Putting the usability of wearable technology in forensic psychiatry to the test: a randomized crossover trial.

Introduction: Forensic psychiatric patients receive treatment to address their violent and aggressive behavior with the aim of facilitating their safe reintegration into society. On average, these treatments are effective, but the magnitude of effect sizes tends to be small, even when considering more recent advancements in digital mental health innovations. Recent research indicates that wearable technology has positive effects on the physical and mental health of the general population, and may thus also be of use in forensic psychiatry, both for patients and staff members. Several applications and use cases of wearable technology hold promise, particularly for patients with mild intellectual disability or borderline intellectual functioning, as these devices are thought to be user-friendly and provide continuous daily feedback. Method: In the current randomized crossover trial, we addressed several limitations from previous research and compared the (continuous) usability and acceptance of four selected wearable devices. Each device was worn for one week by staff members and patients, amounting to a total of four weeks. Two of the devices were general purpose fitness trackers, while the other two devices used custom made applications designed for bio-cueing and for providing insights into physiological reactivity to daily stressors and events. Results: Our findings indicated significant differences in usability, acceptance and continuous use between devices. The highest usability scores were obtained for the two fitness trackers (Fitbit and Garmin) compared to the two devices employing custom made applications (Sense-IT and E4 dashboard). The results showed similar outcomes for patients and staff members. Discussion: None of the devices obtained usability scores that would justify recommendation for future use considering international standards; a finding that raises concerns about the adaptation and uptake of wearable technology in the context of forensic psychiatry. We suggest that improvements in gamification and motivational aspects of wearable technology might be helpful to tackle several challenges related to wearable technology.

Transgressive incidents targeted on staff in forensic psychiatric healthcare: a latent class analysis.

Transgressive incidents directed at staff by forensic patients occur frequently, leading to detrimental psychological and physical harm, underscoring urgency of preventive measures. These incidents, emerging within therapeutic relationships, involve complex interactions between patient and staff behavior. This study aims to identify clusters of transgressive incidents based on incident characteristics such as impact, severity, (presumed) cause, type of aggression, and consequences, using latent class analysis (LCA). Additionally, variations in incident clusters based on staff, patient, and context characteristics were investigated. A total of 1,184 transgressive incidents, reported by staff and targeted at staff by patients between 2018-2022, were extracted from a digital incident reporting system at Fivoor, a Dutch forensic psychiatric healthcare organisation. Latent Class Analysis revealed six incident classes: 1) verbal aggression with low impact; 2) verbal aggression with medium impact; 3) physical aggression with medium impact; 4) verbal menacing/aggression with medium impact; 5) physical aggression with high impact; and 6) verbal and physical menacing/aggression with high impact. Significant differences in age and gender of both staff and patients, staff function, and patient diagnoses were observed among these classes. Incidents with higher impact were more prevalent in high security clinics, while lower-impact incidents were more common in clinics for patients with intellectual disabilities. Despite limitations like missing information, tailored prevention approaches are needed due to varying types of transgressive incidents across patients, staff, and units.

Assessing Implicit Theories in Sexual Offending Using Indirect Measures: Feasibility, Reliability, and Incremental Validity.

This study assessed psychometric qualities of indirect measures assessing Implicit Theories (ITs) of sexual offending: Implicit Association Task (IAT), Implicit Relational Assessment Procedure (IRAP), and Relational Responding Task (RRT). For comparison reasons, aggressive behavior was also assessed. In a male sample from the general population (N = 109), we assessed each measure's (a) feasibility (mean latency, error rate, passing criteria), (b) internal consistency, (c) convergent and discriminant validity, and (d) incremental and predictive validity. Results indicated that no indirect measure met all criteria. Although the IAT was reasonably feasible and reliable in measuring aggression, ITs could not be reliably assessed. The RRT was feasible and somewhat reliable in assessing ITs, whereas the IRAP showed limited feasibility, high task complexity, low reliability, and the presence of a method factor. No measure had incremental predictive validity over the use of self-report measures, although we note that the power to detect such associations was limited. As none of the indirect measures performed satisfactorily on the measured criteria, the use of these measures in clinical practice seems currently unwarranted to assess ITs.

Identity and Personality Pathology in Adult Forensic Psychiatric Patients and Healthy Controls.

Since the publication of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), identity impairment has become a diagnostic criterion for all personality disorders. The current study examined the occurrence of identity dimensions, clinically relevant identity impairments and personality pathology, and associations between these constructs in 92 forensic patients and 139 healthy controls. Patients showed higher levels of almost all identity dimensions, identity impairments, personality disorders, and almost all maladaptive personality traits than controls. Various identity dimensions were associated with consolidated identity as well as identity impairments in both groups. Both patients and controls with high ruminative exploration and identity malfunctioning showed more personality pathology. Different associations between identity functioning and particularly antisocial and borderline personality disorder showed to be stronger in patients than in controls. Our results highlight the importance of identity impairment as a crucial criterion to assess and treat personality pathology in forensic patients.

The Spanish Short Dark Tetrad (SD4): Association With Personality and Psychological Problems.

BACKGROUND: The Short Dark Tetrad (SD4) is a recently developed instrument for assessing the "dark" personality traits of psychopathy, narcissism, Machiavellianism, and sadism. We aimed to examine the SD4's psychometric properties, adapting it into Spanish and exploring its structure, gender invariance, reliability, concurrent validity, and nomological network. METHOD: A sample of 668 adults (Mage = 26.36, SD = 10.64, 69.2% females) completed the SD4 and other self-report questionnaires. RESULTS: The results demonstrated sound indices of reliability and concurrent validity, an adequate four-factor structure, and support for gender invariance. Furthermore, most of the findings about the nomological network were in line with prior hypotheses: All four SD4 scales were associated with low levels of agreeableness and antagonism; psychopathy was also related to low conscientiousness, disinhibition and impulse-control problems; narcissism was positively associated with extraversion and negatively associated with internalizing symptoms; Machiavellianism was uncorrelated with impulsivity-related problems, which made it distinct from the psychopathy profile; finally, sadism showed a similar pattern of associations to psychopathy, albeit less strongly linked to impulsivity problems and externalizing behavior. CONCLUSIONS: Overall, the SD4 presents sound psychometric properties, although the overlap between psychopathy and sadism warrants some caution.

Childhood trauma and psychopathy: The moderating role of resilience.

OBJECTIVE: Despite accumulating evidence of significant albeit moderate associations between childhood trauma and psychopathy, little is known about the potential moderators of these associations. To advance knowledge in this area, the present study investigated the moderating role of resilience in the childhood trauma-psychopathy link. METHOD: A community sample of 521 adult participants from the Netherlands (40.1% men; Mage = 35.27 years, SD = 15.99) completed two self-report questionnaires measuring psychopathic personality traits: a self-report measure of resilience and a retrospective measure of childhood traumatic experiences. Correlation analyses were employed to investigate bivariate associations among study variables. Moderated multiple regression analyses with bootstrapping followed by simple slope analyses were employed to examine Childhood Trauma × Resilience interactions in predicting scores of psychopathy subscales. RESULTS: Childhood trauma had small positive associations with psychopathic traits across the board, with the exception of a small negative association with boldness traits, as well as a small negative association with resilience. Resilience was strongly and positively related to boldness, and negatively related to affective (callousness, meanness) and behavioral (antisocial, disinhibition) traits of psychopathy. Resilience moderated six out of seven associations between childhood trauma and psychopathic traits. CONCLUSIONS: Resilience appeared to represent a significant buffer in the associations between childhood traumatic experiences and psychopathic traits, such that these associations became weaker and nonsignificant (and even negative for boldness) at higher levels compared to lower levels of resilience. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The Effect of Childhood Poly-Victimization on Adulthood Aggression: The Mediating Role of Different Impulsivity Traits.

This study investigated the effect of the poly-victimization pattern of traumatic childhood experiences on aggression via the impulsivity traits positive urgency, negative urgency, lack of perseverance, lack of premeditation, and sensation-seeking in 102 poly-victims of childhood trauma (71.57% were females; Mage = 35.76; SDage = 15.91). Analyses with poly-victimization as an independent variable, impulsivity traits as parallel mediators, (1) reactive aggression or (2) proactive aggression as dependent variables, and gender as a covariate revealed that the poly-victimization did not have a direct or indirect effect on reactive or proactive aggression, nor did it have an effect on any of the impulsivity traits. Moreover, lack of premeditation had a positive direct effect on reactive aggression, while gender was a significant covariate in both models, with males reporting more aggression than females. Findings suggest that the poly-victimization does not influence impulsivity traits and aggression in adulthood. However, in males, the poly-victimization had a positive and moderate correlation with reactive aggression and negative urgency, while these correlations were absent in females. This finding implies that males are more vulnerable to the adverse effects of childhood poly-victimization than females.

The Spanish Short Dark Tetrad (SD4): Association With Personality and Psychological Problems / El Cuestionario Corto de la Tétrada Oscura (SD4) en Español: Asociación con la Personalidad y los Problemas Psicológicos

Background: The Short Dark Tetrad (SD4) is a recently developed instrument for assessing the “dark” personality traits of psychopathy, narcissism, Machiavellianism, and sadism. We aimed to examine the SD4’s psychometric properties, adapting it into Spanish and exploring its structure, gender invariance, reliability, concurrent validity, and nomological network. Method: A sample of 668 adults (Mage = 26.36, SD = 10.64, 69.2% females) completed the SD4 and other self-report questionnaires. Results: The results demonstrated sound indices of reliability and concurrent validity, an adequate four-factor structure, and support for gender invariance. Furthermore, most of the findings about the nomological network were in line with prior hypotheses: All four SD4 scales were associated with low levels of agreeableness and antagonism; psychopathy was also related to low conscientiousness, disinhibition and impulse-control problems; narcissism was positively associated with extraversion and negatively associated with internalizing symptoms; Machiavellianism was uncorrelated with impulsivity- related problems, which made it distinct from the psychopathy profile; finally, sadism showed a similar pattern of associations to psychopathy, albeit less strongly linked to impulsivity problems and externalizing behavior. Conclusions: Overall, the SD4 presents sound psychometric properties, although the overlap between psychopathy and sadism warrants some caution.(AU)

Antecedentes: El Short Dark Tetrad (SD4) es un instrumento recientemente desarrollado para evaluar los rasgos “oscuros” de personalidad de psicopatía, narcisismo, maquiavelismo y sadismo. Nuestro objetivo fue profundizar en las propiedades psicométricas del SD4 adaptando el instrumento al español, y examinar su estructura, invariancia de género, fiabilidad, validez concurrente y red nomológica. Método: Una muestra de 668 adultos (Medad = 26,36, SD = 10,64, 69,2% mujeres) completaron el SD4 y otros cuestionarios. Resultados: Encontramos índices apropiados de fiabilidad y validez concurrente, una estructura de cuatro factores, y apoyo a la invariancia de género. Además, los hallazgos sobre la red nomológica estuvieron mayoritariamente en línea con las hipótesis prerregistradas: las cuatro escalas SD4 se asociaron con baja amabilidad y antagonismo; la psicopatía se relacionó con baja responsabilidad, desinhibición y problemas de impulsividad; el narcisismo se asoció con extraversión y negativamente con síntomas de interiorización; el maquiavelismo no correlacionó con problemas de impulsividad, por lo que mostró un perfil diferenciado al de psicopatía; el sadismo mostró un patrón de asociaciones similar a psicopatía, aunque menos vinculado a problemas de impulsividad y comportamientos externalizantes. Conclusiones: En general, el SD4 presenta buenas propiedades psicométricas, aunque el solapamiento entre psicopatía y sadismo justifica cierta precaución.(AU)

Typicality of Level Change (TLC) as an Additional Effect Measure to NAP and Tau-U in Single Case Research.

Single case research is a viable way to obtain evidence for social and psychological interventions on an individual level. Across single case research studies various analysis strategies are employed, varying from visual analysis to the calculation of effect sizes. To calculate effect sizes in studies with few measurements per time period (<40 data points with a minimum of five data points in each phase), non-parametric indices such as Nonoverlap of All Pairs (NAP) and Tau-U are recommended. However, both indices have restrictions. This article discusses the restrictions of NAP and Tau-U and presents the description, calculation, and benefits of an additional effect size, called the Typicality of Level Change (TLC) index. In comparison to NAP and Tau-U, the TLC index is more aligned to visual analysis, not restricted by a ceiling effect, and does not overcompensate for problematic trends in data. The TLC index is also sensitive to the typicality of an effect. TLC is an important addition to ease the restrictions of current nonoverlap methods when comparing effect sizes between cases and studies.

The impact of childhood maltreatment on aggression, criminal risk factors, and treatment trajectories in forensic psychiatric patients.

Introduction: Children's development into healthy well-functioning adults can be negatively affected by adversity. Adverse childhood experiences (ACEs) have been shown to lead to a variety of poor life outcomes, ranging from mental health problems (e.g., anxiety or suicidality) through problematic health behaviors to serious physical diseases and even early death. ACEs can also make people more prone to aggressive behavior, criminality, and recidivism. In this study, we investigated the association between ACEs, specifically childhood maltreatment (CM), and forensically relevant factors; aggression, criminal risk factors, and treatment trajectories, as little is known about these associations in forensic psychiatric patients. Methods: The study includes data derived from two studies in The Netherlands, of which the first study enrolled 128 patients residing in a Forensic Psychiatric Center (FPC) and the second study included 468 patients who were released unconditionally from FPCs between 2009 and 2013. We expected that more CM would be correlated with higher levels of aggression, higher clinical risk factor scores, and less decrease in clinical risk factor scores over time. To investigate this, we applied correlational analyses and linear growth curve modeling on risk assessment scores and self-report as well as staff report questionnaires on CM and aggression. Results: Consistent with our first hypothesis, patients with higher CM scores also had higher aggression and risk assessment scores. The effect sizes were small to medium (0.12 to 0.34). Unexpectedly, CM did not influence the course of these treatment trajectories, however, we found that patients with histories of CM had a significantly longer length of stay in a forensic facility than patients without CM (respectively, 10.8 years and 9.3 years on average). Discussion: This study underlines the importance of carefully examining the history of ACEs and CM in forensic psychiatric patients and considering this in forensic risk assessment and risk guided treatment. More research is needed to draw conclusions about whether and how histories of ACEs should be considered and targeted during treatment trajectories.

Radicalization Processes and Transitional Phases in Female and Male Detainees Residing in Dutch Terrorism Wings.

BACKGROUND: Radicalization, violent extremism, and terrorism are risks to societal security. Although research on terrorism-related behaviors is increasing, thorough empirical studies are rare. METHODS: This study investigates radicalization processes and transitions in a matched sample of female and male terrorist suspects and convicts (N = 26) residing in Dutch penitentiary terrorism wings. RESULTS: Results show that both men and women often experienced discrimination. A subgroup of women grew up in a stressful family environment and lacked emotional support from their family, whereas the other women did not experience such circumstances. The majority of the study sample was susceptible to connecting with radicalized friends or family members. Interestingly, factors that initially led to radicalization (e.g., a utopian image of the Islamic State) could later turn out to be factors associated with abandoning extremism. CONCLUSIONS: In this study, differences in radicalization processes and transitional phases between women and men emerged. Men more often had police contact prior to a terrorism-related offense. Making an effort to right old mistakes seemed important in the radicalization processes of men, whereas women had a stronger desire for emotional support and were more driven by experienced trauma and feelings of loneliness. This study provides input for gender-specific prevention and disengagement interventions.

How to Evaluate a Tailor-made Social Work Intervention? Some Practice-Based Solutions with Single-Case Designs.

PURPOSE: With the increased attention to the principles of evidence-based practice (EBP), social workers are challenged to adapt their daily interventions accordingly when treating clients. They usually work with individual clients, all with their own specificities. Single-Case Experimental Designs (SCEDs) can be used to inform a social worker about the effectiveness of an intervention at the individual client level. In everyday social work practice, however, it is difficult to meet methodological requirements of SCEDs to find causal explanations. A concern is that repeated measurements prior to an intervention are required in most situations. This study aims to provide researchers with alternatives to repeated measurement when using the logic of SCED to apply EBP in their everyday practice. METHODS: In this study, we reviewed published single-case designs between January 1 and December 31, 2019, on types of SCEDs in the social domain, and how is dealt with baseline conditions. RESULTS: SCEDs and quasi-experimental alternatives are hardly published in situations when baseline data are not available. Four underused quasi-experimental strategies that can be employed when repeated measurement during baseline is not possible are as follows: retrospective baselines, theoretical inference, multiraters, and triangulation with qualitative data. DISCUSSION AND CONCLUSION: The suggestions to work with single-case designs with quasi-experimental elements are meant to enable social workers to evaluate their interventions in a way that enhances mere narrative evaluations of the experiences of an intervention.

Predictive validity on clinical item-level of the HKT-R divided into clinical patient classes.

BACKGROUND: Because of the heterogeneity of forensic groups, latent class analysis (LCA) can allow for the formation of stronger homogeneous patient classes, which can improve the predictive validity of forensic risk assessment tools, such as the Historical Clinical Future - Revised (HKT-R), which was used in this study. In particular, dynamic clinical risk and protective items are important in treatment and are obligatory assessed annually for every forensic patient with a TBS measure in the Netherlands. Therefore, this study investigated the predictive validity of the HKT-R at clinical item-level per patient class. METHOD: A cohort of 332 forensic patients, who were discharged from highly secured Forensic Psychiatric Centers/Clinics (FPCs) in the Netherlands between 2004 and 2008, was followed. LCA was performed to cluster this group of patients based on psychopathology and criminal offenses. The predictive validity of the HKT-R clinical items by class was assessed with official reconviction data two and five years after discharge as outcome measure. RESULTS: Four classes were identified. The predictive validity of the HKT-R clinical items showed differences between and within classes on admission or discharge, and for predicting violent reoffending after two or five years after discharge. DISCUSSION: Different risk/protective factors of the HKT-R may play a role for different subgroups of patients. Therefore, this heterogeneity should be considered for any measure or intervention.

Burnout, work engagement and workaholism in a group of Dutch judges: distinctiveness and two-year structural stability.

The aim of this two-wave study is to investigate whether burnout, work engagement and workaholism can be empirically distinguished in one model and whether this model shows structural stability over a period of 2 years (i.e. whether the distinguishability between the constructs holds across time). The study was conducted among 118 judges in the Netherlands who completed questionnaires measuring burnout, work engagement and workaholism. The results showed that these are relatively distinguishable constructs, despite a considerable overlap of professional efficacy loading on work engagement (instead of burnout; as hypothesized), absorption loading on workaholism (in addition to work engagement; as hypothesized) and exhaustion loading on workaholism (in addition to burnout), which represents a new finding. These extra loadings led to model modifications, which were found at both time points. As hypothesized, this model appeared to be stable over time. Nevertheless, further clarification and conceptualization of these constructs are undoubtedly needed.

Personality moderators of the cross-sectional relationship between job demands and both burnout and work engagement in judges: The boosting effects of conscientiousness and introversion.

The central question of this study is whether buffering, boosting and exacerbating effects of the Big Five personality factors extraversion, openness to experience, agreeableness, conscientiousness and neuroticism can be demonstrated in the relationship between two job demands (i.e., work pressure and working overtime) and both burnout and work engagement in 257 Dutch judges. It is important to better understand the interaction effects between various job demands (work pressure and working overtime) and personality on both burnout and work engagement in judges given their increased risk of burnout and lower work engagement due to cognitively and their emotionally demanding work. Three hypotheses were tested in a cross-sectional design study. Moderation analyses showed that, as expected, conscientiousness significantly boosted the relationship between working overtime and work engagement. Hence, high scorers on conscientiousness showed more work engagement when working overtime. Also, extraversion moderated the relation between working overtime and work engagement, but only at a low level of extraversion. Thus, contrary to expectations, introverts showed more work engagement when they work overtime. Also, significant main effects were found. Work pressure and neuroticism related positively to burnout, while extraversion and agreeableness related negatively to burnout. Moreover, extraversion, agreeableness and conscientiousness related positively to work engagement. In our study, conscientiousness, extraversion and agreeableness can be considered as personal resources for judges, in line with the Conservation of Resources (COR) theory. Especially conscientiousness can facilitate judges to cope with challenging working circumstances and introversion ensures that judges stay engaged despite working overtime.

Longitudinal Change of Risk Factors During Treatment in High-Security Forensic Psychiatry in Flanders.

Empirical studies on the longitudinal change of risk factors during treatment of forensic psychiatric patients are scarce. Therefore, in the current study, changes in risk factors of 341 high-security forensic psychiatric patients in Flanders were investigated using latent growth curve analyses. Annual assessments of the Historical Clinical Future-Revised (HKT-R) at three time points were considered, starting at time of admission. A significant small improvement was found on the future scale and most future factors. However, the clinical scale did not change significantly and only one of the 14 clinical factors (i.e., problem insight) changed significantly over time. Although the forensic treatment seems to be a slow process, the sensitivity of the HKT-R to detect clinically relevant change is questioned, underscoring the importance of determining whether there are instruments capable of detecting small significant changes over time.

Understanding Violent Extremism: Identifying Motivational Classes in Male Jihadist Detainees.

An important step in understanding violent extremist behavior is to identify its underlying motivations. Insights into what drives violent extremists to their behavior may indicate what is needed to reduce existing risk factors. To this end, this study investigated violent extremist motivations in 124 male jihadi suspects and convicts residing in Dutch prison terrorism wings. A Latent Class Analysis resulted in three motivation profiles. The low motivated class scored in general low on risk and motivational indicators of violent extremism. The morally driven class adhered to an ideology justifying violence, experienced some degree of grievances but often saw limitations in the use of violence to achieve ideological goals. The hardened ideologically driven class had an ideology justifying violence, feelings of frustrations and criminal history of violence. This descriptive study provides an important stepping-stone for future studies on how motivation profiles can be used to reduce the risk of violent extremist (re)offending.

Schema therapy for violent PD offenders: a randomized clinical trial.

BACKGROUND: Violent criminal offenders with personality disorders (PD's) can cause immense harm, but are often deemed untreatable. This study aimed to conduct a randomized clinical trial to test the effectiveness of long-term psychotherapy for rehabilitating offenders with PDs. METHODS: We compared schema therapy (ST), an evidence-based psychotherapy for PDs, to treatment-as-usual (TAU) at eight high-security forensic hospitals in the Netherlands. Patients in both conditions received multiple treatment modalities and differed only in the individual, study-specific therapy they received. One-hundred-three male offenders with antisocial, narcissistic, borderline, or paranoid PDs, or Cluster B PD-not-otherwise-specified, were assigned to 3 years of ST or TAU and assessed every 6 months. Primary outcomes were rehabilitation, involving gradual reintegration into the community, and PD symptoms. RESULTS: Patients in both conditions showed moderate to large improvements in outcomes. ST was superior to TAU on both primary outcomes - rehabilitation (i.e. attaining supervised and unsupervised leave) and PD symptoms - and six of nine secondary outcomes, with small to moderate advantages over TAU. ST patients moved more rapidly through rehabilitation (supervised leave, treatment*time: F(5308) = 9.40, p < 0.001; unsupervised leave, treatment*time: F(5472) = 3.45, p = 0.004), and showed faster improvements on PD scales (treatment*time: t(1387) = -2.85, p = 0.005). CONCLUSIONS: These findings contradict pessimistic views on the treatability of violent offenders with PDs, and support the effectiveness of long-term psychotherapy for rehabilitating these patients, facilitating their re-entry into the community.

Does sports participation affect the mediating role of impulsivity in the association between adverse childhood experiences and aggression?

Introduction: Adverse childhood experiences (ACEs) and self-reported aggression have often been associated, however, the mediating and moderating mechanisms underlying this association are not fully understood. In addition, less is known about potential factors that could serve as protection against the development of aggressive behavior. In this study, we investigated a moderated mediation model of sports participation and five impulsivity traits including positive and negative urgency, sensation seeking, and lack of premeditation and perseverance, in the association between ACEs and two forms of aggression. Methods and results: The sample comprised 651 (68.5% females) individuals from a Dutch community ranging in age from 18 to 82 years (M = 34.08). Contrary to our expectations, sports participation did not affect the associations of ACEs, the five impulsivity traits, and reactive and proactive aggression, except the association between ACEs and lack of premeditation. Specifically, the detrimental effect of ACEs on the propensity to act without thinking, increases among individuals with lower levels of sports participation. In addition, it was also found that sports participation directly contributed to higher levels of sensation seeking. Finally, after controlling for sociodemographic variables, the positive association between ACEs and reactive aggression was significantly mediated by negative urgency, lack of perseverance, and lack of premeditation, while the positive association between ACEs and proactive aggression was significantly mediated by lack of premeditation and positive urgency. Conclusion: The findings of this study add to the body of knowledge about the role of sports participation and impulsivity traits in the development of both forms of aggression, however, replication studies among multiple populations are needed before firm conclusions can be drawn.

Violent Recidivism and Adverse Childhood Experiences in Forensic Psychiatric Patients With Impaired Intellectual Functioning.

Accurate risk assessment and insight into which factors are associated with recidivism are essential for forensic correctional practice. Therefore, we investigated whether the Historical, Clinical, and Future-Revised (HKT-R [Historisch Klinisch Toekomst-Revised]) risk assessment instrument could predict violent recidivism over a 2-year follow-up period in forensic psychiatric patients with intelligence quotient (IQ) < 80. We refer to these patients as intellectually disabled (ID) and patients with IQ ≥ 80 as non-ID. Additionally, the associations of the 14 clinical HKT-R factors with ID versus non-ID group membership were investigated, as well as a possible moderating role of adverse childhood experiences (ACE) in these associations. The final sample encompassed 748 forensic psychiatric patients (15.9% were patients with ID) who were unconditionally released from highly secured Dutch forensic psychiatric institutions between 2004 and 2014. The results showed that the HKT-R total score (AUC = 0.705, 95% confidence interval [CI] [0.527, 0.882]) and the clinical domain (AUC = 0.733, 95% CI [0.579, 0.886]) had a large effect size for predictive validity for 2-year violent recidivism, while the future domain (AUC = 0.653, 95% CI [0.524, 0.781]) and the historical domain (AUC = 0.585, 95% CI [0.397, 0.772]) had a medium effect size for predictive validity for 2-year violent recidivism in ID patients. It was also found that lower levels of self-reliance and social skills were associated with ID, indicating that treatment should prioritize these skills. However, ACE was not associated with ID, nor did it moderate the associations of the clinical HKT-R factors with ID. This study contributes to the understanding of both risk assessment and treatment of forensic psychiatric patients with ID.