Doctor, Is This Person Dangerous?

John Hinkley has been found not dangerous and is				treatment protocols. As with the other youth risk tools,
allowed over night family visits. Following his final				the CARE is based on the idea that the more risk
release from jail John Thanos brutally murdered 3				factors that an offender has, the greater his risk for
teenagers in two separate incidents. Every time I hear				recidivism. No one factor predicts youth violence. Each
a story like this one I feel anguish in the pit of my				additional factor increases the risk that a youth will be
stomach: Columbine, Jonesboro, Littleton, the Morrow				violent. The strongest predictors of past youth violence
Federal Building, the Unibomber, and many more. This				are: severity of past behavior problems, assault of an
doesn't have to be. Where along the way could these				authority figure, chronicity of past assaults, psychosis
sequences have been changed?				or self-harm, and inappropriate discipline by a caregiver.
Psychologists and psychiatrists are routinely asked by				Adult Violence Risk Assessment Tools
the Courts and Hospitals, "Doctor, is this person at risk				There have been four stages, thus far in the
for danger to himself or others?" We know that risk of				development of risk evaluation tools. The first
violence should be assessed separately from mental				generation of violence risk assessments
health issues. Consequently, traditional psychological				encompassed primarily clinical judgment supplemented
tests such as the MMPI- 2 (A), MACI, and MCMI-III are				by traditional psychological tests, such as the MMPI.
not intended to be risk tools and should not be used in				However, the MMPI was not intended to measure
that way. We also know from a decade of research				violence and should not be used in that way. Studies
the clinical judgment of future risk of violence based on				of the accuracy of mental health professionals using
interview alone is little better than chance. Fortunately,				unaided clinical judgment to estimate the risk of future
the technology to identify those at risk for future				violence have demonstrated that psychologists,
violence is developing rapidly. Research on risk				psychiatrists, social workers, and counselors make
evaluation tools has determined that we can improve				inaccurate predictions 80% of the time.
the prediction of future violence significantly over clinical				The second generation of tools used clinically derived
judgment by using tools developed from statistical				items that were subjected to statistical analysis. One
analysis of the traits of violent offenders.				such tool is the Psychopathic Checklist (PCL). The
Additionally, previous thinking has been that violence is				Psychopathic Checklist (Hare, 1995) is a clinically
not treatable. However, recent studies indicate that				oriented tool, based on a theoretical construct,
patterns of thinking and behaving can be substantially				Psychopathy. The items center on the behaviors and
changed, thus reducing a person's risk of committing a				personality characteristics associated with
violent act in the future. Once the level of risk is known,				psychopaths. During research, it was determined that
the level of supervision and type of treatment can also				the PCL was also significantly correlated with violent
be established. Rice, Harris and Quinsey (2002) stated,				offending and re-offending (r = .34 with past
"Risk assessments using empirically validated				aggression, r = .27 with future violence). There have
instruments can enhance public safety without				been many studies of the PCL and it is widely
increasing the number of individuals detained."				accepted as the "gold standard" in assessing
The Additive and Interactive Nature of Violence Risk				psychopathy, but not necessarily violence.
and Resiliency Factors				The Level of Service Inventory (LSI) is also a clinically
When the various social, psychological, biological, and				oriented tool used to determine the level of supervision
environmental factors have negative family, school, or				that an offender is likely to need. It is a combination of
community components, difficulty managing emotions,				clinical items and statistical analysis. The LSI is
lack of empathy, poor self-image, lower levels of				correlated .27 with new arrests and .43 with general
problem solving skill, and deficient social skills can be				recidivism. These are relatively weak to moderate
the result. The various social and skill factors that				correlations.
influence children and adults are interactive. There is a				The third generation of actuarial tools includes guided
threshold of higher numbers of negative factors				clinical judgment. These tools are more clinically based
(abuse, neglect, poor school performance, crime				and usually do not have formal scoring systems. There
delinquency) and low levels of positive factors				are some reliability and validity statistics that can be
(prosocial activities and friends, and positive future				found on these tools (HCR-20 and VRAG). These
goals) beyond which there is a greater risk for violent				tools are a combination of clinical items and statistical
behaviors to occur.				analysis. The correlation between the HCR-20 and
Risk Assessment Tools for Youth Violence and				past aggression is .44 to .52. The HCR has a guide to
Severe Behavior Problems				determine risk management procedures.
The completion of the risk assessment tool first				The fourth generation of tools uses clinical items,
requires that the clinician gather a complete				resiliency factors, and risk management plans. Dynamic
psychosocial history, based on record review, direct				risk factors can measure changes in skills that may
interviews with the child or adolescent, and interviews				help reduce recidivism and static factors are items that
with collateral informants such as parents, teachers,				do not change, such as an abuse history. These tools
therapists, social service agency workers, etc.				include the Adult RME (Seifert, unpublished manuscript).
(American Academy of Child and Adolescent				The RME Risk Management Evaluation) is a violence
Psychiatry; Rich, 2003). Each risk tool has				risk evaluation for adults. It was based on the CARE.
characteristics that are unique to that tool. By				The sample includes 250 males and females in an
comparing tools, a practitioner can determine which				outpatient mental health setting. Like the CARE, it uses
tool(s) are best suited to their needs and their				risk and resiliency factors and has a risk management
population(s). The tools listed here are not exhaustive,				planning tool. Studies have found that the risk factors
but include those most commonly used by				for adult violence are similar or the same as the risk
practitioners.				factors for youth violence (Rice, Harris, Quinsey, 2002).
The SAVRY (Borum, Bartel, Forth, 2002) and the				Consequently, the RME uses the same items as the
EARL-20B and Earl 21G (Augimeri, Webster, Koegl,				youth version, but after further research and analysis
Levene, 2001) are empirically-based, structured tools				the items have been re-worded and item weights
for guided clinical assessment. That is, the factors				have been changed to be appropriate for the adult
included in the tools are based on pertinent literature in				sample. Both static and dynamic factors, which the
the field, including published studies, and the instruments				research literature identified as being associated with
provide defined factors to be addressed and a				severe behavior problems and aggression were used
specific structure to be followed by the clinician				(Seifert, 2000; Quinsey, Harris, Rice, & Comier,
completing the evaluation (Rich, 2003). The PCL-YV				1998). Higher rates of violent recidivism and other
(Forth, Kosson, Hare, 1996) and the YLS-CMI (Hogue				offending behaviors are found when there are greater
and Andrews, 1996) have empirically based scoring				numbers of risk factors and fewer resiliency factors.
systems and cut off scores. The DVI (Behavior Data				Risk categories for the RME include 1) individual
Systems) is self-report and includes suggestions for				characteristics such as history of violence, poor anger
treatment as does the YLS/CMI.				management, psychosis, harming animals and enuresis;
The CARE (Seifert, 2003) is an easy to use tool for				2) peer interactions like bullying behaviors, and deviant
assessing the risk of youth violence and creating a				peer group; 3) work, school, and educational problems,
multifaceted case management plan. More than 900				such as lack of work success; 4) family
youth with ethnically diverse backgrounds are in the				characteristics, such as exposure to violence during
CARE sample. Their ages range from 2 through 19				childhood, and a history of harsh disciplinary practices.
years, over half had a history of assaults. The				School and or work success are examples of
participants were taken from all types of settings such				resiliency factors.
as residential, outpatient, and detention centers, a prison				Discussion and Conclusions
for young, violent offenders, as well as groups of				Risk of future violence is a very important forensic
youth and adults with mild or no problems. This sample				task. However, risk assessment is an emerging field.
group of clients was from a large geographical area of				Many tools are in the developmental or research
the United States East Coast and the Mid-West. The				stages. It is likely that several tools will be used
total CARE score was significantly correlated with the				simultaneously because each uses a slightly different
severity past of behavior problems. Significantly higher				risk perspective and may provide unique information.
CARE scores were seen in those with assaultive				Comparing tools allows a practitioner to choose the
histories and these youth were more likely to commit				tool that best suits his/her population and situation.
an assault within the next six months.				Once dangerousness is estimated, there are
The CARE assesses both risk and protective factors.				treatments, which if applied with sufficient intensity and
The significance of the development of a tool such as				length of time, can be effective in reducing future risk
the CARE is widespread and offers an opportunity for				of violence. It can also help with lesser security and
school, social service, criminal justice, and mental health				release determinations. We have the tools and they
professionals to access a reliable tool for determining				are widely used in Canada. They are finding more
the need for additional testing and for specific				acceptance in the US, as well.

Lapsi

Doctor, Is This Person Dangerous?