Associations Between Neurocognitive Characteristics, Treatment Outcome, and Dropout Among Aggressive Forensic Psychiatric Outpatients

• Author: Erik Bulten,Jan Buitelaar,Danique Smeijers,Robbert-Jan Verkes
• Published date: 01 September 2018
• Date: 01 September 2018
• DOI: http://doi.org/10.1177/0306624X17750340
• Subject Matter: Articles

https://doi.org/10.1177/0306624X17750340

International Journal of

Offender Therapy and

Comparative Criminology

2018, Vol. 62(12) 3853 –3872

© The Author(s) 2018

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DOI: 10.1177/0306624X17750340

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Article

Associations Between

Neurocognitive

Characteristics, Treatment

Outcome, and Dropout

Among Aggressive Forensic

Psychiatric Outpatients

Danique Smeijers1,2, Erik Bulten3, Jan Buitelaar2,4,5,

and Robbert-Jan Verkes1,2,3

Abstract

Aggression Replacement Training (ART) is widely used to reduce aggression and

is considered to be effective although there are also inconsistent results. Studies

investigating the effectiveness of ART do not focus on neurocognitive characteristics.

Focusing on these aspects would result in enhanced understanding of underlying

mechanisms of ART. The current open uncontrolled treatment study assessed

whether neurocognitive characteristics were associated with change in aggression

during the social skills and anger control modules of ART among forensic psychiatric

outpatients. Furthermore, differences between treatment dropouts and completers

and change in these characteristics during ART were examined. A reduction of trait

aggression, cognitive distortions, and social anxiety was observed. Neurocognitive

characteristics were not associated with change in aggression, could not distinguish

treatment completers from dropouts, and did not change after ART. It is suggested

that new paradigms should be developed which take into account the social context

in which these impairments appear.

Keywords

aggressive behavior, treatment, responsivity, neurocognitive, forensic psychiatric patients

1Department of Psychiatry, Radboud University Medical Centre Nijmegen, The Netherlands

2Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, The Netherlands

3Forensic Psychiatric Centre Pompestichting, Nijmegen, The Netherlands

4Karakter Child and Adolescent Psychiatry University Center, Nijmegen, The Netherlands

5Department of Cognitive Neuroscience, Radboud University Medical Centre Nijmegen, The Netherlands

Corresponding Author:

Danique Smeijers, Pompestichting, Postbus 31435, Nijmegen 6503 CK, The Netherlands

Email: daniquesmeijers@gmail.com

750340IJOXXX10.1177/0306624X17750340International Journal of Offender Therapy and Comparative CriminologySmeijers et al.

research-article2018

3854 International Journal of Offender Therapy and Comparative Criminology 62(12)

Disproportionate aggressive behavior, defined as aggression disproportionate to the

provocation (Siever, 2008), is one of the most important reasons for referral to forensic

psychiatric institutions (Smith & Humphreys, 1997). Aggression Replacement

Training (ART; Glick & Goldstein, 1987; Goldstein, Glick, & Gibbs, 1998) is fre-

quently used in children and adolescents as well as in adults to reduce aggression

(Brännström, Kaunitz, Andershed, South, & Smedslund, 2016). The ART consists of

three modules: (a) social skills training, which focuses on responding in a prosocial

way to difficult situations instead of using aggression; (b) anger control training,

which learns to gain more control over aggressive thoughts and aggressive impulses;

and (c) moral reasoning training, where patients learn to recognize certain cognitive

distortions relating to aggression by themselves and think in less egocentric way by

means of group discussions. The modules are given in three weekly sessions over 10

weeks.

In general, ART is considered to be effective in decreasing aggressive behavior

among forensic psychiatric outpatients (FPOs), even though there are also inconsistent

results (Brännström et al., 2016). Furthermore, studies indicate that a high disposition

to act aggressively before treatment is associated with more change during treatment

(Hornsveld, van, Dam-Baggen, Leenaars, & Jonkers, 2004; Hornsveld, Kraaimaat,

Muris, Zwets, & Kanters, 2014; Hornsveld, Nijman, Hollin, & Kraaimaat, 2008;

Hornsveld, 2005; Hornsveld, Nijman, & Kraaimaat, 2008; Smeijers, Bulten, Buitelaar,

& Verkes, 2017), whereas presence of cognitive distortions is thought to be related to

a less rapid reduction of aggression (Smeijers et al., 2017). In addition, patients who

dropped out of ART are characterized by more weekly alcohol and cannabis use,

higher levels of psychopathic traits, and proactive aggression (Hornsveld et al., 2014;

Hornsveld, Nijman, & Kraaimaat, 2008; Smeijers et al., 2018).

Studies investigating the effectiveness of the ART, however, often focus on behav-

ioral and/or personality characteristics. However, neurocognitive characteristics are

also found to be associated with aggressive behavior. As suggested by the Social

Information Processing (SIP) model, individuals with severe aggressive behavior have

abnormal response repertoires in social situations due to deficient information pro-

cessing (Crick & Dodge, 1996). In specific two steps of the SIP model are thought to

be impaired: (a) interpretation: aggressive individuals tend to attribute malicious

intent toward other’s intention, and (b) response decision: aggressive individuals eval-

uate aggressive acts in such a way that it is likely to lead to the enactment of aggressive

behavior (Crick & Dodge, 1996). Both of these patterns do not occur consciously such

as the aforementioned cognitive distortions which are defined as inaccurate attitudes,

thought, or beliefs regarding own or others’ behavior. We also can refer to these auto-

matic and implicit deficient patterns as cognitive biases. In specific, two forms of

cognitive biases are frequently associated with aggressive behavior: attentional biases

and hostile attribution/interpretation biases. An attentional bias refers to an a priori

tendency to focus selectively on threatening information and is often measured by use

of the Emotional Stroop Task (EST). An attentional bias toward aggressive- or vio-

lence-related words has been associated with higher levels of aggressive behavior in

student populations as well as offenders and FPOs (e.g., Brugman et al., 2014; Chan,