Assessment Approaches Achieving Best Evidence: A Comparison of Three Interview Strategies for Investigative Interviews in a Forensic Sample with Mild Learning Disabilities David Glasgow Clinical Psychologist Calderstones NHS Trust Rachel Crossley Assistant Psychologist Calderstones NHS Trust Recent legislation and guidance with respect to vulnerable witnesses has very far reaching implications for people with a learning disability who become potential witnesses in criminal proceedings. The foundations of these changes were laid 17 years ago when attempts were made to combine aspects of child protection and criminal investigations involving child abuse. Between the first draft of "working together" and the present legislation there have been numerous significant milestones. Perhaps one of the most significant was the Pigot report published in 1989 (Pigot 1989). This recommended legislative change and the drafting of guidance with respect to conducting videotaped interviews with child witnesses in anticipation of these videotapes being played in criminal proceedings. The Pigot report recommended that children should be able to make a recorded initial statement which would constitute a their 'evidence in chief' and also a subsequent video recorded interview in which aspects of their statement were questioned. This would constitute the cross-examination in court. In fact only the first part became law and the guidance was published in 1992 in the form of V a memorandum of good practice. This partial implementation of the Pigot report enabled professionals to appreciate the strength and potential of videoed evidence, but also problems encountered. One such problem was the fact that cross-examination continued to occur 'live' in court. This meant that the video was played to the court and then the child was asked questions on the content of the video. These questions were often, leading confusing and distressing. Prosecution lawyers, reluctant to have a child suddenly plunged into live cross-examination, adopted the practice of electing to have a live evidence- in chief to 'warm them up' before cross-examination. This generated the somewhat bizarre situation in which child witnesses endured both live cross-examination and examination in chief (as any other witness) and their original statement was presented to the court in the form of a video. Contrary to the hopes and expectations of professionals working with children the reforms did little to reduce inappropriate pressure and distress on young witnesses. It was also patently clear were that the careful conduct of memorandum interviewers was often in stark contrast to the largely unregulated and pressurised questioning that took place in court. The second shortcoming that became evident was that the benefits of memorandum type interviews were not extended to older children and adults with a learning disability. Learning disabled people are much more likely to be victims of offences against the person, but did not enjoy any special measures to enable them to give evidence against their alleged abusers. This irony was not lost on many professionals working with people with learning disabilities. This included the police who, faced with a learning disabled witness were only too aware of facilities and procedures in existence for children that could help them elicit evidence of a crime, but they were not permitted to use them. These two shortcomings, among others (see Sanders et al, 1996) eventually lead to a committee report on the evidence of vulnerable witnesses in 1998 (Home Office, 1998), which made over 70 recommendations for changes in provision and procedure, from the start of an investigation to after a trial. In the following year, a youth justice and Criminal evidence Bill was introduced, which extended the existing provisions available to children and applied them to some adults. It also enabled a full implementation of the original Pigot proposals, namely that both evidence in chief and cross- examination could be conducted during videoed interviews, thus drastically limiting the need for a witness to endure the ordeal of giving live evidence in court. In 2002 substantial extension and revision of the memorandum of good practice was published entitled 'Achieving Best Evidence'. This dramatically changes a number of aspects of the existing procedures, however the basic gist of the new provisions is summarised: Examination in chief – The procedure in the trial where, normally, the lawyer representing the side who has called the witness takes that person through his or her evidence........ The Youth Justice and Criminal Evidence Act 1999 allows a video recording of an interview with an eligible witness to be played as the witness‟s evidence in chief. When such a recording is admitted, the witness is not normally examined in chief by the lawyer at the trial. Depending on the matters raised in cross-examination, the party who called the witness in the first place may choose to conduct a further examination in chief, or re-examination, as it is called. Thus, for example, where the prosecution calls a woman to give evidence that she has been raped by two men, she will give evidence in chief on behalf of the prosecution, and will be open to cross-examination on behalf of both defendants, with the prosecution having the option to re- examine. Where cross-examination is pre-recorded ...... re-examination will take place at the same time. Achieving Best Evidence, Appendix A p131 Thus both examination in chief and cross-examination can be videoed. The adults benefiting from the new provisions ie. „eligible‟ witnesses are described as "vulnerable or intimidated witnesses" , and explicitly includes people with learning disability. The definition of learning disability has been based on two of the three strands required to categorise a person as „Mentally Impaired‟ within the Mental Health Act, that is, the presence of „significant impairment of intelligence and social functioning‟. There is at present a considerable commitment to training professionals in issues relating to identifying witnesses who may have emerging disability and Achieving Best Evidence itself includes the following: "learning disability These are indications only and buy themselves do not necessarily indicate that the witness has a learning disability: A slow and/or confused response to questions Difficulty in understanding simple questions Speech difficulties Difficulties/inability with reading and writing And unclear concept of time and place Difficulty in remembering personal details or events" Whilst identifying witnesses who may have a learning disability is something of a challenge, it is as nothing compared with the challenging face is trained interviewers who wished to formally interview people with a learning disability as potential witnesses in criminal proceedings. Although development of cognition and the motion vary dramatically between children, there are at least useful outlines of child development that enable an a priori a judgement be made about the likely level of ability to be evidenced by a prospective interviewee. Not only is there an extensive literature on development will psychology, many professionals have practical experience of children in their own family and therefore have established internal models of what to expect of a 10 year-old child compared with say a four year-old child. The same is certainly not true with respect to people with learning disability, and thick it is extremely unlikely that those who are responsible for the conduct of interviews have the necessary skills and experience to accommodate the diversity of ability and disability they are likely to encounter. A number of studies and papers have identified some of the characteristics evidenced by interviewees who have a learning disability. These include impaired receptive communication; impaired expressive communication; higher interrogative suggestibility and/or compliance; greater vulnerability to sanctions against communication imposed on the witness by abusers (threats, promises and bribery etc.); difficulties perspective taking; idiosyncratic perceptions of the interview process; greater emotional lability; impaired autobiographical memory; and finally, higher rates of comorbidity for a range of mental health problems that may themselves make interviews even more difficult (see Glasgow, 1993 and Milne & Bull 2001). However, identifying potential difficulties is a far cry from accommodating the strengths and needs of a particular individual in an appropriate investigative interview. In recognition of the potential need for more sophisticated interview techniques, Achieving Best Evidence states: "there are a number of specialised interview techniques which have been developed for interviewing children and these may be acceptable to the courts as an alternative to the Mecca method recommended in this guidance, provided evidential considerations are borne in mind......" [paragraph 2.142] And: "in a systematic approach to gathering evidence or SAGE interview the child is encouraged over a number of separate sessions did talk about significant persons and places in the child's life and his or her attitude towards them. Systematic comparison of the child's responses enables the trained interviewer to identify areas of particular concern which can then be explored more thoroughly using a open-ended questions (Wilson and Powell, 2001)" [paragraph 2.143] SAGE was originally developed for children with special needs (Roberts & Glasgow 1993). It has since been incorporated into a computer assisted interview package called MacInterview. This development project was funded by the Department of Health for approximately 10 years and this included extensive testing on both young and learning disabled children (Calam et al 2000). It has also been piloted on some learning disabled adults, and has been used as an investigative tool on behalf of the police during inquiries relating to serious crimes. MacInterview is divided into modules which can be accessed in different orders depending on the needs of the particular case. The modules are: Introduction This allows the interviewee to choose and name a figure to represent themselves Emotions This introduces to the interviewee and emotions palate which later enables them to communicate their feelings with respect to a range of experiences and significant others Emotions and scenes This module enable the interviewer to practise the use of the emotions palate and to begin to broach with the interview we salient emotional experiences Care settings This enables the interviewee to select drawings representative of significant places in their lives, for example where they live, college, places they visit etc. People Here the interviewee can populate care settings with significant figures about which the interviewee can subsequently express their feelings and thoughts. Somatic experiences This enables interviewees to describe physical experiences involving pain or other sensations, locate them on a body plan, identify accompanying emotions and indicates what caused them. Developing a research programme paradigm to evaluate the effectiveness of such a complex and sophisticated tool is a considerable challenge. One major problem is that victims of offences have typically experienced physical and/or emotional trauma. It is the cause of this trauma that is the focus of questioning, and interviewers are generally 'blind' to these. It is of course unethical to inflict physical or emotional trauma on participants in research, and it is therefore necessary to seek either experimental or naturalistic analogues of such trauma. Ideally one should be able to find out post hoc and details of the cause of the trauma and thus evaluate the accuracy and completeness of the account emerging at interview. Calderstones hospital offers a forensic and challenging behaviour service to approximately 200 individuals. As is often the case in such services 'critical incidents' are not uncommon and in some of which patients suffer physical harm which arises as a result of an accident, the deliberate act of another patient care or deliberate self-harm. The study reported here used standard critical incident reporting systems to identify individuals who had suffered an injury of some significance. It was decided to include a injuries reporting reported to have arisen as a result of both class „C‟ and class „D‟ incidents. These are described as follows: Class „C‟ “These are incidents that seriously affect or have the potential to seriously affect the health or the psychological well-being of the individual involved. They include, but are not limited to, errors of medication,sexual impropriety, sexual, racial, or gender harassment, accidental injuries, assaults and acts of deliberate self harm” Class „D‟ = “Incidents which result in no injury or minor injury or in very minor injury and do not involve any blameworthiness on the part of the staff. They include but are not limited to, minor accidental injury, fights between clients without weapons, and deliberate self harm” Incidents in either category which did not lead to actual physical injury were not included in the study. The interviewer was blind to the nature and cause of injuries and had received only basic training in three interview procedures. The phased approach This is the procedure that was published in the original memorandum of good practice and was based upon the work of Professor Yule and the 'step wise' approach to forensic interviewing. Space prohibits a detailed account of this approach but the main phases are: 1 rapport building 2 free narrative 3 questioning 4 closing MacInterview The computer assisted investigative interview described above. The relevant MacInterview module, „Somatic Experiences‟ offers a graphic representations of body layout, pain type and severity, and emotional response. Figure 1 illustrates a completed 'pain episode' as generated and described by an interviewee. It shows two pain representations (one large and one smaller) placed on a body layout. The emotional salience is represented by a face from the palette at the top of the picture. The verbal description of the episode becomes its label, appearing below the image. Figure 1: The product of the MacInterview Somatic Experiences Module 'Manual' MacInterview This is not an established interview strategy, but was a condition devised in order to investigate whether any differences between the phased approach and MacInterview might be attributable to the use of a computer per se. There are numerous studies which indicate greater levels of disclosure using computer-based clinical assessment, and it may be that the same is the case in forensic investigative interviewing. In his condition the interviewer used the same techniques that are implemented in MacInterview but under took them using a paper, line drawings and a pencil. Participants Forty-five individual cases were identified, of which 24 were excluded from the study for the reasons described in figure 2. Of the remaining 21, 13 were male and 8 were female. The mean IQ was 66.7 (S D 52 - 75). The mean age was 32 (S D 8.7) and the mean delay in days between the incident and interview was 15 (SD 4.7). Figure 2: Attrition of identified cases of physical harm in class C or D incidents 45 individual cases identified 6 unsettled or interview 4 "Too aggressive" potentially unsettling 4 Unavailability of 3 Psychotic interviewer 2 Staff reported no 2 cases police injury involvement 1 Interview tape 1 Too long a time elapsed inadvertently erased since incident 1 deemed unable to consent 21 interviews analysed Measures Three main quantitative measures were taken (with a more detailed qualitative discourse analysis under way): 1. interview length This was simply the total duration of the interview in minutes. Each interview was continued for as long as the interviewee was prepared to, and as long as further information was emerging. 2 Interview facet score Records and narratives can often used fully be subdivided according to 'facets'. These represent domains of information that combine to fully represent an event or circumstance. The facets identified in this study were as follows: 1. Injury 2. Context 3. Agent 4. Action 5. Instrument 6. Experience 7. Motivation The interviewer scored one point for each facet which emerged at interview and was subsequently determined to be correct by checking with independent records. 3. Positive comments regarding the interview (Post Interview) After all interviews were completed the interviewer invited the interviewee to give feedback on the process. Each positive utterance was scored one point and contributed to an overall „acceptability‟ score. Results Given the small number of participants, and the fact that the data were not normally distributed, the non-parametric equivalent of one-way analysis of variance, i.e. Kruskall Wallace, was used to analyse the data. Analysis indicated that there was a significant difference between the interview strategies on all three measures (Figures 3, 4 & 5 below). With respect to the interview facets score (figure 4) the significant difference was not between the MacInterview and the Phased Approach, but between MacInterview and „Manual Macinterview‟. Figure 3: Critical incidents by cause of injury and severity of incident (‘C’, ‘D’ or Unclassified (U/C) C D U/C Totals Self Injury 4 5 0 9 Accident 0 0 5 5 Physical assault 1 4 2 7 Totals 5 9 7 21 Figure 4: Mean duration of interviews Interview Length M 35 e a 30 n D 25 u r a 20 t i o 15 n i 10 n p = .002 M 5 i n s 0 MacIntervie Verbal Phased Figure 5: Facet scores of interviews Interview Method Facet Scores 15 M 10 e a n R a n 5 k P= 0.05 0 MacIntervie Verbal Phased Figure 6: Comparison of positive comments made by interviewees after interview Interview Method Positive Comments 20 15 M e a n 10 R a n k 5 P= 0.02 0 MacIntervie Verbal Phased Discussion It would be premature to conclude that MacInterview can offer a structured supported interview procedure in all cases where the witness has a learning disability. However, the data from this study are very promising. They show that a relatively inexperienced interviewee can elicit a very considerable amount of accurate information using the procedure. Further, interviewees are highly positive about the interview process when the computer is used. In many respects this is consistent with research on clinical use of computers in which there is strong evidence of a high degree of acceptability and greater disclosure of sensitive information when computerised procedures are used. Interpreting the fact that the Macinterview procedure lasted longest is somewhat difficult to interpret. A very simplistic view might be that the short interview is preferable. On the other hand a longer interview which is also a more positive experience may generate the best quality evidence. In this study it was certainly associated with the highest facet scores. Although the difference between the acceptability of a phased approach and the manual MacInterview approach were not significant, it is interesting and that on all three measures the manual MacInterview scored lowest. One possibility is that using the computer engages interviewees in a unique way and adds a 'special ingredient' to the interview process. It is also possible that the task of manually drawing figures and pain representations adds a „task overhead‟ to the interview, which impairs the process. That is, rather than simply clicking an image to indicate feelings or pain location, a greater cognitive burden was imposed on interviewees who were required to generate the same information in a more complex way. This might have little significance for many interviewees, but for those with a disability it might be of crucial significance. MacInterview continues to be researched and refined, and a new cross platform version („Zara‟) will be available at the end of 2003. It has already been used to generate evidence in civil proceedings involving both learning disabled and non-learning disabled children. It has also been used to assist the investigation of two murder enquiries, again involving child witnesses. The data emerging from this study strongly suggests that it has a potential to assist with the very considerable forensic and psychological challenges associated with conducting investigative interviews with adults who have a learning disability. References Calam, RM, Cox, AD, Glasgow, DV, Jimmieson, P and Groth Larsen, S (2000) Assessment and therapy with children: Can computers help? Child Clinical Psychology and Psychiatry, 5(3) 329-343 Glasgow, D (1993) Factors associated with learning difficulties demanding special care during sexual abuse investigations and interviews Newsletter of National Association for the Prevention of Sexual Abuse of Adults & Children with Learning Disabilities Home Office, Department of Health, Crown Prosecution Service, (2001) Achieving Best Evidence in Criminal Proceedings: Guidance for Vulnerable or Intimidated Witnesses, including Children, London HMSO Home Office (1998) 'Speaking up for Justice London HMSO Home Office, Department of Health. (1992) Memorandum of Good Practice on Video Recorded Interviews With Child Witnesses for Criminal Proceedings. London: HMSO Department of Health, Home Office Department for Education and Employment (1999) Working Together to Safeguard Children, London HMSO Milne,R. and Bull, R. (2001). Interviewing witnesses with learning disbalities for legal purposes: A review. British Journal of Learning Disabilities, 29, 93-97 Pigot et al. (1989). Judge Thomas Pigot QC, Report of the Advisory Group on video-recorded evidence. London: HMSO Roberts H & Glasgow, D (1993) SAGE: A Systematic Approach to Gathering Evidence from Children Division of Criminological & Legal Psychology Occasional Papers No. 22 Sanders A, Creaton J, Bird S and Weber L (1996) Witnesses with learning disabilities Home Office Research & Statistics Directorate Research Findings No. 44 The Use of the PCL-R in Forensic Populations with Learning Disability Catrin Morrissey Rampton Hospital, Nottinghamshire Healthcare NHS Trust Abstract Although the PCL- R is widely used for assessing forensic populations in general, there has been no published research relating to the reliability and validity of such assessments with offenders with a learning disability. The problems with applying the PCL-R with this population are discussed. The results of a pilot study analysing data collected for clinical purposes on a high security LD admission ward are described, and recommendations for further development and research are made. In recent years the Psychopathy Checklist-Revised (PCL-R, Hare 1991) has been increasingly employed in forensic settings. Its establishment as a robust predictor of recidivism, and particularly violent recidivism (eg Hemphill et al 1998), has led to its inclusion in several major risk assessment tools (eg HCR-20 (Webster et al 1999); VRAG (Quinsey et al 1998)). There is therefore reason to believe that the PCL-R is a potentially useful tool in the assessment of offenders with learning disabilities (ie those with low intellectual functioning and significant impairment in adaptive functioning). However, although several of the large sample studies of PCL-R with prisoners and forensic psychiatric patients will have included offenders with borderline to mild learning disabilities, there has been no published research relating specifically to the applicability, validity and reliability of the PCL-R with such offenders. Use of the PCL-R with Offenders with Learning Disability Clinical experience with patients with borderline, mild and moderate learning disability (LD) would suggest that scoring PCL-R assessments with this population could be less straightforward than with those patients functioning in the average intellectual range. There are a number of reasons why this may be the case. The first problem is that the item descriptions in the PCL-R manual relate to the way the item presents in people of average intelligence. It is probable that some of the key features of psychopathy (particularly those interpersonal features encompassed by Factor 1) may present differently in people with LD. For example, the item description for Conning/Manipulative (Item 5) states that “behaviours include criminal activities, such as collecting social assistance under many different names, passing bad cheques and setting up phoney businesses … making use of loopholes in the law …[and] convictions for fraud and embezzlement”. While people with LD are undoubtedly capable of manipulating others, this manipulation is likely to take a less broad and criminally sophisticated form than that described in the PCL-R manual. For LD offenders there may need to be a different emphasis: for example on evidence that the person being assessed attempts to use people around them, such as family, staff in institutions or other, less able, patients. Similar arguments apply in relation to the item descriptions for several other PCL-R items, for example Glibness/Superficial Charm (Item 1) and Grandiose (Item 2), and specific examples of how these features manifest themselves in people with LD would facilitate item scoring. A second potential problem with scoring the PCL-R with this group is that the lives of people with LD often restrict opportunities to demonstrate some of the behaviours relevant to the PCL-R. They may have experienced long-term institutional care, have fewer opportunities for sexual relationships and live-in relationships, and do not have the same employment opportunities as more able people. These factors may affect scores on Item 9 (Parasitic Lifestyle), Item 13 (Lack of Realistic Long-Term Goals) and Item 17 (Many Short-Term Marital Relationships) amongst others. In cases where opportunity has been severely restricted, it is therefore arguable whether such items should be omitted. Reduced opportunities combined with limited abilities also narrow the range of types of offences committed by LD offenders: fraud, robbery and firearm convictions, for example, are very rare in this population. It is also important to note that that LD offenders are frequently not processed through the criminal justice system at all. Offenders with LD who commit violent acts while living in institutions, whether or not detained under the Mental Health Act, are often not charged even when serious offences have taken place. These factors will affect scoring on the Criminal Versatility item (Item 20) which is based largely on charges and convictions. A third area of difficulty arises in relation to the clinical features of some people with LD (and syndromes associated with LD) and their relevance to some PCL-R items. Autism, for example, is a condition associated both with learning disability and with a lack of social and emotional reciprocity. Many people with autistic spectrum disorders might score positively on Item 7 (Shallow Affect) which describes “an individual who appears unable to experience a normal range and depth of emotion” and Item 8 (Callous/Lack of Empathy). Some clinicians might argue that if the characteristic can be explained by the autism diagnosis, that this should be taken into account in the scoring. However PCL-R training is clear on the point that there is no clinical override for any long-term condition, and if the feature (e.g. lack of empathy) is present, then it may be relevant to the PCL-R score (and risk) regardless of it‟s aetiology. More generally, emotional and developmental delay may affect characteristics such as reliability and ability to take responsibility for one‟s actions, which is pertinent to Items 15 (Irresponsibility) and 16 (Takes Responsibility). For these items it may be most appropriate to make comparison with a non-offending LD population when considering the evidence, and to code the item as definitely present only if the feature is outside the norm for that population. Finally, a problem arises with the difficulties of administering the standard PCL-R interview with people with moderate (and even mild) intellectual disabilities. Their degree of comprehension, concentration and recall all create potential difficulties. Some people with greater impairment may even be impossible to interview in a structured way. In these cases it would be necessary to score the PCL-R from file information, which could, in turn, be incomplete because few writers will have had informative interviews with the patient. Despite the problems outlined above, for the past four years the author has used the PCL-R as part of a broader assessment of patients admitting to the Learning Disability Service of Rampton Hospital, which is the National Centre for High Secure Learning Disability Services. The second part of this paper describes the basic findings of a small-scale pilot study which analysed this data collected for clinical purposes, and points the way for further research in this area. Description of The Pilot Study The sample comprised 30 patients admitted to (or residing in) a male LD Service admission ward between August 1998 and April 2002. 21 were admitted to the ward from outside the hospital, and represented over 80% of all new admissions to the service during the study period. The remaining 9 were either existing patients on the admission ward or were transferred to the admission ward from other wards for re-assessment. The hospital admission criteria require the patients to have a diagnosed Mental Disorder (as described in the Mental Health Act), and to represent a “grave and immediate danger to the public”. In addition, they need to be clinically assessed as having a learning disability. The patients in the LD Service may have MHA classifications of Psychopathic Disorder, Mental Illness or Mental Impairment, and some patients are dually or triply classified. At the time of the study there were an average of 80-90 patients in total in the LD service. The sample was comparable to the population in the service on most characteristics (including IQ), but because of the focus on new admissions does have a shorter current length of stay. The PCL-R was administered as part of a broader psychological assessment process by an experienced psychologist trained in the use of the PCL-R, and with established inter-rater reliability (with non LD patients). The scores were based on full interview and file review in all cases. Standard Deviation PCL-R Score N Mean Range Total 30 22.5 7.2 9-37 Factor 1 30 8.9 3.4 4-15 Factor 2 30 11.9 3.7 3-17 Table 1: PCL-R scores in Learning Disability Service sample. MENTAL HEALTH SERVICE* LD SERVICE PD Classification MI Classification All Classifications Mean PCL-R Score N = 40 N = 30 N = 30 Total (SD) 20.1 (8.1) 18.3 (8.9) 22.5 (7.2) Factor 1 (SD) 8.2 (3.5) 6.9 (3.7) 8.9 (3.4) Factor 2 (SD) 9.7 (4.5) 9.4 (4.9) 11.9 (3.7) * Hughes et al 2000 Table 2: PCL-R scores for different samples of forensic psychiatric patients within Rampton Hospital. Results The PCL-R scores for the present Rampton Hospital Learning Disability Service sample are presented in Table 1. The mean PCL-R total score was 22.5, with individual scores ranging between 9 and 37. In Table 2 these figures have been compared with a sample of patients detained in Rampton Hospital who were not diagnosed as having a learning disability (Hughes et al 2000). The patients in that study were admitted to the Mental Health Service and were divided into 2 groups: those with a MHA classification of Psychopathic Disorder (n = 40) and those with one of Mental Illness (n = 30). The mean total PCL-R score and Factor 1 score in the LD sample are slightly higher than both the Mental Health Service samples. The Factor 2 score is more than 2 points higher than both samples. In terms of the prevalence of “high” scorers, 5 (16.7%) of the current LD sample scored 30 or above (the original suggested cut off for determining high levels of psychopathy (Hare 1991)), and 10 (33.3%) scored 25 or above (the current agreed British cut off). This compares with 15% scoring over 30 (30% over 25) in the Rampton sample referred to above (Hughes et al 2000), and 10.7% over 30 (27.7%) in the large forensic psychiatric sample described by Hare (1991) in the PCL-R manual. Discussion The results for this sample of the current Learning Disability Service patients at a high secure hospital are broadly comparable with patients without a learning disability in the same hospital. The results are also comparable to those in large forensic psychiatric samples in North America (eg Hare 1991). However the higher Factor 2 in this sample scores may point to higher levels of antisocial lifestyle characteristics and impulsive behaviour in learning disabled forensic psychiatric populations as compared to those without learning disability. The level of psychopathy appears higher than in a representative UK prison sample where the mean total was 16.5 (Hare, Thornton, Clark and Gann 2000). However, this is unsurprising given the admission criteria for the hospital, which include a significant level of dangerousness. It was the author‟s experience that judgements regarding item scores with the LD sample described here, were indeed more complex than for assessment of offenders with IQs in the normal range. This became more problematic when assessing patients in the moderate LD range (ie IQ below 60). The difficulties are due in part to the absence of clear coding instructions and examples relevant to LD patients, development of which would seem appropriate in view of some of the problems outlined in the introduction. Some of these problems could lead to relatively high numbers of omitted items, and hence more pro-rated total scores (12 of the 30 scores in the current study involved pro-rating). Moreover such difficulties may lead to lower inter-rater reliability, and it is recommended that future studies should employ dual ratings. The patients with more severe disability were experienced as more difficult to interview, and there were at least three cases encountered during the assessment period where PCL-R assessments were not conducted for this reason. For example, one patient had a deteriorating neurological condition and had very poor speech, comprehension and concentration. Another had English as a second language in addition to a moderate learning disability, had very limited comprehension, and was not able to sit still long enough to be interviewed. It may therefore be that patients with greater impairment are under represented in this sample. Concerns regarding the validity of the instrument for this latter group led to the author being cautious in utilising such assessments for clinical risk assessment purposes. Further research may well conclude that that the PCL-R is an assessment that cannot usefully be employed with those with moderate LD. This pilot study suggests that the PCL-R is an assessment tool that can be conducted with a borderline to mild LD population. However, further research and development in a number of areas would seems to be appropriate before it can be confidently described as valid and reliable with this group of offenders: 1. Given the problems outlined in the introduction, it is possible that there would be less agreement between raters in relation to assessment of LD populations, as compared to other offender populations. The inter-rater reliability of the PCL-R, specifically with LD populations, therefore needs to be established. 2. In order to facilitate inter-rater reliability, general coding guidelines relating to using the tool with people with LD, and item descriptions incorporating examples relating to this population have been developed (contact author for details). The existence of characteristics relevant to the PCL-R may need to be considered in relation to what is „normal‟ for the LD population. It could be argued that raters may need particular experience with rating LD offenders before embarking on independent assessments with this group. 3. Normative data on the PCL-R for offenders with LD needs to be established. In particular, the relationship between Factor 1 and Factor 2 scores (and scores on the new factor structure to be described in the forthcoming second edition of the PCL-R manual) should be explored in relation to non-LD samples. 4. The predictive validity of the measure for this population also needs to be established via reconviction/re-offending studies, before it can be legitimately employed as part of risk assessments for LD offenders. References Hare, R.D (1991). The Hare Psychopathy Checklist – Revised. Multi Health Systems. Toronto ON. Hare, R.D, Clark, D. Grann, M. Thornton, D. (2000). Psychopathy and the predicitive validity of the PCL-R: an international prespective. Behavioural Sciences and the Law, 18: 623-645. Hemphill J.F, Hare R.D, Wong S. (1998). Psychopathy and recidivism: A review. Legal and Criminological Psychology, 3, 141-172. Hughes, G.V, Sinclair S., Braham, L. (2000) Psychopathy ratings in male forensic psychiatric patients. In Forensic Psychology and the Law. European Association of Psychology and Law. Krakov. Quinsey, V.L., Harris, G.T, Rice M.E, Cormier C.A (1998). Violent offenders : Appraising and Managing Risk. American Psychological Association. Washington DC. Webster, C.D, Douglas K.S, Eaves, D. Hart, S. D (1997). HCR-20: Assessing Risk for Violence. Simon Fraser University, BC. NOTE A version of this paper has appeared in The British Journal of Forensic Practice Volume 5 . Issue 1. February 2000.
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