Managing Risk in Forensic Learning Disability Services 6th International Conference on the Care and Treatment of Offe

1. Managing Risk in Forensic Learning Disability Services6th International Conference on the Care and Treatment of Offenders with a Learning DisabilityUniversity of Central Lancashire, PrestonTuesday, 3rd April 2007 John L Taylor Northumbria University and Northumberland, Tyne & Wear NHS Trust john2.taylor@unn.ac.uk

3. The Applicability of Personality Disorder and Risk Assessment (DSPD) Measures in a Sample of Intellectual Disability Offenders

4. Study Team Members Dr Todd Hogue � Rampton Hospital Dr Sue Johnston � Rampton Hospital Paul Mooney � Rampton Hospital Professor Bill Lindsay � Tayside Primary Care NHS Trust Dr Anne Smith - Tayside Primary Care NHS Trust Lesley Steptoe - Tayside Primary Care NHS Trust Professor John Taylor � NTW NHS Trust Professor Greg O�Brien � NTW NHS Trust Lisa Pinkney � NTW NHS Trust

5. Study Sites 212 men with ID/developmental disabilities and offending and offending-type histories from 3 sites: Rampton Hospital, Nottinghamshire (High Security) N = 73 Northgate & Prudhoe Hospitals, Northumberland (Medium & Low Security) N = 70 Tayside, Scotland (Community Forensic Service) N = 69

6. Study Participants

7. Main Study Findings � Concerning Risk Assessments  A number of established risk assessment measures have good reliability and validity � including predictive validity � when used with (male) offenders with LD The VRAG, HCR-20, SDRS and EPS all showed significant �areas under the curve� using ROC analyses in relation to the prediction of violent incidents The Static-99 showed a significant �area under the curve� using ROC analysis in relation to the prediction of sexually aggressive incidents

8. HCR-20 Reliability and Validity Analysis Sub-Study Aim To evaluate the reliability, validity and utility of the HCR-20 across a range of forensic service settings and levels of security

9. Criterion Measure  HCR-20 (Webster, Eaves, Douglas & Wintrup, 1995) Predictive power has been extensively tested across a range of client groups and cultures Made up of: 10-item Historical scale, e.g. �early maladjustment� 5-item Clinical scale, �negative attitudes� 5-item future Risk scale, �plans lack feasibility� All 20 items yield a Total score Each item is rated on a 3-point scale with 0 = absence; 1 = possible presence; and 3 = definite presence of the factor

10. Comparison Measures I Violence Risk Appraisal Guide (VRAG; Harris, Rice & Quinsey, 1993) Most widely researched actuarial risk assessment in the literature Comprises 12 items related to antisocial behaviour, e.g. childhood behaviour problems, history of personality disorder, history of non-violent offending Short Dynamic Risk Scale (SDRS; Quinsey, 2003) Made up of 8 items rated on 4-point scales concerning dynamic factors including hostile attitude, coping skills, consideration of others

11. Comparison Measures II Emotional Problems Scale (EPS; Prout & Strohmer, 1991) Well validated instrument developed for people with LD Comprises 12-items rated on 5-point scales including anxiety, depression, self-esteem, verbal aggression, physical aggression Violent Incident Data Operationally defined incidents of physical aggression occurring during the previous 12-month period Independently recorded in nursing casenotes

12. Study Procedures Research assistants trained to administer measures during a 5-day programme Inter-rater reliability analyses conducted prior to assessment administration Assessment data collected via file review and interviews with nurse, RMO and psychologist where applicable to complete assessments Procedural issues resolved by local lead and/or project coordinator Regular meetings of lead researchers to review procedural progress and resolve methodological issues

14.  HCR-20 Scales, Reliability Analyses

15. Correlations between HCR-20 and Other Risk Measures, and Violent Incidents

16. Correlations between HCR-20 and selected EPS Scales

17. Mean HCR-20 Scores, Grouped According to Conviction for Violent Offences

18. Mean HCR-20 Scores, Grouped According to Violent/Aggressive Incidents

19. HCR-20 Scales, Receiver Operator Characteristics (ROC) Analysis

20. Conclusions HCR-20 scales show good levels of internal and inter-rater reliability; and concurrent validity and discriminant validity HCR-20 differentiates between clients with convictions for violence, or those who have been violent recently, and those have not in a logically consistent manner HCR-20 scales correlate significantly with proximal violent incident data The scales demonstrate good levels of predictive validity for violent behaviour

21. Implications for Practice The HCR-20 is a robust instrument for guiding structured clinical judgements concerning risk of violence amongst males with LD and forensic histories This approach enables clinicians (and teams) to reach clinically defensible decisions, drawing on historical and clinical data, that are transparent and so accountable

23. Systemic/Organisational Issues -- HCR-20/NORAP Roll-Out Programme For 21 patients 67 recommendations were made at CPA meetings based on HCR-20/NORAP assessments (CPA-1) An audit indicated that just 34 CPA-1 recommendations were discussed � progress reported on � at subsequent CPA meetings (CPA-2) Case example of one patient rated as being a �high risk� of violence on HCR-20 CPA-1 recommendations: a) Patient to be offered individual anger treatment b) Behavioural management approach to aggression to be considered Neither recommendation was recorded on CPA form (3b) and recommendations from CPA-1 not discussed at CPA-2

24. Therapeutic Issues � Treatment of Anger Aggression is the primary reason for people with LD to be prescribed antipsychotic medication and to be admitted to institutional care (Aman et al., 1987; Lakin et al., 1983) Physical violence is a significant clinical/management problem in people with LD in institutional and forensic settings (Novaco & Taylor, 2004) Aggressive behaviour presents significant problems for staff in LD services (e.g. Kiely & Pankhurst, 1998) Anger is a significant activator of, and is predictive of violence in psychiatric, forensic and LD populations (e.g. Novaco & Taylor, 2004)

26. Anger Treatment Maintenance -- Audit 70 patients completed treatment through the Anger Treatment Project At audit point, 47 of these treatment completers remained in hospital The mean length of time since completing anger treatment for this hospital sub-group was approx. 2.5 years (range: 2 months - 4.5 years) Audit showed that just under 25% (11) of these 47 patients were receiving anger treatment maintenance sessions -- although just one of this group was recorded as having declined this input

27. Behavioural Management Issues � Case Study Tim Tim has Mild LD and characteristics of Emotionally Unstable PD � Borderline Type (ICD-10) He has a long history of violence on serious self-harm He is engaged in individual anger treatment progressing reasonably well Has been working on the ward due to poor mental state and risk of self-harm Tim reacted to suggestion that he should return to off-ward work placement by becoming distressed and agitated He was pressed to return to work because of concern that he was �manipulating� the system Threatened violence and self-harm and was physically retrained and given PRN medication

34. Programme Integrity Effectiveness of therapeutic systems is dependent on the rigour of with which the system is implemented Programme integrity requires planning, design and management There are a number of threats to integrity: organisational, client and practitioner resistance A �programmatic approach� to treatment planning, design, delivery and evaluation aims to manage these threats Key reference: Hollin, Epps & Kendrick (1995). Managing Behavioural Treatment. London: Routledge.

35. Implications for Improving Risk ManagementPractice Develop a practice model that is understood by all involved in delivery � training and supervision/support issues Involve all those involved in delivery in decision-making Create an organisational structure that facilitates communication and accountability concerning risk Monitor quality and effectiveness of delivery through service evaluation/research Establish clear arrangements for the management of the process and resources

36. Contact Details Professor John L Taylor Northumberland, Tyne & Wear NHS Trust Northgate Hospital Morpeth Northumberland NE61 3BP Tel: 01670 394228 john2.taylor@unn.ac.uk