Adolescent forensics Flashcards
Developmental perspective
Adolescents have specific needs which are different from adult patients due to the social, emotional, educational and personality development they are undergoing:
they are separating from their parents (or care-givers) socially and emotionally, whilst at the same time developing their own identity and capacity for intimacy
however, they still need support and guidance from their care givers
furthermore, education and training continue to be an important part of the life of an adolescent, and disrupting them may harm their future prospects
becoming unwell or being removed from the normal adolescent trajectory at any stage is not only harmful to the individual at the time, but also problematic (in the long term) in view of what is missed at that time.
An adolescent’s progression through the stages of cognitive, emotional and biological development is variable in this age group, with development across the domains occurring at different ages for each domain in each individual.
Hence, adolescents may appear like children in one domain but like adults in another.
different illness between adult and child
Many mental health difficulties in adolescents are different from those seen in adults (such as ADHD, pervasive developmental disorder).
Even those ‘adult’ mental health illnesses that develop in adolescence require different management and understanding than with adult patients.
Diagnosis and management of ‘adult’ illnesses in adolescence:
Mental illnesses emerging in adolescence may have a prodromal stage which is rarely seen in adults. They are therefore more commonly diagnosed by those working within CAMHS services than by those working with adult patients (e.g. psychosis).
Medication used in adult patients may have increased risks in their use with young people (e.g. specific serotonin reuptake inhibitors) and may therefore have different guidelines for prescribing.
Managing young people who are becoming unwell requires liaison with different agencies than those working with adults (e.g. schools, social workers).
Managing young people who are becoming unwell requires the clinician to work with parents, which is not required when caring for adult patients.
Family therapy has been shown to be a more effective in young people than adult patients for certain disorders (eating disorder, conduct disorder) whereas adult patients respond more to individual therapy.
CHAT
The aim of CHAT (secure estate) is to complete a comprehensive health screen on all young people entering detention to identify all health needs of the young person.
It has 5 parts:
CHAT 1 – a reception screen to be complete within two hours of a young person arriving in the establishment, to identify any immediate physical or mental health needs and risk issues:
CHAT 2 – primary care reception screen, to identify any physical health needs, completed the day after arrival
CHAT 3 – substance misuse screen, to identify any substance misuse treatment needs, completed within three days of detention
CHAT 4 – mental health screen, to identify any mental health needs, completed within three days of detention
CHAT 5 – neurodisability screen, to identify any neurodevelopmental needs such as ADHD, intellectual disability, acquired brain injury, communication difficulties and autistic spectrum disorder.
The CHAT being completed by the Youth Offending Teams, for those receiving a community order, mirrors that used in custody but is not completely identical and has different times scales:
physical health screen, to be completed within 14 days of receiving a community order
mental health screen, to be completed within 14 days of receiving a community order
substance misuse screen, to be completed within 21 days of receiving a community order
neurodisability screen, to be completed within 30 days of receiving a community order
TYPES of risk
Psychiatrists routinely assess a wide range of risks relating to their patients, including risk to/of:
self
violence to others
sexual behaviour
absconding
relapse
non compliance
substance misuse
being manipulated
exploiting others.
unstructured clinical assessment
Unstructured clinical assessment
With the unstructured clinical assessment, the clinician gathers whatever information he thinks is relevant, combines it and processes it to come to a conclusion.
This conclusion may be correct or not, however the lack of transparency regarding the various steps leading to its formation:
makes it difficult to question
leaves it open to challenges such as discrimination
standardised risk assessment
The standardised or actuarial approach was developed in response to the criticisms made about unstructured clinical assessments.
It involves collecting a standardised set of data about an individual which is used to classify the person into one of a number of groups. Each group is considered to present a different level of violence risk.
This approach is similar to the approach adopted by life insurance companies, whereby they:
gather a systematic set of historical data about their clients
classify them into groups (e.g. smoker or non-smoker)
compare them with the whole population
determine the probability of their overall risk of death and therefore their insurance premiums.
Although there will be exceptions within the group (e.g. not all smokers will die young) overall the group trends will hold.
dowfalls of standardised assessments
The standardised or actuarial approach was developed in response to the criticisms made about unstructured clinical assessments.
It involves collecting a standardised set of data about an individual which is used to classify the person into one of a number of groups. Each group is considered to present a different level of violence risk.
This approach is similar to the approach adopted by life insurance companies, whereby they:
gather a systematic set of historical data about their clients
classify them into groups (e.g. smoker or non-smoker)
compare them with the whole population
determine the probability of their overall risk of death and therefore their insurance premiums.
Although there will be exceptions within the group (e.g. not all smokers will die young) overall the group trends will hold.
structural clinical assessments
structured clinical assessment instruments
Structured clinical assessment instruments were developed as an attempt to combine the best aspects of clinical and standardised (or actuarial) approaches to risk assessment in forensic populations.
They require clinicians to:
gather specified information (based on known associations with violence risk)
consider other information about the individual before finally drawing conclusions about their level of risk.
Many of these instruments also facilitate clinicians with the development of risk management plans on the basis of the findings of the risk assessment.
Criticism of the structured clinical assessment approach includes:
it is more time consuming than the other two methods
it does not result in a ‘neat’ answer such as the simple percentage provided by an actuarial approach
assessing violence risk in adults vs adol
Is there any difference between assessing violence risk with adolescents and with adults?
The nature of adolescence means that there needs to be some caution in the interpretation of risk assessments undertaken on this group.
Adolescence is a time of rapid developmental change. This process of change can also extend to the dynamic risk factors exhibited by a young person. Such factors may increase or decrease in significance over the adolescent period. As a result, the level of risk that a young person presents to others may also increase or decrease.
Much of the research supporting the predictive validity of violence risk assessment in adolescents is based on follow-up data of less than three years. For adults, data exists for longer follow up periods.
As a result of these points, it is essential to note that the estimate of violence risk should be re-evaluated:
after a period of at most, two years, or
following significant social, environmental, familial, sexual, affective, physical or psychological change.
risk assessment instruments
The majority of risk assessment instruments used to determine the risk of recidivism in young people were developed in Canada.
Some have already been validated in European or British populations but for the most part this work is still being completed.
For the remainder of this section we will consider the following instruments:
Structured Assessment of Violence Risk in Youth (SAVRY)
Estimate of Risk of Adolescent Sexual Offense Recidivism (ERASOR)
Psychopathy Check List – Youth Version (PCL-YV)
Assessment, Intervention and Moving On Project (AIM-II Assessment).
SAVRY
The Structured Assessment of Violence Risk in Youth (SAVRY) is the most widely used risk assessment tool in the United Kingdom.
It is a structured clinical assessment instrument and is designed for use with young people aged between 12 and 18 years old.
Developed in Canada, it has been validated in both North American and European populations.
It is used by the national adolescent forensic medium secure units to assess risk. It is also used by many of the specialist community adolescent forensic teams.
The SAVRY bears a strong resemblance to the HCR-20 (a structured risk assessment instrument that is widely used to assess risk of violence in adults). Indeed one of the authors of the HCR-20 was also involved in the development of the SAVRY.
However, a unique feature of the SAVRY is that in addition to considering 24 factors (static and dynamic) that increase a young person’s risk of future violence, it also considers six factors that are thought to protect against future violence (Borum & Forth, 2003).
ERASOR
Estimate of Risk of Adolescent Sexual Offense Recidivism (ERASOR)
The ‘Estimate of Risk of Adolescent Sexual Offense Recidivism’ (ERASOR) is a Canadian instrument developed specifically for determining the risk of further sexual offending by adolescent sex offenders.
It is designed for use with 12- to 18-year-old males.
It is a standardised (or actuarial) risk assessment tool.
It has not yet been validated in a European population but, in the absence of a suitable alternative, is often used to assess risk of future sexual offending in the United Kingdom.
AIM II
Assessment, Intervention and Moving On Project (AIM-II Assessment)
A promising new tool for assessing the risk of sexual offending in young people has been developed in the UK.
The Assessment, Intervention and Moving On Project (AIM-II Assessment) is a manualised assessment and intervention for young offenders who have been convicted of a sexual offence by the G-MAP team in Manchester.
The assessment:
takes several appointments
should be conducted with two practitioners
facilitates structured decision making about the level of surveillance required to prevent the young person reoffending with the same offence.
There are four domains, which are all subdivided into static and dynamic factors:
sexual
developmental
family and carers
environment.
Initial research has shown this assessment to be valid. Longer term longitudinal research is ongoing.
PSYCHOPATHY check list
The term psychopathy is an emotive one and many people are uncomfortable with its use. However, the concept has gained new currency in adult forensic mental health after Hare developed an actuarial risk assessment tool called the ‘Psychopathy Check List - Revised’ (PCL-R) based upon Checkley’s definition of psychopathy.
The instrument involves scoring a person against 20 items, to give a total score out of 40. High scores on the instrument (above 30 for North American populations and above 25 for European populations) have been found to correlate with violence levels in a range of criminal justice and psychiatric populations.
A major limitation of the PCL-R is that it is based on static risk factors and is therefore unable to detect change. Thus, once a person has screened high for psychopathy he cannot reduce his result at a later date.
Considerable research has taken place using the PCL-R, and a number of related instruments have been developed. One of these newer instruments is:
the Psychopathy Check List –Youth Version (PCL-YV)
This instrument shares many of the characteristics of the PCL-R including being unable to detect change. However, it has not been validated in a UK population and is not currently widely used as a risk assessment instrument in the UK
treatment for conduct disorder
Conduct disorder
Evidence of the effectiveness of interventions aimed at reducing conduct disorder has been found for the following:
multi-systemic therapy (MST)
Studies have shown that this is an effective treatment to reduce antisocial behaviour, offending and violent behaviour.
This intervention offers intensive therapy.
The aim of therapy is to effect change in the young person’s behaviour by working with the young person and the systems in which the young person lives e.g. home, school and peer systems.
This model originated in the USA where it has been shown to reduce adult offending in a 13 year follow-up study.
It has been piloted with some success by the YOT in Cambridge and some London sites, and is being offered from various sites across the country.
solution focused, interpersonal therapy
some parenting interventions (e.g. The Incredible Years, Triple P and Stengthening Families).
