Forensic Risk Assessment in Intellectual Disabilities: The Evidence Base and Current Practice in One...

Forensic Risk Assessment in IntellectualDisabilities: The Evidence Base andCurrent Practice in One English Region

Stephen TurnerCentre for Social Research on Dementia, Department of Applied Social Science,

University of Stirling, Stirling, FK9 4LA, and Hester Adrian Research Centre, University of

Manchester, Oxford Road, Manchester M13 9 PL, UK

Paper accepted July 2000

The growing interest in forensic risk assessment in intellectual disability services re¯ects the

perception that deinstitutionalization has exposed more people to a greater risk of offending.

However, `risk' and the related idea of `dangerousness' are problematic concepts because of

connotations of dichotomous de®nition, stability and predictability. Assessment instruments in

mainstream forensic psychiatry often combine actuarial and clinical data, and increasingly

stress the dynamic nature of risk as well as the importance of situational and accidental trig-

gers. Despite this increasing sophistication of research in mainstream forensic psychiatry, the

ability to predict future offending behaviour remains very limited. Furthermore, actuarial pre-

dictors developed in studies of psychiatric or prison populations may not be valid for indivi-

duals with intellectual disabilities. Offending behaviour among people with intellectual

disabilities is also hard to circumscribe because it often does not invoke full legal process or

even reporting to the police. In order to discover how such problems were re¯ected in practice,

a survey of providers in the North-west Region of England was undertaken. Seventy out of 106

providers identi®ed as possibly relevant to this inquiry responded to a short postal question-

naire. Twenty-nine (42%) respondents ± mainly in the statutory sector ± reported operating a

risk assessment policy relating to offending. The number of risk assessments completed in the

previous year varied from none to `several hundred'. Providers reported three main kinds of

problems: (1) resources or service con®guration; (2) interagency or interdisciplinary cooperation

or coordination; and (3) issues relating to the effectiveness, design and content of assessment.

Introduction

The present paper brie¯y reviews the research base for forensic risk assessment relating

to intellectual disabilities and then presents the results of a survey of providers in one

English region. The increasing interest in techniques of risk assessment has arisen lar-

gely from the need for the new patterns of community services to take on the responsi-

bilities for public safety once entrusted to the institutions. The transfer of

responsibilities was also perceived to be accompanied by an increase in risk. The report

of the committee set up to review health and social services for offenders with mental

disorders and others requiring similar services (The Reed Report) cites evidence that

`one effect of contemporary service patterns was to expose more of the intellectually

disabled population to the risk of offending' (DoH/Home Of®ce 1992, paragraph 4.3,

p. 29). Service providers have come under increasing pressure to measure and control

these risks. However, the forensic and research literature indicates that there are both

= 2000 BILD Publications 239

Journal of Applied Research in Intellectual Disabilities 2000, 13, 239±255

conceptual and measurement problems relating to `risk' and the related concept of

`dangerousness'.

Risk and dangerousness

Pollock & Webster (1990) pointed out that legal and clinical concepts of risk and dan-

gerousness are very different. They argued that the lawyer's question `Will he do it

again?' is:

`From a scienti®c view . . . impossible to answer since it is based on an unscienti®c

assumption about dangerousness, namely that it is a stable and consistent quality exist-

ing within the individual.' (Pollock & Webster 1990, p. 493)

On the other hand, theories of personality would argue that all behaviour is a result

of complex interactions between environmental and personal factors, implying that

de®nitive judgements of dangerousness are rarely achievable. Therefore, Pollock &

Webster (1990) argued that it is preferable to examine the psychological, social and bio-

logical factors in¯uencing behaviour, and thus, the implications for future behaviour

and for change. This view is supported by the Royal College of Psychiatrists (RCP) in

Council Report CR 53 (RCP 1996), which emphasizes that risk cannot be eliminated or

outcomes guaranteed, and that risk is dynamic and may change over brief periods of

time.

Walker (1991) argued that risk and dangerousness are not unconditional attributes,

and posited a four-fold typology to clarify this. He termed the ®rst two types of risk

`conditional dangerousness', covering situations (1) where bad luck gives rise to provo-

cation or temptation and (2) where an individual seeks out such circumstances by

choice. Type 3 is where an individual is constantly on the look out for opportunities to

offend and type 4 is where the individual actually contrives to bring about the oppor-

tunity. These last two types of situation were termed `unconditionally dangerous' by

the above author. Walker (1991) went on to criticize actuarial estimates of dangerous-

ness and recidivism, and policies which place undue con®dence on our ability to pre-

dict future behaviour.

In respect to the reaction of authority to risk, Davis (1995) identi®ed two approaches:

(1) risk minimization and (2) risk-taking. Risk minimization is characterized as invol-

ving a narrow de®nition of risk (i.e. serious violence) and a focus on a small minority

of `high risk' individuals identi®ed through a combination of psychiatric symptoms,

past behaviours, legal status and service positioning. In this approach, risk is assessed

by clinical interview matched with risk factors derived from clinical or forensic psy-

chiatry. Risk issues as these affect the majority of service users are not considered. This

approach is also resource driven, attempting to contain costs and limit service utiliza-

tion (Borum 1996).

On the other hand, the risk-taking approach is rooted in normalization theory. It

emphasizes the individual's rights, and that risk-taking is an essential element in work-

ing with service users to avoid dependency, passivity and incompetence (Manthorpe &

Walsh 1997). The procedure also highlights risks relating to service use. In this

approach, the quality of risk work is linked directly to the establishment of relation-

ships of trust and empathy, and requires a strong system of organizational supervision

and support (Davis 1995). Tension may occur when different organizations or profes-

sions work to different approaches ± typically, the administrative and criminal justice

systems stressing risk minimization, and social work or therapeutic professions stres-

sing the bene®ts of risk-taking (Halstead 1997).

240 Journal of Applied Research in Intellectual Disabilities

= 2000 BILD Publications, Journal of Applied Research in Intellectual Disabilities, 13, 239±255

Risk assessment

The purpose of risk assessment has been described as:

`The prevention of vulnerability, namely taking care not to place the offender/offen-

der-patient in a situation in which he or she may be highly likely to re-enact the pre-

vious pattern(s) of dangerous conduct.' (Prins 1996, p. 50)

Department of Health guidance on the assessment of mentally ill offenders suggests

that assessment should be based on: evidence and clinical opinion on the past history

of the patient; self-reporting of the patient at interview; observation of her or his beha-

viour and mental state; discrepancies between reports and observation; and statistics

derived from studies of related cases and prediction indicators derived from research

(DoH 1994).

It has been argued that there are currently three serious de®cits in the ®eld of risk

assessment. Firstly, research on the prediction of violence on one hand and clinical

practice of assessment on the other have remained unconnected (Webster et al. 1995).

Secondly, the accuracy of any systematic method of risk assessment, whether short- or

long-term, in inpatient or community settings, or for particular categories of prisoners,

clients or patients, has yet to be established (Litwack et al. 1993; Mossman 1994; Otto

1994). In particular, there is evidence that clinical judgement is a poor predictor of

future offending, with no obvious advantages over actuarial methods or assessments

by non-clinical care staff (Mossman 1994). Thirdly, assessment validation research is

almost exclusively concerned with psychiatric offenders or patients, and not with those

with intellectual disabilities (Day 1990; Clare & Murphy 1998).

The state of the art in forensic risk assessment development in mainstream psychia-

try is probably best represented by the MacArthur Foundation Risk Assessment Study

(Monahan & Steadman 1994). This study incorporates many methodological and

design re®nements based on critiques of earlier work. It examines risk factors in four

domains: (1) dispositional (e.g. demographic, personality and cognitive factors); (2) his-

torical (e.g. prior hospitalization and treatment compliance, social history, and a history

of criminal and violent behaviour); (3) contextual (e.g. perceived stress, social support

and means for violence); and (4) clinical (e.g. diagnosis, symptom pro®le, functioning

and substance abuse). The above study has developed or re®ned measures of risk fac-

tors within these domains, including social support, anger and psychopathy. It makes

distinctions in the level of seriousness and the type of victim (e.g. spouse, child or

stranger). Information on outcome comes from face-to-face interviews with subjects,

independent interviews with someone said by the informant to be knowledgeable

about her or his actions, police reports, and mental hospital records. This use of multi-

ple sources of information has resulted in a much higher base rate of violence than in

studies which rely on arrest statistics alone (Monahan & Steadman 1994). More recent

®ndings place a new emphasis on neighbourhood context for risk of violence, which

has been reported to predict violence over and above individual characteristics (Silver

et al. 1999).

Offending and intellectual disability

Assessment of risk must be informed by evidence on the prevalence and nature of the

risks under consideration (Webster & Eaves 1995). This is a particularly dif®cult chal-

lenge in relation to people with intellectual disabilities. Studies by Kiernan & Alborz


241Journal of Applied Research in Intellectual Disabilities

(1991), Lyall et al. (1995a) and Clare & Murphy (1998) have indicated that, where there

is contact between an alleged offender and the intellectual disability services, the level

of reported offending, even of offences as serious as rape, is likely to be suppressed.

Staff may be reluctant to involve the police, courts may re¯ect an attitude that the per-

son is already in care, and the police may feel that conviction on evidence from other

service users will be problematic (Lyall et al. 1995b). Such issues of recognition and evi-

dence may be particularly relevant in relation to sexual offences (Thompson 1997). In a

review of the literature on sexual offending among men with intellectual disabilities,

Thompson & Brown (1997) concluded that there are dif®culties in making a judgement

about whether such offences are more common in this group than among other men.

Staff attitudes towards offending, and therefore its apparent prevalence, may vary by

service setting (Kemshall & Pritchard 1995; Wilson et al. 1996). The level of intellectual

disability may also be relevant to any attempt to de®ne prevalence: Kiernan & Alborz

(1991) pointed out that psychometric assessment of intellectual disability is particularly

unreliable in borderline cases, and such individuals may refuse or be denied registra-

tion with learning disability service providers, with the result that their learning dis-

ability goes unrecognized.

What evidence there is on the nature of offences among people with intellectual dis-

abilities suggests that: sexual misconduct may be more common (but relatively less ser-

ious), with other people with learning disabilities as the most common victims

(Thompson 1997); alcohol- and drug-related problems are less common; and physical

violence is less common, at least among men, compared with the general population

(Koller et al. 1982; Day 1990). Day (1990) concluded that the most common offences are

petty theft, burglary and vandalism. Kiernan & Alborz (1991) also concluded that

property offences are the most common type of offence committed by those on hospital

orders (as in the general prison population). Arson may be over-represented among

male offenders with intellectual disabilities (Day 1990; Kiernan & Alborz 1991; Murphy

& Clare 1996).

With regard to predictors of offending, there may be suf®cient evidence to draw

three general conclusions with which to guide the content and focus of assessment.

Firstly, previous behaviour predicts future behaviour, although there is evidence that

different offences have different recidivism rates (Payne et al. 1974; Gibbens & Robert-

son 1983a, b). Secondly, there is some evidence that offences are more likely to be com-

mitted by those with milder intellectual disabilities (Kiernan & Dixon 1995; Thomas &

Singh 1995), although this may well re¯ect their capacity to be involved in the legal

system as much as any increased propensity to offend. Thirdly, offending appears to

be more likely where there is also psychiatric disorder, particularly where compliance

with treatment is poor, and adverse psycho-social factors, such as behaviour problems

in childhood, or unstable and ®nancially disadvantaged backgrounds (Day 1990; Lina-

ker 1994; Clare & Murphy 1998). Such evidence suggests that there are similarities in

predictors of offending among people with intellectual disabilities and those identi®ed

in mainstream forensic psychiatry by researchers such as Monahan & Steadman (1994)

in the MacArthur Foundation studies.

Method

In order to investigate the extent to which systematic risk assessment was conducted

among service providers in one English Region, a postal survey was distributed



among statutory and independent sector organizations thought to provide services for

people with learning disabilities. A two-page questionnaire was designed, containing

eight speci®c questions concerning current policy and practice, and three open-ended

prompts for comments, problems and suggestions in relation to risk assessment and

offending. The questionnaire was sent to 106 organizations thought to be providers of

learning disability services. Out of the 106 services, 61 (58%) were statutory sector pro-

viders [24 social services departments, 18 community or priority health trusts, 16 other

National Health Service (NHS) trusts, and three joint services; and 45 (42%) were

voluntary sector providers. These contacts were provided by the North-west Regional

Of®ce of the NHS Executive and the North-west Training and Development Group.

Reminders were sent to non-respondents after approximately one month.

Results

Seventy providers responded: 46 statutory sector organizations and 24 independent

sector providers. This represents a response rate of 66% of the 106 apparently eligible

contacts. The response rate was higher for statutory sector providers (71%) than for

independent sector providers (53%). It is possible that some voluntary organizations

did not respond because they were not in fact providers of relevant services. Within

the statutory sector, response rates were 58% for social services contacts, 72% for com-

munity health trusts, 81% for other NHS Trusts and 100% for the three joint services.

This indicates some bias towards health service providers and possibly towards the

statutory sector in general. Fifty-three respondents supplied additional comments or

suggestions, and 18 included documentation relating to their risk assessment policy or

procedures.

Current practice in risk assessment

Twenty-nine (41%) out of the 70 responding providers replied positively to the ques-

tion, `Has your organization developed any guidelines, protocol or policy by which the

risk of offending and/or the level of dangerousness of individual learning disability

service users is assessed/reviewed?' These policy developments were more common

among statutory providers: 22 (48%) reported they had such a policy, compared with

seven (29%) independent sector providers. Another 19 (27%) of the providers (11 statu-

tory and eight independent) said that plans to develop policies or guidelines were in

progress. Thus, two-thirds of respondents said policies were either in place or being

planned. However, it is possible that non-responders were less likely to have such poli-

cies or plans than those who did respond. Therefore, it could be the case that around

half of providers in the Region operated or planned a risk assessment policy.

The 29 respondents who reported the existence of a risk assessment policy were

asked to provide further information on its scope and format by answering a further

seven questions. Firstly, they were asked, `Is this procedure speci®c to people with

learning disabilities, or does it cover other groups?' Most (21) said the guidelines or

policy were speci®c to clients with learning disabilities, while in six cases, the policy

covered other client groups (most commonly those with mental illness). Two did not

answer this question. Respondents were then asked, `Does risk assessment form part of

a general assessment of needs?' The majority (20 out of 29) said that it did.



The next question, relating to current practice, asked, `Is it normal practice to assess

risk of offending or dangerousness in the following circumstances?' Table 1 shows the

seven situations quoted and responses to each one.

There is evidence that familiarity with making risk assessments varied greatly

between providers. Asked `How many such risk assessments were made by your orga

nization last year?', 22 respondents gave an estimate of the number, as shown in Table 2.

The highest estimate was `several hundred'. Independent providers indicated a

lower level of familiarity with risk assessment practice than did statutory providers.

Responses to the question `Does a named individual normally act as lead or coordi-

nator in the risk assessment exercise (please state grade of staff)?' suggested that inde-

pendent sector providers also tend to adopt a different pattern of coordination.

Twenty-four (83%) providers said that their risk assessment and management process

was coordinated by a named individual. Independent sector providers tended to

involve managers in coordination, while statutory sector providers used social workers

or nurses. Six respondents were unspeci®c about the profession involved.

Providers were then asked, `What provision is made for training and supervision of

staff involved in risk assessment?' Five providers said training and/or supervision did

not happen. Five more referred to plans to develop training. Fourteen referred to in-

house training and four to externally run training. There were seven references to indi-

vidual supervision, including two which also referred to the role of team meetings or

other disciplines in supervision. Three others made brief reference to normal trust or

social service department supervision procedures.

Examples of current risk assessment practice

In response to the question `Does the assessment process utilize any standard measure

Table 1 When is risk assessment undertaken? Total number of respondents� 29

Circumstance Number of respondents (%)

1. Following report of incident or allegation 22 (76)2. Discharge from secure or medium security accommodation 19 (66)3. Resettlement from long-stay institution 18 (62)4. Move to more independent living 16 (55)5. Medication review 15 (52)6. Following reduction of service support or supervision 14 (48)7. Transition to adult services 7 (24)

Table 2 Familiarity with risk assessment practice

Estimated number of risk assessments in last 12 months

Providers

Statutory Independent

R 5 3 56±12 6 0r 20 7 1



or checklists in order to quantify the level of risk?', 40% (12) of 29 services, including

nine statutory and three independent sector providers, said that it did. They were

asked to detail these measures.

Three broad types of assessment instrument were reported. It may be useful to relate

these to Davis' (1995) distinction between risk-taking and risk minimization, as sum-

marized above.

1. Risk-taking approach

The ®rst type re¯ects Davis' (1995) risk-taking approach. Rather than focusing on dan-

ger to public or property, these were broad-based instruments covering a range of

other risks (e.g. personal safety). This broader remit does not necessarily imply greater

complexity in assessment since several simple measures of this type were described.

This may be because of their intended use with a wide range of clients and not just a

small number of potentially dangerous individuals, and therefore, simplicity and speed

of completion become a high priority. Some of these measures were externally devel-

oped, others in-house. Some featured a numerical scale of relative risk. Five such

schemes were submitted, including one from a voluntary organization.

(a) Institute of Occupational Safety and Health Rating Scale

This scheme scores risk on two counts, i.e. likelihood and seriousness, using a six-point

scale from (0) `no risk' to (6) `certain', and in relation to seriousness, from (0) `no acci-

dent' to (6) `fatal'. Total scores of between 2 and 5 are deemed `low risk', 6 to 8 `med-

ium risk' (requiring a risk management plan formulation) and r9 `high risk' (urgent

review). A Risk Identi®cation Form is used to apply the scale to a risk of suicide/self-

harm, a risk to personal safety and a risk to others/violent behaviour, and to record

trigger factors. The rating scale is used in conjunction with checklists of risk factors

relating to risk to others and violent behaviour.

(b) General risk assessment

This risk assessment is also in response to health and safety legislation. The procedure

involves a risk assessment rating of likelihood and hazard severity, each scored from 1

to 5 (improbable to very probable; negligible to very dangerous), which are then multi-

plied together, giving a maximum possible score of 25. The resulting score is used to

establish the degree of risk, classi®ed as insigni®cant (0±5), low (6±12), medium (13±18)

or high (19±25). Each of these classi®cations are linked to required preventive or pre-

cautionary measures. The project leader commented that the procedure remains depen-

dent on subjective judgements ± views on the level of risk could vary, and the nature

or level of risk might change.

(c) Risk analysis, assessment and management

This information describes a general risk assessment (i.e. covering risks of daily living

as well as those relating to offending and dangerousness) based on interviews with ser-

vice users and carers. Four different types of risk are considered: (1) to themselves, (2)

to parent/carer/co-tenant, (3) to members of the public and (4) to the service. These

are related to communication skills, relationships, mobility, degree of independence (in

personal, domestic and community domains), behaviour, medical/nursing needs, spe-

cialized equipment needs, community participation, work, special interests and feel-

ings. Separate guidance is given on how to identify risk (e.g. the service user has



problems recognizing or avoiding danger, or in taking action when danger threatens

or has occurred), but the presence or absence of risk is treated as a dichotomy.

(d) Guidelines on risk taking

These guidelines were supplied by an NHS Trust. They provide for a framework for

risk-taking which covers the nature of the risk, the degree of risk and the objective of

risk-taking. It also outlines the mechanics of risk-taking, based on individual patient

planning and team meetings. It does not include a means of quantifying the level or

severity of risk, although this provider is currently developing further guidelines relat-

ing speci®cally to offenders.

(e) Clinical risk management and security: policy and procedures

This document was supplied by a large, specialist NHS provider of secure accommoda-

tion that is the most experienced agency in the region in terms of the numbers of risk

assessments performed and the specialist knowledge accumulated. The 24-page docu-

ment covers clinical risk, assessing risk, communications, levels of authority, differ-

ences of opinion, security, systems for managing security and safety, and risk

management of the individual resident.

The document describes: clinical risk (including harm to self and colleagues, self-

neglect, being harmed, seriously irresponsible conduct, inappropriate treatment,

neglect, and unreasonable restriction); uncertainty (the extent to which information

relevant to assessment is available); and social impact (the effect on society of a parti-

cular behaviour). It is argued that these three elements are interrelated, thereby produ-

cing eight categories which determine clinical risk management, from high social

impact, high probability and high certainty to low social impact, low probability and

low certainty. It also makes an important point, not referred to in other documentation,

that risks may be oppositional, i.e. action to decrease one type of risk may increase

another.

2. Assessment of general risk of offending

The second type of measure obtained through the survey of providers represents the

risk minimization approach (Davis 1995). Measures supplied addressed a general risk

of offending and included a numerical rating scale. Two examples were submitted.

(a) Policy for risk assessment

The documentation provided by one NHS trust was in three parts: (1) risk assessment

guidelines; (2) a risk assessment form relating to risk identi®cation and strategy for

risk avoidance; and (3) a planned risk-taking assessment form. Risk identi®cation cov-

ers 15 categories on a yes/no basis. The categories are similar to those in the care pro-

gramme approach document summarized above, but also include risk of drug abuse,

sexually inappropriate behaviour, accidental harm, disorientation, addiction and vul-

nerability (to abuse). There is no reference to risk of suicide or serious property

damage.

(b) Risk assessment draft policy

This document, supplied by an independent sector provider, details the potential

sources of information (e.g. people, documentation and observation) and goes on to

list circumstances under which risk would increase. These are given as: signs of mental



ill-health; medication non-compliance; failure to attend appointments; substance abuse;

high levels of agitation, anger and hostility; failure to comply with contracts on accep-

table standards of behaviour; availability of victims; availability of weapons; context/

situation-related factors; and stress factors such as changes in environment and new

staff. The document also comments on the need to include `hunches' arising from long-

standing relationships between the staff and the individual, re¯ecting subtle factors

which heighten the possibility of risks, and which are not based on facts but on a gen-

eral experience of similar individuals.

The policy prioritizes risks as low, medium or high by both frequency [low (rare/

unpredictable), medium (occasional but too often to ignore) and high (often and

expected)] and severity [low (inconvenient), medium (major disruptive) and high (cata-

strophic)]. Risk exposure is quanti®ed by multiplying frequency scores (1±3) by sever-

ity scores (1±3). The service provider noted that the prioritizing of risks must also take

into account the cost of implementing a plan, the time-frame, action to be taken and

feasibility of implementation. The document then outlines the process of risk manage-

ment: identi®cation of risks; assess risks for potential frequency and severity; identify

risks which can be eliminated; and reduce the effect of those risks which cannot be

eliminated.

3. Assessment of risk of speci®c offences

The third type of assessment has an even narrower focus within the risk minimization

approach, targeting speci®c risks or circumstances. The three examples given relate to

sex offending, violence and the requirements of the care programme approach (CPA)

where mental illness is present.

(a) Care programme approach risk assessment

A CPA risk assessment form is used by an NHS Trust for those people with a learning

disability who also have a current mental illness, or who have been identi®ed as pos-

ing particular risks for other reasons such as challenging behaviours or personality dis-

orders. The risks covered are: violence to family members, other clients, the general

public or staff; sexual assault; arson/®re setting; serious damage to property; suicide;

self-injury; self-neglect; and other speci®ed risks. For each problem identi®ed, the form

requires details of the risk (i.e. evidence, circumstances which increase risk, individuals

at particular risk and warning signs) and the action to be taken (i.e. general steps to

minimize risk and speci®c reaction to warning signs/increased risk). The form also

records the extent of information on which it is based, the need for placement on the

Supervision Register, and the distribution and review of the assessment.

(b) RESPOND assessment

Two statutory sector providers reported that they used documentation from

RESPOND, a specialist psychotherapy and counselling service for both victims and

perpetrators of sexual abuse among people with learning disabilities. It has developed

a detailed assessment programme for offenders, covering personal history (including

offending history and attachment history), details of the offending cycle (including clin-

ical interview details), and the results of psychological and psychiatric assessments.

The assessment also covers: self-assessment of risk (on a scale of 1±10); denial stages

(offence, responsibility and future problems); acceptance of responsibility (i.e. the abil-

ity to discuss the offence, and tally with the victim's account and victim's feelings); fan-



tasies and their relationship with the offence; components of the offending cycle;

grooming and maintenance behaviours; triggers; high-risk situations and client-sug-

gested avoidance; external controls and who applies these; internal controls (client

offered reasons to avoid re-offending); client's target age/sex and access to members of

target group; problems with impulse control, anger management, drink, drugs and sol-

vents; and whether the family of origin was a setting for physical or sexual abuse, emo-

tional neglect of the client/other or problems in family functioning (from Trinity of

Pain, RESPOND, 24±32 Stephenson Way, London NW1 2HD, UK).

(c) HCR-20 checklist

Since its development, the HCR-20 has become one of the most well known and

researched risk assessment instruments for the prediction of violence. Studies using the

HCR-20 have involved prison, civil psychiatric and forensic psychiatric populations,

and have reported good predictive ability (Scottish Executive, 2000). No studies invol-

ving people with intellectual disabilities or in the UK which use the HCR-20 have been

reported.

A community trust reported using the HCR-20 scheme. Its authors (Webster &

Eaves 1995) described the scheme as designed for use in the assessment of risk for

future violent behaviour in criminal and psychiatric populations. The scheme aims for

accessibility, scienti®c integrity, testability, administrative feasibility and ef®ciency.

Borum (1996) commented that, since data on reliability and validity are preliminary, its

primary value is as a checklist to prompt the major relevant areas of inquiry. The

above author added that its advantages are clearly de®ned items (some of which do

not require a clinician to administer), the capacity to be compiled from documents, and

its grounding on a conceptual model and on empirical literature; for example, its scor-

ing system weights historical factors most highly because of their established predictive

value.

The 10 H (historical) Scale variables in the scheme are: previous violence, mental dis-

order, age at ®rst violent offence, psychopathy, relationship stability, early home/

school maladjustment, employment stability, personality disorder, alcohol or drug

abuse, and prior release or detention failure. The ®ve C (clinical) Scale variables com-

prise insight (on the part of the client), stability, attitude (predisposition), treatability

and symptoms. Finally, the ®ve R (risk) Scale variables are: plan feasibility, compliance

(motivation to succeed), access (e.g. to victims, weapons and drugs), stress (e.g. from

family, peer group and work), support and supervision.

3. Managing aggression ± risk assessment

This social service department document aims to prevent or manage aggressive beha-

viour where there is `an identi®ed cause for concern'. It records: the history of previous

incidents or concern, including violent or aggressive behaviour, offences or threats to

staff or others; current behaviour, risks or concerns presented by those close to the cli-

ent; and the identi®cation of risks to staff, other clients or members of the public. The

intervention plan also records information on known triggers of aggressive behaviour

in the individual. However, it does not list potential risk factors or attempt to quantify

risk, and relies on staff knowing what is relevant in each individual case.

More details of these and other assessment procedure documents are contained in

the two reports produced for the NHS Management Executive North-west of®ce

(Turner 1998a, b).



Problems

Twenty-six respondents mentioned problems. Problems were reported just as often by

organizations with no risk assessment policy in place as by those that had one, i.e. a

lack of a policy was not necessarily because there were no problems. Only seven com-

ments came from independent sector providers. Problems were of three main kinds: (1)

resources or service con®guration; (3) interagency or interdisciplinary cooperation or

coordination; and (3) issues relating to the effectiveness, design and content of assess-

ment. Details of these responses are given in Table 3.

Suggestions

The 32 individual suggestions may be placed under two main headings: (1) the need

for progress; and (2) the need for resources. Sixteen providers made suggestions about

the need for or the nature of a future risk assessment strategy, including 13 which wel-

comed the idea of greater information sharing, the holding of a regional conference on

the subject or the development of guidelines.

Another 10 organizations followed up the issue of resources for more training (5),

greater specialist input (2), assessment facilities (1), community support funding (1) or

local NHS beds (1). Six suggestions referred to: more regional support; the develop-

ment of continuing care criteria relating to high-risk clients; the improvement of dis-

charge planning; the involvement of learning disability teams in court diversion teams;

and better liaison between management and grassroots.

Discussion

The present paper has sought to link a review of research into risk assessment with

current practice in one area. Evidence of such a link was clear. Monahan & Steadman's

Table 3 Reported problems in risk assessment practice

Sector Problem

Resources or service con®guration (n� 21) Level or source of fundingNeed for more community supervisionNeed for more residential provisionOut-of-district placementsOngoing reviewCommunity/residential balanceNeed for trainingCosts of assessment in time and money

Coordination between agencies and professions (n� 18) Coordinating different agency viewsPolice liaisonResponsibilities vis-aÁ-vis probationMulti-agency assessment formatInaccurate documentationLack of assessment strategy

Effectiveness, design and content of assessment (n� 10) No effective, reliable procedureNo legislative frameworkDe®ning offending behaviourHigh-risk non-offenders



(1994) disaggregation of `dangerousness' into predictors of violence (i.e. historical, dis-

positional, contextual and clinical `risk factors'), the amount and type of violence being

predicted (`harm') and the likelihood that harm will occur (`risk') underpins many of

the assessment instruments currently in use in both mainstream forensic psychiatry

and in the intellectual disability ®eld (Monahan & Steadman 1994; Chiswick 1995;

O'Rourke et al. 1997; Clare & Murphy 1998). Nevertheless, Borum (1996) and collea-

gues have commented on the gulf between research and practice. It is essential that

risk assessment techniques and instruments developed in research studies are usable

and reliable in practice settings. For example, many risk assessment models appear to

assume a level and depth of information which may be unavailable or unobtainable

because of constraints of time in service settings. Webster & Eaves (1995) argued that

predictive accuracy could be signi®cantly improved if clinicians decline to make an

assessment because they lack the knowledge or expertise needed, or hold a relevant

bias. The checking of information, the appropriate weighting of predictors according to

a developed scheme and the allowance of suf®cient time to the assessment exercise are

also likely to improve accuracy. There have been some recent efforts to bridge the

research±practice gulf. Lindquist & Skipworth (2000) attempted to identify manage-

ment and therapeutic strategies derived from the actuarial probabilities of risk assess-

ment. Monahan et al. (2000) argued that clinical relevance can be increased by re-

formulating the main-effects regression analysis model of risk to a classi®cation tree,

and suggested two decision thresholds to identify high and low risk.

The review of the learning disability literature suggests that much of the evidence

relating to the prevalence and pattern of offending by people with learning disabilities

is undermined by methodological weaknesses. These include the identi®cation of an

individual as having learning disabilities, which may prompted by the detection of the

offending behaviour; and the treatment of the behaviour as offending, which may in

turn be heavily in¯uenced by whether or not the disability has been recognized. Stu-

dies based on prison or hospital order populations may not be applicable to other

groups with intellectual disabilities. A complete identi®cation both of intellectual dis-

ability and of all behaviours which may be offending is clearly not possible. Without it,

it is equally impossible to identify the true pattern of relationships between this group

of individuals and these types of behaviour, and therefore, to obtain a full understand-

ing of the risk factors which need to be assessed. Awareness of the fact that the knowl-

edge base for risk assessment is at best partial, and at worst misleading, should

underpin the process of assessment, management and review.

The survey of providers was limited to one English region, and therefore, may not

re¯ect service developments nationally or provide the best examples of good practice.

The postal questionnaire used in the survey focused only on policy and practice

regarding people with intellectual disabilities who were offenders or potential offen-

ders, and not victims. Therefore, the survey could be accused of giving a one-sided

view of forensic issues in learning disability services.

The survey found that, while many providers recognized problems associated with

assessing and managing risk, only a minority had adopted relevant procedures or poli-

cies. Alaszewski & Manthorpe (1998) reported a similar ®nding in their investigation

of risk in the social welfare of people with learning disabilities and of vulnerable chil-

dren. The above authors found that, while a majority recognized risk as an issue, only

a minority had adopted explicit risk policy and practice.



In the current study, the adoption of such practice was found to be more common

among statutory sector providers. This may be partly a result of their greater involve-

ment in providing communal accommodation compared with independent providers,

which, it has been suggested, may afford greater opportunity for physical and sexual

assault (Wilson et al. 1996). More generally, it has been argued that smaller organiza-

tions may be more risk tolerant and larger organizations more risk averse (Kemshall &

Pritchard 1995).

Despite the fact that most of the providers who took part in the present survey said

that assessment formed part of a general assessment of need, risk assessment appeared

to be a responsive rather than proactive exercise, taking place within the context of

heightened concern or new information regarding the behaviour of an individual

(Table 1). At one extreme, the focus may be on a relatively narrow set of circumstances

where `risk assessment' takes place as a formal service response to a proven offending

act by a person administratively de®ned as being learning disabled; for example,

Davis's risk minimization model. In this model, the individual's apparent high-risk sta-

tus ± gained by awareness of previous offences (or of a record of behaviour likely to be

de®ned as an offence if brought before a court) ± is the central concern. This model

may also be applied to offenders whose mild learning disability has gone unrecog-

nized, or who are denied access to learning disability services because of their rela-

tively high level of ability.

However, risk assessment may also be relevant to those whose status is about to

change in some way; for example, because of a move to new accommodation or a new

district, or change from child to adult services. In such situations, there may be no

recent instances of offending behaviour. In these circumstances, risk to the client and

the bene®ts of risk taking may be given as much weight as the minimization of the

risk of offending. The responses shown in Table 1 suggest that most assessments

appear to function as part of a risk-minimization policy (Davis 1995).

As an aid to clarifying which elements of these models are appropriate for different

providers and in different circumstances, it may be helpful to compare their character-

istics, shown in Table 4.

These different models may give rise to different issues relating to cross-agency liai-

son or co-ownership of risk management plans, and the mechanisms necessary to

ensure systematic review. It may be useful for providers to check how their actual or

planned risk assessments relate to these models, and to assure themselves of their

appropriateness given the client group they serve.

There remains the problem of ensuring the involvement and cooperation of different

agencies and professions in risk assessment and management. Comments from provi-

ders responding to the survey refer to the problems caused by lack of interagency and

interprofessional cooperation in risk assessment, and by de®ciencies in service provi-

sion and resources. These comments are re¯ected in a recent report by the Department

of Health (DoH 1999) that highlights the lack of local forensic services for people with

learning disabilities. One project which attempts to address these issues, based on the

setting up of a interagency signi®cant risk advisory group charged with collating

reports and assessments, quantifying risk, and recommending risk management and

care options, was reported by Hutchinson (2000). Services are provided through a com-

munity-based intensive support service that the above author reported has prevented

re-offending and maintained care packages.



Tab

le4

Ris

k-t

akin

gan

dri

skm

inim

izat

ion

(aft

erD

avis

1995

)

Fac

tor

Ris

k-ta

kin

gR

isk

min

imiz

atio

n

1R

isk

asse

ssm

ent

tak

esp

lace

wit

hin

gen

eral

care

pla

nR

isk

asse

ssm

ent

isa

com

pre

hen

siv

ein

ves

tig

atio

nw

ith

ina

fram

ewo

rko

ffo

ren

sic

pro

cess

2A

do

pte

das

go

od

pra

ctic

efo

ral

lcl

ien

tsS

pec

i®c

toa

few

hig

h-r

isk

ind

ivid

ual

s3

Att

emp

tto

bal

ance

risk

min

imiz

atio

nw

ith

risk

tak

ing

Pu

bli

c/st

aff

safe

typ

rim

ary

con

sid

erat

ion

4A

lso

app

lied

too

ther

risk

s(e

.g.

chal

len

gin

gb

ehav

iou

r,o

rh

ealt

han

dsa

fety

)E

mp

has

iso

na

lim

ited

nu

mb

ero

fri

sks

(i.e

.v

iole

nce

,se

xo

ffen

ces

and

arso

n)

5A

sses

smen

tn

ot

spec

i®c

too

ne

pro

fess

ion

Cen

tred

on

fore

nsi

cp

sych

iatr

icex

per

tise

6C

om

mu

nit

yb

ased

Inst

itu

tio

nb

ased

(e.g

.se

cure

un

it,

ho

spit

alo

rp

riso

n)



It is clear from both the literature review and the survey responses that providers

are increasingly using assessment instruments to replace or supplement clinical judge-

ments of risk. The following questions may be helpful in assessing the relevance, relia-

bility and acceptability of assessment instruments. Firstly, does the purpose and design

of the instrument ®t the nature of risk assessment being planned? For example, assess-

ment may need to include risk of suicide and self-harm as well as violence to others or

property offences. Secondly, has the instrument been used on comparable populations

and in comparable settings? Can the experience of other intellectual disability services

in its use be drawn on? Thirdly, what information is available concerning the profes-

sional time and other resources required to complete the assessment? For example, is it

possible to simplify assessment of low-risk individuals? Is it easily completed, under-

standable and unambiguous? Fourthly, given the problems concerning the validity and

reliability of risk assessment instruments, what evidence is there that the instrument

can predict outcome, particularly in this population? If such evidence is scanty, how

feasible is it to audit its operation? Does it produce similar results if completed by dif-

ferent professionals? Fifthly, how well does the instrument allow for multiple contribu-

tions from different stakeholders while establishing clear accountability? In particular,

does it attempt to maximize the involvement of users and carers, both in assessment

and in any subsequent management plan? Sixthly, does it re¯ect the dynamic nature of

risk? Does it identify settings, circumstances and relationships which alter the risk pro-

®le? Finally, does assessment generate a risk management framework with clear

review and coordination procedures? This may include the involvement of relevant

purchasers in agreeing policies, and the use of a named coordinator with clear and

accepted responsibility and authority to oversee risk assessment and follow through

risk management plans across service boundaries and changes in service responsibility.

Acknowledgments

Thanks are due to the managers and ®eldwork staff who contributed to the survey

described in this paper, and to Jacqui Howard, John Taylor and Mark Burton for their

contributions at a risk assessment workshop that was held as part of this commission

and that informed the discussion in this paper. Drs I. Clare, J. Manthorpe, M. O'Rourke

and P. Patel kindly provided comments and material on assessment tools. Professors

Eric Emerson and C. Kiernan commented on earlier drafts. The views expressed in this

paper do not necessarily re¯ect those of the North-west Regional Of®ce of the NHS

Management Executive, which funded this work.

Correspondence

Any correspondence should be directed to Stephen Turner, Senior Research Fellow,

Centre for Social Research on Dementia, Department of Applied Social Science, Univer-

sity of Stirling, Stirling FK9 4LA, UK.

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