Taking “the boss” into the real world: Field interrater reliability of the Short‐Term Assessment of Risk and Treatability: Adolescent Version

There is emerging evidence that the performance of risk assessment instruments is weaker when used for clinical decision‐making than for research purposes. For instance, research has found lower agreement between evaluators when the risk assessments are conducted during routine practice. We examined the field interrater reliability of the Short‐Term Assessment of Risk and Treatability: Adolescent Version (START:AV). Clinicians in a Dutch secure youth care facility completed START:AV assessments as part of the treatment routine. Consistent with previous literature, interrater reliability of the items and total scores was lower than previously reported in non‐field studies. Nevertheless, moderate to good interrater reliability was found for final risk judgments on most adverse outcomes. Field studies provide insights into the actual performance of structured risk assessment in real‐world settings, exposing factors that affect reliability. This information is relevant for those who wish to implement structured risk assessment with a level of reliability that is defensible considering the high stakes.     

A retrospective study on risk assessment and management of forensic psychiatric inpatients in Hong Kong

The Department of Forensic Psychiatry of Castle Peak Hospital is the only facility in Hong Kong that provides territory-wide forensic psychiatric services for patients with criminal involvement. This retrospective study aimed to explore whether the rehabilitation programs provided by the department could significantly reduce the risks of forensic psychiatric inpatients as measured by the Short-Term Assessment of Risk and Treatability (START). START ratings of inpatients who were hospitalized in the department for more than 3 months and were discharged to the community during the period from 11 April 2015 to 31 March 2019 were analyzed. A total of 79 patients were assessed, of whom 61 (77.2%) were males. Fifty-four (68.4%) patients suffered from schizophrenia. START scores upon admission (strength score = 5.67; vulnerability score = 17.43) and upon discharge (strength score = 6.87, vulnerability score = 11.18) indicated significant reduction of risks among inpatients (p < 0.05).     

Using dynamic risk and protective factors to predict inpatient aggression: Reliability and validity of START assessments

The Short-Term Assessment of Risk and Treatability (START; C. D. Webster, M. L. Martin, J. Brink, T. L. Nicholls, & S. L. Desmarais, 2009; C. D. Webster, M. L. Martin, J. Brink, T. L. Nicholls, & C. Middleton, 2004) is a relatively new structured professional judgment guide for the assessment and management of short-term risks associated with mental, substance use, and personality disorders. The scheme may be distinguished from other violence risk assessment instruments because of its inclusion of 20 dynamic factors that are rated in terms of both vulnerability and strength. This study examined the reliability and validity of START assessments in predicting inpatient aggression. Research assistants completed START assessments for 120 male forensic psychiatric patients through review of hospital files. They also completed Historical-Clinical-Risk Management-20 (HCR-20; C. D. Webster, K. S. Douglas, D. Eaves, & S. D. Hart, 1997) and Hare Psychopathy Checklist: Screening Version (PCL:SV; S. D. Hart, D. N. Cox, & R. D. Hare, 1995) assessments. Outcome data were coded from hospital files for a 12-month follow-up period using the Overt Aggression Scale (OAS; S. C. Yudofsky, J. M. Silver, W. Jackson, J. Endicott, & D. W. Williams, 1986). START assessments evidenced excellent interrater reliability and demonstrated both predictive and incremental validity over the HCR-20 Historical subscale scores and PCL:SV total scores. Overall, results support the reliability and validity of START assessments and use of the structured professional judgment approach more broadly, as well as the value of using dynamic risk and protective factors to assess violence risk. (PsycINFO Database Record (c) 2012 APA, all rights reserved).     

Short-Term Assessment of Risk and Treatability (START): The case for a new structured professional judgment scheme

The Short-Term Assessment of Risk and Treatability (START) is a new structured professional judgment scheme intended to inform multiple risk domains relevant to everyday psychiatric clinical practice (e.g. risk to others, suicide, self-harm, self-neglect, substance abuse, unauthorized leave, and victimization). The article describes the processes involved in establishing an interdisciplinary approach to risk assessment and management. The authors present a review of the rationale for START, including the value of dynamic variables, the importance of strengths, and the extent to which clinicians must be attentive to multiple risk domains, reflecting theoretical and scientific evidence of the overlap among risks. Using the development, validation, and implementation of START as an example, the authors describe the processes by which other researchers, clinicians, and administrators could adapt existing assessment schemes or create new ones to bridge some remaining gaps in the risk assessment and management continuum.     

Short-Term Inpatient DBT Combined with Metacognitive Interventions for Personality Disorders: A Pilot Acceptability and Effectiveness Study

This study aims at evaluating the effectiveness of an intensive 1-month residential treatment course in an Italian psychiatric unit for patients meeting criteria for personality disorders (PD). This study involved 189 patients consecutively admitted to the unit and assessed at admission and discharge. The inpatient program was based on Dialectical Behavior Therapy (DBT) combined with Metacognitive interventions. Primary outcome was a reduction of general symptom severity (as measured by SCL-90-R). Secondary outcomes were reduction in depression (BDI), interpersonal problems (IIP-47). Other outcomes were impulsivity (BIS-11), aggressiveness (AQ), and dissociation (DES). We found a significant reduction in symptom severity, as well as in depression, interpersonal problems, dissociation, impulsivity and aggressiveness. The size of this benefit was predicted mostly by number of criteria met at SCID-II and intake scores mostly for impulsiveness and dissociation. In conclusion, intensive 1-month residential DBT combined with metacognitive interventions can be effective in treating patients with any PD presenting with severe global suffering, prominent self-harm and suicidal risk.

     

Resilience and successful community reintegration among female forensic psychiatric patients: a preliminary investigation

Research on resiliency and recovery in forensic psychiatric patients is still limited. Information pertaining to factors associated with successful community reintegration would contribute to a more comprehensive assessment of functioning and informed treatment planning that fits within a recovery approach of service provision. Using a retrospective design involving file reviews and a 3-year follow-up period, the authors investigated the rate of successful/unsuccessful community reintegration (defined by the presence or absence of an absolute discharge/readmission to hospital) in female forensic psychiatric patients (N = 48). The study evaluated the extent to which the risk and protective factors captured in the Short-Term Assessment of Risk and Treatability (START) predicted a range of positive and negative outcomes in the study sample. Results showed that 47.9% of the women qualified as having successfully reintegrated into the community, with the remaining 52.1% qualifying as still being in recovery. Successful individuals possessed significantly more protective factors and significantly fewer risk factors than individuals still in recovery. Furthermore, both the vulnerability and the strength scale of the START demonstrated good predictive validity, however we did not find evidence of incremental validity of the strength scale. Copyright © 2011 John Wiley & Sons, Ltd.     

Characteristics of START Assessments Completed in Mental Health Jail Diversion Programs

Many different instruments have been developed to assist in the assessment of risk for violence and other criminal behavior. However, there is limited evidence regarding how these instruments work in the 'real world'. Even less is known about how these instruments might work for assessing risk in jail diversion populations, whether in research or practice. To address these knowledge gaps, the present study examined the characteristics of risk assessments completed by program staff (n?=?10) on 96 mental health jail diversion clients (72 men and 24 women) using the Short-Term Assessment of Risk and Treatability (START). The findings provide preliminary support for the reliability and validity of START assessments completed in jail diversion programs, the first evidence of the transportability of START outside psychiatric settings, and further evidence regarding the reliability and validity of START assessments completed in the field. They additionally support the consideration of an eighth, general offending risk domain in START assessments. Copyright ? 2012 John Wiley & Sons, Ltd.     

Operationalizing the Assessment and Management of Violence Risk in the Short-term

Assessing risk of violence in the short term is crucial for managing and preventing violence, especially in institutions such as psychiatric units and prisons. Despite a lack of consensus on the definition of "short term", a number of recent tools and guidelines have been developed to aid short-term clinical decision-making. Whereas the supporting evidence for the new tools is impressive, limitations remain in terms of the focus on prediction, limited consideration of strengths, and poor integration with formulation and risk management. The Short-Term Assessment of Risk and Treatability (START) is a brief clinical guide for the dynamic assessment of risks, strengths and treatability. It focuses on short-term risks and the characteristics of the individual that, if changed, might lead to an increase or decrease in risk. The START has the potential to operationalize the structured professional judgment (SPJ) approach in order to inform the evaluation of multiple risk domains relevant to everyday psychiatric clinical practice. However, explicit guidance on integrating risk assessment, formulation and management is limited in the START and this paper describes the SPJ approach, reviews recent developments in approaches to risk, and considers how the START can be used to inform SPJ approaches and link risk assessment, formulation, and management. Copyright ? 2012 John Wiley & Sons, Ltd.     

Childhood predictors of adolescent substance use in a longitudinal study of children with ADHD

Children diagnosed with attention-deficit/hyperactivity disorder (ADHD; n = 142) were prospectively monitored into adolescence (13-18 years old) to evaluate their risk for elevated substance use relative to same-aged adolescents without ADHD (n = 100). Probands reported higher levels of alcohol, tobacco, and illicit drug use than did controls. Group differences were apparent for alcohol symptom scores but not for alcohol or marijuana disorder diagnoses. Within probands, severity of childhood inattention symptoms predicted multiple substance use outcomes: childhood oppositional defiant disorder/conduct disorder (ODD/CD) symptoms predicted illicit drug use and CD symptoms. Persistence of ADHD and adolescent CD were each associated with elevated substance use behaviors relative to controls. Further study of the mediating mechanisms that explain risk for early substance use and abuse in children with ADHD is warranted.     

Family psychological factors in relation to children's asthma status and behavioral adjustment at age 4

The objectives of this study were to determine whether family psychosocial factors influenced asthma development by age 4, and whether family factors and early wheezing illness were associated with behavioral adjustment at age 4. Participants were 98 children enrolled in an intervention study at 9-24 months and followed to age 4. Baseline evaluations assessed infants' respiratory illness severity, family psychosocial characteristics, and parental risk factors for asthma development. Active asthma categorization at age 4 utilized both parent report and objective data. Parents completed the Child Behavior Checklist (CBCL). Caregiver single-parent status, a composite of baseline family stresses, and early wheezing illness severity were associated with active asthma at age 4. The contribution of prenatal smoke exposure and early hospitalization to active asthma varied with racial/ethnic group membership. Maternal mental health and family stresses predicted CBCL scores at age 4, whereas early illness severity and hospitalization were unrelated to CBCL scores. CBCL scores were not elevated for children with active asthma at age 4. Family factors consistent with a negative emotional environment were associated with both active asthma and adjustment problems at age 4, suggesting that both outcomes may be influenced by a common factor.     

Cumulative risk,teacher-child closeness,executive function and early academic skills in kindergarten children

We tested the role of teacher-child closeness in moderating the associations between early childhood adversity, measured as a cumulative risk index, and child outcomes during the kindergarten year. Using the ECLSK:11, a national dataset of kindergarteners in the 2010–11 academic year, we examined three dimensions of executive function (cognitive flexibility, inhibitory control, working memory), as well as early reading and math scores, as key skills that facilitate the transition to school. Cumulative risk was negatively associated with all outcomes, and teacher-child closeness was positively associated with all outcomes. Teacher-child closeness moderated the relation between cumulative risk and working memory and cumulative risk and reading scores in a protective manner, but not cognitive flexibility, inhibitory control, or math scores. Implications for research in early childhood adversity and education are discussed.     

Treating Prepartum Depression to Improve Infant Developmental Outcomes: A Study of Diabetes in Pregnancy

Whether and how the co-occurrence of depression and diabetes in pregnancy may worsen infant development has not been reported. Pregnant women with diabetes and with (n?=?34) or without (n?=?34) major depressive disorder (MDD) were followed during pregnancy and 6-months postpartum. The MDD subset received randomly assigned treatment with cognitive behavior therapy (CBT) or supportive counseling (SC). Depression severity was measured with the Beck Depression Inventory (BDI); infant developmental outcomes were measured with the Bayley Scales of Infant Development (BSID) and its Behavior Rating Scale (BRS). Infants of women with MDD had lower BRS scores (p?=?.02). Reduction in depression scores was associated with better infant outcomes on the BSID and BRS (p values <.03). These preliminary findings suggest depression occurring in pregnant women with diabetes is associated with poorer infant development and improvement in prepartum depression is associated with improvement in measures of infant development.     

Implications of naturalistic use of pharmacotherapy in CBT treatment for panic disorder

This study examined naturalistic medication use and cognitive behavioral therapy (CBT) treatment outcomes in 105 patients meeting DSM-IV criteria for panic disorder (PD), assessed by structured clinical interview. The association between pre- and post-treatment use of SSRIs, benzodiazepines (BZs), and any anti-anxiety or anti-depressant (A/D) medication were investigated for three indicators of treatment outcome (PD severity, presence of agoraphobia (AG), anxiety sensitivity) at post-treatment and 6-month follow-up. Controlling for pre-treatment severity, pre-treatment SSRI use was associated with worse outcomes for AG (p=.04) and anxiety sensitivity (p=.047); post-treatment SSRI use was associated with delayed improvements in PD severity (p=.05). Pre-treatment use of A/D was associated with poorer PD severity outcomes (p=.04). Post-treatment use of A/D was associated with higher anxiety sensitivity scores across post-treatment and 6-month follow-up (p=.03). BZ use was not associated with significantly worse outcomes. However, there was a decrease in the number of patients using BZs from pre-treatment to post-treatment (p=.06) and follow-up (p=.006). In conclusion, controlling for pre-treatment severity, pre- and post-treatment use of SSRIs and A/D was associated with poorer outcomes, particularly for PD severity and anxiety sensitivity.     

Risky assessments: participant suicidality and distress associated with research assessments in a treatment study of suicidal behavior

The purpose of this study was to examine patterns of self-reported suicidality and distress during research assessments in a sample of 63 women meeting criteria for borderline personality disorder and current and chronic suicidality. The risk management protocol we used during the two-year study period (University of Washington Risk Assessment Protocol; UWRAP) is described. Results indicated that changes in suicidality following assessments were small and relatively infrequent, and were just as likely to reflect decreases in suicidality as increases (17.5% versus 16.4% of sessions, respectively). Further, longitudinal analyses indicated that changes in suicidality became increasingly rare over the course of the 2-year study. Ratings of distress were more changeable than suicidality, underscoring the need for separate measurement of these constructs when assessing risk. With the aid of the UWRAP, our assessors judged 15 participants as high-risk status in 28 assessment sessions (3.7% of all sessions). In comparison to the rest of the sample, these individuals were of significantly greater clinical severity as measured by the HRSD 17-item, GAF scores, number and severity of previous suicide attempts, and number of previous psychiatric hospitalizations. Low-intensity risk intervention strategies (e.g., validating participant's feelings) were typically sufficient to reduce risk in these participants. Overall, our findings indicate that research with highly suicidal individuals can be done safely with the use of well-trained assessors and an appropriate crisis management protocol.     

A randomized trial of a representational intervention to decrease cancer pain (RIDcancerPain).

OBJECTIVE: Based on theories regarding cognitive representations of illness and processes of conceptual change, a representational intervention to decrease cancer pain (RIDcancerPain) was developed and its efficacy tested. DESIGN: A two-group RCT (RIDcancerPain versus control) with outcome and mediating variables assessed at baseline (T1) and 1 and 2 months later (T2 and T3). Subjects were 176 adults with pain related to metastatic cancer. MAIN OUTCOME MEASURES: Outcome variables were two pain severity measures (BPI and TPQM), pain interference with life, and overall quality of life. Mediating variables were attitudinal barriers to pain management and coping (medication use). RESULTS: One hundred and fifty subjects completed the study. Subjects in RIDcancerPain (T1-T2 and T1-T3) showed greater decreases in Barrier scores than those in control. Subjects in RIDcancerPain (T1-T3) showed greater decreases in pain severity than those in control. Change in Barriers scores mediated the effect of RIDcancerPain on pain severity. CONCLUSION: RIDcancerPain was efficacious with respect to some outcomes. Further work is needed to strengthen it.     

Social risk and protective factors for African American children's academic achievement and adjustment during the transition to middle school

The transition to middle school is often marked by decreased academic achievement and increased emotional stress, and African American children exposed to social risk may be especially vulnerable during this transition. To identify mediators and protective factors, the authors related severity and timing of risk exposure to academic achievement and adjustment between 4th and 6th grade in 74 African American children. Longitudinal analyses indicated that severity more than timing of risk exposure was negatively related to all outcomes and that language skills mediated the pathway from risk for most outcomes. Transition to middle school was related to lower math scores and to more externalizing problems when children experienced higher levels of social risk. Language skills and parenting served as protective factors, whereas expectations of racial discrimination was a vulnerability factor. Results imply that promoting parenting and, especially, language skills, and decreasing expectations of racial discrimination provide pathways to academic success for African American children during the transition from elementary to middle school, especially those exposed to adversity.     

Predicting Military Flight Training Success by a Compensatory Tracking Task

This study evaluated the validity of a compensatory tracking task for pre- dicting success in naval flight training. Its purpose was to determine if psychomotor test scores would add unique variance to the current aviation selection model. Aviation candidates (N = 187) admitted on the basis of current selection test scores were administered a 20-min computer-based tracking task before beginning flight training. Performance on the task was compared with flight training outcomes as measured by passlfailure and cu- mulative flight grade. The results indicated that the tracking task scores differentiated candidates who completed training from those who failed. Multiple regression analyses confirmed that the tracking task scores added unique variance to the current selection model.     

The Effect of Concurrent Depression on PTSD Outcomes in Trauma-Focused Psychotherapy: A Meta-Analysis of Randomized Controlled Trials

The co-occurrence of depression with posttraumatic stress disorder (PTSD) is common and associated with greater severity and impairment than PTSD alone, but the effects on PTSD treatment outcomes are unclear. This study investigated the impact of baseline depression on PTSD symptom change and dropout in a meta-analysis of 44 randomized controlled trials (N = 4,866) of trauma-focused psychotherapies for PTSD. Analyses included 107 active (k = 71) and control (k = 36) conditions. Baseline depression was indexed within samples as (a) continuous symptom severity (e.g., Beck Depression Inventory), standardized across depression measures and (b) proportion of patients with comorbid depressive disorder diagnosis. Among active conditions reporting continuous depression scores (k = 62), greater depression severity predicted smaller PTSD treatment effect sizes (ß = -.36, p = .002), but not dropout (ß = .25, p = .18). Categorical depressive diagnosis rates (k = 29)—reported less frequently—were not associated with treatment effects or dropout in active conditions. Greater depression severity may reflect a risk factor for attenuated response in PTSD psychotherapies, potentially demanding complementary strategies within trauma-focused interventions. Variability between trials in baseline depression symptoms may suggest the need to consider this sample characteristic when comparing treatment outcomes across studies.     

The role of risk avoidance in anxiety

Various forms of disinhibitory psychopathology (e.g., substance use disorder) are characterized by a tendency to make overly risky decisions. The current paper reports on data suggesting that, in contrast, anxiety is associated with an exaggerated tendency to engage in risk-avoidant decision making. In a nonclinical sample of university students, trait anxiety was associated with relatively low willingness to take risks, across a range of behavioral contexts. Trait anxiety was also associated with pessimistic risk appraisals (e.g., heightened perceptions of the likelihood and severity of negative outcomes). Furthermore, these associations were apparent while controlling for depression. Additional findings suggest that heightened perceptions of the severity of negative outcomes might mediate the link between trait anxiety and risk avoidance. This research has implications for understanding the role basic risk decision-making processes may play in the nature and treatment of anxiety.     

Risk factors and the Child Behavior Checklist in a child mental health center setting

The relationship between risk factors and the severity and type of childhood disorder, as measured by parent-completed Child Behavior Checklists, was examined for 768 children, ages 4–16, seen at a child mental health center. Regression analyses revealed no significant relationships between any combination of risk factors and the total number of behavior problems, internalizing, or externalizing scores for the entire group, males and females separately, or for the age and sex groupings of 6- to 11- and 12-to 16-yearolds. Chi-square tests revealed no relationship of profile type with any risk factor or with total number of risk factors. Implications for broad-based child assessment and risk factor research within a clinical population are discussed.We wish to thank Orin Bolstad, Linda Magnuson, and Julian Taplin for their assistance in this project.