Risk factors and risk equations

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Chapter 3 Risk factors and risk equations

To recap:

It is now necessary to examine the group of two factors that, when considered together, help determine the likelihood of the event occurring.

Measuring the likelihood of the event occurring is a combination of the static risk factors and the dynamic risk factors. Or put mathematically:

Risk factors1

Risk factors can be divided into two main categories:

In some forensic settings, static factors are referred to as enduring factors and dynamic factors are referred to as variable factors.

Static risk factors are factors that do not change. They are usually laid down either as a result of the patient’s developmental history or are related to the patient’s past external environment. Static factors give an indication of an individual’s longer term propensity for the risk.

Some examples of static factors include:

Lists of risk factors for violence and suicide can be found in Chapter 9 (Tables 9.1 and 9.2, pp 80, 84).

The static factors set the context in which a clinician works.3 Empirically it makes sense that the closer the patient is to these factors in time, the greater the influence they will have. However there is currently no literature available to support this. An extreme example would be of a man who was repeatedly violent in his youth but is now presenting at the age of 75. The weighting given to these factors is likely to be less than had he presented at the age of 25.

Dynamic risk factors are those factors which are more likely to change:

Dynamic factors capture the fluctuating nature of risk. Dynamic factors may change in both duration and intensity. A single event may cause changes to a number of dynamic risk factors creating a change to the overall risk. Assessing the dynamic factors is essential for considering the particular conditions, patterns and circumstances that place individuals at special risk. Hanson and Harris (2000)4 distinguished between stable and acute dynamic factors. Stable dynamic factors (e.g. traits of impulsivity or hostility) are unlikely to change over short periods of time, but can change gradually. In contrast, acute dynamic factors (e.g. drug use and mental state) can change daily or even hourly.

Further understanding of risk factors comes from knowing that certain risk factors are more likely to be relevant to certain types of risks. This knowledge is of immense importance in risk assessment as commonly occurring factors can be looked for. These factors are being refined with increasing research.

It is not sufficient to consider risk factors in isolation and manage them individually. Risk factors can affect each other in various ways. For example, one risk factor may moderate the effect of another or a second risk factor may only become relevant if the first risk factor is present. There are many possible permutations which will need to be formulated by clinicians for each patient. Whenever there are more than two causal risk factors these issues must be considered.5 (A causal risk

factor is one that can be changed by manipulation and when changed can be shown to alter the risk.)

Finally, there will be risk factors that will be specific to individual patients. These have been termed ‘signature risk signs’ by Fluttert (2005). She states:

These personal signature risk signs and patterns of behaviour can be useful concepts for clinicians to consider when assessing patients. The concept of ‘signature risk signs’ has been incorporated into the thinking behind ‘START’, an assessment tool currently being evaluated.7 Along similar lines, the concept of ‘critical risk factors’ is also worth considering. These are 2–3 risk factors which will be of great importance for specific individuals and can be highlighted in management plans as flags for rapid intervention.

Looked at diagrammatically, risk factors can be presented as shown in Figure 3.1.8

When it comes to documenting the risk, this diagram can be referred to. The risk documentation framework used in the book is to a large degree based on this model.

Example 1 — violence risk factors

Jimmy was brought up in a violent household (static factor). He was diagnosed with conduct disorder when 11 (static factor). He is currently experiencing command auditory hallucinations (dynamic factor — mental state) and wants to kill the Prime Minister. He lives down the road from Parliament (dynamic factor — situational) and has stopped his medication (dynamic factor — situational).

When knowledge of the static risk factors is combined with that of the dynamic risk factors, an estimation of the likelihood of the risk occurring can be made. This can be used to help plan an intervention in the here and now. Efforts can then be made to reduce the likelihood of dynamic risk factors occurring again or if they do, early interventions can be implemented.

The synthesis of the static and dynamic risk factors combines to give the current ‘risk state’.9, 10 The risk state is a term used in some literature to describe the likelihood of the risk occurring at a given time.

The graphs in Figures 3.2 and 3.3 help describe the idea of risk being a synthesis of static and dynamic factors. The second graph also shows how the likelihood of the risk occurring can change quickly.

Example 211

Figure 3.2

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