Using dynamic risk and protective factors to predict inpatient aggression: reliability and validity of START assessments

Can an animal welfare risk assessment tool identify livestock at risk of poor welfare outcomes?

If livestock at risk of poor welfare could be identified using a risk assessment tool, more targeted response strategies could be developed by enforcement agencies to facilitate early intervention, prompt welfare improvement and a decrease in reoffending. This study aimed to test the ability of an Animal Welfare Risk Assessment Tool (AWRAT) to identify livestock at risk of poor welfare in extensive farming systems in Australia. Following farm visits for welfare- and non-welfare-related reasons, participants completed a single welfare rating (WR) and an assessment using the AWRAT for the farm just visited. A novel algorithm was developed to generate an AWRAT-Risk Rating (AWRAT-RR) based on the AWRAT assessment. Using linear regression, the relationship between the AWRAT-RR and the WR was tested. The AWRAT was good at identifying farms with poor livestock welfare based on this preliminary testing. As the AWRAT relies upon observation, the intra- and inter-observer agreement were compared in an observation study. This included rating a set of photographs of farm features, on two occasions. Intra-observer reliability was good, with 83% of Intra-class Correlation Coefficients (ICCs) for observers ≥ 0.8. Inter-observer reliability was moderate with an ICC of 0.67. The AWRAT provides a structured framework to improve consistency in livestock welfare assessments. Further research is necessary to determine the AWRAT's ability to identify livestock at risk of poor welfare by studying animal welfare incidents and reoffending over time.

Are there risk factors commonly observed on Australian farms where the welfare of livestock is poor?

The objective of this study was to identify factors more commonly observed on farms with poor livestock welfare compared to farms with good welfare. Potentially, these factors may be used to develop an animal welfare risk assessment tool (AWRAT) that could be used to identify livestock at risk of poor welfare. Identifying livestock at risk of poor welfare would facilitate early intervention and improve strategies to promptly resolve welfare issues. This study focuses on cattle, sheep and goats in non-dairy extensive farming systems in Australia. To assist with identifying potential risk factors, a survey was developed presenting 99 factors about the farm, farmers, animals and various aspects of management. Based on their experience, key stakeholders, including veterinarians, stock agents, consultants, extension and animal welfare officers were asked to consider a farm where the welfare of the livestock was either high or low and rate the likelihood of observing these factors. Of the 141 responses, 65% were for farms with low welfare. Only 6% of factors had ratings that were not significantly different between high and low welfare surveys, and these were not considered further. Factors from poor welfare surveys with median ratings in the lowest 25% were considered potential risks (n = 49). Considering correlation, ease of verification and the different livestock farming systems in Australia, 18 risk factors relating to farm infrastructure, nutrition, treatment and husbandry were selected. The AWRAT requires validation in future studies.

An analysis of substantiated complaints made about incidents of poor livestock welfare, in Victoria, Australia

Incidents of poor welfare on farm in Victoria, Australia, are generally identified during an investigation that follows receipt of a complaint. Using deidentified records of complaints received by the Victoria State Government between 2011 and 2020, this study aimed to describe the source, number and the relationship between rainfall/stock prices and substantiated welfare complaints (SWC). Only incidents involving non-dairy cattle, sheep and goats in extensive farming systems will be considered. The main source of complaints received by the Victorian Government is the general public. Almost half of all complaints were made for cattle (48%), 39% for sheep, 11% for mixed species, and 2% for goats. The number of SWC varied between months, each year and across the different regions of Victoria. The ratio of the actual mean rainfall of the last three seasons to the long-term mean of the last three seasons of rainfall (RL3SR) and livestock prices together were the best predictors of the total number of SWC (adjusted R square value for heavy lamb-RL3SR was highest (0.590), followed by merino lamb-RL3SR (0.588), goat-RL3SR (0.545) and steer-RL3SR (0.478) all were significant (p ≤ 0.05)). The rainfall by region and town were not good predictors of the number of SWC. There was a correlation between rainfall and the number of SWC, possibly due to changes in pasture availability. Favorable seasonal conditions however, were not protective of livestock welfare and it is likely a number of factors may be implicated.

Screening for Behavioral Health Patient Aggression in Emergency Departments to Reduce Workplace Violence

INTRODUCTION

Patient violence in health care facilities occurs daily. Structured risk assessments, when regularly completed, have been effective in prompting interventions to reduce aggression in Behavioral Health (BH) settings.

METHODS

This quasi-experimental study evaluated the effectiveness of the Dynamic Appraisal of Situational Aggression - Inpatient Version (DASA) validated screening tool to reduce aggressive outbursts in an emergency department (ED) setting with BH patients awaiting transfer to a psychiatric facility. The tool was used in 4 non-psychiatric EDs from a large health care system. Chart audits were completed to record initial patient DASA scores observed at triage and at subsequent intervals during the ED encounter. ED staff documented interventions used for patients. Inclusion criteria included adults 21 years and older following a telepsychiatry consultation with a recommendation for BH inpatient admission. Pre-/post-implementation aggressive events were collected to assess ED DASA use. DASA scores from BH ED patients were examined to increase understanding of patient utilization. Staff workplace safety was examined to compare staff safety perception pre- and post-DASA implementation.

RESULTS

Violent events were reported statistically significantly higher post-DASA implementation. There was an increased risk of elevated DASA scores for specific diagnoses and genders. An increased awareness of the importance of reporting workplace violence improved documentation.

DISCUSSION

Using an evidence-based screening tool helped identify BH patients with behaviors associated with aggressive ED events. Proactive use of interventions, including use of Comfort Cart items, de-escalation, and prescribed medications, can positively influence reduction of risk from aggressive behaviors within BH patient populations in EDs.

Predictive Utility of the Imminent Risk Rating Scale: Evidence From a Clinical Pilot Study

In an effort to prevent inpatient violence on forensic psychiatric units, it is necessary to have a feasible and effective measure for nursing to screen for risk of short-term verbal and physical aggression. The Imminent Risk Rating Scale (IRRS; Starzomski & Wilson, 2015) showed promise in an initial validation study. This study aimed to further examine the predictive validity of the IRRS by utilizing clinical pilot data collected from a forensic inpatient unit. Nursing staff scored the IRRS for adults who were hospitalized for at least 1 week ( n = 109), as well as outcomes related to verbal and physical aggression as measured by the Modified Overt Aggression Scale. The results from the clinical pilot data provided additional support for the potential use of the IRRS for predicting physical and verbal aggression in a forensic inpatient setting, although further rigorous empirical research is needed. The findings are important for nursing staff in the prediction and prevention of inpatient violence.

Validity of Short-Term Assessment of Risk and Treatability in the Japanese Forensic Probation Service

This study aimed to evaluate the predictive validity and reliability of the Short-Term Assessment of Risk and Treatability (START) in the context of the Japanese forensic probation service. START is a structured professional judgement guide for risk domains concerning negative behaviors such as violence, self-harm, suicide, substance abuse, unauthorized leave, victimization, and self-neglect. In this study, rehabilitation coordinators evaluated community-dwelling patients who were treated under the Medical Treatment and Supervision Act at baseline and followed-up for 6 months. The results revealed that START vulnerability scores significantly predicted self-harm, suicide, physical aggression, substance abuse, and self-neglect. START strength scores predicted physical violence and unauthorized leave. Specific risk estimates predicted physical violence and self-neglect. Risk judgement for future substance use may require adjustments for cultural differences, because of the lower prevalence in Japan. These results suggest that START offers a feasible and valid tool that allows clinicians to plan treatment and promote recovery of forensic patients in Japan.

Principles and practices of risk assessment in mental health jail diversion programs

Eligibility criteria for participation in mental health jail diversion programs often specify that, to be diverted, a candidate must not pose a level of threat to public safety that cannot be managed in the community. Risk assessment tools were developed to increase consistency and accuracy in estimates of threat to public safety. Consequently, risk assessment tools are being used in many jurisdictions to inform decisions regarding an individual's appropriateness and eligibility for mental health jail diversion and the strategies that may be successful in mitigating risk in this context. However, their use is not without controversy. Questions have been raised regarding the validity and equity of their estimates, as well as the impact of their use on criminal justice outcomes. The purpose of this review is to provide an overview of the science and practice of risk assessment to inform decisions and case planning in the context of mental health jail diversion programs. Our specific aims include: (1) to describe the process and components of risk assessment, including differentiating between different approaches to risk assessment, and (2) to consider the use of risk assessment tools in mental health jail diversion programs. We anchor this review in relevant theory and extant research, noting current controversies or debates and areas for future research. Overall, there is strong theoretical justification and empirical evidence from other criminal justice contexts; however, the body of research on the use of risk assessment tools in mental health jail diversion programs, although promising, is relatively nascent.

Inpatient violence in forensic psychiatry: Does change in dynamic risk indicators of the IFTE help predict short term inpatient violence?

Inpatient violence is a form of recidivism in forensic psychiatric treatment and is stated as an adverse outcome of treatment and a predictor for recidivism after release from the institution. Dynamic Risk Indicators (DRI) are critical key indicators that can predict inpatient violence, but little is known about the effects of change in DRI during forensic psychiatric treatment on the prediction of inpatient violence. This study examines the effects of change in DRI on the prediction of short-term inpatient violence using the Instrument for Forensic Treatment Evaluation (IFTE). A group of 96 patients is followed from entering a high secure forensic hospital until their fifth measurement approximately three years later. The outcome measure is defined as any inpatient violence six months after measurement five. Repeated measures are used to study whether there was a difference in change in DRI between the group of patients who did or did not committed inpatient violence. Binary logistic regression is used to establish the extent to which changes in DRI add to the predictive power of the last measurement. At the group level, the extent of change in DRI did not discriminate between the two patient groups. A large part of the 96 patients already scored low on DRI when entering the hospital and did not (need to) change. At all five measurements violent patients had significant higher scores on DRI than nonviolent patients. Logistic regressions showed that the last measurement predicts inpatient violence sufficiently, the change in DRI during the first four measurements did not contribute to this prediction. The change in dynamic risk indicators does not help to predict short term inpatient violence. The last measurement is the most practical predictor for short term inpatient violence, but because of the dynamic nature of these indicators it is necessary to frequently monitor these indicators to detect imminent risks.

Violence risk-assessment screening tools for acute care mental health settings: Literature review

BACKGROUND

Violence is a large concern for mental health professionals: 90% of physicians and nurses working in mental health areas have been subject to violence from patients. Approximately 80% of violent acts from patients are directed toward nurses.

OBJECTIVE

The purpose of this integrative literature review was to identify violence risk-assessment screening tools that could be used in acute care mental health settings.

DESIGN

The Stetler model of evidence-based practice guided the literature search, in which 8 violence risk-assessment tools were identified, 4 of which were used for further examination.

RESULTS

The Brøset Violence Checklist and Violence Risk Screening-10 provided the best assessment for violence in the acute care mental health setting.

CONCLUSIONS

Using a violence risk assessment screening tool helps identify patients at risk for violence allowing for quick intervention to prevent violent episodes.

Predicting physically violent misconduct in prison: A comparison of four risk assessment instruments

Violence in correctional facilities is an important issue for both prisoners and prison staff. Risk assessment instruments have demonstrated their accuracy in predicting the risk of (re) offending and institutional violence in psychiatric settings, but less is known about their ability to predict violent misconduct in prison. The present study applied four risk assessment instruments (Structured Assessment of Protective Factors for violence risk, Historical Clinical Risk Management-20, Psychopathy checklist - Revised, and Violent Risk Appraisal Guide) to 52 violent offenders in a Swiss prison in order to evaluate the instruments' predictive validities. Outcomes were instances of physically violent, other and any misconduct as recorded in prison files during the 12 months following the prisoners' assessments. Approximately 15% of offenders committed physically violent misconduct and approximately 42% committed any misconduct. The results show that mainly dynamic assessment tools are as good predictors of physically violent misconduct as mainly static assessment tools. Targeting dynamic factors could increase the effectiveness of interventions to reduce the risk of physical violence in prison.

Assessing Risk for Victimization in a Forensic Psychiatric Setting Using the Short-Term Assessment of Risk and Treatability

Although a growing literature on community-based victimization of people with mental illness exists, victimization within institutional settings is comparatively understudied. The current study seeks to fill this gap by exploring factors related to risk of victimization in a male forensic psychiatric sample using a relatively new risk assessment measure. The Short-Term Assessment of Risk and Treatability (START) is a short-term risk assessment measure that compiles information about several clinically relevant risk factors to evaluate risk of victimization, among other adverse outcomes. Nearly one-third (31.3%) of the sample experienced some type of victimization during their hospitalization. The summary risk judgment and subsets of select START items effectively predicted risk of victimization in this sample with a fair degree of accuracy over a 2-month period.

Assessing Protective Factors for Violence Risk in U.K. General Mental Health Services Using the Structured Assessment of Protective Factors

Violence risk assessment and management are key tasks in mental health services and should be guided by validated instruments covering both risk and protective factors. This article is part of an international effort to validate the Structured Assessment of Protective Factors (SAPROF) for violence. The SAPROF, Historical, Clinical, Risk Management-20 (HCR-20) and the Psychopathy Checklist-Screening Version (PCL-SV) were administered in a sample of 261 patients in U.K. forensic, general inpatient, and community mental health settings. There was significant variation between these groups on SAPROF scores with fewer protective factors in the forensic group. The prospective validity of the SAPROF for nonviolence in the general inpatient and community samples was moderate (area under the curve [AUC] = .60). Adoption of the SAPROF or similar instruments as a supplement to risk-focused assessments has the potential to improve awareness of protective factors and enhance therapeutic engagement in a range of mental health services.

Psychometric Properties in Forensic Application of the Screening Version of the Psychopathy Checklist

The Psychopathy Checklist: Screening Version (PCL: SV) is a short form of the Psychopathy Checklist-Revised (PCL-R), an expert-rated assessment that measures psychopathic personality traits in research, clinical, and community settings. The PCL-R is an extensively relied upon tool in psycho-legal contexts. The screening version is also widely used; however, it has received far less empirical attention than the PCL-R. This review examines the psychometric properties of the PCL: SV, specifically in relation to forensic samples, and evaluates its comparability with the full PCL-R. Previously reported similarity in the reliability and validity of the PCL: SV as established for the PCL-R was supported through further testing in forensic samples. However, limitations in terms of available normative data are highlighted, and the review engages with wider debate concerning the measurement of psychopathy.

[Patients assaulted in psychiatric institutions: Literature review and clinical implications]

BACKGROUND

The psychiatric ward is a place where all forms of violence are treated. Occasionally, this violence involves acts of aggression between patients in emergency psychiatric units or hospital wards. Such events can lead to the development or worsening of posttraumatic stress disorder.

METHODS

To establish the context, we first examined the epidemiology data concerning posttraumatic stress disorder in psychiatric patients who were frequently exposed to assaults. Secondly, we examined the issue of sexual and physical assaults between patients receiving treatment in a psychiatric ward. In this context, we studied possible occurrence of posttraumatic stress disorder associated with exposure to assaults of this kind.

RESULTS

In certain cases, potentially traumatic exposure to violence was unknown to the medical staff or not taken into consideration. This would induce a risk of later development of posttraumatic stress disorder that would not be treated during the stay in psychiatry.

CONCLUSION

To date, few scientific studies have focused on the proportion of patients assaulted by other patients during treatment in a psychiatric ward and the subsequent development of peritraumatic reactions and/or posttraumatic stress disorder associated with these assaults. We know that an insufficient number of public and private health institutions report the existence of such facts to the competent authorities. Also, a minority of clinicians and caregivers are trained in screening and management of trauma victims. Yet, these issues are particularly relevant in the scope of public health and health promotion.

Predictive validity of the Short-Term Assessment of Risk and Treatability (START) for multiple adverse outcomes: The effect of diagnosis

The Short-Term Assessment of Risk and Treatability (START) assists risk assessment for seven risk outcomes based on scoring of risk and protective factors and assignment of clinically-informed risk levels. Its predictive validity for violence and self-harm has been established in males with schizophrenia, but accuracy across pathologically diverse samples is unknown. Routine START assessments and 3-month risk outcome data of N = 527 adult, inpatients in a UK secure mental health facility were collected. The sample was divided into diagnostic groups; predictive validity was established using receiver operating characteristics regression (rocreg) analysis in which potential covariates were controlled. In most single-diagnosis groups START risk factors ('vulnerabilities'), protective factors ('strengths'), and clinically-informed estimates predicted multiple risk outcomes with effect sizes similar to previous research. Self-harm was not predicted among patients with an organic diagnosis. The START risk estimates predicted physical aggression in all diagnostic groups, and verbal aggression, self-harm and self-neglect in most diagnostic groups. The START can assist assessment of aggressive, self-harm, and self-neglect across a range of diagnostic groups. Further research with larger sample sizes of those with multiple diagnoses is required.

Reliability and Validity of START and LSI-R Assessments in Mental Health Jail Diversion Clients

Risk assessment instruments are increasingly used in mental health jail diversion programs. This study examined the reliability and validity of Short-Term Assessment of Risk and Treatability (START) and Level of Service Inventory–Revised (LSI-R) assessments overall and by client race. Research assistants completed START and LSI-R assessments for 95 diversion clients. Arrests and jail days were collected via official records and self-report 3, 6, 9, 12, and 18 months after baseline. Assessments demonstrated good interrater reliability and convergent validity. START strength total scores and LSI-R risk estimates were the strongest predictors of recidivism. Total scores and risk estimates did not differ as a function of client race, but there were some differences in accuracy of START vulnerability and LSI-R total scores and risk estimates in predicting jail days (but not arrests), over shorter follow-ups. No such differences were found for START strength total scores across any follow-up period or recidivism measure.

Prevalence and predictors of verbal aggression in a secure mental health service: Use of the HCR-20

Despite evidence about the negative effects of verbal aggression in mental health wards there is little research about its prevalence or about the factors that predict the behaviour among inpatients. This study aimed to determine the prevalence of verbal aggression in a secure mental health service, and to examine the relationship of verbal aggression with risk factors for aggression in the risk assessment tool HCR-20 in order to establish whether, and with which factors, the behaviour can be predicted. Verbal aggression was measured using the Overt Aggression Scale (OAS) over a 3-month period across a heterogeneous patient group (n = 613). Over half the patients (n = 341, 56%) engaged in 1594 incidents of verbal aggression. The HCR-20 total, clinical, and risk management subscale scores predicted verbal aggression, though effect sizes were not large. Item-outcome analysis revealed that impulsivity, negative attitudes, and non-compliance with medication were the best predictors of verbal aggression and, therefore, should be targeted for intervention. There are key synergies between factors predicting verbal aggression and the core mental health nursing role. Nurses, therefore, are in a prime position to develop and implement interventions that may reduce verbal aggression in mental health inpatients.

The Predictive Validity of the Short-Term Assessment of Risk and Treatability (START) for Multiple Adverse Outcomes in a Secure Psychiatric Inpatient Setting

The Short-Term Assessment of Risk and Treatability (START) aims to assist mental health practitioners to estimate an individual’s short-term risk for a range of adverse outcomes via structured consideration of their risk (“Vulnerabilities”) and protective factors (“Strengths”) in 20 areas. It has demonstrated predictive validity for aggression but this is less established for other outcomes. We collated START assessments for N = 200 adults in a secure mental health hospital and ascertained 3-month risk event incidence using the START Outcomes Scale. The specific risk estimates, which are the tool developers’ suggested method of overall assessment, predicted aggression, self-harm/suicidality, and victimization, and had incremental validity over the Strength and Vulnerability scales for these outcomes. The Strength scale had incremental validity over the Vulnerability scale for aggressive outcomes; therefore, consideration of protective factors had demonstrable value in their prediction. Further evidence is required to support use of the START for the full range of outcomes it aims to predict.

Understanding Clinicians' Use of Cues When Assessing the Future Risk of Violence: A Clinical Judgement Analysis in the Psychiatric Setting

Research is sparse on how clinicians' judgement informs their violence risk assessments. Yet, determining preferences for which risk factors are used, and how they are weighted and combined, is important to understanding such assessments. This study investigated clinicians' use of static and dynamic cues when assessing risk in individual patients and for dynamic cues considered in the recent and distant past. Clinicians provided three violence risk assessments for 41 separate hypothetical cases of hospitalized patients, each defined by eight cues (e.g., psychopathy and past violence severity/frequency). A clinical judgement analysis, using regression analysis of judgements for multiple cases, created linear models reflecting the major influences on each individual clinician's judgement. Risk assessments could be successfully predicted by between one and four cues, and there was close agreement between different clinicians' models regarding which cues were relevant for a given assessment. However, which cues were used varied between assessments: history of recent violence predicted assessments of in-hospital risk, whereas violence in the distant past predicted the assessed risk in the community. Crucially, several factors included in actuarial/structured risk assessment tools had little influence on clinicians' assessments. Our findings point to the adaptivity in clinicians' violence risk assessments, with a preference for relying on information consistent with the setting for which the assessment applies. The implication is that clinicians are open to using different structured assessment tools for different kinds of risk assessment, although they may seek greater flexibility in their assessments than some structured risk assessment tools afford (e.g., discounting static risk factors).

KEY PRACTITIONER MESSAGE

Across three separate violence risk assessments, clinicians' risk assessments were more strongly influenced by dynamic cues that can vary over time (e.g., level of violence) than by static cues that are fixed for a given individual (e.g., a diagnosis of psychopathy). The variation in the factors affecting risk assessments for different settings (i.e., in hospital versus in the community) was greater than the variability between clinicians for such judgements. The findings imply a preference for risk assessment strategies that offer flexibility: either using different risk assessment tools for different purposes and settings or employing a single tool that allows for different inputs into the risk assessment depending upon the nature of the assessment. The appropriateness of these clinical intuitions about violence risk that are implied by our findings warrants further investigation.

Progress in violence risk assessment and communication: hypothesis versus evidence

We draw a distinction between hypothesis and evidence with respect to the assessment and communication of the risk of violent recidivism. We suggest that some authorities in the field have proposed quite valid and reasonable hypotheses with respect to several issues. Among these are the following: that accuracy will be improved by the adjustment or moderation of numerical scores based on clinical opinions about rare risk factors or other considerations pertaining to the applicability to the case at hand; that there is something fundamentally distinct about protective factors so that they are not merely the obverse of risk factors, such that optimal accuracy cannot be achieved without consideration of such protective factors; and that assessment of dynamic factors is required for optimal accuracy and furthermore interventions aimed at such dynamic factors can be expected to cause reductions in violence risk. We suggest here that, while these are generally reasonable hypotheses, they have been inappropriately presented to practitioners as empirically supported facts, and that practitioners' assessment and communication about violence risk run beyond that supported by the available evidence as a result. We further suggest that this represents harm, especially in impeding scientific progress. Nothing here justifies stasis or simply surrendering to authoritarian custody with somatic treatment. Theoretically motivated and clearly articulated assessment and intervention should be provided for offenders, but in a manner that moves the field more firmly from hypotheses to evidence.

From Risk Assessment to Risk Management: Matching Interventions to Adolescent Offenders' Strengths and Vulnerabilities

Though considerable research has examined the validity of risk assessment tools in predicting adverse outcomes in justice-involved adolescents, the extent to which risk assessments are translated into risk management strategies and, importantly, the association between this link and adverse outcomes has gone largely unexamined. To address these shortcomings, the Risk-Need-Responsivity (RNR) model was used to examine associations between identified strengths and vulnerabilities, interventions, and institutional outcomes for justice-involved youth. Data were collected from risk assessments completed using the Short-Term Assessment of Risk and Treatability: Adolescent Version (START:AV) for 120 adolescent offenders (96 boys and 24 girls). Interventions and outcomes were extracted from institutional records. Mixed evidence of adherence to RNR principles was found. Accordant to the risk principle, adolescent offenders judged to have more strengths had more strength-based interventions in their service plans, though adolescent offenders with more vulnerabilities did not have more interventions targeting their vulnerabilities. With respect to the need and responsivity principles, vulnerabilities and strengths identified as particularly relevant to the individual youth's risk of adverse outcomes were addressed in the service plans about half and a quarter of the time, respectively. Greater adherence to the risk and need principles was found to predict significantly the likelihood of externalizing outcomes. Findings suggest some gaps between risk assessment and risk management and highlight the potential usefulness of strength-based approaches to intervention.

Dynamic relationship between multiple START assessments and violent incidents over time: a prospective cohort study

BACKGROUND

Dynamic risk factors need to be assessed repeatedly over time rather than at a single time point to examine the relationship with violence. This predictive validity study sought to examine the degree of dynamic change in risk assessed in a group of mentally disordered offenders and the relationship between change and the occurrence of violence.

METHODS

Routine structured assessments of Strengths and Vulnerabilities on the Short-Term Assessment of Risk and Treatability (START) instrument (n = 475) were linked prospectively with 275 violent incidents using logistic regression in a sample of 50 patients.

RESULTS

Stability within patients estimated using the intra-class correlation coefficient was high (>.80) for both Strengths and Vulnerabilities. In the overall sample, a 10 point increase in START Vulnerabilities score was associated with a three-fold increased risk of violence (OR = 3.1; 95% CI, 1.47-7.46) but there was no association for Strengths score (OR = 0.91, 95% CI, 0.34-2.47). When examined within patients, both Vulnerabilities (OR = 1.77, 95% CI, 0.56-5.54) and Strengths (OR = 2.26, 95% CI, 0.38-13.42) were associated with an increased risk of violence but in both cases precision was low due to reduced sample sizes.

CONCLUSIONS

Risk factors which are considered to have the capacity to fluctuate dynamically did not do so substantially in this group of mentally disordered offenders. When fluctuations did occur there was some tentative evidence that they are associated with violent outcomes and could guide the use of prevention measures.

Aggression Among Psychiatric Inpatients: The Relationship Between Time, Place, Victims, and Severity Ratings

BACKGROUND

The rate of aggressive acts perpetrated by psychiatric inpatients remains a pressing issue. To date, few studies have distinguished between incident severities.

OBJECTIVE

The aims of the current study were to identify rates of inpatient aggression in an inpatient forensic psychiatric facility and describe the severity of the aggression reported for aggressive incidents.

DESIGN

All documented acts of aggression at a 1,500-bed forensic hospital between 2009 and 2013 provided data about the time, location, and victims of aggressive acts. In total, 52,109 unique incidents were analyzed.

RESULTS

The findings showed an increase in violence rates during meal, medication, and shift change times. Patients (n = 3,436, 62%) were victimized more often than staff members (n = 2,103, 38%). Fall and winter months showed more acts of aggression than summer and spring, but there were no mean differences between severity ratings by season. The results showed that the swing shift saw more severe aggressive incidents than the morning or overnight shifts, p = .001, and significantly more serious incidents occurred when there were staff members working over time, p = .050.

CONCLUSIONS

The current study reports some key findings about aggression rates with a very large sample and presents some valuable data regarding the severity of aggressive acts.

Community violence perpetration and victimization among adults with mental illnesses

OBJECTIVES

In a large heterogeneous sample of adults with mental illnesses, we examined the 6-month prevalence and nature of community violence perpetration and victimization, as well as associations between these outcomes.

METHODS

Baseline data were pooled from 5 studies of adults with mental illnesses from across the United States (n = 4480); the studies took place from 1992 to 2007. The MacArthur Community Violence Screening Instrument was administered to all participants.

RESULTS

Prevalence of perpetration ranged from 11.0% to 43.4% across studies, with approximately one quarter (23.9%) of participants reporting violence. Prevalence of victimization was higher overall (30.9%), ranging from 17.0% to 56.6% across studies. Most violence (63.5%) was perpetrated in residential settings. The prevalence of violence-related physical injury was approximately 1 in 10 overall and 1 in 3 for those involved in violent incidents. There were strong associations between perpetration and victimization.

CONCLUSIONS

Results provided further evidence that adults with mental illnesses experienced violent outcomes at high rates, and that they were more likely to be victims than perpetrators of community violence. There is a critical need for public health interventions designed to reduce violence in this vulnerable population.

Taking Stock and Taking Steps: The Case for an Adolescent Version of the Short-Assessment of Risk and Treatability

The field of violence risk assessment has matured considerably, possibly advancing beyond its own adolescence. At this point in the field's evolution, it is more important than ever for the development of any new device to be accompanied by a strong rationale and the capacity to provide a unique contribution. With this issue in mind, we first take stock of the field of adolescent risk assessment in order to describe the rapid progress that this field has made, as well as the gaps that led us to adapt the Short-Term Assessment of Risk and Treatability (START; Webster, Martin, Brink, Nicholls, & Desmarais, 2009) for use with adolescents. We view the Short-Term Assessment of Risk and Treatability: Adolescent Version (START:AV; Nicholls, Viljoen, Cruise, Desmarais, & Webster, 2010; Viljoen, Cruise, Nicholls, Desmarais, & Webster, in progress) as complementing other risk measures in four primary ways: 1) rather than focusing solely on violence risk, it examines broader adverse outcomes to which some adolescents are vulnerable (including self-harm, suicide, victimization, substance abuse, unauthorized leave, self-neglect, general offending); 2) it places a balanced emphasis on adolescents' strengths; 3) it focuses on dynamic factors that are relevant to short-term assessment, risk management, and treatment planning; and 4) it is designed for both mental health and justice populations. We describe the developmentally-informed approach we took in the adaptation of the START for adolescents, and outline future steps for the continuing validation and refinement of the START:AV.

Pilot Implementation and Preliminary Evaluation of START:AV Assessments in Secure Juvenile Correctional Facilities

The Short-Term Assessment of Risk and Treatability: Adolescent Version (START:AV) is a new structured professional judgment guide for assessing short-term risks in adolescents. The scheme may be distinguished from other youth risk assessment and treatment planning instruments by its inclusion of 23 dynamic factors that are each rated for both vulnerability and strength. In addition, START:AV is also unique in that it focuses on multiple adverse outcomes-namely, violence, self-harm, suicide, unauthorized leave, substance abuse, self-neglect, victimization, and general offending-over the short-term (i.e., weeks to months) rather than long-term (i.e., years). This paper describes a pilot implementation and preliminary evaluation of START:AV in three secure juvenile correctional facilities in the southern United States. Specifically, we examined the descriptive characteristics and psychometric properties of START:AV assessments completed by 21 case managers on 291 adolescent offenders (250 boys and 41 girls) at the time of admission. Results provide preliminary support for the feasibility of completing START:AV assessments as part of routine practice. Findings also highlight differences in the characteristics of START:AV assessments for boys and girls and differential associations between the eight START:AV risk domains. Though results are promising, further research is needed to establish the reliability and validity of START:AV assessments completed in the field.

Assessment of Multiple Risk Outcomes, Strengths, and Change with the START:AV: A Short-Term Prospective Study with Adolescent Offenders

The Short-Term Assessment of Risk and Treatability: Adolescent Version (START:AV; Nicholls, Viljoen, Cruise, Desmarais, & Webster, 2010; Viljoen, Cruise, Nicholls, Desmarais, & Webster, in preparation) is a clinical guide designed to assist in the assessment and management of adolescents' risk for adverse events (e.g., violence, general offending, suicide, victimization). In this initial validation study, START:AV assessments were conducted on 90 adolescent offenders (62 male, 28 female), who were prospectively followed for a 3-month period. START:AV assessments had good to excellent inter-rater reliability and strong concurrent validity with Structured Assessment of Violence Risk in Youth assessments (SAVRY; Borum, Bartel, & Forth, 2006). START:AV risk estimates and Vulnerability total scores predicted multiple adverse outcomes, including violence towards others, offending, victimization, suicidal ideation, and substance abuse. In addition, Strength total scores inversely predicted violence, offending, and street drug use. During the 3-month follow-up, risk estimates changed in at least one domain for 92% of youth, and 27% of youth showed reliable changes in Strength and/or Vulnerability total scores (reliable change index, 90% confidence interval; Jacobsen & Truax, 1991). While these findings are promising, a strong need exists for further research on the START:AV, the measurement of change, and on the role of strengths in risk assessment and treatment-planning.