Background: Identification of risks is foundational to the development of strategies to prevent conduct problems in children. The Early Assessment Risk List Version 3 (EARL-V3) is a Structured Professional Judgment (SPJ) instrument designed for application to children exhibiting antisocial behavior. The revised EARL-V3 (2021) encourages users to be responsive to gender and cultural issues and is designed to assist in treatment planning. While previous versions of the EARL have undergone extensive testing, reliability has not been established for the new version. Methods: The present study yields Intraclass Correlation Coefficients (ICCs) for the three EARL-V3 subscales and the total score. Additional analyses are based on Gwet's AC1 method for examining individual items. Four rater pairs assessed a selection of 124 children (50 girls, 74 boys; six to 12 years). Case files included child and caregiver interviews and clinical assessments. Results: We found moderate to excellent agreement for two of the three subscales and the total score, and poor to moderate agreement for one subscale. The individual items ranged from fair to almost perfect agreement. The Overall Clinical Risk Judgement revealed fair to moderate inter-rater agreement. The results largely remained when analyzed based on gender. Some differences were seen for individual risk factors. Conclusion: The EARL-V3 has a good level of inter-rater reliability, comparable or superior to previous versions of the EARL and to other SPJ instruments.

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Abstract Background Identification of the risk factors underlying impulsivity related to violent acts is an essential component of risk assessment and management to reduce violent offending. Aims Our aim was to develop a clinically useful measure for assessing impulsivity related to violence. Our research questions were which items in the newly developed measure are associated with later violent recidivism and what is the measure's predictive validity? Methods A new scale, the impulsivity measure related to violence (IMP‐V), was studied by completing the scale, blind to outcome, from information in the forensic psychiatric examination reports of 63 of a 1‐year referral cohort of 181 Finnish offenders. Data on reoffending for up to 15 years after release were collected from official criminal records. Results The predictive accuracy of the IMP‐V continuous ratings was 78% and for the categorical summary risk ratings 77%. Univariate analyses of categorical summary risk ratings of the risk factors revealed that, with two exceptions, each additional score on the IMP‐V was associated with a significant increase in violence recidivism. Conclusions These preliminary results indicate that the IMP‐V is a promising decision‐enhancing guide for assessing the risk of violence in impulsive people and that the measure is worth developing for use with impulsivity‐prone offenders and forensic psychiatric patients. The IMP‐V organises information on the nature of impulsivity in violence‐prone persons and thus also creates opportunities for more effective risk management.

We draw on an article published in 1973 in this journal. We described how we taught “Geoff,” a 6-year old boy with autism, an elementary form of sign language during the course of 24 one-hour sessions held over a 12-week period (Webster et al. in J Autism Child Schizophr 3:337–346, 1973; Fruchter in Autism: new directions in research and education, pp 184–186, 1980). Here, we describe how it is that Geoff has maintained the vestiges of what we taught him (and indeed what he taught us) over the long span. This basic communication strategy has endured well and continues to contribute to his enjoyment of life.

We analyze relevant aspects in the history of forensic mental health services in the Toronto area, which offers a well-documented historical record for contextualizing current public debates and controversies. Spanning the late 18th century to the present, we trace the development of common and statute law, and service responses in the forensic and criminal justice systems, through the evolution of asylums to latter-day psychiatric facilities and services. Addressing themes of evolving interfaces between the practices of law and mental health care reveals that the balance, as enacted in law and interpreted by the courts, has generally favoured legal interpretations of mental illness, despite psychiatry's steadily-increasing claim to superior insights and evidence on what constitutes mental illness in juridical contexts. The experience of forensic psychiatry over this 200-year period points to relevant implications for continued refinement of legal, court and clinical provisions for this service, and directions for future research.

The HCR-20 Version 3 (HCR-20V3) was published in 2013, after several years of development and revision work. It replaces Version 2, published in 1997, on which there have been more than 200 disseminations based on more than 33,000 cases across 25 countries. This article explains (1) why a revision was necessary, (2) the steps we took in the revision process, (3) key changes between Version 2 and Version 3, and (4) an overview of HCR-20V3's risk factors and administration steps. Recommendations for evaluating Version 3 are provided.

BACKGROUND:Findings from violence risk assessment prediction-outcome studies suggest that there is no overall 'standout' scheme.AIM:This paper aims to highlight that even greater attention is now required on intervention-focused research.METHODS:Recent advances in the development of structured professional judgement schemes, such as the Historical, Clinical, Risk Management-20 (Version 3), are considered when applied to the tasks of refining individual case formulation and risk management planning. The paper also considers social science research relevant to improving interventions aimed at preventing violence and related risks.RESULTS:A sequential redirection treatment model is proposed on the basis of our limited understanding of how interventions 'work' when applied to mentally disordered offenders.CONCLUSIONS AND IMPLICATIONS FOR PRACTICE:Future developments in violence-reduction interventions will require improved integration between the worlds of research and clinical practice.

The HCR-20 is widely used to assess risk of violence among patients with schizophrenia. Further understanding of the accuracy and changes over time in C and R scores is needed. Using prospectively collected data on 248 men with schizophrenia, the present study found that the HCR-20 significantly predicted aggressive behavior over 24 months. The H, C, R, HCR-20 total, and final risk judgment scores were unable to predict aggressive behavior better than chance among the general psychiatric patients in the first six months after discharge. Changes in three C items, the total R score, and in three R items significantly predicted changes in aggressive behavior.

The historical perspective of a book reviewer often affects how he appreciates a scholarly compilation. My earliest memory regarding the assessment of dangerousness occurred during the first week of my internship when the California Supreme Court issued its ruling in the 1976 rehearing of Tarasoff v. Regents of the University of California. This decision was handed down amid concerns of the limited accuracy of assessments of dangerousness as captured by the then often-echoed catchphrase, “flipping coins in the courtroom.” Since then, I have witnessed gradual clinical advances in the assessment of dangerousness and violence risks along with the evolving legal and social landscape in which these assessments are performed. The authors of the second edition of Violence Risk Assessment have captured the historical essence of these four decades and describe the current state of affairs for violence risk assessment. The second edition has added an author from the United Kingdom (psychiatrist Quizi Haque, Honorary Lecturer at the King’s College Institute of Psychiatry) to the two Canadian authors from the first edition (psychologist Christopher D. Webster, Professor Emeritus of Psychiatry at the University of Toronto and Professor Emeritus of Psychology at Simon Fraser University and psychiatrist Stephen J. Hucker, Professor of Psychiatry at the University of Toronto). They are well known in the North American forensic mental health community. Relative to the previous edition, the book’s focus shifts from the use of structured professional judgment in violence risk assessment to emphasis on the value of violence risk assessment as an essential component of clinical treatment that should guide an individual’s treatment plan. In fact, the subtitle of their book, Advances Through Structured Professional Judgment and Sequential Redirection, underscores this additional focus, which is preached throughout the book. The book has 20 chapters: 16 of them written by Drs. Webster, Haque, and Hucker. The authors summarize the historical development of violence risk assessment, provide a thorough discussion of the identifying various risk factors for violence, and describe the birth and evolution of specific tools that have become an integral part of these assessments, such as the Historical Clinical Risk Management (HCR)-20. There is a review of the usual components of a competent forensic assessment, including the importance of having an adequate database and identifying the type and parameters of the potential harm being assessed. Of note, there is a cautionary discussion about what seems to be a real limitation (or sound barrier) to the predictive accuracy of these assessments, even under optimal conditions. The authors champion the use of structured professional judgment, which tempers the contribution of an assessment tool by considering characteristics and factors that are specific to the evaluee. The book does a credible job of convincing the reader that violence risk assessment plays an important, if not critical, role in the treatment and management of persons in general, correctional, and forensic mental health systems. The major assets of this book include the historical development of structured professional judgment and the generic description of the risk assessment process. This approach permits programs to use the principles to tailor violence risk assessment to apply to their specific situations. R. Karl Hanson’s chapter on assessment of sex offenders is one of the best, if not the best, I have seen on the topic in a single compact chapter, especially in its discussion of the Static-99 and its progeny, the most recognizable of assessment tools used in sex offender evaluations. Violence Risk Assessment and Management is a compact book that excels in educating and enlightening the psychiatrist-in-training and the seasoned forensic psychiatrist about this important topic. I have waited nearly 40 years for this book.

SummaryStructured professional judgement risk management schemes such as the Historical, Clinical, Risk Management - 20 (HCR-20) can be described as clinical guidelines produced by a collaborative process between mental health clinicians and researchers. The purpose is to provide clinicians with a framework to guide interventions designed to manage specific risks such as violence against others. The use of evidence-based clinical methods, especially in a multidisciplinary setting, is now commonly considered a best-practice approach when managing violence and related risks. This article describes some of the practical implementation challenges that may arise when using schemes such as the HCR-20 in multi-disciplinary team meetings.

The field of violence risk assessment has matured considerably, possibly advancing beyond its own adolescence. At this point in the field's evolution, it is more important than ever for the development of any new device to be accompanied by a strong rationale and the capacity to provide a unique contribution. With this issue in mind, we first take stock of the field of adolescent risk assessment in order to describe the rapid progress that this field has made, as well as the gaps that led us to adapt the Short-Term Assessment of Risk and Treatability (START; Webster, Martin, Brink, Nicholls, & Desmarais, 2009) for use with adolescents. We view the Short-Term Assessment of Risk and Treatability: Adolescent Version (START:AV; Nicholls, Viljoen, Cruise, Desmarais, & Webster, 2010; Viljoen, Cruise, Nicholls, Desmarais, & Webster, in progress) as complementing other risk measures in four primary ways: 1) rather than focusing solely on violence risk, it examines broader adverse outcomes to which some adolescents are vulnerable (including self-harm, suicide, victimization, substance abuse, unauthorized leave, self-neglect, general offending); 2) it places a balanced emphasis on adolescents’ strengths and vulnerabilities; 3) it focuses on dynamic factors that are relevant to short-term assessment, risk management, and treatment planning; and 4) it is designed for both mental health and justice populations. We describe the developmentally-informed approach we took in the adaptation of the START for adolescents, and outline future steps for the continuing validation and refinement of the START:AV.

Current best practice guidelines recommend clinicians consider clients’ strengths as well as their deficits (APA, 2006; Department of Health, 2007). The Short-Term Assessment of Risk and Treatability (START) is one of the few structured professional judgment (SPJ) measures that facilitate this balanced approach to assessment and treatment planning. START is a concise clinical guide for the assessment and management of seven short-term (i.e., weeks to months) risk estimates (violence, self-harm, suicide, substance abuse, unauthorized leave, self-neglect, and being victimized) that occur at elevated rates in populations of individuals living with mental illness and personality disorders. Research on START has focused to some extent on assessments completed by research assistants. This study examined the implementation of START into a large forensic psychiatric service and reports on the psychometric properties of the measure when completed by multidisciplinary treatment teams. All START forms completed over a one-year period were evaluated ( N= 1057). Results indicate good structural reliability and excellent dispersion across the items, scales, and risk estimates. Few differences were noted by patient gender. Signature risk signs were much more common than expected (27%). It is notable that few patients were determined to be high risk on any of the seven risk estimates, with the exception of substance abuse. Overall, the results provide preliminary evidence for the success of the implementation and the value of the START for informing needs and treatment planning in forensic services.

F orty years ago in this journal, Jay Haley wrote an article entitled ‘‘How to Fail as a Psychotherapist.’’ In his article, he outlined the ‘‘daily dozen’’ of what could be construed as sub-optimal psychotherapy practices (e.g., ‘‘Insist that the problem which brought the patient into therapy is not important’’; ‘‘Insist that only years of therapy will really change a patient’’; ‘‘Avoid the poor because they will insist upon results and cannot be distracted with insightful conversations’’; ‘‘Avoid evaluating the results of therapy’’). The true purpose of Haley’s article was, of course, to show that much knowledge exists about strategies for effective, ethical psychotherapy. More than a decade ago, Christopher Webster emulated Haley in a book chapter describing how to fail as an assessor of risk of violence (‘‘The Art of Being a Failure as an Assessor: Twenty Suggestions’’). Analogously, the real purpose was to create a framework for the conduct of assessments of risk of violence that would meet or exceed general professional standards. For example, Webster satirically exhorted readers to avoid clarifying the purpose of the evaluation, using a systematic approach to assessment, and obtaining outcome data. At the time when Webster’s chapter appeared, researchers were beginning to explore the predictability of institutional and community violence. Scholars intended, in part, to test earlier views that clinicians have very limited capacity for fulfillment of this task. The publication of a variety of risk assessment schemes helped subsequent researchers substantially. Although not originally intended as predictive devices, some of these instruments (e.g., the Hare Psychopathy Checklist Revised [PCL-R]) appeared to have potential as tools for forecasting violence. Although none of these many schemes have yielded truly impressive predictive power, most have performed better than would have been expected 30 or 40 years ago. Psychometric differences among contemporary instruments tend to be small—unsurprisingly, given that item content tends to overlap considerably. As Randy Otto and Kevin Douglas have shown, the new challenge is not to find instruments with acceptable predictive power but instead to ensure fidelity of application. Design of a risk assessment device may be easier than ensuring its true-topurpose application in forensic, civil mental health, and correctional settings. Because such instruments have a proven, albeit imperfect ability to separate the patients who present risks from those whom politicians can safely ignore, there will always be a market for a good implementation

A description is offered of how colleagues in a variety of mental health disciplines were helped to implement a structured professional judgment (SPJ) risk assessment guide, the HCR-20 (Webster, Douglas, Eaves, & Hart, 1997), in a maximum secure forensic psychiatric institution in Ontario, Canada. It is argued, in this descriptive study, that the implementation process in an institution can go awry in a variety of different ways at a number of important junctures. Yet it is possible, given encouraging consultation and support at the outset and continued technical assistance, to weave such a SPJ scheme into the fabric of routine clinical work and decision making. The point is made that such implementation efforts pay off by liberating creativity in the construction of post-release plans. In addition, they assist in ensuring reports prepared for formal boards are thorough, on point, and take full advantage of the information available from all team members. We identify and discuss eight factors that appeared to facilitate implementation.