Treatment of aggression regulation problems with virtual reality: study protocol for a randomized controlled trial.

Background: Aggressive conduct among delinquents presents a pervasive issue, bearing substantial implications for not only society at large but also for the victims and the individuals displaying the aggression. Traditional approaches to treating aggression regulation deficiencies generally employ Cognitive Behavioral Therapy (CBT) in conjunction with analog role-playing exercises. A body of research supports the efficacy of various therapeutic models for aggression regulation, including Responsive Aggression Regulation Therapy (Re-ART). Role-playing within a therapeutic context has been shown to contribute significantly to reductions in violent reoffending. However, the practical application of these skills in real-world settings remains challenging due to the inherent risk of aggressive outbreaks. Additionally, the conventional role-playing scenarios, often conducted in a therapy room, lack contextual realism and may induce role confusion between the patient and the therapist. Virtual Reality (VR) technology could offer a viable solution to these limitations by allowing for skill training in both behavioral and cognitive domains within a realistic yet safe and controlled setting. The technology also facilitates real-time awareness of emotional states and tension levels in the patient. This paper describes the study protocol of a randomized controlled trial in which Re-ART offered in a virtual environment (Re-ART VR) is compared to Re-ART offered as treatment as usual. Methods and analysis: Adult forensic outpatients with aggression regulation problems are randomly assigned to either Re-ART VR or Re-ART. The Controlling Skills, Influence of Thinking and Handling Conflicts modules will be offered to both groups during 3-6 months. Pre- and post-intervention measurements are performed. The primary outcome measurement is the degree of aggression regulation, while secondary outcome measurements include impulsivity and cognitive biases. Additionally, patient motivation and therapist motivation are expected to act as moderating factors. Discussion: To date, scarcely previous research has been done on the effectiveness of VR in treatment of aggression regulation problems in forensic outpatients. Forensic outpatients who do not benefit sufficiently from mainly CBT-based interventions may benefit more from experiential learning. The unique capabilities of VR in this regard have the potential to enhance the treatment effect.Clinical trial registration: [https://clinicaltrials.gov/], identifier [NL78265.018.21].

A literature review of outcome and treatment options after acquired brain injury: Suggestions for adult offenders using knowledge from the general population.

BACKGROUND: Acquired brain injury (ABI) is a major health problem, often with negative effects on behaviour and mental health as well as cognition. Prevalence of ABI is exceptionally high among offenders and increases their re-offending risk. Information on risk factors for ABI and its outcomes among offenders that could guide effective treatment for them is, nevertheless, scarce and dispersed. However, there is a more substantial literature about the general population that could inform work with brain-injured offenders, especially when selecting for samples or subgroups with similar relevant characteristics, such as lower socio-economic status (SES), pre-injury lower tested intelligence score (<85) and pre-injury mental health problems. AIMS: To explore brain injury data from non-offender samples of otherwise similar socio-economic and mental health and ability characteristics to offenders then, first, to describe their untreated outcomes and, secondly, outcomes after frequently used interventions in these circumstances, noting factors associated with their effectiveness. METHOD: Three databases were systematically searched for the years 2010-2022; first, using terms for brain injury or damage and cognitive (dys)function, mental health or quality of life. Second, in a separate search, we used these terms and terms for interventions and rehabilitation. In the second review, studies were selected for clear, distinguishable data on age, sex, SES and lifestyle factors to facilitate inferences for offenders. A narrative analytical approach was adopted for both reviews. RESULTS: Samples with characteristics that are typical in offender groups, including lower SES, lower pre-injury intelligence quotient (<85), prior cognitive impairments and prior mental health problems, had poorer cognitive and behavioural outcomes following ABI than those without such additional problems, together with lower treatment adherence. With respect to treatment, adequate motivation and self-awareness were associated with better cognitive and behavioural outcomes than when these were low or absent, regardless of the outcome measured. CONCLUSIONS: More complex pre-injury mental health problems and social disadvantages typical of offenders are associated with poorer post-brain injury recovery. This paper adds to practical knowledge by bringing together work that follows specific outcome trajectories. Overall, succesful ABI-interventions in the general population that aim at pre-injury difficulties comparable to those seen among offenders, show that personalising injury-specific treatments and taking account of these difficulties, maximised positive outcomes.

Neuropsychological assessment of aggressive offenders: a Delphi consensus study.

Objective: This study explores the intricate relationship between cognitive functioning and aggression, with a specific focus on individuals prone to reactive or proactive aggression. The purpose of the study was to identify important neuropsychological constructs and suitable tests for comprehending and addressing aggression. Methods: An international panel of 32 forensic neuropsychology experts participated in this three-round Delphi study consisting of iterative online questionnaires. The experts rated the importance of constructs based on the Research Domain Criteria (RDoC) framework. Subsequently, they suggested tests that can be used to assess these constructs and rated their suitability. Results: The panel identified the RDoC domains Negative Valence Systems, Social Processes, Cognitive Systems and Positive Valence Systems as most important in understanding aggression. Notably, the results underscore the significance of Positive Valence Systems in proactive aggression and Negative Valence Systems in reactive aggression. The panel suggested a diverse array of 223 different tests, although they noted that not every RDoC construct can be effectively measured through a neuropsychological test. The added value of a multimodal assessment strategy is discussed. Conclusions: This research advances our understanding of the RDoC constructs related to aggression and provides valuable insights for assessment strategies. Rather than suggesting a fixed set of tests, our study takes a flexible approach by presenting a top-3 list for each construct. This approach allows for tailored assessment to meet specific clinical or research needs. An important limitation is the predominantly Dutch composition of the expert panel, despite extensive efforts to diversify.

A Pilot Study of the Convergent and Discriminant Validity of the Dutch Version of the Parametric Go/No-Go Task.

BACKGROUND: The parametric go/no-go (PGNG) task is a computerized task that is designed to measure cognitive flexibility, response inhibition, and working memory. The PGNG task has been shown to measure core executive functions (EFs) in a psychometrically sound, brief, and ecologically valid manner. OBJECTIVE: To analyze the psychometric properties of the Dutch version of the PGNG task in a convenience sample of nonclinical adults. METHOD: The sample consisted of 74 highly educated adults, with an average age of 36 years. Forty-two participants completed test battery A to investigate the task's convergent validity; 36 participants completed test battery B to investigate the task's discriminant validity. The results were analyzed using a repeated-measures ANOVA, Friedman's test, paired-samples t test, and correlation analyses. RESULTS: Level 3 of the PGNG task places increased demands on sustained attention, response inhibition, and set-shifting. Several moderate correlations between level 3 and a complex EFs measure supported the convergent validity of this level of the PGNG task. The convergent validity of levels 1 and 2 was not supported. No significant correlations were found between PGNG levels and non-EF tests, supporting discriminant validity. CONCLUSION: Our study included a rather homogenous sample of highly educated participants, which might explain the convergent validity of level 3 of the Dutch version of the PGNG task. Hence, to overcome these potentially confounding factors, the Dutch version of the PGNG task should be investigated in a larger and more heterogeneous population in terms of age and educational level.

A Multilevel Meta-Analysis of Dynamic Risk Factors for Emerging Adults who Abuse their Parents.

Purpose: Even though five to 11% of child-to-parent abuse (CPA) perpetrators are emerging adults (age 18-23 years), relevant risk factors underlying CPA in this group are understudied. Method: A multilevel meta-analysis was performed on nine studies (450 effect sizes, N = 1,043), comprising eight static (e.g., age and gender of perpetrator) and dynamic (e.g., substance abuse, financial problems) risk factors. Results: Emerging adults who fell victim of domestic violence, or had antisocial cognitions, authority problems, or empathy problems displayed CPA more often. Moderator analyses revealed that the relation between gender of perpetrator and CPA was moderated by gender of victim (p = .033) and CPA type (p = .021). Gender of victim (p < .001) also moderated the relationship between single-parent household and CPA. Finally, the relation between witness to DV and CPA was moderated by age (p = .007). Conclusions: This was the first multilevel meta-analysis focusing exclusively on CPA displayed by emerging adults. The results can be used as a basis for further research into relevant risk factors for CPA in this group and hopefully contribute to the development of health care interventions to reduce chances of CPA occurring. Supplementary Information: The online version contains supplementary material available at 10.1007/s10896-022-00469-4.

Acquired Brain Injury and Interventions in the Offender Population: A Systematic Review.

Background and Aims: The prevalence of acquired brain injury (ABI) in offender populations appears much higher than in the general population, being estimated at 50% compared to 12%, respectively. Taking into account ABI-related cognitive and social impairments or behavioral changes in forensic treatments might be relevant and may improve treatment outcomes. The aim of the current review is to summarize and integrate the literature on psychological interventions or treatments for consequences of ABI in the forensic setting. Reviewing this literature could provide crucial information for improving treatment options for offenders with ABI, which may contribute to reducing recidivism. Methods: The PubMed/MEDLINE, PsychInfo, CINAHL, COCHRANE, and Web of Science databases were searched for studies in adult offenders with ABI that evaluated the effect of psychological interventions with a focus on ABI-related impairments and recidivism. Results: This review identified four intervention studies that met the inclusion criteria. These included an adult population (≥18-year-old) in a forensic setting (given the focus of the current review on treatment, defined here as an environment in which offenders are treated while being incarcerated or as outpatients), non-pharmacological treatments and were published in English or Dutch between 2005 and 2020. All studies reported some positive effects of the intervention on interpersonal behavior, cognition and recidivism. The aspects of the interventions that seemed most beneficial included personalized treatment and re-entry plans, support for the individual and their environment and psychoeducation about the effects of ABI. Discussion: Although positive effects were reported in the studies reviewed, all studies had methodological limitations in terms of sample size, study design and outcome measures which affects the strength of the evidence. This limits strong conclusions and generalizability to the entire offender population. Conclusion: Despite high prevalence of ABI in offender populations, interventions in forensic settings seldom address the effect of ABI. The few studies that did take ABI into account reported positive effects, but those results should be interpreted with caution. Future studies are warranted, since this does seem an important venue to improve treatment, which could eventually contribute to reducing recidivism.

The Forensic Symptoms Inventory-Youth Version-Revised: Development and Age Invariance Testing of a Broad-Spectrum Questionnaire for Forensic Assessment.

Covering both individual and neuropsychological factors, the Forensic Symptom Inventory-Youth Version-Revised (FSI-YV-R) is the first broad spectrum questionnaire for adolescents in forensic care, measuring several deficits, such as executive dysfunctions, anger, and inadequate coping to enhance treatment goals and evaluate interventions. In this study, both the factor structure and the measurement and structural invariance of the FSI-YV-R were investigated. The sample consisted of 159 forensic juvenile outpatients (79.9% males and 20.1% females) aged 12 to 19 with a mean age of 16.07 (SD = 1.57). Multi-Group Confirmatory Factor Analyses identified a second-order model (measuring executive functioning) and proved measurement and structural invariant across age groups (younger adolescents, 12-15 years and older adolescents, 16-18 years). Contrary to the expectations none of the FSI-YV-R subscales differentiated between younger adolescents (N = 74) and older adolescents (N = 85). These results and implications for both theory and practice are discussed.

Comparing the Central Eight Risk Factors: Do They Differ Across Age Groups of Sex Offenders?

Following the risk-need-responsivity (RNR) model, cognitive-behavioral therapy is considered most effective in reducing recidivism when based on dynamic risk factors. As studies have found differences of these factors across age, exploring this seems beneficial. The current study investigates the Central Eight (C8) risk factors across six age groups of outpatient sex offenders ( N = 650). Results showed that recidivism rates and age were inversely related from 19 years and up. Half of the C8 did not predict general recidivism at all, substance abuse, antisocial cognition, antisocial associates, and history of antisocial behavior in only one or several age groups. However, factors differed between age groups, with the youngest group demonstrating the most dysfunction in several areas and the oldest group the least. It is concluded that the C8 risk factors seem to lose significance in the older age groups. Results may benefit targeting treatment goals.

The Forensic Symptoms Inventory-Revised (FSI-R Adults): Measurement and Structural Invariance Across Gender and Age Groups.

This article investigates the measurement and structural invariance of a newly developed self-report questionnaire, the Forensic Symptoms Inventory-Revised, aimed at measuring eight cognitive, emotional, and behavioral deficits (aggression, lack of social support, problematic substance use, lack of concentration, anger, poor self-regulation, impulsivity, and sexual problems) among adult forensic outpatients. The sample consisted of 716 outpatients (603 males, 113 females) with a mean age of 38.19 (SD = 12.47). Multi-Group Confirmatory Factor Analyses supported the measurement and structural invariance with respect to gender and age groups (18-23 years and ≥24 years). Between-group comparisons revealed that, compared to females, male outpatients reported more substance related problems, as well as incapacities to control verbal and/or physical aggression. Compared to adults, young adults displayed more inadequate self-regulation skills and reported more social support. These findings may promote the formulation of gender- and age-specific treatment goals.

Alliance and adherence in a systemic therapy.

BACKGROUND: The client-therapist working alliance is a key contributor to effective adult psychotherapy. However, little is known about its role in family and systemic therapy. Moreover, few studies have assessed alliance longitudinally or have investigated how it interrelates with other process variables, such as therapist adherence (i.e. the extent to which the therapist adheres to the treatment protocol or manual). We hypothesised that alliance and adherence interrelate over the course of the therapy. METHOD: This study investigated the bidirectional associations between alliance and therapist adherence using cross-lagged panel analyses for a sample of 1970 adolescents and their families participating in Multisystemic Therapy (MST). A number of client characteristics were included as moderators, namely demographic characteristics, type and severity of adolescent problem behaviour, and whether or not the MST treatment was court ordered. Alliance and adherence were scored by the primary caregiver through telephone interviews at monthly intervals during treatment. RESULTS: Alliance in 1 month predicted therapist adherence in a subsequent month. Adherence only predicted subsequent alliance during the middle part of the treatment process. The results were not moderated by any of the client factors. CONCLUSIONS: The results suggest that alliance and therapist adherence may reinforce one another during therapy. Although alliance may facilitate the development of therapist adherence, adherence may subsequently deepen and consolidate the client-therapist alliance. These results are independent of client characteristics.

The Relationship Between the Level of Program Integrity and Pre- and Post-Test Changes of Responsive-Aggression Regulation Therapy (Re-ART) Outpatient: A Pilot Study.

Responsive-Aggression Regulation Therapy (Re-ART) Outpatient is a cognitive behavioral-based intervention for adolescents and young adults (16-24 years) with severe aggressive behavioral problems. This pilot study (N = 26) examined the level of program integrity (PI; that is, the delivery of the intervention as it is originally intended) of Re-ART. We also investigated the pre- and post-test changes in several outcome variables, and the relation between the level of PI and these changes. Participants were recruited from three different outpatient forensic settings. Results showed that the PI of half of the treatments was not sufficient (e.g., the intensity of the program was too low and some standard modules were not offered). In addition, this pilot study demonstrated that sufficient PI was related to positive changes in aggression, cognitive distortions, social support, coping (reported by therapist), and distrust (responsiveness to treatment).