Understanding the risk factors for violence and criminality in women: the concurrent validity of the PCL-R and HCR-20

This study explores the performance of 132 female maximum-security inmates on the Psychopathy Checklist-Revised (PCL-R) and the HCR-20 (Historical, Clinical, and Risk Management Scheme) to examine the concordance between these two risk assessment instruments, and to assess their potential usefulness in determining level of risk for violent behavior and other forms of criminality. The two instruments demonstrated consistent and highly significant correlations across total scores, factor scores, and subscale scores. When the two instruments were entered into a multiple regression analysis to predict violent and non-violent crime, the HCR-20 did not add to the variance explained by the PCL-R. These results confirm earlier research that suggests that there is little or no difference between these two risk assessment instruments in their relationship to community or institutional violence. Further, Receiver Operating Characteristics (ROC) analyses show that both instruments demonstrated an inverse ability to predict convictions for murder, a close to chance ability to predict violent crime, but a shared ability to predict property and minor crime. Broadly, these results suggest that psychopathic women are involved in chronic patterns of non-violent criminality, while women charged and convicted of murder generally do not have elevated scores on the PCL-R or HCR-20. The relevance of these findings to rehabilitation and treatment is discussed.     

Violence risk profile of medium- and high-security NGRI offenders in Belgium

Under Belgian law, offenders not guilty by reason of insanity (NGRI) are committed by the courts to forensic mental health treatment. The use of violence risk assessment tools has become routine in these settings. However, there are no national statistics regarding violence risk assessment in the Belgian forensic population. A study was undertaken to collect risk assessment data (PCL-R, VRAG, HCR-20) on a large cohort of forensic patients committed to Medium Security units in the Flanders region and in High-Security units in the Walloon region. Flemish patients were expected to present a lower risk compared with their Walloon counterparts. Instead, data yielded by a structured risk assessment method demonstrate the opposite. Moreover, the majority of patients in Flemish facilities had committed violent offenses and were institutionalized for shorter periods whereas the majority of Walloon patients had committed sexual offenses and were institutionalized for markedly longer periods.     

Prediction of violent and sexual offences: A replication study of the VRAG in Switzerland

Abstract

The Violence Risk Appraisal Guide (VRAG) is a widely used actuarial risk assessment instrument and has been validated in different countries. However, there is no investigation supporting the predictive accuracy of the VRAG in the German language area. The VRAG scores of 79 violent and sexual offenders in Switzerland were assessed based on data from their psychiatric expert opinions. The VRAG scores were compared to subsequent recidivism as shown in the official criminal records. Consistent with past research in the English language area, the VRAG yielded a satisfying predictive accuracy (ROC area = .73), demonstrating its usefulness for risk assessment of violent delinquency in the Swiss cultural and German language area.     

Applying a forensic actuarial assessment (the Violence Risk Appraisal Guide) to nonforensic patients

The actuarial Violence Risk Appraisal Guide (VRAG) was developed for male offenders where it has shown excellent replicability in many new forensic samples using officially recorded outcomes. Clinicians also make decisions, however, about the risk of interpersonal violence posed by nonforensic psychiatric patients of both sexes. Could an actuarial risk assessment developed for male forensic populations be used for a broader clientele? We modified the VRAG to permit evaluation using data from the MacArthur Violence Risk Assessment Study that included nonforensic male and female patients and primarily self-reported violence. The modified VRAG yielded a large effect size in the prediction of dichotomous postdischarge severe violence over 20 and 50 weeks. Accuracy of VRAG predictions was unrelated to sex. The results provide evidence about the robustness of comprehensive actuarial risk assessments and the generality of the personal factors that underlie violent behavior.     

Assessing change in dynamic risk factors in forensic psychiatric inpatients: relationship with psychopathy and recidivism

This study explored change in dynamic risk for violence using the Clinical and Risk Management subscales of the Historical Clinical and Risk Management-20 version 3 (HCR-20 v3) and sought to determine whether change was associated with violent recidivism. The association between the magnitude of change and psychopathy was also assessed. Participants were 40 male (n = 32) and female (n = 8) forensic psychiatric inpatients discharged from a secure forensic mental health service. Results showed that participants significantly improved on the HCR-20v3 Clinical subscale but significantly worsened on the Risk Management subscale. Psychopathy was unrelated to change in Clinical and Risk Management subscales. The hypothesis that changes in dynamic risk would predict recidivism over and above total pre-treatment risk (HCR-20v3 Total score) and psychopathy was not supported. These results suggest that improvements in mental state risk factors alone are insufficient with regard to lowering violence risk.     

HCR-20 violence risk assessments as a guide for treating and managing violence risk in a forensic psychiatric setting

Abstract

Over the past decades there has been a vast development in the research into risk factors for violence and the development of risk assessment instruments. One instrument that has been given special attention is the HCR-20 violence risk assessment scheme. However, little attention has been paid to the clinical applicability of this tool, i.e. how does this assessment scheme perform when utilized in clinical practice as a tool to guide intervention and management in order to alleviate risk of violent behaviour? The present study was a true prospective study into the utilization of the HCR-20 as a clinical routine. Data on forensic psychiatric patients (n = 81) from a forensic unit in Denmark are presented. As part of a clinical routine all patients were assessed for risk of future violence utilizing the structured professional judgement model, the HCR-20. Outcome measures were aggressive episodes during hospitalization and new convictions post discharge. The predictive validity of the HCR-20 was lower compared with previous findings. It is argued that this does not necessarily indicate poor predictive accuracy of the HCR-20. Rather, it may indicate that the HCR-20 is suitable for guiding risk management in order to prevent violent behaviour.     

A Comparative Test of Clinical Judgment Versus Actuarial Prediction of Future Violence

This study tested how graduate level psychology graduate students (n = 20) using the Adapted Violence Risk Appraisal Guide (Adapted VRAG) would do relative to practicing psychologists/psychiatrists (n = 16) using clinical judgment when predicting violence in 10 narratives from the MacArthur Violence Risk Assessment study (Monahan et al., The MacArthur violence risk assessment study. . Retrieved 10 Oct 2005). Results indicated that the practicing psychologists/psychiatrists made significantly more correct predictions than the master’s level students. The professional group demonstrated sensitivity levels of 77.7% and specificity of 96.3%. For the use of the adapted VRAG method by the graduate student group, specificity levels were modest at 54.0%. Sensitivity levels, however, were lower than earlier demonstrated levels at 58.0%. These findings are at variance with earlier reports comparing clinical and actuarial methods. The results may reflect the short amount of time the master’s level students were trained using the Adapted VRAG as well as the small number of participants in this study. Additional research comparing other professions is recommended, as well as examining if experience in the forensics field would affect one’s ability to predict violence.     

Validity and reliability of the VRAG in a forensic psychiatric medium security population in Flanders

Since the development of the Violence Risk Appraisal Guide (VRAG), one of the most widely used actuarial risk assessment instruments, numerous replication studies have shown its usefulness in predicting (violent) recidivism among various offender populations. It is not clear, however, whether these findings can be generalized to forensic psychiatric patients admitted to a medium security forensic psychiatric unit in the Flemish part of Belgium. Therefore, the main aim of this study was to test the predictive validity and reliability of the VRAG in a sample of 191 Flemish medium security patients. The mean follow-up period was 2.4 years. Contrary to the expectations, the VRAG was unable to significantly predict any kind of outcome. Possible explanations are discussed and further research with the VRAG in Flanders, and its recently revised version, is recommended.     

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.     

Characteristics and offences of women with borderline personality disorder in forensic psychiatry: a multicentre study

Although female forensic patients diagnosed with borderline personality disorder (BPD) are generally considered taxing in clinical practice, little is known about their specific characteristics or offences. In this study, 156 female forensic psychiatric patients diagnosed with BPD were compared to 113 diagnosed otherwise. Information on demographic and psychiatric characteristics, victimization, index offences, and incidents during treatment was gathered from patient files. Risk factors for recidivism were assessed using the PCL-R and historical items of the HCR-20, including items from the new Female Additional Manual (FAM). Compared to non-BPD women, BPD women were more likely to have been abused as children and to have a history of outpatient treatment. While less likely to be convicted for (attempted) homicide, a higher percentage of BPD women was convicted for arson. Comorbid substance abuse was more frequent in the BPD group and incidents towards others and themselves were more violent in nature. The PCL-R and the H-scale of the HCR-20/FAM indicated several risk factors especially important for BPD women, such as poor behavioural control, impulsivity, and irresponsibility. The results support the clinical impression that women diagnosed with BPD are a subgroup within the female forensic psychiatric population, with specific focus points for treatment and management.     

Field validity of the HCR-20 in forensic medium security units in Flanders

Structured risk assessment has become a part of routine practice in forensic settings. However, little attention has been paid to the clinical applicability of existing tools. The present research focused on the performance of the Historical Clinical Risk Management-20 (HCR-20) – one of the most commonly used tools for structured professional judgment – in the daily practice of three medium security units in Flanders. Areas under the curve for the prediction of violent recidivism during (N?=?168) and after (N?=?105) medium security treatment were non-significant. In addition, analyses showed that the HCR-20 was mainly of interest in identifying low-risk individuals. Further research measuring different aspects of predictive validity in applied settings is recommended.     

An Indepth Actuarial Assessment for Wife Assault Recidivism: The <Emphasis Type="Italic">Domestic Violence Risk Appraisal Guide</Emphasis>

An actuarial tool, the Ontario Domestic Assault Risk Assessment (ODARA), predicts recidivism using only variables readily obtained by frontline police officers. Correctional settings permit more comprehensive assessments. In a subset of ODARA construction and cross-validation cases, 303 men with a police record for wife assault and a correctional system file, the VRAG, SARA, Danger Assessment, and DVSI also predicted recidivism, but the Hare Psychopathy Checklist (PCL-R) best improved prediction of recidivism, occurrence, frequency, severity, injury, and charges. In 346 new cases, ODARA and PCL-R independently predicted recidivism. An algorithm was derived for a combined instrument, the Domestic Violence Risk Appraisal Guide (DVRAG), and an experience table is presented (N=649). Results indicated the importance of antisociality in wife assault.     

A Comparison of Logistic Regression,Classification and Regression Tree,and Neural Networks Models in Predicting Violent Re-Offending

Previous studies that have compared logistic regression (LR), classification and regression tree (CART), and neural networks (NNs) models for their predictive validity have shown inconsistent results in demonstrating superiority of any one model. The three models were tested in a prospective sample of 1225 UK male prisoners followed up for a mean of 3.31 years after release. Items in a widely-used risk assessment instrument (the Historical, Clinical, Risk Management-20, or HCR-20) were used as predictors and violent reconvictions as outcome. Multi-validation procedure was used to reduce sampling error in reporting the predictive accuracy. The low base rate was controlled by using different measures in the three models to minimize prediction error and achieve a more balanced classification. Overall accuracy of the three models varied between 0.59 and 0.67, with an overall AUC range of 0.65–0.72. Although the performance of NNs was slightly better than that of LR and CART models, it did not demonstrate a significant improvement.     

Using the Violence Risk Appraisal Guide (VRAG) to predict in-prison aggressive behavior in a Swiss offender population

The present study is a first-time evaluation of the Violence Risk Appraisal Guide's (VRAG) predictive quality for institutional violence in a German-speaking country. The VRAG was assessed for 106 violent and sexual offenders based on their files. Violent infractions during imprisonment were evaluated using the files of the state penitentiary. Results show in accordance with previous studies only a moderate effect between VRAG scores and institutional misconduct. However, these findings were only significant for participants with a sex crime as index offense. In the study, the VRAG was unable to predict verbal and physical violence by violent offenders. The implications of these findings for institutional risk management and the future development of intramural detection of participants at risk in the German-speaking part of Europe are discussed.     

Risk assessment and offender victim relationship in juvenile offenders

The present study compares the Historical, Clinical, and Risk Management-20 (HCR-20) checklist in a male offender population of 108 adolescents using the relationship between the offender and the victim as a classification factor. Two types of relationship were retained for comparison purposes: family victim/known victim and unknown victim. All adolescents admitted to the Adolescent program of Montréal's Philippe-Pinel Institute from February 1998 to April 2003 were assessed and their families were met. The HCR-20 checklist was completed for each adolescent. Statistically significant differences were observed for the mean rank of the total score of the HCR-20 and two sub-scales, the historical subscale (H) and the risk management subscale (R). The results indicate that the adolescents who victimize strangers have more violent risk factors compared to those who victimize family/known victims. These results have important implications regarding prevention and treatment.     

Examining the Role of Static and Dynamic Risk Factors in the Prediction of Inpatient Violence: Variable- and Person-Focused Analyses

Although the construct of psychopathy is related to community violence and recidivism in various populations, empirical evidence suggests that its association with institutional aggression is weak at best. The current study examined, via both variable-level and group-level analyses, the relationship between standard violence risk instruments, which included a measure of psychopathy, and institutional violence. Additionally, the incremental validity of dynamic risk factors also was examined. The results suggest that PCL-R was only weakly related to institutional aggression and only then when the behavioral (Factor 2) aspects of the construct were examined. The clinical and risk management scales on the HCR-20, impulsivity, anger, and psychiatric symptoms all were useful in identifying patients at risk for exhibiting institutional aggression. These data suggest that factors other than psychopathy, including dynamic risk factors, may be most useful in identifying forensic patients at higher risk for exhibiting aggression.     

Predictors of sex offender treatment dropout: psychopathy,sex offender risk,and responsivity implications

Abstract

We examined sex offender treatment dropout predictors, in particular, the relationship of psychopathy and sex offender risk to treatment dropout in a sample of 154 federally incarcerated sex offenders treated in a high intensity sex offender treatment program. Demographic, criminal history, mental health and treatment-related data as well as data on risk assessment measures including the Static 99, Violence Risk Scale – Sexual Offender version (VRS-SO), and Psychopathy Checklist – Revised (PCL-R) were collected. Logistic regression and discriminant function analyses were used to identify predictors that made significant and unique contributions to dropout among all the variables under study. The Emotional facet of Factor 1 of the PCL-R and never being married were found to be the most salient predictors of treatment dropout and correctly identified about 70% of the cases. The implications of the findings for managing treatment dropout and for the treatment of psychopathic offenders are discussed.     

The Impact of Confidence on the Accuracy of Structured Professional and Actuarial Violence Risk Judgments in a Sample of Forensic Psychiatric Patients

Some previous research indicates that confidence affects the accuracy of probabilistic clinical ratings of risk for violence among civil psychiatric inpatients. The current study investigated the impact of confidence on actuarial and structured professional risk assessments, in a forensic psychiatric population, using community violence as the outcome criteria. Raters completed the HCR-20 violence risk assessment scheme for a sample of 100 forensic psychiatric patients. Results showed that accuracy of both actuarial judgments (HCR-20 total scores) and structured professional judgments (of low, moderate, and high risk) were substantially more accurate when raters were more confident about their judgments. Findings suggest that confidence of ratings should be studied as a potentially important mediator of structured professional and actuarial risk judgments.     

The PCL-R and violent recidivism in a prospective follow-up of a nationwide sample of female offenders

Psychopathy has been linked to violent reoffending in men, but the findings in women have been contradictory. The aim of this study was to examine the predictive validity of the Psychopathy Checklist-Revised (PCL-R) for violent recidivism in a nationwide sample of female violent offenders. The offenders (n = 48) had been assessed by the PCL-R and were followed after their release from prison or a psychiatric hospital. The average follow-up period was 8 years. Of the offenders, 16 (33%) had been reconvicted of a violent crime. Current findings of the performance indicators did not support the use of the PCL-R as a predictive instrument assessing risk of violent recidivism in females. The findings indicate that impulsivity plays a crucial role in female violent recidivism and that the PCL-R should be used with caution in risk assessment with female populations.     

Prospective Replication of the Violence Risk Appraisal Guide in Predicting Violent Recidivism Among Forensic Patients

An exhaustive survey of a cohort of forensic patients provided an opportunity for a prospective replication of the predictive accuracy of the Violence Risk Appraisal Guide (VRAG). Data collected during the original survey also permitted a test of the predictive accuracy of clinical assessments of risk on the same cohort. The VRAG yielded a large effect size in predicting violent recidivism (ROC area = .80) over a constant 5-year follow-up and performed significantly better than averaged clinical opinions. The superiority of the VRAG was also observed at very short follow-up times and for very serious violence. Moreover, for 16 subsamples, observed rates of violent recidivism did not differ significantly from the expected rates. VRAG score was unrelated, and clinical judgments inversely related to violent recidivism in the small low-risk sample of female forensic patients. The authors conclude that, regardless of length of opportunity or severity of outcome, actuarial methods are more accurate than is clinical judgment.