Assessing and managing risk for violence among juveniles is an important forensic task. Clinical judgement is never sufficient for this important job. This presentation outlines methods of assessing and managing risk of violence among young people.

1. Assessment Of Highly Complex
Cases
Dr. Kathy Seifert
k.seifert@espsmd.com

2. ASSESSMENT
Targets of Assessment
Types of Assessment
Assessments inform treatment

3. OBJECTIVES
1. Participants will be able to state the purposes of
the three levels of assessment.
2. Participants will be able to name 2 assessments
for risk of dangerousness to others
3. Participants will be able to name 5 risk factors for
violence
4. Participants will be able to explain how
assessments can inform treatment

4. THREE LEVELS OF ASSESSMENT – LEVEL 1
1) Initial screening with a psycho-social interview and review of records
using an Integrated Health Model
1) Be logical and systematic about your assessment
2) Define Types of problems across domains - physical, mental, family,
school, substance abuse, environment, stressors
3) Look at information from a variety of psychological paradigms
4) Assess level of severity and acuteness
5) List strengths of youth and family
6) Be culturally sensitive
7) Assess for smoking, weight, exercise, physical symptoms, family history
of chronic disease and refer to MD when needed.
8) Determine need for further assessment and treatment needs

5. ASSESSMENT LEVEL 2
If there are problems, a more in depth assessment is needed in that area.
Areas might include Behavioral health, substance abuse, physical health,
cognitive health, safety
1. Get information from other systems, such as schools, when you can
2. Assessment may be done by a specialist in that area
3. Be methodical and organized
4. Assessment should determine types and intensity of treatment
5. A variety of tools are available

6. ASSESSMENT LEVEL 3
When problems are severe, chronic, acute, dangerous, immediate specialty
assessments are needed to determine immediacy of danger, as well as type,
and intensity of treatment needed.
1. Get 3rd party information when possible
2. Psychological Testing may be needed
3. Interventions that meet the needs of the client and his or her family
4. Safety must be the number 1 priority. You cannot help children if they are not safe.
1. Dangerousness
2. Suicidality
3. Domestic violence

7. DANGER TO SELF
Suicide Risk vs. Self Harm

8. DANGER TO SELF
 Assessment of suicidal risk is complex
 “the assessment of suicidal risk should be made and documented
with frequency during ongoing treatment, especially at times of
impending transition, heightened stress, or changes in environmental
supports.”
 Berman, Alan L. Jobes, David A. Silverman, Morton M. , (2006).
Adolescent suicide: Assessment and intervention (2nd ed.)., (pp.
119-167). Washington, DC, US: American Psychological Association,
ix, 456 pp. doi: 10.1037/11285-009

9. TREATMENT
 "one-size treatment" does not fit all – Berman, et al.
 using more treatment options in a synthesized
manner is superior to rigidly adhering to only one or
two approaches – Berman, et al.

10. SAFE-T
 http://store.samhsa.gov/product/Suicide-Assessment-Five-Step-
Evaluation-and-Triage-SAFE-T-/SMA09-4432
 Assess Risk factors, especially those that can be changed
 Assess resiliency factors especially those that can be increased
 Conduct suicide inquiry
 Determine risk level and intervention
 Document

11. ONTARIO HOSPITAL ASSOCIATION GUIDEBOOK
 http://www.oha.com/KnowledgeCentre/Documents/Final%20%20Sui
cide%20Risk%20Assessment%20Guidebook.pdf
 Each client is assessed for risk of suicide at regular intervals, or as
needs change
 Clients at risk of suicide are identified
 Client’s immediate safety needs are addressed
 Treatment and monitoring strategies to ensure client safety are
implemented
 Treatment and monitoring strategies are documented in the
client’s health record

12. SELF-INJURY
 Attempt to Cope with internal or external stressors
 Generating endorphins
 Managing emotions
 Eliciting response from environment
 Trigger dissociative state
 Treatment issue based on the function of the behavior

13. DANGER TO OTHERS
 Each client is assessed for risk of dangerousness at regular intervals,
or as needs change
 Clients at risk of dangerousness are identified and charted
 Immediate safety needs of others are addressed
 Treatment and monitoring strategies to ensure procedures for
safety of others are implemented
 Treatment and monitoring strategies are individualized and
documented in the client’s health record
 Outcomes of strategies are charted

14. BASIC PRINCIPLES OF ASSESSMENT LEVEL 3 (VERY
COMPLEX CASES)
 Assess for dangerousness: Domestic Violence, Abuse, risk of
violence, risk of sexual offending, and suicidality and take
appropriate safety measures. Agencies that actively employed
standardized risk and need assessments had a greater impact on
recidivism than agencies that did not (correlations with effect sizes of
.33 and .16, respectively (CRIME & DELINQUENCY, Vol. 52 No. 1, January 2006 7-27;
DOI: 10.1177/0011128705281756)
 Assess developmental level of parents and child in a variety of skill
areas. Behavior Objective Sequence (Braatan). Skills must be
taught in developmentally appropriate sequence.
 Assess systems for cooperation, communication, and mutual support
 Determine types and levels of treatment needed

15. Instrument Risk of
Violence
Ages Case
Manag
ement
Can be
Administe
red
Unaided
Clinical
Judgement
r =.12;
AUC =.51
Any No NA Many studies
SAVRY
(Handbook of
Violence Risk
Assessment
By Randy K Otto)
R = .56-
.67; AUC
= .77-.80
12-
18
No Hand Structured
Professional
Judgment;
CARE2 (The
Handbook of Forensic
Psychology
edited by Irving B.
Weiner, Allen K. Hess)
r = .62;
AUC = .87
6-18 Yes Hand or
online
Risk and Needs;
1,026 males and
females, ages 6-18
LS-CMI (Int J
Offender Ther Comp
Criminol. 2012
Feb;56(1):113-33.
Epub 2011 Feb 13)
r = .39;
AUC =
.75
16+ Yes Hand or
computer
Risk and Needs;
250,000 youth and
adult offenders in
US and Canada
PCL-YV (Int J
Law Psychiatry. 2008
Jun-Jul;31(3):287-96.)
AUC =
.73 males
.50
females
12-
18
No Hand Measure of
Psychopathic traits
(Kosson, et. al. Psychol
Assess. 2002 Mar;14(1):97-
109.)

16. SAVRY
http://savry.fmhi.usf.edu/ (ranks as most accurate by Singh JP, Grann M, Fazel
S, 2011) The SAVRY is composed of 25 items (Historical, Clinical, and Contextual)
drawn from existing research and professional literature in adolescent development and
on violence and aggression in youth. An additional five Protective Factors are also
provided. (Bartel, Borum, & Forth, 1999; Borum, Bartel, & Forth, 2000). Ages 12-18
years.

17. LS-CMI – TREATMENT PLANNING FOR
DELINQUENCY
1. LS-CMI http://www.mhs.com/product.aspx?gr=saf&prod=ls-cmi&id=overview
The Level of Service/Case Management Inventory (LS/CMI) is an
assessment that measures the risk and need factors of late
adolescent and adult offenders. The LS/CMI is also a fully
functioning case management tool. This single application provides
all the essential tools needed to aid professionals in the treatment
planning and management of offenders in justice, forensic,
correctional, prevention and related agencies. (16 years +). Male
and female norms.

18. CARE2
http://care2systems.com The CARE-2 (Child & Adolescent Risk Evaluation)
Assessment by Dr. Kathy Seifert works to identify youth who are at risk for
violence and determines specific interventions needed to prevent any
future risk of aggressive behavior. Updated and enhanced, this invaluable
tool examines every factor that may be affecting the youth's development, and
puts a plan in place for the youth to mature into a positively pro-social
functioning member of society. (ages 6-19)

19. USING THE CARE2

20. CARE2
4 NORMS
 Male/female
 Pre-teen/Teen
 Mark all that apply
 Items with scores are added and resiliency scores
subtracted
 risk scale are statistically derived on a sample of
1000+ youth and studies of subsets
 Evidence based intervention plans

21. HISTORICAL FACTORS
 Past behavior problems
 Past Assaults
 Chronicity
 Severity
 Escape from custody
 Firesetting
 Harmed
 Animals
 Early behavior problems
 Enuresis
 Delinquency

22. RECENT MENTAL HEALTH AND BEHAVIORAL
HEALTH ISSUES
 Anger management
 Runaway
 Lacks remorse
 Poor problem solving
 Belief in the legitimacy of aggression
 Social skill deficits
 Bullying behavior
 Deviant peer group
 Limited association with pro-social peers
 Paranoia
 IQ below 80

23. RECENT MENTAL HEALTH AND BEHAVIORAL
HEALTH ISSUES II
 School problems
 Risk for placement
 Impulsive
 Emotions poorly regulated
 Psychosis
 Self-harm

24. RESILIENCY FACTORS
 Average or better IQ
 Positive experiences with caregivers
 Positive school experience
 Lack of untreated psychiatric or substance abuse
problems in caregivers
 Positive future goals
 Positive activities
 Effective treatment
 Pro-social peers
 Modulates emotions well
 Takes medication as prescribed

25. HISTORICAL FACTORS II
 Attachment problems
 Abuse and neglect
 Family violence, abuse, neglect, or criminality
 Parental insufficientcy
 Parental absense
 Bullying

26. HISTORICAL SUBSTANCE ABUSE &
NEUROLOGICAL PROBLEMS
 Substance abuse
 Neurological
 Mental health

31. PCL-YV
http://www.mhs.com/product.aspx?gr=edu&prod=pclyv&id=overview (Ranks
as least accurate by Singh JP, Grann M, Fazel S, 2011 meta-analysis)
Correlations with female violence is NS. The Hare Psychopathy Checklist:
Youth Version (PCL:YV) is a 20- item rating scale for the
assessment of psychopathic traits in male and female offenders aged
12 to 18. The PCL:YV uses an expert-rater format that emphasizes
the need for multidomain and multisource information. Using a
semistructured interview and collateral information, the PCL:YV
measures interpersonal, affective, and behavioral features related to
a widely understood, traditional concept of psychopathy. Ages 12-18

32. SAVRY – BORUM, BARTEL, FORTH
 The SAVRY is composed of 24 items in three risk domains (Historical
Risk Factors, Social/Contextual Risk Factors, and Individual/Clinical
Factors), drawn from existing research and the professional literature
on adolescent development as well as on violence and aggression in
youth. Not designed to be a formal test or scale, there are no assigned
numerical values nor are there any specified cutoff scores. Based on
the structured professional judgment (SPJ) model, the SAVRY helps
you structure an assessment so that important factors will be
emphasized when you formulate a final professional judgment about a
youth’s level of risk.
 http://www4.parinc.com/Products/Product.aspx?ProductID=SAVRY
 Ages 12 – 18

33. SAVRY ITEMS SIMILAR ON 4 SCALES
Risk Item/Factors
Items/Factors included in the
SAVRY
Historical Risk Factors
- History of Violence
- History of Nonviolent Offending
- Early initiation of Violence
- Past Supervision/Intervention
Failures
- History of Self-Harm or Suicide
Attempts
- Exposure to Violence in the Home
- Childhood History of Maltreatment
- Parental/Caregiver Criminality
- Early Caregiver Disruption
- Poor School Achievement

34. SAVRY ITEMS 2
Social and Contextual
Risk Factors
- Delinquency
- Peer Rejection
- Stress and Poor Coping
- Poor Parental Management
- Lack of Personal/Social Support
- Community Disorganization
Individual/Clinical
Risk Factors
- Negative Attitudes
- Risk Taking/Impulsivity
- Substance-Use Difficulties
- Anger Management Problems
- Low Empathy/Remorse
- Attention Deficit/Hyperactivity
Difficulties
- Poor Compliance
- Low Interest/Commitment to
School

35. SAVRY ITEMS – PROTECTIVE FACTORS
Protective Factors
- Prosocial Involvement
- Strong Social Support
- Strong Attachments and Bonds
- Positive Attitude Toward
Intervention and Authority
- Strong Commitment to School
- Resilient Personality Traits

36. DEVELOPMENTAL
ASSESSMENT

37. 6 CORE CONCEPTS OF CHILD
DEVELOPMENT
 Children are always learning and development
has a sequence that must be followed and age is
not a determinate of developmental level (roll
over, sit up, crawl, stand up, walk)
 Skill building usually follows developmental
sequences and be taught within the context of a
healthy, nurturing, dependable relationship.
 Attachment experiences (good, bad, or ugly) and
trauma change the brain.

38. CHILD DEVELOPMENT - 2
 Corrective developmental experiences and
healthy relationships can also change the brain.
 The balance between healthy and unhealthy
biology (including genes), environment and
experiences will determine the health of
development.
 Healthy skill development is necessary to
function effectively in the world of people.

39. WHAT DEVELOPMENTAL AREAS ARE AFFECTED
BY TRAUMA
 Problem solving
 Self management
 Moral reasoning
 Logic
 Affect regulation
 Interpersonal relatedness
 Task behavior
 Concentration
 Impulsivity
 Effective Communication

40. THE MARSHMALLOW EXPERIMENT

41. Trauma Negatively Affects Moral Development, Kohlberg, 1969
(Expanded from Piaget)
Can be blocked by Trauma
Can be blocked by Trauma
Can be blocked by Trauma

42. ERIKSON’S STAGES
• 1 Hopes: Trust vs. Mistrust (Oral-sensory, Birth-2
years) (Safe Base)
• 1.2 Will: Autonomy vs. Shame & Doubt (Muscular-
Anal, 2-4 years) (Exploration from Safe Base)
• 1.3 Purpose: Initiative vs. Guilt (Locomotor-Genital,
Preschool, 4-5 years) (I can do things on my own)
• 1.4 Competence: Industry vs. Inferiority (Latency, 5-
12 years) (I am Competent)
• 1.5 Fidelity: Identity vs. Role Confusion
(Adolescence, 13-19 years) (Who am I?)
• 1.6 Love: Intimacy vs. Isolation (Young adulthood,
20-24) (Establishing a family/ career)

43. TRAUMA CAN INTERRUPT THE SEQUENCES OF
DEVELOPMENT

44. ASSESS WHERE A CHILD IS ON A
DEVELOPMENTAL SCALE
 Many are at immediate gratification and seeking a
safe base.
 Immediate gratification and needs of the self are
primary
 Must learn perspective taking and reciprocity before
empathy
 If the youth is still seeking a safe base, that must be
established before exploration of the world and
information gathering
 A safe environment is essential for healthy development
 You need some type of developmental guide for use in
your treatment plan

45. ASSESSMENT OF CHILDREN – LEVEL 3
Level 3 is for children and teens with severe
behavioral disturbances.
 8 Symptom Categories
 Traumatized Brain
 3 or 4 Attachment Patterns
 Holistic Assessment and Treatment Practices
 Assessing Development Using the BOS

46. LEVEL 3. 8 SYMPTOM CATEGORIES OF DTD/CPTSD/RAD –
PAST & PRESENT; FREQUENCY, DURATION, AND SEVERITY. WHAT
OTHER DISORDERS HAVE THESE SYMPTOMS?
 Behavior – Lack of eye contact, enuresis, violence,
out of control behavior, hoarding food, lies, steals,
oppositional and defiant, breaks the rules,
impulsive, destructive, hyperactive, self-destructive,
harms animals, irresponsible
 Emotions – intense anger & temper, sad,
depressed, hopeless, moody, fearful, anxious,
irritable, inappropriate emotional reactions,
emotions not well regulated

47. SYMPTOMS – 2.
THOUGHTS – NEGATIVE BELIEFS ABOUT OTHERS AND RELATIONSHIPS, LACKS
CAUSE AND EFFECT THINKING, ATTENTION & LEARNING PROBLEMS
negative beliefs about self

48. Symptoms 3.
Relationships – lacks
trust, controlling (bossy)
with children and
adults, is not genuinely
affectionate with family,
indiscriminately
affectionate with
strangers, unstable
peer relationships,
blames others for
misdeeds, victimizes
others and is
victimized.

49. SYMPTOMS - 4
 Physical - failure to thrive, poor hygiene, tactilely
defensive, enuresis & encopresis, accident prone, high
pain tolerance,
 Moral/Spiritual – lack faith, compassion, remorse, pro-
social values, identification with evil or the “dark side”
 Development - delayed development
 Core Beliefs/Internal Working Model of self, others, and
world is Negative

50. HOLISTIC ASSESSMENT PRACTICES
 Measure all areas of strengths, stressors, and
symptoms for youth and family
 Anything you change within the system will affect
other subsystems, but try to affect as many areas
as possible

51. THE BEHAVIOR OBJECTIVE SEQUENCE
 By Sheldon Braatan
 A developmentally sequenced group of skills in 6 Domains.
 Age is not the determiner of skill level
 Youth must learn skills in appropriate developmental
sequence.
 Find out at what level they have mastered skills (can do it 90%
of the time without prompting)

52. ADAPTIVE SKILLS
Responds in a developmentally appropriate manner
to rules and expectations
AND
Changes those responses as the circumstances
change
Example
I expect a __ year old to walk into the counseling
office and be able hold a conversation with the
counselor AND when the format is changed to
group therapy, the youth is able to adapt to the
different format and relate to peers in the group, not
just counselor.

53. Adaptive: Responds appropriately to
routine and new expectations
respond independently to materials for amusement
appear alert and able to focus attention
bring no weapons to school
use amusement materials appropriately
wait for turn without physical intervention
use and return equipment without abuse
accept positive physical contact
touch others in appropriate ways
refrain from stealing
respond when angry without hitting
recognize and show regard for possessions
accept verbal cue for removal from a situation
respond when angry without abuse of property
respond appropriately to substitute
respond when angry without threats
walk to timeout without being moved by an adult
work or play without disrupting others
refrain from inappropriate behavior when others
lose control
respond to provocation with self-control
respond when angry with self-removal

54. SELF-MANAGEMENT SKILLS
Responds appropriately to challenging experiences
with self-control in order to achieve success
 (E) Appear alert and able to focus attention on activities
 Wait or take turns when directed without physical intervention –
verbal prompts may be use
 Respond when angry without verbal threats or intent to harm
 (M) Seek adult help in personal and/or group crisis
 Maintain personal control and routinely comply with established
procedures in group situations without reminders.
 (H) Maintain self-control when faced with disappointment, frustration,
or failure without adult intervention.
 Obey new or temporary authority figure, without presence of other
permanent staff

55. COMMUNICATION
 Ability to share with and receive information from
other people to meet a need or affect another
person in a positive way.
 Speak using a volume appropriate to the situation
 Wait until a speaker is finished before responding
 Express feelings about self or others to an adult appropriately
 Spontaneously participate in group discussions
 Maintain appropriate social distance when speaking to another
 Speak courteously to others, using appropriate references, with
no cues.
 Describe personal strengths that will enable success

56. INTERPERSONAL BEHAVIORS
 Interacting with others in social and task situations
in ways that meet personal and interdependence
needs and contribute to a sense of belonging
 Respond to an adult when his or her name is called
 Accept help from an adult when offered
 Sit quietly for 15 minutes or more in a group listening activity
 Develop positive relationships with more than 1 adult
 Share materials and equipment with peers with minimal
reminders from adults
 Physically or verbally come to the support of another student by
offering assistance in a difficult situation
 Spontaneously resist negative peer pressure

57. TASK BEHAVIORS
 Student engages in task or activity with or without
assistance
 Accept assistance from an adult on academic tasks
 Refrain from inappropriate behavior when asked by an adult to
correct errors
 Complete daily assignments
 Choose and actively participate in elective classes
 Ignore distractions of others while working
 Self-chart progress in reading or math
 Participate in structured role-playing activities
 Complete and turn in assigned homework when due

58. PERSONAL BEHAVIORS
 Student engages in a counseling dialogue with a
helping person, permitting adult to help resolve
issues or solve problems or build self esteem.
 Express negative feelings to an adult
 Follow through with specific directions from an adult to modify
behavior in a given situation
 Participate in determining a short term plan for dealing with an
immediate situation
 Attend to a peer when a peer is speaking
 Express feelings about self to peers
 Seek counseling t avoid conflict
 Contribute to group rule making and consequences
 Verbally demonstrate knowledge of alternative coping strategies
for managing stress

59. ASSESSING PARENTS

60. PARENTS
 Attachment/trauma history
 Awareness of Emotional & Environment Triggers
 Parenting Attitudes and Competencies
 The child needs a loving home with
nurturing, affection, routine, structure and boundaries.
 There are skills to learn about anger management, reframing the
meaning of behaviors, teaching, rather than punishing
 Parent Mental Health, Substance Abuse, Offending
Behavior, Dangerousness & Stability
 Parents must take care of their mental health to do this job effectively
 Safety
 Parenting knowledge and style
 Parents need to learn about attachment and trauma and skills to help
their children

61. MARITAL RELATIONSHIP & CO-PARENTING
THE CHILD WILL DO BEST IF THE CAREGIVERS TAKE CARE
OF THEIR RELATIONSHIP HEALTH, AS WELL
DOES THE COUPLE NEED COUPLES THERAPY?

62. ASSESSMENT OF FAMILY SYSTEM
 Family backgrounds
 Families of origin
 Marital relationship
 Relationships among siblings and between children
and parents
 Structure – Family Systems Work
 Ongoing Patterns (“family dance”)
 Support Systems
 Stressors and Stress Management
 Rules, Roles, and Boundaries

63. INTERVENTIONS

64. EVIDENCE BASED TREATMENT FOR COMPLEX
CASES
 EBP
 Case management
 Multi-system integration
 Family Therapy
 Developmental approaches with skill building
 CBT
 Role playing
 Dosage is important
 Holistic approaches
 Neuro-feedback & CES
 Wrap-around

65. PROMISING PRACTICES
 Trauma and attachment work
 Routine and structure
 Healthy, safe environments
 Narrative Therapy

66. DEVELOPMENTAL INTERVENTIONS
WITH BOS

67. BOS - Level 3 (skills typically mastered
during preschool years):
Focus: Self; Significance; Success
Issues: Trust; Pleasure; Security; Support
Interventions: Routines; Repetitions;
Modeling; Concrete Rewards; Limit Setting;
Consistent and Planned Consequences;
Continuous Supervision
Adult Role: “Benevolent Dictator”

68. Level 2 (skills typically mastered during elementary
years):
Focus: Group membership; Competence; Sensitivity to
Others; Awareness of Values; Communication Skills
Issues: Applying Skills in Groups; Balancing Personal and
Group Needs; Responding to New Settings and People;
Managing Movement
Interventions: Routines; Repetitions; Verbal Rewards;
Limit Setting with Expanded Choices; Consistency with
Group Consequences; Natural and Logical
Consequences
Adult Role: “Group Leader”

69. Level 1 (skills typically mastered during
adolescence and early adulthood):
Focus: Belonging; Cooperation; Personal
“Power,” Individualtion
Issues: Applying Skills in New Situations;
Expanding and Reinforcing Competencies;
Transitions to New Environments
Interventions: “Normal” Expectations; Social
Rewards; Expanded Choices; Group Problem
Solving; Self Selected Goals
Adult Role: “Guide/Facilitator”

70. SUMMARY
 3 levels of assessment
 Initial screening
 Specialty assessment, ie. Addictions, trauma
 Assessment for dangerousness and types and intensity
of treatment
 Assessment for dangerousness at Level 3
 SAVRY & CARE2

71. OTHER ASPECTS OF ASSESSMENT
 Assessment of youth, family, family system
 Developmental Assessment with BOS
 Neurological Assessment
 Medical Assessment
 Educational Assessment
 Assessment for intensity, longevity, and types of
treatment – EBP and Promising Practice

72. QUESTIONS AND ANSWERS