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
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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).
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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
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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
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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.
= 2000 BILD Publications, Journal of Applied Research in Intellectual Disabilities, 13, 239±255
243Journal of Applied Research in Intellectual Disabilities
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
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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
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245Journal of Applied Research in Intellectual Disabilities
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
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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-
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247Journal of Applied Research in Intellectual Disabilities
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).
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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
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249Journal of Applied Research in Intellectual Disabilities
(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.
250 Journal of Applied Research in Intellectual Disabilities
= 2000 BILD Publications, Journal of Applied Research in Intellectual Disabilities, 13, 239±255
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.
= 2000 BILD Publications, Journal of Applied Research in Intellectual Disabilities, 13, 239±255
251Journal of Applied Research in Intellectual Disabilities
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)
252 Journal of Applied Research in Intellectual Disabilities
= 2000 BILD Publications, Journal of Applied Research in Intellectual Disabilities, 13, 239±255
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.
References
Alaszewski A. & Manthorpe J. (1998) Welfare agencies and risk: the missing link? Health and SocialCare in the Community 6, 4±15.
= 2000 BILD Publications, Journal of Applied Research in Intellectual Disabilities, 13, 239±255
253Journal of Applied Research in Intellectual Disabilities
Borum R. (1996) Improving the clinical practice of violence risk assessment: technology, guide-lines, and training. American Psychologist 51, 945±956.
Chiswick D. (1995) Dangerousness. In: Seminars in Practical Forensic Psychiatry (eds D. Chiswick &R. Cope), pp. 210±242. Royal College of Psychiatrists, London.
Clare I. C. H. & Murphy G. H. (1998) Working with offenders or alleged offenders with intellec-tual disabilities. In: Clinical Psychology and People with Intellectual Disabilities (eds E. Emerson,C. Hatton, J. Bromley & A. Caine), pp. 154±176. John Wiley & Sons, Chichester.
Davis A. (1995) Risk work and mental health. In: Good Practice in Risk Assessment and Risk Manage-ment (eds H. Kemshall & J. Prichard), pp. 109±120. Jessica Kingsley, London.
Day K. (1990) Mental retardation: clinical aspects and management. In: Principle and Practice of For-
ensic Psychiatry (eds R. Bluglass, P. Bowden & N. Walker), pp. 399±418. Churchill Livingstone,Edinburgh.
Department of Health (DoH) (1999) Facing the Facts ± Services for People with Learning Disabilities. A
Policy Impact Study of Social Care and Health Services. Department of Health, London.Department of Health (DoH)/NHSME (1994) Guidance on the discharge of mentally disordered offen-
ders. HSG/94/27, Department of Health/NHSME, London.Department of Health (DoH)/Home Of®ce (1992) Review of Health and Social Services for Mentally
Disordered Offenders and Others Requiring Similar Services (The Reed Report), Vol. 7: People withLearning Disabilities (Mental Handicap) or with Autism. Cmnd 2088, HMSO, London.
Gibbens T. C. N. & Robertson G. (1983a) A survey of the criminal careers of hospital orderpatients. British Journal of Psychiatry 143, 362±369.
Gibbens T. C. N. & Robertson G. (1983b) A survey of the criminal careers of restriction orderpatients. British Journal of Psychiatry 143, 370±373.
Halstead S. (1997) Risk assessment and management in psychiatric practice: inferring predictors ofrisk. A view from learning disability. International Review of Psychiatry 9, 217±224.
Hutchinson R. (2000) A risky business. Healthcare Risk Resource 3, 2±5.Kemshall H. & Prichard J. (eds) (1995) Good Practice in Risk Assessment and Risk Management. Jes-
sica Kingsley, London.Kiernan C. & Alborz A. (1991) People with Mental Handicap who Offend. Hester Adrian Research
Centre, University of Manchester, Manchester.Kiernan C. & Dixon C. (1995) People with Learning Disability Who Have Offended or Are at Risk of
Offending. Communicare NHS Trust and Hester Adrian Research Centre, University of Manche-ster, Manchester.
Koller H., Richardson S. A., Katz M. & McLaren J. (1982) Behaviour disturbance in childhood andearly adult years in populations who were and were not mentally retarded. Journal of Preventive
Psychiatry 1, 453±468.Linaker O. M. (1994) Assaultiveness among institutionalised adults with mental retardation. Brit-
ish Journal of Psychiatry 164, 62±68.Lindquist P. & Skipworth J. (2000) Evidence-based rehabilitation in forensic psychiatry. British
Journal of Psychiatry 176, 320±323.Litwack T. R., Kirscjhner S. M. & Wack R. C. (1993) The assessment of dangerousness and predic-
tions of violence: recent research and future prospects. Psychiatric Quarterly 64, 245±273.Lyall I., Holland A. J. & Collins S. (1995a) Offending by adults with learning disabilities and the
attitudes of staff to offending behaviour: implications for service development. Journal of Intellec-
tual Disability Research 39 (6), 501±508.Lyall I., Holland A. J. & Collins S. (1995b) Offending by adults with learning disabilities: identify-
ing need in one health district. Mental Handicap Research 8, 99±108.Manthorpe J. & Walsh M. (1997) Issues in risk practice and welfare in learning disability services.
Disability Society 12, 69±82.Monahan J. & Steadman H. J. (1994) Towards a rejuvenation of risk assessment research. In: Vio-
lence and Mental Disorder: Developments in Risk Assessment (eds H. Steadman & J. Monahan), pp.1±17. University of Chicago Press, Chicago, IL.
Monahan J., Steadman H. J., Appelbaum P. S., Robbins P. C., Mulvey E. P., Silver E., Roth L. H. &Grisso T. (2000) Developing a clinically useful actuarial tool for assessing violence risk. British
Journal of Psychiatry 176, 312±319.Mossman D. (1994) Assessing predictions of violence: being accurate about accuracy. Journal of
Consulting and Clinical Psychology 62, 783±792.
254 Journal of Applied Research in Intellectual Disabilities
= 2000 BILD Publications, Journal of Applied Research in Intellectual Disabilities, 13, 239±255
Murphy G. H. & Clare I. C. H. (1996) Analysis of motivation in people with mild leaning disabil-ities (mental handicap) who set ®res. Psychology, Crime and Law 2, 153±164.
O'Rourke M. M., Hammond S. M. & Davies E. J. (1997) Risk assessment and risk management:the way forward. Psychiatric Care 4, 104±106.
Otto R. (1994) On the ability of mental health professionals to predict dangerousness: a commen-tary and interpretation of the dangerousness literature. Law and Psychology Review 18, 43±68.
Payne C., McCabe S. & Walker N. (1974) Predicting offender-patients' convictions. British Journalof Psychiatry 125, 60±64.
Pollock N. & Webster C. (1990) The clinical aspects of dangerousness. In: Principle and Practice ofForensic Psychiatry (eds R. Bluglass, P. Bowden & N. Walker), pp. 489±498. Churchill Living-stone, Edinburgh.
Prins H. (1996) Risk assessment and management in criminal justice and psychiatry. Journal of For-ensic Psychiatry 7, 42±62.
Royal College of Psychiatrists (RCP) (1996) Assessment and clinical management of risk of harm toother people. Council Report CR 53, Royal College of Psychiatrists, London.
Scottish Executive (2000) Report of the Committee on Serious Violent and Sexual Offenders: Annex 6:Current Risk Assessment Instruments, 151±157, (SE/2000/68). Scottish Executive, Edinburgh.
Silver E., Mulvey E. & Monahan J. (1999) Assessing violence among discharged psychiatricpatients: toward an ecological approach. Law and Human Behavior 23, 237±255.
Thomas D. H. & Singh T. H. (1995) Offenders referred to a learning disability service: a retrospec-tive study from one county. British Journal of Learning Disabilities 23, 24±27.
Thompson D. (1997) Pro®ling the sexually abusive behaviour of men with intellectual disabilities.Journal of Applied Research in Intellectual Disabilities 10, 125±139.
Thompson D. & Brown H. (1997) Men with intellectual disabilities who abuse: a literature review.Journal of Applied Research in Intellectual Disabilities 10, 140±158.
Turner S. (1998a) The Assessment of Risk and Dangerousness as Applied to People with Learning Disabil-ities Considered at Risk of Offending. Part 1: Literature Review. Hester Adrian Research Centre, Uni-versity of Manchester, Manchester.
Turner S. (1998b) The Assessment of Risk and Dangerousness as Applied to People with Learning Disabil-ities Considered at Risk of Offending. Part 2: Developing Good Practice. Hester Adrian Research Cen-tre, University of Manchester, Manchester.
Walker N. (1991) Dangerous mistakes. British Journal of Psychiatry 158, 752±757.Webster C. D. & Eaves D., with Douglas K. S. & Winthrop A. (1995) The HCR-20 Scheme: The
Assessment of Dangerousness and Risk. Simon Fraser University and Forensic Services Commis-sion of British Columbia, Burnaby.
Wilson C., Seaman L. & Nettlebeck T. (1996) Vulnerability to criminal exploitation: in¯uence ofinterpersonal competence differences among people with mental retardation. Journal of Intellec-tual Disability Research 40, 8±16.
= 2000 BILD Publications, Journal of Applied Research in Intellectual Disabilities, 13, 239±255
255Journal of Applied Research in Intellectual Disabilities
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