Stephanie R. Penney

Gender differences in risk factors for violence: an examination of the predictive validity of the Structured Assessment of Violence Risk in Youth

The research literature on predicting violence is particularly lacking in specifying risk factors for violence in adolescent girls. The recently developed Structured Assessment of Violence Risk in Youth [SAVRY; Borum et al., 2006] shows promise as it is empirically derived and incorporates dynamic factors in its assessment of risk. To date, there exists little information attesting to the reliability and validity of the SAVRY, and few investigations of the SAVRYs utility across gender. This study investigated the SAVRY in a sample of 144 high-risk adolescents (80 males and 64 females), focusing on gender discrepancies in the predictive utility of the measure. Results indicate that the SAVRY moderately predicts violent and non-violent reoffending in the entire sample, and also suggest that the SAVRY operates comparably across gender. Although not precluding the existence of gender-specific domains of risk, current results suggest that validated risk factors in boys hold relevance for the prediction of violence and delinquency in girls.

The recovery paradigm in forensic mental health services

Rooted in the psychiatric rehabilitation and mental health consumers’ movements of the 1960s and 1970s, recovery-based philosophies have come to dominate expectations on mental health services in many countries. In its broadest sense, the recovery paradigm is founded on principles of hope, empowerment, healing and connection (Jacobson & Greenley, 2001); it promotes patient choice, responsibility and self-determination while opposing coercive forms of treatment (Pouncey & Lukens, 2010). In a model of recovery reflective of international understandings, the Mental Health Commission of Canada (2009) defines recovery as encompassing the following elements: finding, maintaining and repairing hope and optimism towards the future, re-establishing a positive identity, building a meaningful life despite illness, taking responsibility and feeling in control of illness and of life (see also the definition of the US National Consensus Statement on Mental Health Recovery; Substance Abuse and Mental Health Services Administration, 2006). Other authors have proposed similar ‘core values’ for recovery-based services (e.g. Copeland, 1994; Farkas and Anthony, 1989). However, because recovery is noted to be a highly personal experience, varying from one individual to the next, it is understandably difficult, and perhaps artificial, to reach a consensus about what specific elements constitute the recovery process (Curtis, 1997). Definitions of recovery have increasingly shifted from clinical-based or service-based definitions to personal-based or client-based ones (Schrank & Slade, 2007). Whereas the former emphasise a reduction in psychiatric symptoms and functional impairments, the latter seek to move beyond these markers of rehabilitation to include important attitudinal changes that are conducive to leading a life with meaning and purpose. From a person-based perspective, an important concept in recovery is that of ‘participatory self-management’, that

Moderators of informant agreement in the assessment of adolescent psychopathology: Extension to a forensic sample

A well-documented finding in developmental psychopathology research is that different informants often provide discrepant ratings of a youths internalizing and externalizing problems. The current study examines youth- and parent-based moderators (i.e., youth age, gender, and IQ; type of psychopathology; offense category; psychopathic traits; parental education, income, and stress) of informant discrepancies in a sample of young offenders and compares the utility of youth and caregiver reports against relevant clinical outcomes. Results indicate that gender moderated the discrepancy between informant reports of somatic complaints, while parenting stress moderated the discrepancies across reports of internalizing and externalizing psychopathology. Variables unique to the forensic context (e.g., offense category) were found to moderate cross-informant discrepancies in reports of internalizing and externalizing psychopathology. Further, youth self-reports of internalizing symptoms predicted a clinician-generated diagnosis of a mood disorder, while caregiver reports of aggressive behaviors predicted the presence of an externalizing diagnosis. Results highlight the importance of assessing informant agreement in the context of forensic assessment and raise questions surrounding the optimal use of informant data in this setting.

The Roles of Affect Dysregulation and Deficient Affect in Youth Violence

Children with high dysregulated affect experience a range of emotional and behavioral problems, including aggression, delinquency, and low levels of prosocial behavior. Alongside this research, the psychopathy literature suggests that abnormally low levels of affect and emotional reactivity are associated with aggression and violence. The current study builds on prior research in the fields of affect regulation and psychopathy by testing the effects of affect dysregulation and deficient affect in predicting aggression and antisociality in 179 high-risk youth. Using structural equation modeling, results suggest that affect dysregulation and deficient affect are separate risk factors for aggression, as both constructs contributed independently to aggression while showing marginal relations with one another. Features of deficient affect, but not dysregulation, were robust predictors of violent and nonviolent offending. We discuss the importance of recognizing that diverse risk factors may lead to similar outcomes and highlight the heterogeneity in risk factors underlying aggressive behaviors.

Multirater Reliability of the Historical, Clinical, and Risk Management-20

The assessment and management of risk for future violence is a core requirement of mental health professionals in many settings. Despite an increasing need for violence risk assessments across diverse contexts, little is known regarding the ecological validity of many widely used risk assessment schemes or the level of reliability with which actual practicing clinicians score these instruments. The current study investigated the interrater reliability of the Historical, Clinical, and Risk Management-20 (HCR-20), a widely used structured professional tool to assess violence risk, among 21 practicing clinicians in a forensic psychiatric program in Ontario, Canada. Results suggest that clinicians with varying professional training backgrounds and experience were able to rate the HCR-20 with good to excellent levels of reliability across three patients who varied in risk level. Consistent with studies investigating rater reliability for research purposes, we found that the risk management scale of the HCR-20 was the most challenging for clinicians to rate reliably. Importantly, results from generalizability theory analyses revealed that less than 3% of the variance in HCR-20 total scores and summary risk ratings is attributable to rater effects, whereas the majority of variance is attributable to differences among patients.

Motivational Influences in Persons Found Not Criminally Responsible on Account of Mental Disorder: A Review of Legislation and Research

This paper provides a review of the legislative reforms and case law that have impacted the defense of Not Criminally Responsible on Account of Mental Disorder (NCRMD) in Canada over the past three decades. As in other jurisdictions internationally, we observe that legislative reforms of procedural, as opposed to substantive, aspects of the NCRMD defense have impacted the manner in which NCRMD criteria are applied in common practice. More people are being declared NCRMD in recent years, and there is greater heterogeneity in the offending and psychiatric profiles of these individuals, suggesting that NCRMD criteria are being applied more liberally over time. In light of the substantial growth of the forensic mental health system over the past two decades, witnessed both in Canada and abroad, we propose that the study of motivational influences underlying the offending behaviors of persons with serious mental illness (SMI) is necessary to begin disentangling symptom-based offending from violent and antisocial behaviors that may have other motives. This, in turn, can help to determine legal issues, better define the nature of each persons offending and treatment needs, and provide a more fine-grained analysis of the drivers behind the growth experienced by the forensic system.

The assessment of dynamic risk among forensic psychiatric patients transitioning to the community.

Individuals with serious mental illness (SMI; i.e., psychotic or major mood disorders) are vulnerable to experiencing multiple forms of adverse safety events in community settings, including violence perpetration and victimization. This study investigates the predictive validity and clinical utility of modifiable risk factors for violence in a sample of 87 forensic psychiatric patients found Not Criminally Responsible on Account of Mental Disorder (NCRMD) transitioning to the community. Using a repeated-measures prospective design, we assessed theoretically based dynamic risk factors (e.g., insight, psychiatric symptoms, negative affect, treatment compliance) before hospital discharge, and at 1 and 6 months postdischarge. Adverse outcomes relevant to this population (e.g., violence, victimization, hospital readmission) were measured at each community follow-up, and at 12 months postdischarge. The base rate of violence (23%) was similar to prior studies of discharged psychiatric patients, but results also highlighted elevated rates of victimization (29%) and hospital readmission (28%) characterizing this sample. Many of the dynamic risk indicators exhibited significant change across time and this change was related to clinically relevant outcomes. Specifically, while controlling for baseline level of risk, fluctuations in dynamic risk factors predicted the likelihood of violence and hospital readmission most consistently (hazard ratios [HR] = 1.35-1.84). Results provide direct support for the utility of dynamic factors in the assessment of violence risk and other adverse community outcomes, and emphasize the importance of incorporating time-sensitive methodologies into predictive models examining dynamic risk. (PsycINFO Database Record

Assessing illness- and non-illness-based motivations for violence in persons with major mental illness.

Research on violence perpetrated by individuals with major mental illness (MMI) typically focuses on the presence of specific psychotic symptoms near the time of the violent act. This approach does not distinguish whether symptoms actually motivate the violence or were merely present at the material time. It also does not consider the possibility that non-illness-related factors (e.g., anger, substance use), or multiple motivations, may have been operative in driving violence. The failure to make these distinctions clouds our ability to understand the origins of violence in people with MMI, to accurately assess risk and criminal responsibility, and to appropriately target interventions to reduce and manage risk. This study describes the development of a new coding instrument designed to assess motivations for violence and offending among individuals with MMI, and reports on the schemes interrater reliability. Using 72 psychiatric reports which had been submitted to the court to assist in determining criminal responsibility, we found that independent raters were able to assess different motivational influences for violence with a satisfactory degree of consistency. More than three-quarters (79.2%) of the sample were judged to have committed an act of violence as a primary result of illness, whereas 20.8% were deemed to have offended as a result of illness in conjunction with other non-illness-based motivating influences. Current findings have relevance for clarifying the rate of illness-driven violence among psychiatric patients, as well as legal and clinical issues related to violence risk and criminal responsibility more broadly.

Gender Comparisons in a Forensic Sample: Patient Profiles and HCR-20:V2 Reliability and Item Utility

ABSTRACT Given documented gender differences in risk factors and manifestations of violence, researchers have advocated for gender-sensitive approaches to violence risk assessment. This study compares male (n = 292) and female (n = 68) forensic psychiatric patients on an array of demographic, clinical, behavioral, and legal variables to gain a clearer understanding of the prevalence of different risk factors and types of violence in this population. We investigate the interrater reliability and item utility of the Historical, Clinical, Risk Management-20 (HCR-20:V2), and examine whether individual HCR-20 items exhibit differential relationships to the tools summary risk rating across gender. More women carried a diagnosis of borderline personality disorder, whereas antisocial personality disorder, substance use problems and extensive criminal histories were more often noted in men. These clinical differences were reflected in the distribution of HCR-20 item and subscale scores across gender. Interrater reliability was excellent, especially for women. A lack of personal support increased the odds of being deemed high risk in women to a greater extent than in men. We discuss the utility of structured professional judgment tools such as HCR-20 in women, and consider the importance of a gender-sensitive approach to risk assessment.

Challenges in the Assessment of Aggression in High-Risk Youth: Testing the Fit of the Form-Function Aggression Measure

Recent efforts have focused on disentangling the forms (e.g., overt and relational) and functions (e.g., instrumental and reactive) of aggression. The Form-Function Aggression Measure (FFAM; Little, Jones, Henrich, & Hawley, 2003) shows promise in this regard; however, it is a new measure and its psychometric properties across different populations are unknown. The current study tested the underlying structure of the FFAM using confirmatory factor analysis in male and female high-risk adolescents (n= 381). Results indicated that none of the models tested demonstrated an acceptable fit in either males or females. However, a 6-factor model comprised of pure-overt, reactive-overt, instrumental-overt, pure-relational, reactive-relational, and instrumental-relational subtypes provided an improved fit relative to other models in both males and females. A multi-form, multi-function model equivalent to the model proposed by Little and colleagues (2003) also evidenced a relatively improved fit, highlighting the utility of disentangling form from function when examining aggression. Implications and challenges for assessing the forms and functions of aggression among high-risk adolescents are discussed.