from Ontario and B.C. federal corrections and Ontario forensic hospitals VRAG and SORAG very similar (correlated .931 with each other) and significantly better than RRASOR and Static-99 in predicting violent and sexual recidivism Both yielded ROC area of .73 for prediction of violent recidivism in combined sample.

40. Prediction of sexually violent recidivism: A comparison of risk assessment instruments. Dempster, R.J., Hart, S.D., Boer, D.P. (2001, unpublished manuscript).  Compared the VRAG, SORAG, PCL-R, RRASOR, and SVR-20 in predicting the violent and sexual recidivism of 95 sex offenders released from Canadian prisons Although full scale VRAG and SORAG scores were not used, VRAG and SORAG categories yielded the best prediction of violent recidivism (ROC areas of .83 and .88, respectively), and both were statistically significant predictors of sexual recidivism (ROC areas of .71 and .77, respectively).

41. Evaluating the predictive accuracy of six risk assessment instruments for adult sex offenders. Compared PCL-R, SORAG, VRAG, Static-99, RRASOR, and a guided clinical assessment in predicting the recidivism of 215 convicted sex offenders followed for 2.3 years RRASOR was the best predictor of sexual recidivism only (ROC area = .77) SORAG was the best predictor of violent recidivism (ROC area = .73) Guided clinical assessment not significantly related to either outcome.

42. Assessment of risk for criminal recidivism among rapists: A comparison of four different measures. Sjöstedt, G. & Langström, N. (2002). Psychology, Crime and Law, 8, 25-40. Compared the Sexual Violence Risk 20 (SVR-20), PCL-R, RRASOR and VRAG (some VRAG items were unavailable or approximated) in predicting the recidivism of 51 convicted Swedish rapists. Scoring reliability tended to be low. Only the VRAG and PCL-R yielded total scores statistically significantly predictive of violent recidivism. Only the RRASOR was able to significantly predict sexual recidivism.

43. Other replications of the VRAG A comparison of predictors of general and violent recidivism among high risk federal offenders. Glover, A.J.J., Nicholson, D.E., Hemmati, T., Bernfeld, G.A., & Quinsey, V.L. (2002). Criminal Justice and Behavior, 29, 235-249. Predictive validity of the Violence Risk Appraisal Guide: A tool for assessing violent offender's recidivism, Loza, W., Villeneuve, D.B., & Loza-Fanous, A. (2002). International Journal of Law and Psychiatry, 25, 85-92. The relative efficacy of predicting criminal behavior: A comparison of five instruments. Kroner, D. & Mills, J. (2001). Criminal Justice and Behavior, 28, 471-489. The effectiveness of the self-appraisal questionnaire in predicting offenders' postrelease outcome. Loza, W. & Loza-Fanous, A. (2001). Criminal Justice and Behavior, 28, 105-121. Also Kroner, D.G. & Loza, W. (2001). Evidence for the efficacy of self-report in predicting violent and nonviolent criminal recidivism. Journal of Interpersonal Violence, 16, 168-177. Predicting violence among federal inmates. McBride, M. (1999, February). Corrections Research Forum. Toronto. Also her Ph.D. Dissertation at Psychology Department, University of British Columbia The PCL-R and VRAG as predictors of institutional behaviour. Nadeau, J., Nadeau, B., Smiley, W.C., & McHattie, L. (1999, November). Paper presented at conference on "Risk assessment & risk management: Implications for the prevention of violence" Vancouver, B.C. The use of detention legislation: Factors affecting detention decisions and recidivism among high-risk federal offenders in Ontario. Nugent, P.M. (2001). Dissertation Abstracts International: Section B: The Sciences & Engineering. Vol 61(12-B), (pp. 6716). Queen's University at Kingston, Ontario. Risk factors for recidivism among spousal assault and spousal homicide offenders. Grann, M. & Wedin, I. (2002). Psychology, Crime and Law, 8, 5-23.

44. SORAG Replications

45. 1. Sex offender recidivism prediction. Bélanger, N. & Earls, C. (1996). Forum on Correctional Research, 8, 22-24. 2. A multi-site followup study of sex offenders: The predictive accuracy of risk prediction instruments. An overlapping sample of these subjects were reported in Rice, M.E., and Harris, G.T. (2002). Men who molest their sexually immature daughters: Is a special explanation required? Journal of Abnormal Psychology , 111, 329-339. 3. Prediction of sexually violent recidivism: A comparison of risk assessment instruments. Dempster, R.J., Hart, S.D., Boer, D.P. (2001, unpublished manuscript). 4. Sex Offender Risk Appraisal Guide: Validity and Utility for Hawaii Sex Offender Risk Assessments. Hartwell, L.L. (2001). Unpublished Clinical Research Project, American School of Professional Psychology, Hawaii Campus 5. Evaluating the predictive accuracy of six risk assessment instruments for adult sex offenders. Barbaree, H.E., Seto, M.C. Langton, C.M. & Peacock. E.J. (2001). Criminal Justice and Behavior, 28, 490-521. 6. A comparison of modified versions of the Static-99 and Sex Offender Risk Appraisal Guide. Nunes, K.L., Firestone, P., Bradford, J.M., Greenberg, D.M., & Broom, I. (2002). Sexual Abuse: A Journal of Research and Treatment, 14, 253-269. 7. Assessment of the Static- 99 in a Belgian sex offenders forensic population. Ducro, C., Claix, A., & Pham, T.H. (2002, September). Presented at the European Conference on Psychology and Law, Leuven, Belgium.

46. Replications of VRAG/SORAG (n=26)

47. The future of prediction efforts Improving performance of actuarial tools Constant followup No missing items Reliably scored Actual items vs. approximations

48. ROC Areas for Fixed vs mean followup Mean Fixed Violent 5yrs 2yrs 12yrs VRAG .73 .80 .73 SORAG .73 .80 .75 RRASOR .63 .63 .50 Static-99 .56 .69 .57 Sexual VRAG .65 .75 .72 SORAG .66 .75 .74 RRASOR .62 .69 .54 Static-99 .59 .73 .59

49. Violent recidivism (VRAG) : Penetanguishene samples # Missing Items: 0 <2 <4 ROC area .83 .80 .81 .

50. Challenges for dynamic prediction of who is likely to be violent Static predictors alone yield very high effect sizes (ROC areas >.84 under optimal conditions) Prediction tools that incorporate interactions promise higher accuracy SO...Not much room for improvement on static predictors given noise in outcome measure

51. Dynamic Predictors of ViolenceQuinsey & Jones (in preparation) Approximately 400 forensic patients in Ontario Month by month scores on Problem Checklist Predict violence in next month See if anything can add to VRAG Prospective and blind scoring:

52. Dynamic Predictors of ViolenceQuinsey & Jones (cont.) Results: Denies all problems Therapeutic alliance

53. Summary & Conclusions The VRAG has shown good predictive accuracy in many different populations of offenders and mentally ill including those with special needs Developmentally handicapped Women Youthful offenders Others ROC areas optimized by using exact followup times, having no missing items, verified reliable and unmodified scoring Comparing instruments across studies depends on equivalency on above variables

54. Summary & Conclusions Dynamic predictors can likely make only a very modest contribution to the prediction of who is likely to reoffend, but offer promise in predicting when an offender will reoffend