Acute aggression risk: an early warning signs methodology

DOIhttps://doi.org/10.1108/14636641311299059
Date08 February 2013
Published date08 February 2013
Pages21-31
AuthorAlan Meaden,David Hacker,Kerry Spencer
Subject MatterHealth & social care,Public policy & environmental management,Sociology
Acute aggression risk: an early warning
signs methodology
Alan Meaden, David Hacker and Kerry Spencer
Abstract
Purpose – Predicting the imminence of high risk behaviours in in-patients with schizophrenia is an
ongoing concern. The purpose of this paper is to explore the utility,validity and reliability of an adapted
early warning signs methodology for dynamic risk assessment.
Design/methodology/approach – Nursing staff were interviewed to identify operationally defined early
warning signs of high risk behaviours. Frequency of occurrence of the early warning signs and the high
risk behaviour were rated over a one week period to establish the predictive validity of the methodology.
Findings – Support was found for the reliability of staff ratings of the relevance of identified early
warning signs and their occurrence within a specified time period. ROC analysis indicates some modest
predictive validity in predicting aggressive risk behaviours but effect sizes were small, and there were
high rates of false positive predictions.
Research limitations/implications The small sample size limits generalisability. A longitudinal
prospective study to better establish the added predictive power of the method over the use of largely
actuarial methods is needed.
Originality/value – A dynamic risk assessment methodology to assess changes in risk for inpatients
would benefit both staff and inpatients. No such methodology has been assessed to date.
Keywords Mental illness, Patients, Behaviour, Risk assessment, Aggression, Dynamic risk factors,
Early warning signs, Schizophrenia
Paper type Research paper
Introduction
A diagnosis of schizophrenia is associated with an increased risk of aggressive and violent
acts compared to the general population (Mullen, 2006). This finding applies to both
community (Bonta et al., 1998) and inpatient settings (Larkin et al., 1988). Indeed, rates
of inpatient aggression have been estimated to be around 10-45 per cent with a median rate
of 25 per cent (Monahan, 1992; Daffern et al., 2007). Admission itself can often precipitate an
increased risk of aggression, with one in four aggressive incidents (and a third of physical
attacks) occurring in the first three days of admission (Abderhalden et al., 2007). Similarly,
people with a diagnosis of schizophrenia are at increased risk of suicide with a rate of
4-6.8 per cent (Pompili et al., 2005) or around eight times that of the general population. Even
higher rates (20-40 per cent) are present for attempted suicide (Drake, cited in Pompili et al.,
2005). Notably, a minority of inpatients are responsible for a large proportion of violent
incidents (Blumenthal and Lavender,2000; Abderhalden et al., 2007). Andrews et al. ’s(1990)
principles of ‘‘risk, need and responsivity’’ are of particular relevance here: they propose that
increased resources should be allocated to service users at highest risk; their treatment
should focus on specific risk factors and should be tailored to the individual. Suicide risk is
increased shortly after admission to hospital and shortly following discharge (Pompili et al.,
2005), with a substantial proportion of suicides by people with schizophrenia committed
whilst on leave from hospital or during absconscion (Shah and Ganesvaran, 1999).
DOI 10.1108/14636641311299059 VOL. 15 NO. 1 2013, pp. 21-31, QEmerald Group Publishing Limited, ISSN 2050-8794
j
JOURNAL OF FORENSIC PRACTICE
j
PAGE 21
Alan Meaden and
David Hacker are based at
the Birmingham and
Solihull Mental Health NHS
Foundation Trust,
Birmingham, UK.
Kerry Spencer is based at
the Worcestershire
NHS Health and Social
Care Trust, Worcester, UK.

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