Consensus building on definitions and types of child maltreatment to improve recording and surveillance in Europe: protocol for a multi-sectoral, European, electronic Delphi study

INTRODUCTION

Child maltreatment (CM) is a complex global public health issue with potentially devastating effects on individuals' physical and mental health and well-being throughout the life course. A lack of uniform definitions hinders attempts to identify, measure, respond to, and prevent CM. The aim of this electronic Delphi (e-Delphi) study is to build consensus on definitions and types of CM for use in surveillance and multi-sectoral research in the 34 countries in the Euro-CAN (Multi-Sectoral Responses to Child Abuse and Neglect in Europe) project (COST Action CA19106).

METHODS AND ANALYSIS

The e-Delphi study will consist of a maximum of three rounds conducted using an online data collection platform. A multi-disciplinary expert panel consisting of researchers, child protection professionals (health and social care), police, legal professionals and adult survivors of CM will be purposefully recruited. We will approach approximately 100 experts, with between 50 and 60 of these anticipated to take part. Participants will rate their agreement with a range of statements relating to operational definitions and types of CM, and free-text comments on each of the statements to give further detail about their responses and areas of uncertainty. Consensus has been defined a priori as ≥70% of the panel agreeing or disagreeing with the statement after the final round. The responses to the open-ended questions will be analysed using a 'codebook' approach to thematic analysis, and used to refine the statements between rounds where no consensus is reached.

ETHICS AND DISSEMINATION

Ethical approval has been granted from the Cardiff University School of Medicine ethics committee (reference number SMREC22/96). Results will be submitted for publication in a peer-reviewed journal and presented at workshops (including for the participants) and international academic conferences. The Euro-CAN network will also be used to disseminate the results, with results briefings and presentations to key public health and other relevant organisations in the field.

Development and initial validation of the THL Adverse Childhood Experiences Questionnaire (ACE-THL)

BACKGROUND

The research on adverse childhood experiences (ACEs) has deepened our understanding of the long-lasting and cumulative effects of childhood adversities. However, the instruments measuring ACEs have several shortcomings, including limited item coverage, collapsing of items and response options, simplistic scoring, and inadequate psychometric assessments.

OBJECTIVE

To design and conduct preliminarily psychometric testing for a brief new self-report instrument-the THL Adverse Childhood Experiences questionnaire (ACE-THL)-with a comprehensive set of clearly formulated items and appropriate response options.

METHODS

A previously published process model was applied to develop the ACE-THL questionnaire, which was validated by cognitive interviews (N = 20). Interviewers and interviewees completed the questionnaire separately for a cross-informant comparison. In a separate survey panel validation, the respondents filled out the ACE-THL twice, two weeks apart (N = 513, with 426 in the follow-up). Interview data were used to improve item clarity, and test-retest reliability and structural validity were assessed with repeated survey data.

RESULTS

The final 14-item questionnaire, including 12 ACE items and two items measuring protective experiences, was highly acceptable to the respondents. In the factor analysis of the quantitative data, a sufficiently single-dimensional construct was found, remaining stable in retesting two weeks later. The internal consistency (omega) of the a priori one-dimensional model was 0.89 and 0.90 at baseline and follow-up, respectively. The high test-retest reliability (mean score rank order correlation 0.93) of the ACE-THL indicated that the probed perceptions of childhood experiences are stable.

CONCLUSION

Based on the initial validation, the 14-item ACE-THL questionnaire is a reliable and valid instrument to measure adverse childhood experiences, as well as protective experiences.

Current issues and challenges in the definition and operationalization of child maltreatment: A scoping review

BACKGROUND

Studies show considerable variability in the definitions and operationalization of child maltreatment (CM), which limits research, policy formation, surveillance, and cross-country and cross-sector comparisons.

OBJECTIVE

To review the recent literature (2011-2021) to understand current issues and challenges in defining CM, to assist in the planning, testing and implementing of CM conceptualizations.

METHODS

We searched eight international databases. Articles were included if the substantive content was related to issues, challenges, and debates in defining CM, and the article was an original study, review, commentary, report, or guideline. The review followed methodological guidance for the conduct of scoping reviews and was reported in accordance with the PRISMA-ScR checklist. Four experts in CM conducted a thematic analysis to summarize findings. Methodological rigor of the included studies was not formally assessed.

RESULTS

We identified 7372 potentially relevant articles; 55 full-text studies were assessed for eligibility, 25 satisfied the inclusion criteria. We identified three themes: 1) strategies to define CM, including the integration of child and victim perspectives; 2) difficulties in defining specific CM types; and 3) real-world implications for research, prevention and policy.

CONCLUSIONS

Despite longstanding concerns, challenges regarding the definitions of CM persist. A small minority of studies have tested and implemented CM definitions and operationalizations in practice. The findings will inform international multi-sectoral processes to develop uniform definitions of CM, for example by highlighting the need to acknowledge challenges in defining some CM types and emphasizing the importance of considering the perspectives of children and CM survivors.

International perspective on guidelines and policies for child custody and child maltreatment risk evaluations: A preliminary comparative analysis across selected countries in Europe and North America

Little knowledge exists on how evaluators in child custody and child maltreatment cases are informed by guidelines, the kinds of qualifications required and the types of training provided in different countries. The purpose of this paper is to provide an international preliminary comparison on how child custody and child maltreatment risk assessments are conducted in selected Western countries, and how the assessments are informed by best practice guidelines. Another aim is to increase knowledge on how the guidelines and best-practice standards could be developed further to reflect recent research findings. A total number of 18 guidelines were included in the analyses: four from Canada, five from the United States, three from the United Kingdom, three from the Netherlands, two from Finland, and one from Germany. We conducted a content analysis of the included guidelines in the database, focusing on how the guidelines address the best interest of the child criteria, guidelines for conducting the assessments, considerations for evaluative criteria, and specific guidance for conducting specific assessment procedures (e.g., interviews and observations). Findings show that the qualifications of and training provided to evaluators in child custody and child maltreatment risk evaluations are largely heterogeneous across the countries represented. Guidelines differ in whether and how they highlight the importance of evidence-based practices and scientifically validated assessment measures. Implications are drawn from the review and contextualized by international expert authors in the fields of forensic psychology, and family law. After the content analysis, discussion sessions within the expert group were held. The authors provide both commentaries and suggestions to improve the development of standard methods for conducting both child custody and child maltreatment risk evaluations and to consider a more transparent and judicious use of social science research to guide methods and the recommendations offered within these assessments.

Being a parent in Finland: a culturally-tailored psychoeducative parental support programme

Problem

Migrant origin children are overrepresented in child protective services and among cases of suspected maltreatment against children. Language barriers, poor understanding of the child welfare system and differences in perceptions of child rearing and disciplinary practices create additional burden during the assessment process. Authorities struggle to meet the needs of migrant origin families.

Description of the problem

A variety of universal, selective and indicative parenting support programmes are available. While these have been shown to be effective also among persons of migrant origin, cultural adaptation has also been suggested to increase the benefits. Any adaptation to a trial-tested programme may, however, impact its integrity. To avoid this, a separate culturally sensitive Being a Parent in Finland programme was developed to complement other parenting interventions and supporting services offered by the health and social welfare authorities. Intervention was developed as part of the Barnahus project coordinated by the Finnish Institute for Health and Welfare.

Results

The aim of the Being a Parent in Finland psychoeducational group programme is to increase the wellbeing and safety of children through group-based parental support. The programme consists of three two-hour meetings offered to parents of children aged 3 to 12 years. The main themes include the Finnish service system, parenting practices that support the child's development and wellbeing and wellbeing of the family as well as children's rights. Psychoeducational videos were produced as supportive material. Groups of maximum 8-10 participants are led by trained instructors, assisted by professional interpreters.

Lessons

The programme will be piloted by the city of Helsinki, with the first two groups starting in May 2021. Experiences and lessons learned from these groups will be presented. Impact assessment of the programme and will be launched in autumn 2021.

Key messages

While culturally sensitive adaptations may increase positive outcomes of parental programmes, there is a risk for compromising programme integrity, leading to minimized or even adverse consequences. Being a parent in Finland aims at supporting the wellbeing and safety of families through culturally sensitive psychoeducative groups administered as complementary support measure to other services.

Effectiveness of child protection practice models: a systematic review

BACKGROUND

Attempts to improve child protection outcomes by implementing social work practice models embedded in a particular theory and practice approach, have increased internationally over the past decade.

OBJECTIVE

To assess the evidence of the effectiveness of child protection practice models in improving outcomes for children and families.

PARTICIPANTS AND SETTING

Children < 18 years and their families involved in child protection services.

METHODS

A systematic review was conducted to synthesize evidence regarding the effectiveness of child protection practice models. Systematic searches across 10 electronic databases and grey literature were conducted to identify quasi-experimental studies minimally. Included studies were critically appraised and the findings summarized narratively.

RESULTS

Five papers, representing six studies, focusing on three practice models (Solution-Based Casework; Signs of Safety; and Reclaiming Social Work) met the inclusion criteria. All studies applied a quasi-experimental design. Overall, the quality of the evidence was rated as being poor, with studies suffering from a risk of selection bias, small sample sizes and short-term follow up.

CONCLUSIONS

Despite the popularity of practice models, the evidence base for their effectiveness is still limited. The results suggest that high-quality studies are urgently needed to evaluate the impact of practice models in improving the outcomes of child-protection-involved families. The findings also illustrate the difficulties of conducting high-quality outcome evaluations in children's social care, and these challenges and future directions for research, are discussed. PROSPERO registration number: CRD42018111918.

Eyberg Child Behavior Inventory (ECBI): Normative data, psychometric properties, and associations with socioeconomic status in Finnish children

Assessment of behavioral disorders is one of the most commonly encountered tasks in child psychiatry. The Eyberg Child Behavior Inventory (ECBI) is a widespread measurement tool used for assessing conduct problems, though the psychometric properties of the tool have varied in different samples. In this study, the ECBI was evaluated in a Finnish population based sample of children aged 4 to 12 years (n = 1,715). Factor structure and internal consistency of the ECBI and associates of behavioral problems in Finnish children were evaluated. The results showed that a unidimensional one-factor solution for the ECBI intensity scale was the best fit for the data. The ECBI mean scores were considerably higher in our sample compared to other Nordic countries. Boys scored higher than girls on both ECBI scales, and the mean scores decreased with child's age. Socioeconomic status (SES) was weakly connected to the ECBI scores. Our results highlight the need for country specific reference norms in order to improve the clinical utility of evidence-based measures for assessing conduct problems.

Interpersonal Relationships as Protective and Risk Factors for Psychopathy: A Follow-up Study in Adolescent Offenders

Friendships and romantic relationships may function as protective and risk factors for psychopathic traits. To better understand potential causal associations, we investigated whether within-individual changes in relationship characteristics were related to changes in psychopathic traits over time. Data were derived from ten repeated measurements of the Pathways to Desistance longitudinal study of 1354 offending adolescents (14.3% female; 40.1% Black). Analyses were adjusted for age, gender, ethnicity, self-reported offending and living facilities. Relationships of high quality were associated with lower psychopathic traits, whereas antisocial behavior and antisocial influence in relationships were related to higher psychopathic traits. Within-individual analysis indicated that time-invariant individual characteristics did not confound these associations. The findings suggest that the quality and antisocial activities of interpersonal relationships can affect positively or negatively on the levels of psychopathy.

Evaluation of verbal list learning as a predictor of psychosis

AIM

We explored whether cognitive performance, and verbal learning in particular, predicts psychosis or psychiatric hospitalizations among unselected first-admission adolescent patients in general psychiatric care.

METHODS

Up to 152 adolescents aged 15-18 were interviewed with the SIPS, tested with a cognitive test battery in the beginning of their psychiatric treatment, and followed for a maximum of 9 years (median 4.5 years).

RESULTS

The composite factors of processing speed, verbal performance and visuospatial performance did not predict psychosis (n = 7) or all-cause psychiatric hospitalizations (n = 26) beyond psychosis risk symptoms. However, those who developed psychosis performed worse on California Verbal Learning Test (CVLT) compared to other adolescents. Lower scores of CVLT immediate recall predicted psychosis (P = .003, HR = 1.13 per CVLT point decrease). However, when general verbal ability was adjusted for, CVLT did not reach significance.

CONCLUSIONS

Impaired verbal list learning may predict psychosis also among adolescent psychiatric patients not preselected for psychosis risk suspicion.

Suicidality, self-harm and psychotic-like symptoms in a general adolescent psychiatric sample

AIM

We investigated the associations between clinical high-risk for psychosis (CHR), psychotic-like symptoms and suicidality among adolescent psychiatric patients.

METHODS

The sample consisted of 54 CHR and 107 non-CHR psychiatric patients aged 15-18 in Helsinki, Finland, who were assessed at the beginning of their psychiatric treatment with the Structured Interview for Prodromal Syndromes (SIPS). Current suicidality was measured with the Beck Depression Inventory (item 9), while lifetime suicidality was evaluated from all available data, including patient files. The participants were followed for 2.8-8.9 years via the national hospital discharge register, with the follow-up outcome being intentional self-harm. Data on suicides were also gathered from the Causes of Death statistics.

RESULTS

Only 30.5% of the adolescents had no suicidal ideation at the beginning of their treatment. CHR risk state and SIPS-assessed delusions, suspiciousness, and hallucinations were associated with higher current suicidality. Of the 154 adolescents with register follow-up, there were five (3.2%) with intentional self-harm resulting in hospital treatment, all female. CHR status was not associated with self-harm. Current suicidality, familial risk of psychosis, and SIPS decreased expression of emotions were associated with self-harm during follow-up. In a Cox regression analysis model among girls, only decreased expression of emotions remained a significant predictor of intentional self-harm. Baseline suicidality measures were not associated with transitions to psychosis.

CONCLUSIONS

CHR status was associated with higher current suicidality but did not predict follow-up intentional self-harm in treatment-seeking adolescents. Decreased expression of emotions may indicate higher risk of intentional self-harm in adolescent treatment-seeking girls.

Victimization and psychopathic features in a population-based sample of Finnish adolescents

We examined different forms of victimization experiences in relation to psychopathic features and whether these associations differed in boys and girls among 4855 Finnish school adolescents aged 15-16 years. Psychopathic features were measured with the Antisocial Process Screening Device- Self Report (APSD-SR). Victimization was assessed with questions about violent and abusive experiences across lifetime and within the last 12 months. Results from linear regression analysis showed that victimization was significantly associated with higher APSD-SR total scores, more strongly in girls than boys. Recent (12-month) victimization showed significance in the relationship between victimization and psychopathic features; especially recent sexual abuse and parental corporal punishment were strong determinants of higher APSD-SR total scores. The present study demonstrates novel findings on how severe victimization experiences relate to psychopathic features in community youth, especially in girls. The findings underscore the need for comprehensive evaluation of victimization experiences when psychopathic features are present in youth.

To tell or not to tell? Psychopathic traits and response integrity in youth delinquency surveys

BACKGROUND

Individuals with high psychopathy scores are capable of providing valid self-reports on their own personality traits, but there have been no empirical studies of the effect of psychopathic features on responding to sensitive survey questions about specific behaviours.

AIMS

The aim of this study is to investigate any relationship between facets of psychopathy and participants' willingness to report antisocial acts in youth delinquency surveys, controlling for demographic variables known to be associated with response integrity.

METHODS

In a nationally representative sample of 4,855 Finnish mainstream adolescents aged 15-16, honesty of responding was assessed through direct response integrity questions related to violence, property crime and drug use. Psychopathy was measured with the Antisocial Process Screening Device - Self Report (APSD-SR).

RESULTS

Callous-unemotional traits and, to a lesser degree, narcissistic features were associated with a dishonest response style, although the effect size was modest.

CONCLUSIONS

Although psychopathy does not seem to influence the capability and willingness to report personality traits accurately, it may be associated with endorsing dishonest responses to questions about specific behaviours that have possible repercussions. Our findings suggest that previously observed associations between adolescents' self-reported delinquent behaviour and psychopathic traits may be underestimations of the strength of the effects.

[Callous and unemotional--do children have psychopathic features?]

The essence of psychopathic personality disorder is considered to consist of emotional deviations, the most central ones of which being the lack of feelings of guilt and empathy along with impoverishment of experiencing emotions. The interest in the occurrence of these callous-unemotional features in children and adolescents has increased over the past few years. According to the most recent studies, parental interventions promoting a positive, warm, and attentive parenting and interaction style are effective in the treatment of children having a conduct disorder accompanied by callous-unemotional features.

Homicidal behaviour among people with avoidant, dependent and obsessive-compulsive (cluster C) personality disorder

BACKGROUND

Despite a growing forensic psychiatry literature, no previous study has examined in detail homicidal behaviour among offenders with cluster C personality disorders - the avoidant, dependent or obsessional personality disorders.

AIMS

This study aims to compare homicide offenders with cluster C personality disorders with those with other personality disorders on criminal history, offender-victim relationship and post-offence reaction variables.

METHODS

The sample was drawn from all Finnish homicide cases of 1996-2004 for whom a forensic psychiatric evaluation had been conducted. Data were extracted from forensic psychiatric and crime reports.

RESULTS

In a nationwide sample of 593 homicide offenders, 21 had at least one cluster C personality disorder. These offenders had significantly shorter criminal histories than the others. Offender-victim relationship did not differ between the groups, but confession to the crime and feelings of remorse were more common among people with cluster C disorders. In addition, compared with other personality disorder clusters, co-morbid depression was more common.

CONCLUSIONS

Cluster C personality disorders are rare, but not nonexistent, among homicide offenders. Observed differences in their backgrounds and post-offence behaviours indicate that they may have special needs.

Psychopathic traits in Finnish homicide offenders with schizophrenia

There is a paucity of studies examining psychopathy in comparable samples of violent individuals with and without psychotic illness. The main goal of the study was to assess the prevalence and nature of psychopathic traits as measured by PCL-R among Finnish homicide offenders with schizophrenia. Further, the impact of co-morbid psychopathy on the homicidal incidents, as well as the associations of psychopathy and offender background factors, among offenders with schizophrenia was investigated. A retrospective study was performed using extensive forensic psychiatric evaluation reports and crime reports as sources of information. The sample consisted of 72 homicide offenders with schizophrenia and 72 controls without psychotic illness. Psychopathic features were prevalent among Finnish homicide offenders with schizophrenia, although for the most parts to a lesser extent compared to other homicide offenders. Like non-mentally ill psychopathic offenders, offenders with schizophrenia and many psychopathic traits are likely to present early starting problems in many areas of life and they also commit homicides that resemble other psychopathic offenders' in their choice of victims, intoxication and post-offense behavior. The observed prevalence of psychopathic traits highlights the importance of psychopathy assessment among violence-prone individuals with schizophrenia. In most respects, offenders with schizophrenia and high levels of psychopathic traits seem to be similar to psychopathic offenders without psychotic illness, which has implications for early intervention and management.

Homicide of strangers by people with a psychotic illness

BACKGROUND

The homicide of strangers by people with psychosis, referred to here as "stranger homicides," are rare and tragic events that generate adverse publicity for mental health services and have resulted in significant changes in mental health policy and law.

AIM

To estimate the incidence of stranger homicides, using data from previously published studies, and to compare the characteristics of psychotic offenders who killed strangers with the characteristics of those who killed a close relative.

METHOD

Meta-analysis of the population-based studies of homicide by persons suffering from a psychosis in which the number of subjects who killed strangers was also reported. Characteristics of stranger homicide and family homicide offenders were examined in a multicenter case-control study of homicide during psychotic illness in four high-income countries.

RESULTS

A pooled estimate of 1 stranger homicide per 14.3 million people per year (95% confidence interval, 1 in 18.9 million to 1 in 11.5 million people per year) was calculated by meta-analysis of 7 studies. The characteristics of the 42 stranger homicide offenders from New South Wales [NSW], Quebec and Eastern Ontario, Finland, and the Netherlands were identified. Twenty seven (64%) of these had never previously received treatment with antipsychotic medication. The stranger homicide offenders were more likely to be homeless, have exhibited antisocial conduct, and had fewer negative symptoms than those who killed family members. The victims of stranger homicide were mostly adult males and the homicides rarely occurred in the victim's home or workplace.

CONCLUSIONS

Stranger homicide in psychosis is extremely rare and is even rarer for a patient who has received treatment with antipsychotic medication. A lack of distinguishing characteristics of stranger homicide offenders and an extremely low base rate of stranger-homicide suggests that risk assessment of patients known to have a psychotic illness will be of little assistance in the prevention of stranger homicides.

The relationship between psychotic-like symptoms and neurocognitive performance in a general adolescent psychiatric sample

INTRODUCTION

The current criteria for detecting a Clinical High-Risk (CHR) state for psychosis do not address cognitive impairment. A first step for identifying cognitive markers of psychosis risk would be to determine which aspects of neurocognitive performance are related with more severe psychotic-like symptoms. This study assessed cognitive impairment associated with prodromal symptoms in adolescents receiving public psychiatric treatment.

METHODS

189 adolescents were recruited from consecutive new patients aged 15-18 attending mainly outpatient adolescent psychiatric units in Helsinki. They had been screened for prodromal symptoms using the Prodromal Questionnaire, and all screen-positives as well as a random sample of screen-negatives were interviewed using the Structured Interview for Prodromal Symptoms (SIPS) and underwent testing using a large, standardized neurocognitive test battery. The sample included 62 adolescents who met the CHR criteria (CHR) and 112 who did not (non-CHR). A healthy control sample (n=72) was also included to provide age- and gender-matched norms.

RESULTS

The CHR group performed worse on visuospatial tasks than the non-CHR group. Among CHR adolescents, negative symptoms were associated with slower processing speed and poorer performance on verbal tasks. Among non-CHR adolescents, positive symptoms were associated with poorer performance on visuospatial tasks, and negative symptoms with poorer performance on verbal tasks.

CONCLUSION

Clinical high-risk status is associated with impaired visuospatial task performance. However, both positive, psychotic-like symptoms and negative symptoms are associated with lower levels of neurocognitive functioning among adolescents in psychiatric treatment regardless of whether CHR criteria are met. Thus, even mild positive and negative symptoms may have clinical relevance in adolescents in psychiatric care. Adolescents with both psychotic-like symptoms and neurocognitive deficits constitute a group requiring special attention.

[Risk symptoms of psychosis in the young]

Early intervention may postpone or even prevent the onset of psychosis and relieve symptom-related anxiety. Support and follow-up observation requires up-to-date knowledge of the nature of the risk symptoms of psychosis and of the therapy of the person having symptoms within the healthcare system. Healthcare professionals should be aware of the limitations of present research information in order to assess the correct magnitude of the risk of psychosis. Although a person assigned by current methods to the risk group presents a higher than tenfold risk compared with the rest of the population, improvement of prognostic accuracy remains as the central research issue.

Psychopathic traits and offender characteristics - a nationwide consecutive sample of homicidal male adolescents

BACKGROUND

The aim of the study was to evaluate psychopathy-like personality traits in a nationwide consecutive sample of adolescent male homicide offenders and to compare the findings with those of a randomly sampled adult male homicide offender group. A further aim was to investigate associations between psychopathic traits and offender and offence characteristics in adolescent homicides.

METHODS

Forensic psychiatric examination reports and crime reports of all 15 to 19- year- old male Finnish offenders who had been subjected to a forensic psychiatric examination and convicted for a homicide during 1995-2004 were collected (n = 57). A random sample of 57 adult male homicide offenders was selected as a comparison group. Offence and offender characteristics were collected from the files and a file-based assessment of psychopathic traits was performed using the Hare Psychopathy Checklist-Revised (PCL-R) by trained raters.

RESULTS

No significant differences existed between the adolescents and adults in PCL-R total scores, factor 2 (social deviance) scores, or in facets 3 (lifestyle) and 4 (antisocial). Adults scored significantly higher on factor 1 (interpersonal/affective) and facets 1 (interpersonal) and 2 (affective). The adolescent group was divided into two subgroups according to PCL-R total scores. One in five homicidal male adolescents met criteria for psychopathic personality using a PCL-R total score of 26 or higher. These boys significantly more often had a crime history before the index homicide, more frequently used excessive violence during the index homicide, more rarely lived with both parents until 16 years of age, had more institutional or foster home placements in childhood, had more school difficulties, more often had received special education, and, more often had contact with mental health services prior to age 18 years than boys scoring low on the PCL-R. They also more often had parental criminal history as well as homicide history of parents or near relatives than the group scoring low on the PCL-R.

CONCLUSION

Homicidal boys behaved as antisocially as the homicidal adults. The adults, however, showed more both affective and interpersonal features of psychopathy. Homicidal adolescents with psychopathy-like personality character form a special subgroup among other homicidal youngsters. Recognizing their characteristics, especially in life course development, would facilitate effective prevention and intervention efforts.

Excessive violence and psychotic symptomatology among homicide offenders with schizophrenia

BACKGROUND

It is not currently known how psychotic symptoms are associated with the nature of violence among homicide offenders with schizophrenia, or, more specifically, whether different psychotic symptoms are differentially linked with excessive violence.

AIM

To identify factors associated with the use of excessive violence among homicide offenders with schizophrenia.

METHODS

Forensic psychiatric examination statements and Criminal Index File data of 125 consecutive Finnish homicide offenders with a diagnosis of schizophrenia were analysed.

RESULTS

Nearly one-third of the cases in this sample involved extreme violence, including features such as sadism, mutilation, sexual components or multiple stabbings. Excessive violence was a feature of acts when the offender was not the sole perpetrator or when there was a previous homicidal history. Positive psychotic symptoms, including delusions, were not associated with the use of excessive violence.

CONCLUSIONS

These results highlight the importance of variables other than clinical state when examining qualitative aspects of homicidal acts, such as the degree and nature of violence, by offenders with schizophrenia. Further study is needed with a more specific focus on the qualities of the violence among different subgroups of offenders, but inclusive of those with psychosis.