Childhood maltreatment and the risk of institutional violence in forensic settings: a systematic review; and, The relationship between adverse childhood experiences, violence, empathy and psychosis within forensic settings

Abstract

BACKGROUND: The experience of childhood trauma has been linked with several negative health and behavioural outcomes, one of which is the perpetration of violence. Despite high levels of violence within forensic inpatient services, research within this population is limited. This thesis portfolio aimed to add to the evidence base in this area by conducting a systematic review of the literature exploring the experience of childhood maltreatment as a risk factor for perpetration of institutional violence in forensic settings. Relatedly, a research project was conducted exploring the relationship between adverse childhood experiences (ACEs) and violence whilst examining empathy and symptoms of psychosis as potential mediating factors.

METHOD: A systematic review of studies investigating the relationship between childhood maltreatment and institutional violence in forensic settings was carried out. Comprehensive searches were carried out of relevant databases. Using pre-defined inclusion and exclusion criteria 10 studies were selected for review and quality assessment and relevant data extracted and synthesised. In the empirical project case-note and database searches were utilised to extract data for N = 343 participants across 10 sites in the Scottish Forensic Network to examine if total ACE score and each of the six included ACE categories predicted inpatient violence whilst controlling for potential covariates. Subsample analyses were conducted to explore positive symptoms, insight, and empathy as potential mediators. Data relating to violent incidents were extracted pseudo-prospectively via the NHS DATIX system.

RESULTS: The systematic review found four studies which demonstrated an increased risk of institutional violence following exposure to childhood maltreatment and six studies which did not find this. Studies conducted in prisons were more likely to demonstrate an association than those in forensic mental health settings. There were significant methodological limitations across studies; including smaller sample sizes in some studies which did not demonstrate a positive relationship. Findings of the empirical project demonstrated high rates of ACEs within forensic mental health populations and indicated a significant association between total ACE score and both, any violence and verbal aggression. Total ACE score was found to be significantly associated with an increase in verbal aggression and history of sexual abuse was significantly associated with an increase in violence. Previously completed psychological interventions were associated with a decrease in violence and verbal aggression. Positive symptoms, insight and empathy did not mediate the relationship between ACEs and violence but did predict all types of violence.

DISCUSSION: Both the systematic review and the empirical project highlight extremely high rates of childhood trauma experienced by individuals within the forensic mental health system, reinforcing the importance of trauma-informed services. Findings of the systematic review partially support the hypothesis that childhood maltreatment increases the risk of institutional violence perpetration although any potential to draw definitive conclusions is limited by methodological issues and further high-quality research would be of benefit. Similarly, findings from the empirical project partially support the hypothesis that ACEs predict increased violence and indicate a predictive relationship between empathy, positive symptoms of psychosis, insight and all types of violence. Consideration of these key variables in treatment is key in reducing the likelihood of violence perpetration within forensic inpatient services. Limitations of both papers are discussed and recommendations for future research provided.