The Office of the Senior Practitioner
Positive solutions in practice: clinical risk
assessment and risk management in people with an
intellectual disability
October 2009
This guide has been developed as a reference source for senior disability managers and
specialist services staff.
Overprotection may appear on the surface to be kind, but it can be really evil. An oversupply can
smother people emotionally, squeeze the life out of their hopes and expectations, and strip them of
their dignity. Overprotection can keep people from becoming all they could become. Many of our best
achievements came the hard way: We took risks, fell flat, suffered, picked ourselves up, and tried
again. Sometimes we made it and sometimes we did not. Even so, we were given the chance to try.
Persons with special needs need these chances, too. Of course, we are talking about prudent risks.
People should not be expected to blindly face challenges that, without a doubt, will explode in their
faces. Knowing which chances are prudent and which are not – this is a new skill that needs to be
acquired. On the other hand, a risk is really only when it is not known beforehand whether a person can
succeed. The real world is not always safe, secure, and predictable, it does not always say “please,”
“excuse me”, or “I’m sorry”. Every day we face the possibility of being thrown into situations where we
will have to risk everything … In the past, we found clever ways to build avoidance of risk into the
lives of persons living with disabilities. Now we must work equally hard to help find the proper amount
of risk these people have the right to take. We have learned that there can be healthy development in
risk taking and there can be crippling indignity in safety! (Perske, 1972)1
The quote above by Robert Perske while written in 1972, still has as much bearing today as
it did back then. There still is a strong tendency for us to limit the exposure of people
with an intellectual disability to experiences that might promote growth and skill
development. Perhaps one area where these attitudes and practices are foremost is in the
application of restrictive practices in attempting to address behaviours of concern. The
development and implementation of the Disability Act (2006) and the Charter of Human Rights
and Responsibilities (2007) however, now challenges us to work with our clients in the
least restrictive and least risk averse manner.
The word “risk” is a term that we have increasingly heard references to over the last 20
years or so. The word is defined in a typical dictionary as being “exposure to the chance
of injury or loss; a hazard or dangerous chance”2. Modern day risk assessment and
management practices have been used to minimize the chance of injuries or death occurring
in a whole raft of day to day activities to the extent that they have significantly changed
the way that we live. This is highlighted for those of us who are old enough to remember
enjoying activities that would just not be permitted today.
Risk assessment and management within a
human service context
The occupational health and safety risk assessments, in the Victorian disability context is
1
Slayter, E.M. (2007). Substance abuse and mental retardation: Balancing risk management with the “dignity
of risk”. Families in Society: The Journal of Contemporary Social Services, 88(4), 651-659.
2
Delbridge, A. et al. (1992). The Macquarie Encyclopedic Dictionary, Sydney, Australia: The Macquarie
Library Pty Ltd.
characterized by the Occupational Violence Risk Assessment and Management Tool (OVRAMT),
are predominantly orientated around protecting staff and others, as they are focused on the
fostering of a safe working and residential/day placement environment. The client
orientated (clinical) assessments on the other hand are focused on the individual
presenting with the behaviour(s) of concern and the factors specific to themselves or their
environment that either increase or decrease their risk of engaging in their specific
behaviours of concern.
There is a subtle yet significant difference between these two approaches. It has sometimes
been the case that occupational health and safety risk assessments have been used in an
attempt to assess risk in the individual displaying the behaviours of concern. The outcome
of these assessments often results in significant restrictions being placed on the person
because the orientation of these assessments necessarily concerns the protection of staff
and others surrounding the person, rather than being focused on the individual. This would
be similar to conducting an occupational health and safety risk assessment on a person with
convictions for bank robberies who is currently working in a fully functioning bank! A
comprehensive risk assessment and management approach must therefore take into account both
the individual and the working environment they are placed in.
Clinical risk assessment approaches
The first type of risk assessments relied on what is referred to as unstructured clinical
judgement, which subsequently proved to be fairly inaccurate in predicting whether someone
would offend or not3 4. Where unstructured clinical judgement falls down with risk
assessment is in the way people will have different ideas about what is an important risk
factor or what is not. As a consequence two risk assessors using this method could arrive
at completely different risk assessments for the same individual.
The second type of risk assessments were based on research that examined what factors were
found to have the best ability to predict the offender’s long term risk potential. These
assessments were developed to be actuarial in nature, meaning that they were based on
statistics obtained from a common set of risk factors that were weighted to produce a
definite score. The major problem with these actuarial assessments however is that because
they are unchanging they cannot be used to measure a person’s response to treatment
programs or how to manage their risk, nor do they take into account potential protective
factors such as crippling disease and the development of significant positive
relationships5 6.
The third type of risk assessments looked at this problem of actuarial risk assessments not
being able to measure change, with the research focusing on what are referred to as dynamic
or changeable risk factors. Examples of dynamic risk factors include interpersonal
relationships, the degree and nature of social support networks, vocational involvement,
participation in treatment programs, and substance abuse. They are divided into a further
two categories of stable and acute dynamic risk factors. Stable dynamic risk factors are
changeable but change slowly, such as social skills and substance abuse. Acute dynamic risk
factors are those that can rapidly change such as intoxication and feelings7 8. The dynamic
3
Birgden, A. & Ward, T. (2003). Pragmatic psychology through a therapeutic jurisprudence lense:
Psycholegal soft spots in the criminal justice system. Psychology, Public Policy, and Law, (3-4), 334360.
4
Eccleston, L., Brown, M., & Ward, T. (2001). The assessment of dangerous behavior. In F. Columbus (Ed.),
Advances in Psychology Research (pp. 167-207). Nova Science.
5
Hudson, S.M., Wales, D.S., Bakker, L., & Ward, T. (2002). Dynamic risk factors: The Kia Marama
evaluation. Sexual Abuse: A Journal of Research and Treatment, 14, 103-119.
6
McCarthy, J. (2001). Risk assessment of sexual offenders. Psychiatry, Psychology and Law, 8, 56-64.
7
Lambrick, F. (2003). Issues surrounding the risk assessment of sexual offenders with an intellectual
disability. Psychiatry, Psychology and Law, 10(2), 353-358
8
Lindsay, W.R. and Beail, N. (2004). Risk assessment: Actuarial prediction and clinical judgement of
offending incidents and behavior for intellectual disability services. Journal of Applied Research in
Intellectual Disabilities, 17, 229-234.
risk factor assessments that were developed from this research are referred to as
structured clinical guideline assessments. This focus on dynamic or changeable risk factors
reflected a shift in emphasis away from risk prediction in the second type assessments to a
focus on risk management9.
A more recent approach to risk assessment and management has recommended the use of both
actuarial and structured clinical guideline approaches. The actuarial risk assessment
provides a “risk baseline” for the risk assessment. This risk baseline provides a static
(unchanging) risk estimate that can be used to determine the intensity of treatment and
supervision that the person should receive; the higher the score on this risk assessment,
the greater the level of treatment intensity and supervision that the individual needs to
receive. The structured clinical guideline assessment on the other hand, provides us with
an assessment of the dynamic risk factors that are important to monitor and evaluate with
the individual over the course of treatment. This process in turn, provides a basis for
evaluating the person’s degree of progress in treatment programs, also referred to as
assessing the person’s degree of “risk manageability”. In order to effectively undertake
this evaluation process the same guided clinical guideline assessment tool needs to be readministered at key intervals throughout the treatment process10 11.
Risk assessment and people with an intellectual
disability
Until relatively recently no risk assessments, either second or third types, have been
checked to see if they are useful with predicting risk for people who have offended and
have an intellectual disability.
There are a number of significant issues that can arise for offenders with an intellectual
disability when appropriate risk assessment and management tools are not used. In not using
a structured risk assessment tool, staff run the risk of feeding into their personal
beliefs, own ideas and maybe faulty assumptions regarding what risk factors are relevant.
For example, it is often assumed that denial of the sexual offence is related to risk of
re-offending, when research has demonstrated that it is not12. A further issue is that by
not using a common structured risk assessment process, indicators of risk are decided on at
an individual or agency level, thereby confusing communication about risk and its
management at a wider level. This obviously can have potential serious implications for the
ongoing management of the individual and for service system co-ordination, planning and
development.13.
Perhaps the most significant reason for using structured risk assessment and management
tools with offenders with an intellectual disability, is that it can lead to far more
effective targeting of support to the individual and in many cases, to a less restrictive
set of circumstances. There is usually a tendency within service systems to be overly
cautious in viewing client risk in the absence of objective and structured means of
assessing risk14. The use of structured risk assessments ensures that treatment programs
9
Birgden, A. & Ward, T. (2003). Pragmatic psychology through a therapeutic jurisprudence lense:
Psycholegal soft spots in the criminal justice system. Psychology, Public Policy, and Law, (3-4), 334360.
10
Boer, P.D., Tough, S. & Haaven, J. (2004). Assessment of risk manageability of intellectually disabled
sex offenders. Journal of Applied Research in Intellectual Disabilities, 17, 275-283.
11
Harris, A.J.R. & Tough, S. (2004). Should actuarial risk assessments be used with sex offenders who are
intellectually disabled? Journal of Applied Research in Intellectual Disabilities, 17, 235-241.
12
Harris, A.J.R. & Tough, S. (2004). Should actuarial risk assessments be used with sex offenders who are
intellectually disabled? Journal of Applied Research in Intellectual Disabilities, 17, 235-241.
13
Lindsay, W.R., Hogue, T.E., Taylor, J.L., Steptoe, L., Mooney, P. et al. (2008). Risk assessment in
offenders with intellectual disability. International Journal of Offender Therapy and Comparative
Criminology, 52(1), 90-111.
14
Harris, A.J.R. & Tough, S. (2004). Should actuarial risk assessments be used with sex offenders who are
and support are targeted more appropriately to client need, and ultimately freeing up
resources to provide more intensive treatment programs and support to individuals who are
assessed as high risk.
Useful risk assessments
Since approximately 2004 a number of risk assessments have been used in populations of
offenders with mild levels of intellectual disability. These assessments include the
following risk assessment tools which have been the most frequently used across Australia
and New Zealand within the forensic disability area over recent years:

The STATIC-99 which is an actuarial assessment for sexual offending15

The Sexual Violence Risk – 20 (SVR-20) which is a structured clinical guideline
assessment for sexual offending17 18

The Historical Clinical Risk – 20 (HCR-20) which is a structured clinical guideline
assessment for non-sexual violent offending. The historical factor section of this
scale is also used as an actuarial measure19 20

The Violence Risk Appraisal Guide (VRAG) which is an actuarial assessment for nonsexual violent offending21 22

The Psychopathy Checklist Revised (PCL-R), which is not a risk assessment in itself
but has been shown to be a significant factor and is therefore incorporated into most
of the above assessments23 24
16;
While all of these risk assessments have been used in populations of offenders with an
intellectual disability, the structured clinical guideline assessments can have a tendency
to over-estimate risk in this population if they are not interpreted carefully. A guide has
been developed by Morrisey et al. (2007) for the use and interpretation of the PCL-R with
offenders with an intellectual disability, which provides highly useful guidance around the
specific use of this tool, as well as advice that can be applied to the other instruments;
this guide is available by contacting the main author (Morrisey). Two guidelines are also
intellectually disabled? Journal of Applied Research in Intellectual Disabilities, 17, 235-241.
15
Hanson, R.K. & Thornton, D. (1999). Static-99: Improving actuarial risk assessments for sex offenders
(User Report No. 1999-02). Ottawa, Ontario, Canada: Department of the Solicitor General of Canada.
16
Lindsay, W.R., Hogue, T.E., Taylor, J.L., Steptoe, L., Mooney, P. et al. (2008). Risk assessment in
offenders with intellectual disability. International Journal of Offender Therapy and Comparative
Criminology, 52(1), 90-111.
17
Boer, D.P., Hart, S.D., Kropp, P.R., & Webster, C.D. (1997). Manual for the Sexual Violence Risk-20:
Professional guidelines for assessing risk of sexual violence. Vancouver, British Columbia, Canada: BC
Institute Against Family Violence and Mental Health.
18
Lambrick, F., & Glaser, W. (2004). Sex offenders with an intellectual disability. Sexual Abuse: A Journal
of Research and Treatment, 16(4), 381-392.
19
Webster, C.D., Eaves, D., Douglas, K.S., & Wintrup, A. (1995). The HCR-20: The assessment of
dangerousness and risk. Vancouver, British Columbia, Canada: Simon Fraser University and British Columbia
Forensic Psychiatric Services Commission.
20
Lindsay, W.R., Hogue, T.E., Taylor, J.L., Steptoe, L., Mooney, P. et al. (2008). Risk assessment in
offenders with intellectual disability. International Journal of Offender Therapy and Comparative
Criminology, 52(1), 90-111.
21
Quinsey, V.L., Harris, G.T., Rice, M.E., & Cromier, C.A. (1998). Violent offenders: Appraising and
managing risk. Washington, DC: American Psychological Association.
22
Lindsay, W.R., Hogue, T.E., Taylor, J.L., Steptoe, L., Mooney, P. et al. (2008). Risk assessment in
offenders with intellectual disability. International Journal of Offender Therapy and Comparative
Criminology, 52(1), 90-111.
23
Hare, R.D. (1991). The Hare Psychopathy Checklist – Revised. Toronto, Ontario, Canada: Multi Health
Systems.
24
Morissey, C., Hogue, T., Mooney, P., Allen, C., Johnston, S., Hollin, C., Lindsay, W.R., & Taylor, J.L.
(2007). Predictive validity of the PCL-R in offenders with intellectual disability in a high secure
hospital setting: Institutional aggression. Journal of Forensic Psychiatry and Psychology, 18, 1-15.
in the process of being developed for the administration and interpretation of the SVR-20
and HCR-20 but are not yet available.
There are a number of important criteria that need to be followed in terms of who should
administer and interpret these assessments:

The person should have postgraduate qualifications in behavioural or medical
sciences;

Have training in psychopathology, statistics and psychometric theory;

Have registration with a relevant professional body;

Have experience with forensic or other relevant populations;

Ensure that they have adequate training and/or supervision in the use of the risk
assessment instrument.
Specific risk assessment and management issues for people
with intellectual disability
The ARMIDILO25
The Assessment of Risk and Manageability of Intellectually Disabled IndividuaLs who Offend
(ARMIDILO) is a risk assessment and management tool specifically designed to take into
account issues of particular relevance to this population (such as limited communication
skills, environmental factors etc). The ARMIDILO is a collaborative project currently being
trialed in Victoria, Australia by University of Waikato in New Zealand, RMIT University,
Corrections Victoria and supported by the Office of the Senior Practitioner. The assessment
tool is designed to assess risk in both the offender and challenging behaviour groups and
covers a broad range of offending and challenging behaviours. The ARMIDILO will be relevant
for all individuals with an intellectual disability who require assessment for risk and
risk manageability.
The ARMIDILO is comprised of four sections. Two sections ask about stable and acute dynamic
risk factors associated with the environment of the person and the other two item groups
are concerned with stable and acute dynamic risk factors as they relate to the individual.
These individual risk factors are similar to those contained in the mainstream structured
guided clinical assessments outlined above but the criteria have been modified to take into
account specific issues associated with intellectual disability.
The two other sections measure the environment specific to people with an intellectual
disability. Stable dynamic environmental factors include staff attitude, communication
among supervisory staff, client specific knowledge by supervisory staff, consistency of
supervision and situational consistency. Acute dynamic environmental factors include
changes in social relationships, personnel or monitoring changes, accommodation changes,
changes in victim access and changes in access to intoxicants.
The ARMIDILO will be available for use by all suitably experienced staff, regardless of
qualification, subject to satisfactory attendance and participation in a training program.
These training programs will be available after the completion of the research study most
likely in 2010.
The DRAMS26
25
The ARMIDILO is a structured risk assessment and management guideline instrument under development by
Boer, Lambrick, Lindsay, McVilly, Maddumage, and Sakdalan.
26
Steptoe, L.R., Lindsay, W.R., Murphy, L., & Young, S.J. (2008). Construct validity, reliability and
predictive validity of the dynamic risk assessment and management system (DRAMS) in offenders with
intellectual disability. Legal and Criminological Psychology, 13, 309-321.
The Dynamic Risk Assessment and Management System (DRAMS) was developed within a high
security hospital setting in Scotland, to assist in the maintenance of clients in positive
behaviour program activities. The idea behind the instrument was that it could be used to
anticipate the likelihood of a client being involved in a serious incident, thereby
alerting staff to provide the client with additional supports or temporarily suspending the
program, therefore avoiding significant program disruption if the incident had actually
occurred.
The DRAMS is comprised of 31 questions. The assessment is designed to be completed
collaboratively with the client and is presented in a readily understandable format, with
traffic light pictorial cues to assist scale point choice on the four point scale for each
item. While the DRAMS was developed and trialed within a high security setting, it has
significant potential for use in supervised community settings in positively managing
program and community access for people who engage in offending and associated challenging
behaviours27. The DRAMS is currently being subject to limited trials by Office of the
Senior Practitioner and may be available for wider use at a later date.
In summary, it is important to remember the following points when considering risk issues
in relation to offenders with an intellectual disability:

A formal structured risk assessment process should be used to objectively assess risk
and how to manage it;

An actuarial risk assessment tool should be used to assess the intensity of treatment
and supervision that the person needs (base line level of risk);

A structured clinical guideline risk assessment should be used to assess what dynamic
risk factors need to be monitored and evaluated over time, as treatment targets and
as measures of treatment progress;

The same structured clinical guideline risk assessment should be used to re-evaluate
dynamic risk factors;

The risk assessment tools used should be those that have been validated or trialed
with offenders with an intellectual disability and are in common use in the service
system.
Written by Dr Frank Lambrick, Practice Leader, Office of the Senior Practitioner
For more information please contact Frank Lambrick at Frank.Lambrick@dhs.vic.gov.au
27
Steptoe, L.R., Lindsay, W.R., Murphy, L., & Young, S.J. (2008). Construct validity, reliability and
predictive validity of the dynamic risk assessment and management system (DRAMS) in offenders with
intellectual disability. Legal and Criminological Psychology, 13, 309-321.