Paul Mooney

Risk Assessment in Offenders With Intellectual Disability: A Comparison Across Three Levels of Security

In mainstream offender samples, several risk assessments have been evaluated for predictive validity. This study extends this work to male offenders with intellectual disabilities. Participants from high-, medium-, and low-security settings, as well as community settings, were compared on a range of risk assessments. The Violence Risk Appraisal Guide, HCR-20—Historical Scale, the Risk Matrix 2000-C (combined risk), and the Emotional Problems Scales—Internalising discriminated between groups, with participants from high security having higher scores than those in medium security, who had higher scores than those in the community. The Violence Risk Appraisal Guide, all HCR-20 scales, the Short Dynamic Risk Scale, and the Emotional Problems Scales (Internalising and Externalising) showed significant areas under the curve for the prediction of violence. The Static-99 showed a significant area under the curve for the prediction of sexual incidents. The discussion reviews the value of these various scales to intellectual disability services.

Two studies on the prevalence and validity of personality disorder in three forensic intellectual disability samples

Abstract There is an extensive research literature on the association between personality disorder, antisocial personality disorder, and risk of future violent and sexual offences. Several studies have found an elevated prevalence of personality disorder diagnoses amongst those individuals with severe mental illness and criminal populations. While there has been some work on the prevalence of personality disorder among intellectual disability populations, it has been criticised as being unreliable and inconsistent. The present authors have taken account of these criticisms and recommendations in this comparison of 164 offenders with intellectual disability across three settings – community, medium/low secure, and high secure. In Study 1, DSM-IV diagnoses were made on the basis of four information sources: file review, interview with clinician, observations by care staff, and the Structured Assessment of Personality Interview. Across the samples, total prevalence of PD was 39.3%. The most common diagnosis was antisocial personality disorder. There was a higher rate of diagnosis in the high security setting, with no significant differences between the other two settings. There was no diagnosis of dependent PD, indicating that assessors were not overly influenced by the developmental disability itself. In Study 2 it was found that increase in severity of PD (as indicated by PCL-R scores and/or the number of PD diagnoses) showed a strong lawful relationship with instruments predicting future violence (VRAG, RM 2000/V) and a weaker relationship with instruments predicting future sexual offences (Static-99, RM 2000/S). The results indicate the utility of PD classification in this client group and that a number of individuals with PD classification are being managed successfully in community settings. These findings have considerable implications for staffing, both in terms of which individuals can be treated by these services and staff training.

Predictive validity of the PCL-R for offenders with intellectual disability in a high security hospital: treatment progress

Abstract Background Among mainstream offenders, the severe personality disorder of psychopathy has considerable importance as a construct. The disorder has long been associated with failure to make treatment progress. Previous work has identified that psychopathy as a disorder occurs in samples of offenders with intellectual disability (ID), and suggests that the Psychopathy Checklist – Revised (PCL‐R: Hare, 1991, 2003) as a measure of the disorder has adequate reliability and validity (Morrissey et al., 2005). The present study aimed to compare the predictive power of the PCL‐R in relation to treatment progress with a more general assessment of violence risk, the HCR‐20 (Webster, Douglas, Eaves, & Hart, 1997). Method A sample of 73 residents in a high security intellectual disability service, who had previously been assessed using the PCL‐R and the HCR‐20, were followed up at 2 years post‐assessment, and their outcome determined in terms of two distinct dichotomous variables reflecting definite positive treatment progress and definite negative treatment progress respectively. Results In line with predictions, the PCL‐R Total score and Factor 1 score (Interpersonal and Affective aspects of psychopathy) and the HCR‐20 Total score were significantly inversely associated with a positive move from high to medium security hospital conditions within 2 years of assessment. However against prediction, the PCL‐R Total score had incremental validity over the HCR‐20. The PCL‐R Total and Factor 1, but not the HCR‐20 Total score, were also significantly associated with negative treatment progress in terms of a move to more restricted treatment conditions. Conclusion Psychopathy, and in particular its interpersonal and affective manifestations, is a construct which appears to be associated with indirect measures of treatment progress in this high security ID group. However, caution should be applied in the use of a construct with potentially negative connotations in an already devalued population.

Applicability, Reliability and Validity of the Psychopathy Checklist-Revised in Offenders with Intellectual Disabilities: Some Initial Findings

As a part of a larger study, the Psychopathy Checklist-Revised (PCL-R) was used to assess psychopathy in 203 individuals from three UK National Health Service settings for offenders with intellectual disabilities (ID): a high security hospital, a medium and low security hospital and a community based service. The PCL-R was rated from file review combined with a clinician interview. Internal consistency and inter-rater reliability were acceptable, and broadly comparable to that reported for other offender populations. The instrument was also associated in largely expected ways with level of security, and with measures of antisocial personality disorder, risk, and current behavioural functioning, providing some preliminary indications of convergent validity. However, further empirical investigation is required before the PCL-R can be used with confidence to make clinical and risk-based decisions in this population.

Internal consistency and factor structure of personality disorders in a forensic intellectual disability sample

Abstract Background The publication of the DSM‐III (American Psychiatric Association (APA), 1980) prompted a significant increase in interest and research on personality disorder (PD), and the concept has subsequently been incorporated into mental health legislation in the developed world. Despite this, such research on people with intellectual disability (ID) has been sporadic, with widely varying results. The present study addresses a number of criticisms directed at previous research. Method DSM‐IV (APA, 2000) diagnoses of PD were made on 164 participants with ID on the basis of four independent sources of classification. Results Reliability data for each PD was acceptable and alpha was .74 or above, with the exception of schizotypal PD (.63). Exploratory and confirmatory factor analyses were conducted, with the former revealing a 4‐factor solution accounting for 58.9% of the variance, and a 2‐factor solution accounting for 37.2% of the variance emerging for the latter. The factors were orthogonal, and we called the first factor “avoidant/rumination/inhibited” and the second factor “acting out”. Discussion We review these findings in relation to previous research on PD and alternative frameworks for the understanding of personality. We hypothesise consistencies between these findings and previous work on personality and ID. A number of drawbacks to the research are discussed, including a caution on the pejorative nature of a diagnosis of PD in an already devalued population.

Relationship between Assessed Emotion, Personality, Personality Disorder and Risk in Offenders with Intellectual Disability

In mainstream studies on offenders and on individuals with psychopathology, relationships have been found between personality characteristics, emotional problems and personality disorders. This study reviewed the relationships between the Emotional Problems Scale, two circumplex measures of personality, personality disorder assessments and risk assessments in 212 offenders with intellectual disability. Previous studies had established the reliability and validity of these measures with the client group. Strong relationships emerged between externalizing emotional problems and dominant and hostile personality dimensions with weaker but significant relationships between internalizing problems and submissive and hostile dimensions. Externalizing problems were strongly associated with risk for violence, while internalizing problems had a weaker but significant relationship with some historical and clinical risk scales. Dominant personality dimensions were associated with narcissistic personality disorder and nurturant personality dimensions negatively associated with anti-social personality disorder. It would seem that there are orderly, significant relationships among measures of personality, personality disorders, emotional problems and risk. We discuss the implications of emotional assessment for the evaluation of risk and prediction of treatment progress.

Social climate in Learning Disability services

Purpose – The social climate of psychiatric institutions correlates with multiple outcomes related to staff and patients. Research into social climate in Learning Disability services is limited. Staff and patients in Learning Disability services have documented both positive and negative experiences. No research has directly compared the social climate of Learning Disability and non-Learning Disability psychiatric services. The purpose of this paper is to understand how these compare. The study will also compare staff and patient views of social climate and the impact of security on social climate in Learning Disability services. Design/methodology/approach – A total of 64 patients and 73 staff, from Learning Disability and non-Learning Disability psychiatric hospitals completed the Essen Climate Evaluation Schema (EssenCES) measure of social climate. Findings – Patients in Learning Disability and non-Learning Disability services did not differ in their perceptions of social climate. Staff in non-Learning...

Is sexually abusive behaviour in personality disordered inpatients analogous to sexual offences committed prior to hospitalization

Abstract Sexually abusive behaviour by personality disordered patients presents a serious threat to the integrity of staff–patient relationships and the safety of other residents. The occurrence of such behaviour is also problematic for the offending patient, as it may impact on perceived treatment needs and their access to the community. This paper reports on a study of sexually abusive behaviour in a high security psychiatric hospital. It also examines the relationship between these behaviours and patients’ history of sexual offending. The results showed a high frequency of low-severity sexually abusive behaviour and no significant associations between sexually abusive behaviour during hospitalization and sexual offence history. These findings imply that low-severity sexually abusive behaviour within secure settings may be determined, partly, by environmental conditions. This sexual abuse may also be functionally dissimilar to severe sexual abuse perpetrated in the community. The meaning and determinants of sexual abuse within secure settings must be scrutinized carefully and comprehensively before they are considered analogous to previous sexual offences.

A comparison of seclusion rates between intellectual disability and non-intellectual disability services: the effect of gender and diagnosis

Abstract Introduction: The use of seclusion as a means of managing the extreme behaviours forensic patients in secure settings is a controversial yet often common practice, despite there being little evidence that seclusion as a practice has any significant therapeutic value for the patient. The aim of this study was to explore the use of seclusion and whether this differs as a function of gender and diagnosis across secure services. Method: This study collated data from 11 medium and low secure hospitals that admit male and female patients, with some services providing services for patients with intellectual disability (with or without co-morbid disorders), and others for patients with mental illness and/or personality disorder only. Results: Both gender and diagnosis were associated with differential seclusion rates. Seclusions were three times longer for patients in the non-ID compared to the ID service. Male seclusions (for any diagnosis) were around twice as long as those in female services. Female ID patients spent significantly less time in seclusion compared to other groups. Female ID was associated with two to three times the number of seclusion events per patient compared to other groups. No statistically significant association between the type of service and the reason for a patient being secluded. Conclusions: A range of organisational factors that determine the use and duration of seclusion are cited and merit further exploration. High rates of psychiatric co-morbidity and the complexity of patients admitted to services may also mediate risk and use of seclusion. The study supports the use of early intervention techniques and the adoption of positive behaviour support.

Structure, fit and coherence of two circumplex assessments of personality in a population with intellectual disabilities

BACKGROUND Little research has been conducted investigating the way in which personality constructs relate to people with intellectual disabilities. The small amount of research that does exist suggests that underlying personality structure may be considerably different to that found in mainstream research. This hypothesis is, however, untested because so little work has been conducted with this population. METHOD Two circumplex models, the Interpersonal Adjective Scales and the CIRCLE, were employed to explore the factor structure, coherence and fit of these models with this population. One hundred and twenty-three participants from forensic intellectual disability services were rated by staff on the assessments, although not all assessments were completed for all participants. RESULTS The factor structures for both assessments conform broadly with a theoretical structure. Hypotheses concerning the magnitude and direction of Spearmans correlations both within and between assessments were generally confirmed. CONCLUSION While results would support the applicability of mainstream personality assessments to this client group, cautions were expressed in relation to the source of the sample and to the method of data collection.