Clinical and Actuarial Prediction of Physical Violence in a Forensic Intellectual Disability Hospital: A Longitudinal Study

Cognitive behavioural anger treatment for adults with intellectual disabilities: effects of therapist experience on outcome

BACKGROUND

Anger has been shown to be associated with aggression and violence in adults with intellectual disabilities in both community and secure settings. Emerging evidence has indicated that cognitive behavioural anger treatment can be effective in reducing assessed levels of anger and violent behaviour in these patient populations. However, it has been suggested that the effectiveness of these types of interventions is influenced by the experience and training of the therapists.

METHOD

In this service evaluation study, the pre- and post-treatment and 12-month follow-up assessment scores of 88 detained in-patient adults with intellectual disabilities and forensic histories who received cognitive behavioural anger treatment were examined in order to investigate whether participants' responsiveness to treatment was associated with treatment being delivered by qualified versus unqualified therapists.

RESULTS

Overall significant reductions in self-reported measures of anger disposition and anger reactivity were found with no significant time × therapist experience interaction effects. However, the patients treated by qualified therapists improved significantly on measures of anger control compared with those allocated to unqualified therapists.

CONCLUSIONS

Male and female detained patients with intellectual disabilities and forensic histories can benefit from an individual cognitive behavioural anger treatment intervention delivered by qualified and unqualified therapists, but therapist experience may be important in supporting patients to develop more complex anger control coping skills.

Physical Assault in the Psychiatry Emergency Room

Previous studies of physical assaults in hospitals focused primarily on inpatient psychiatric units, leaving unanswered questions about the extent to which findings generalize to psychiatric emergency rooms. Assault incident reports and electronic medical records from one psychiatric emergency room and two inpatient psychiatric units were reviewed. Qualitative methods were used to identify precipitants. Quantitative methods were used to describe characteristics of each event, as well as demographic and symptom profiles associated with incidents. During the five-year study period, there were 60 incidents in the psychiatric emergency room and 124 incidents on the inpatient units. Precipitating factors, incident severity, means of assault, and interventions were similar in both settings. Among patients in the psychiatric emergency room, a diagnosis of schizophrenia, schizoaffective disorder, or bipolar disorder with manic symptoms (Adjusted Odds Ratio (AOR) 27.86) and presenting with thoughts to harm others (AOR 10.94) were associated with an increased likelihood of having an assault incident report. Similarities between assaults in the psychiatric emergency room and inpatient psychiatric units suggest that the broader literature from inpatient psychiatry can be generalized to the psychiatric emergency room setting, although some differences exist. Reprinted from J Am Acad Psychiatry Law 2020; 48:484-495, with permission from The American Academy of Psychiatry and the Law. Copyright © 2020.

Violent incidents in a secure service for individuals with learning disabilities: Incident types, circumstances and staff responses

BACKGROUND

The issue of violence in secure services has long been recognized both in the UK and worldwide. However, there is currently scarce literature available about violence within learning disability (LD) secure settings.

METHODS

Secondary data analysis was conducted on violent incidents, using information routinely collected by the staff over a 1-year period.

RESULTS

Physical assaults were the most frequent type of incident, and the distribution in terms of days or months was homogenous and incidents were concentrated in the corridors, lounges and dining rooms of secure facilities. Antipsychotic medication was not regularly prescribed. Generalized linear modelling analyses revealed significant predictors that increased the chances of seclusion and physical restraint, such as being female or directing the violence towards staff.

CONCLUSIONS

These findings can inform staff training on violence prevention and suggest that increased ward-based supervision and enhanced use of psychological formulations may help in reducing violence within this service context.

The protective scale of the Armidilo-S: The importance of forensic and clinical outcomes

BACKGROUND

The Armidilo has two scales-the risk scale and the protective scale. Research has been confined to the risk scale which appears to predict future incidents with medium to large effect sizes. There have been no publications on the use of the protective scale.

METHODS

The Armidilo was completed on four individuals with IDD who were either moving on from their placement or whose placement was in jeopardy because of new information or altered policies in the organization. The Armidilo was completed in the usual fashion.

RESULTS

Risk and protective results show that for each individual, recommendations could be made that ensured the best outcome. For two participants, restrictive placements were avoided because of the data on protective factors.

CONCLSIONS

The protective scale can be a powerful support for the clinician's case in offenders with IDD. The protective scale should be completed routinely for clinical evaluation.

Effectiveness of the 'Who's Challenging Who' support staff training intervention to improve attitudes and empathy towards adults with intellectual disability and challenging behaviours: study protocol for a cluster randomised controlled trial

Background

Findings suggest approximately one in six people with intellectual disability engage in ‘challenging behaviours’, which include aggression towards others/property and self-injurious actions. In residential settings, actions of staff members can make challenging behaviours more likely to occur, or make these behaviours worse. In particular, negative attitudes from members of staff and lack of understanding about the reasons for challenging behaviour are contributory factors. ‘Who’s Challenging Who?’ (WCW) training is designed to emphasise the role of staff in residential settings as a challenge also to people with intellectual disability. The course is delivered jointly by a trainer with intellectual disability who has been labelled as having challenging behaviour, along with a trainer without intellectual disability.

Methods

This is a cluster randomised two-arm trial of WCW training versus a waiting list control. Overall, 118 residential settings will be recruited and randomised on a 1:1 ratio. Within each setting, two members of staff will be invited to take part in the trial. Participants will complete assessments at baseline and at 6 and 20 weeks. WCW is a half day initial training course with some follow-on coaching to ensure implementation. The primary outcome is changes in staff empathy towards people with challenging behaviour. Secondary outcomes at the staff level include confidence, attitudes and work-related well-being. Secondary outcomes at the residential setting level include recorded incidents of aggressive challenging behaviour, and use of any restrictive practices.

Discussion

If the results of the cluster randomised trial are positive, we will disseminate the findings widely and make all training manuals and materials freely available for anyone in intellectual disability services (and beyond) to use. Our training approach may have wider implications in other areas of social care. It may also provide a generally applicable model for how to train people with intellectual disability to act as co-trainers in intellectual disability social care settings. People with intellectual disability and challenging behaviour have already been involved centrally with the design, development and pilot evaluation of WCW and will also be fully involved throughout this trial.

Trial registration

Registered on the International Standard Randomised Controlled Trial Number registry on 8th December 2015: ISRCTN53763600.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2175-1) contains supplementary material, which is available to authorized users.

Researching outcomes from forensic services for people with intellectual or developmental disabilities: a systematic review, evidence synthesis and expert and patient/carer consultation

Background

Inpatient services for people with intellectual and other types of developmental disabilities (IDD) who also have forensic or risk issues are largely provided in secure hospitals. Although this is a health service sector with high levels of expenditure, there is limited empirical information on patient outcomes from such services. In order for a future substantive longitudinal outcomes study in forensic IDD services to be informed and feasible, more needs to be understood about the outcome domains that are of relevance and importance and how they should be measured. A preliminary series of studies was therefore undertaken.

Objectives

To synthesise evidence in relation to the outcome domains that have been researched in the existing literature from hospital and community forensic services for people with IDD, within the broad domains of service effectiveness, patient safety and patient experience. To identify a definitive framework of outcome domains (and associated measures and indicators) based both on this research evidence and on the views of patients, carers and clinicians. To synthesise the information gathered in order to inform design of future multisite longitudinal research in the sector.

Design

Three linked studies were conducted. Stage 1 was a systematic review and evidence synthesis of outcome domains and measures as found within the forensic IDD literature. Stage 2 was a consultation exercise with 15 patients with IDD and six carers. Stage 3 was a modified Delphi consensus exercise with 15 clinicians and experts using the information gathered at stages 1 and 2.

Results

At stage 1, 60 studies that researched a range of outcomes in forensic IDD services were identified from the literature. This resulted in the construction of an initial framework of outcome domains. The consultation with patients and carers at stage 2 added to these framework domains that related particularly to carer experience and the level of support post discharge in the community. The Delphi process at stage 3 confirmed the validity of the resulting framework for clinician. This survey also identified the outcome measures preferred by clinicians and those that are currently utilised in services. Thus, indicators of appropriate measures in some important domains were identified, although there was a paucity of measures in other domains.

Conclusions

Together, these three linked studies led to the development of an evidence-based framework of key outcome domains and subdomains. A provisional list of associated measures and indicators was developed, although with the paucity of measures in some domains development of specific indicators may be required. With further refinement this could eventually be utilised by services and commissioners for comparative purposes, and in future empirical research on outcomes in forensic IDD services. An outline research proposal closely linked to recent policy initiatives was proposed. Limitations of the study include the relatively small number of carers and patients and range of experts consulted.

Future work

This would comprise a national longitudinal study tracking IDD in patients through hospitalisation and discharge.

Study registration

This study is registered as PROSPERO CRD42015016941.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

A systematic review and synthesis of outcome domains for use within forensic services for people with intellectual disabilities

BACKGROUND

There is limited empirical information on service-level outcome domains and indicators for the large number of people with intellectual disabilities being treated in forensic psychiatric hospitals.

AIMS

This study identified and developed the domains that should be used to measure treatment outcomes for this population.

METHOD

A systematic review of the literature highlighted 60 studies which met eligibility criteria; they were synthesised using content analysis. The findings were refined within a consultation and consensus exercises with carers, patients and experts.

RESULTS

The final framework encompassed three a priori superordinate domains: (a) effectiveness, (b) patient safety and (c) patient and carer experience. Within each of these, further sub-domains emerged from our systematic review and consultation exercises. These included severity of clinical symptoms, offending behaviours, reactive and restrictive interventions, quality of life and patient satisfaction.

CONCLUSIONS

To index recovery, services need to measure treatment outcomes using this framework.

DECLARATION OF INTEREST

None.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Attribution (CC BY) licence.

The Structured Assessment of Violence Risk in Adults with Intellectual Disability: A Systematic Review

BACKGROUND

While structured professional judgement approaches to assessing and managing the risk of violence have been extensively examined in mental health/forensic settings, the application of the findings to people with an intellectual disability is less extensively researched and reviewed. This review aimed to assess whether risk assessment tools have adequate predictive validity for violence in adults with an intellectual disability.

METHODS

Standard systematic review methodology was used to identify and synthesize appropriate studies.

RESULTS

A total of 14 studies were identified as meeting the inclusion criteria. These studies assessed the predictive validity of 18 different risk assessment tools, mainly in forensic settings. All studies concluded that the tools assessed were successful in predicting violence. Studies were generally of a high quality.

CONCLUSIONS

There is good quality evidence that risk assessment tools are valid for people with intellectual disability who offend but further research is required to validate tools for use with people with intellectual disability who offend.

Reductions in aggression and violence following cognitive behavioural anger treatment for detained patients with intellectual disabilities

BACKGROUND

Aggression is a significant problem amongst people with intellectual disabilities (ID), particularly those residing in hospital settings. Anger is related to aggression in secure services working people with ID, and the effectiveness of psychological interventions in reducing anger has been demonstrated in this population. However, no studies have systematically examined whether levels of aggression reduce following anger treatment with people with ID detained in secure settings.

METHOD

This programme evaluation study concerns individually delivered cognitive anger treatment delivered to 50 patients (44 men and 6 women) with mild to borderline ID, delivered twice weekly for 18 sessions in a specialist forensic hospital service. Aggressive incidents and physical assault data were obtained from records 12 months pre-treatment and 12 months post-treatment.

RESULTS

Following completion of treatment, the total number of aggressive incidents recorded in patients' files fell by 34.5%, and the post-treatment reduction in the number of physical assaults was 55.9%. Analysis of the data partitioned into 6-month blocks over the 24-month study period showed that significant reductions in aggressive and violent incidents occurred in the assessment intervals following anger treatment.

CONCLUSIONS

These findings reinforce the efficacy of cognitive behavioural anger treatment for detained patients with ID and histories of aggression; and despite its methodical limitations the study indicates the ecological validity of this treatment approach.

Predicting institutional violence in offenders with intellectual disabilities: the predictive efficacy of the VRAG and the HCR-20

BACKGROUND

There is a developing evidence base to support the use of risk assessment instruments in offenders with intellectual disability (ID). The aim of this study was to try to develop this literature with the inclusion of a control group of mentally disordered offenders without an ID, using the HCR-20 and VRAG.

MATERIALS AND METHODS

The VRAG and the HCR-20 were completed for a group of offenders with an ID (n = 25) and a control group (n = 45), in four medium-secure units across the UK. The outcome measure was physical aggression measured over 6 months.

RESULTS

Both instruments consistently produced large effect sizes predicting any physical aggression and severe physical aggression. The structured clinical judgement based on the HCR-20 was especially good.

CONCLUSIONS

The HCR-20 and the VRAG have excellent predictive efficacy in offenders with an ID. A structured clinical judgement based on the HCR-20 was especially predictive.

Prevalence and risk factors of inpatient aggression by adults with intellectual disabilities and severe challenging behaviour: a long-term prospective study in two Dutch treatment facilities

Over five years, various types of aggressive incidents by 421 intellectually disabled inpatients were recorded on a daily basis, using an adapted version of the Modified Overt Aggression Scale. Stable patient characteristics (e.g., gender, intelligence, DSM IV classification at the start of treatment) and pre-treatment scores of two treatment outcome measures (e.g., Adult Behavior Checklist and Dynamic Risk Outcome Scale) were used to predict aggression during the treatment. At an overall average of one incident per patient per week, about ten times more aggression occurred on admission compared to resocialisation wards, and the 20% most aggressive individuals caused 50% of the verbal and 80% of the physical incidents. The best predictor of aggressive behaviour was aggression early in treatment, followed by coping skills deficits and impulsiveness. The relevance of the results for the treatment of aggressive behaviour and methodological issues in the recording of inpatient aggression are discussed.

A multilevel meta-analysis of single-case and small-n research on interventions for reducing challenging behavior in persons with intellectual disabilities

The effectiveness of different interventions for challenging behavior (CB) in persons with intellectual disabilities (ID) was reviewed by means of a two-phase study. First, a systematic review of 137 meta-analyses and reviews on group-study interventions for CB in persons with ID was conducted. Based on this review, hypotheses concerning the effectiveness of divergent interventions for CB and concerning the impact of variables moderating treatment effectiveness were systematically generated. Second, these hypotheses were tested by means of a multilevel meta-analysis of single-case and small-n research. Two hundred and eighty-five studies reporting on 598 individuals were examined. The average treatment effect was large and statistically significant. However, this effect varied significantly over the included studies and participants. Compared to the meta-analyses and reviews focusing on group-studies in this research domain, the results of the present multilevel meta-analysis of single-case and small-n intervention research provided more detailed knowledge on which specific CB and intervention components moderate the interventions' effectiveness.

Referrals into services for offenders with intellectual disabilities: variables predicting community or secure provision

BACKGROUND

There is a need for research to promote an understanding among service developers on why people with intellectual disabilities (ID) are referred to offender services in order for them to receive appropriate assessment and treatment. Previous studies investigating referrals into forensic ID services have concentrated on referral sources and administrative variables such as legal status.

AIMS

To construct a predictive model for choice of service referral based on a comprehensive range of information about the clientele.

METHOD

We conducted a case record study of 336 people referred to community services and 141 to secure provision. We gathered information on referral source, demographics, diagnosis, index behaviour, prior problem behaviours and history of abuse.

RESULTS

Comparisons revealed 19 candidate variables which were then entered into multivariate logistic regression. The resulting model retained six variables: community living at time of referral, physical aggression, being charged, referral from tertiary health care, diverse problem behaviour and IQ < 50, which correctly predicted the referral pathway for 85.7% of cases.

CONCLUSIONS

An index act of physical aggression and a history of diversity of problem behaviours as predictors against the likelihood of community service referral suggest that professionals have similar concerns about people with ID as they do about their more average offending peers; however, the more severe levels of ID mitigated in favour of community referral, regardless. Offenders with ID tend to be referred within levels of service rather than between them, for example, form tertiary services into generic community services.

Markers for aggression in inpatient treatment facilities for adults with mild to borderline intellectual disability

In high care settings for persons with intellectual disability (ID) aggressive incidents often occur. Still little is known about factors that are associated with an increased risk for aggressive behavior in clients who are admitted to an inpatient treatment facility. In four inpatient facilities, 108 adults with mild and borderline ID and behavior problems were categorised into three aggressive incidents groups (no, mild, severe) according to their actual aggressive behavior observed for six months. The three groups were compared with regard to background and admission characteristics, psychiatric co-morbidity and emotional and behavioral problems. Results show that antisocial behaviors, behaviors indicative of a lack of impulse control, psychotic behaviors, mood related behaviors, and auto-aggressive behavior increased the likelihood of severe aggression. The three groups did not differ with regard to client and admission characteristics or psychiatric co-morbidity. Behaviors that are predictive of severe inpatient aggression in settings for adults with mild to borderline ID and behavior problems closely resemble those that are distinguished in risk assessment instruments for forensic non-disabled individuals.

Clinical and Benefit—Cost Outcomes of Teaching a Mindfulness-Based Procedure to Adult Offenders With Intellectual Disabilities

The effects of a mindfulness-based procedure, called Meditation on the Soles of the Feet, were evaluated as a cognitive-behavioral intervention for physical aggression in 6 offenders with mild intellectual disabilities. They were taught a simple meditation technique that required them to shift their attention and awareness from the precursors of aggression to the soles of their feet, a neutral point on their body. Results showed that physical and verbal aggression decreased substantially, no Stat medication or physical restraint was required, and there were no staff or peer injuries. Benefit—cost analysis of lost days of work and cost of medical and rehabilitation because of injury caused by these individuals in both the 12 months prior to and following mindfulness-based training showed a 95.7% reduction in costs. This study suggests that this procedure may be a clinically effective and cost-effective method of enabling adult offenders with intellectual disabilities to control their aggression.

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.

Exploratory factor analysis and convergent validity of the Dundee Provocation Inventory

Background The prevalence and consequences of anger and aggression in people with intellectual disability (ID) are of great concern. It is essential that appropriate assessment tools are developed to aid formulation of treatments and to evaluate progress and outcomes. Method This study evaluates the Dundee Provocation Inventory (DPI), a 20-item assessment measure for anger provocation. A group of 114 participants were administered the DPI, and 62 of these were also administered the Novaco Anger Scale (NAS) and NAS Provocation Inventory (NAS-PI), two well-validated measures. Results Preliminary analysis revealed that the DPI correlated significantly with the NAS (r = .57) and NAS-PI (r = .77). The DPI had high internal consistency (alpha = .91) and moderate to high inter-item and item-to-total score correlations. Factor analysis revealed a 5-factor solution which accounted for 63% of the variance and was most easily interpreted. Conclusion The analysis suggests that the DPI is a suitable tool for assessing anger in people with ID. Further replication of the factor structure would be valuable.

Trends and challenges in forensic research on offenders with intellectual disability

BACKGROUND

The Journal of Intellectual & Developmental Disability has a well-respected history of establishing the parameters and contributing to developments in the field of offenders with intellectual disability (ID).

METHOD

The field has seen a number of developments over the past 15 years, and this paper identifies several trends that have emerged in the research during this period, including work on prevalence of ID in prison populations, development of risk assessment, consideration of staff issues, developing the psychometrics of offence-specific assessments, evaluating treatment methods, and testing the underlying theoretical frameworks which attempt to account for offending.

RESULTS AND CONCLUSIONS

We refer to a number of studies which have advanced these developments in the field and draw the reader's attention to the way in which papers in this special issue contribute to and further develop each of these research trends.

Forensic aspects in people with intellectual disabilities

PURPOSE OF REVIEW

The past few years have seen a growth in research of forensic issues relating to people with intellectual disabilities. This review examines a broad spectrum covering 2005 and 2006, for which articles are already available. Given the diversity of publications, reference will also be made to some of the main articles of 2004 to provide a context.

RECENT FINDINGS

We are now at the stage where people are questioning the existing forensic psychiatry evidence base for people with intellectual disabilities. This review examines the assessment and treatment of three different groups, that is, fire setters, sexual offenders and those with problems of anger and aggression along with service outcome research, the criminal justice system, and a round up of other related research.

SUMMARY

The growth of research in this area has aided the development of assessment and treatment instruments and treatment models for people with intellectual disabilities. This has helped to highlight the specialist and complex nature of this group. The review also looks at services from the point of delivery and the difficulty in research methodology and quantifying outcomes that take into account a changing society and current health inequalities.

Assessment in intellectual disability

PURPOSE OF REVIEW

This review examines an eclectic selection of publications from the past 12 months under the broad heading of 'assessment in intellectual disability'. Being unable to cover all possible publications the authors have concentrated on the assessment of pain (in those with severe intellectual disability), psychopathology, risk assessment and offending, autism, preference and choice, and dementia.

RECENT FINDINGS

Research into assessment has generally taken the form of developing new instruments, or adapting existing ones, or comparing the performance of a range of scales in a certain area. Researchers are using increasingly sophisticated psychometric analyses and refining the nature and purpose of tools for a range of clinical purposes.

SUMMARY

The result of recent effort in this area is better instruments, often developed by experienced researchers who have been working in their chosen area of speciality for some years. It has been a very worthwhile period of extension and consolidation.