risk assessment in people with developmental disabilities and ...

“As long as a decision is based on the best evidence, 

information and clinical judgement available, it will be the 

best decision that can be made at the time.” 

(DOH, 2007) 

LD Spring One-Day Meeting 30/03/2012

DEFINITION OF RISK 

“A risk is a hazard that is incompletely understood and 

therefore can be forecast only with uncertainty.” 

� Incorporates notions of nature, severity, frequency, 

imminence and likelihood – not just probability of 

harm 

� Risk is context specific 

� Risk is never known, but estimated 

LD Spring One-Day Meeting 30/03/2012 

(Hart, Laws and Kropp, 2003)

ACTUARIAL APPROACH 

� Based on statistical calculations of the probability of 

an event (recidivism) occurring 

� Used only for risk predictions 

� Predominantly relies on static/historical risk factors 

� Meta-analytical studies (studies of large numbers of 

empirical research) used to identify base rates of 

offending and identify factors that are evidenced to be 

statistically predictive of recidivism 

� Comparison with standardised group 

� Fixed not dynamic 


STRUCTURED CLINICAL JUDGEMENT 

� Take into account static/historical information as well 

as dynamic risk factors which change over time and 

can be targeted in interventions. 

� Use risk factors that have been empirically evidenced 

to be related to offending behaviour 

� Can reflect the dynamic nature of risk and therefore 

can monitor progress over time 

� Explore risk management factors such as exposure to 

destabilisers and problems with planning and 

supervision; with the development of risk 

management plans integral to the process 


SPECIFIC RISK ASSESSMENTS FOR 

VIOLENCE ACTUARIAL 

� HARE PSYCHOPATHY CHECKLIST REVISED 

(PCL-R) Hare 1991 and 20012 

• 20 item rating scale 

• Semi structured interview and collateral information 

� PSYCHOPATHY CHECKLIST – SCREENING 

VERSION (PCL-SV) Hart, Cox, Hare, 1995 

• 12 item abbreviated tool to screen for possible presence 

of psychopathy 

• Suited for community samples 


� VIOLENT RISK APPRAISAL GUIDE – VRAG Quinsey, 

Harris, Rice, Cormier 1998 

• 12 item 

• Used clinical record particularly psycho-social history 

• Incorporates the Hare PCL-R score 

• Not available as stand alone 

� CLASSIFICATION OF VIOLENCE RISK – COVR – 

2005 


� SEX OFFENDER RISK APPRAISAL GUIDE – SORAG 

Quinsey, Harris, Rice, Cormier 1998 

� 14 item instrument 

� Modification of the VRAG 

� Risk of violent and sexual recidivism 

� Incorporates PCL-R scores 

� Not available as stand alone 


STRUCTURED CLINICAL GUIDES 

� HISTORICAL CLINICAL RISK 20 VERSION 2 (HCR- 

20) Webster, Douglas, Eaves and Hart 1997 

� 20 items and Hare PCL-R 

� 10 historical 

� 5 clinical 

� 5 risk management 

� Captures past present and future variables 

� Significant predictive value in detecting recidivist rates 

among violent offenders with mental health problems 


� SEXUAL VIOLENCE RISK – 20 (SVR-20) Boer, Hart, 

Kropp and Webster 1997) 

� 20 item 

� Assessment of violence risk in sex offenders 

• 11 items – psychosocial adjustment 

• 7 items – sexual offenders 

• 2 items – future plans 


� SAPROF – STRUCTURED ASSESSMENT OF PROTECTIVE 

FACTORS FOR VIOLENCE RISK 

Vivienne de Vogel et al 

� Creates a more balanced assessment of risk of future (sexual) 

violence 

� Creates opportunities for effective and achievable treatment 

interventions 

� Dynamic factors inform treatment goals, progress and risk 

communication 

� Retrospective research in Dutch samples of violent and sexually 

violent offenders showed good predictive validity for non 

recidivism 

� SAPROF scores showed significant improvements during 

treatment 

� Suitable for use with adults with intellectual disabilities 


� Structured clinical judgement checklist designed for 

use in combination with other structured risk 

assessment tools e.g. HCR-20 


adam.burgess@manchester.ac.uk

� START – SHORT TERM ASSESSMENT OF RISK AND 

TREATABILITY 2004, 2006 Webster et al 

� Structured clinical judgement guideline 

� Covers risk to others, suicide, self harm, self neglect, 

substance misuse, unauthorised leave and victimisation 

� 20 specific items – strength and risks 

� Covers multiple risk domains 

� 2008 implementation study adult forensic MSU 

recommended addition of risk history and clarification 

to distinguish long term and acute risk 


� IRMP – INDIVIDUAL RISK MITIGATION PROCESS 

CALDERSTONES PARTNERSHIP NHS FOUNDATION TRUST 

� For use in secure and community services 

� Regional pilot 2010 for six months 

� 13 categories plus individual ‘custom’ risk 

� Considers vulnerability as well as risk to others 

� Rates current and historical risks 

� Harm to self 

� Self injury, suicide 

� Vulnerability to physical assault/sexual exploitation/ financial 

exploitation 

� Substance misuse, self neglect 

Contd…… 


CONTINUED…. 

� IRMP – INDIVIDUAL RISK MITIGATION PROCESS 

CALDERSTONES PARTNERSHIP NHS FOUNDATION TRUST 

� Harm to others 

� Violence/aggression, sexual violence, arson and fire setting, theft 

and robbery 

� Organisational risk 

� Damage to property 

� Going missing 

� Custom risks 

� Individual unique risks e.g. making allegations 

� Complete risk mitigation form – triggers, risk management 

strategies and interventions 


THE PURPOSE OF RISK PROFILE 

TO ASSESS THE LIKELIHOOD OF RISK EVENTS OCCURRING 

� To promote collaborative working with the MDT and 

individual around risk issues 

� Work with the individual, carers etc to identify ways of 

reducing risk events occurring 

� To promote positive risk taking in line with person centred 

approaches 

� To identify trigger factors 

� To promote risks and management over time 


BEST PRACTICE IN MANAGING RISK 

� Make decisions based on knowledge 

� Risk management that is part of a constructed plan 

� Collaborative 

� Good management should aim to prevent and reduce harm 

� Include formulation 

� Focus on individual’s strengths and recovery 

� Communicate to relevant others 

� Regular reviews 


BOUNDED RATIONALITY 

Gigerenzer et al 1999 

Bounded rationality assumes that humans are not 

completely rational in their decision making and that 

this can be adaptive. 

For example, it may have greater utility to make a 

decision on less information rather than expend time 

and energy on accumulating more information of 

marginal utility 


ROYAL COLLEGE REPORT CRISO 

MARCH 2008 

� Risk assessment needs to be put in its place as an imperfect tool which 

vast amounts of research have not improved very much over the years 

(ID 452) 

� ‘Tick box’ mentality ignores dynamic risk factors 

� Different tools for different purposes 

� HCR-20 useful in forensic psychiatry 

� Unsuitable for children (Subotsky 2003) 

� Unsuitable for adults with intellectual disabilities (Bradley & Lofchy 

2005) 

� Link assessment of needs with risk assessment 


Contd…

Continued… 

ROYAL COLLEGE REPORT CRISO 

MARCH 2008 

� Involvement of service users, families and carers 

� Seamless relationship between risk assessment and risk 

management 

� Useful adjunct to good clinical practice 

� No existing tool is suitable for all circumstances 

� College recommends Trusts phase out local forms without 

scientific evidentiary basis 


THE RISKS OF RISK ASSESSMENT 

ADVANCES IN PSYCHIATRIC TREATMENT 

13, 4, 291-298, Guy Undrill – July 2007 

� A risk assessment is often a subjective, plastic and context 

dependent statement about a patient that carries strong 

moral overtones. 

� Uncertainty about the future is impossible to eliminate 

� Risk of getting it wrong 

� Assessor minimises anxiety in a rationally selfish way 


Continued…. 

THE RISKS OF RISK ASSESSMENT 

ADVANCES IN PSYCHIATRIC TREATMENT 13, 4, 291-298, 

Guy Undrill – July 2007 

� 5 definitions of risk 

� Risk as chance – synonym for odds/lottery 

� Risk as belief – subjective probability 

� Risk as danger/hazard 

� Risk as unacceptable danger/hazard 

� Risk as combined measure of chance/belief and 

impact/probability and impact 


REDUCING RISKS OF RISK 

ASSESSMENT 

� Continue research to develop better quality risk assessment 

tools 

� Protecting the patient protects the staff 

� focus on risks faced by the patient 

� patient and clinician strive for common language and goals 

� Share risk assessments with patients 

� Provision of a safe setting for trust and therapeutic 

closeness 


Continued… 

REDUCING RISKS OF RISK ASSESSMENT 

� Bounded rationality assumes humans are not completely 

rational in decision making which can be adaptive 

� Institutional anxiety often impaired by risk assessment. 

Containment of patient anxiety necessitates containment 

of staff anxiety 

� Clinical supervision of staff seen as a priority to manage 

patient risk 


THE KEEPING ME SAFE AND WELL SCREEN 

Lee, Kaur, Cookson and Greenhill, 2008 

� A human rights based approach to multi-disciplinary 

risk assessment 

� Takes into account service users’ views

risk assessment in people with developmental disabilities and ...

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