Screening for Risk of Future Physical Injury in Reported Cases of Intimate Partner Violence in a Military Sample. Research Goal

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1 Screening for Risk of Future Physical Injury in Reported Cases of Intimate Partner Violence in a Military Sample Intimate Partner Physical Injury (IPPI): Risk Assessment Tool (RAT) Center for the Study of Family Violence and Sexual Assault Brown Bag Presentation March 20, 2015 Joel S. Milner, Matthew Fleming, and Julie L. Crouch Center for the Study of Family Violence and Sexual Assault Northern Illinois University Sandi Stith Marriage and Family Therapy Program Kansas State University Renè J. Robichaux Behavioral Health Division United States Army Medical Command Presentation Overview 1. Project Goal 2. Project Background 3. Study Design 4. Study Results 5. Roll Out of Risk Assessment Tool 6. The Next Study Research Goal The goal was to predict the risk for future physical injury among all couples presenting to US military Family Advocacy Programs (FAP) with a reported incident of intimate partner maltreatment regardless of whether or not the case was reported for intimate partner physical injury and whether or not the case was judged to have met criteria. In our predictive validity study, the two study groups were: Group 1: reported cases in which future intimate partner physical injury was self-reported (whether or not they had met criteria for the reported incident). (Experimental Group) Group 2: reported cases that had not met criteria combined with all other types of reported intimate partner maltreatment that had met criteria. (Comparison Group)

2 Project Background In the Spring of 1999, a joint services (United States Air Force [USAF] and United States Army [USA]) FAP working group was convened to develop a risk assessment instrument (a list of putative risk factors) designed to assess the risk of future maltreatment among clients being assessed by USAF and USA FAP for IPV At the initial meeting, the working group discussed the criteria for a risk assessment tool. To the extent possible, the working group sought to develop a risk assessment tool that was: - State of the art - Valid and reliable - Clinically relevant - Informed practice - Feasible at all levels - User friendly - Legally defensible Project Background continued. The initial task was to develop a large group of risk items that was exhaustive with respect to theory, research, and practice wisdom. The working group wanted to include risk factors unique to the offender, the victim, and the relationship. The working group sought to develop a risk assessment tool that considered military-specific risk factors and, if possible, to develop a single tool that could be used with both male and female offenders. They also sought to develop one tool that could be used by all military services. Project Background continued. An initial list of IPV risk items was developed by starting with a review of the civilian literature for risk factors including risk factors for recidivism (which resulted in a published meta-analysis of risk factors). Following the literature review, putative military specific risk items were added by the Office of the Secretary of Defense (OSD), by FAP staff, and by FAP service providers. Results: A 76 item IPV risk survey. Project Background continued. The 76 IPV risk items were evaluated in a variety of ways. (Phase I) Evaluations included examination of the wording of the risk items, the definitions, and the base rates of occurrence. We also examined the use of the risk factors by clinicians when they were asked to evaluate videotapes of IPV cases (using actors) and then we examined the use of the survey items by clinicians when they were used with 350 reported IPV cases at different military instillations. Results: A 56 item IPV risk survey.

3 Project Background continued. Next, from august 2002 to July 2003, FAP staff completed the 56-item risk survey for 584 IPV cases at 12 installations across military services: USAF, N = 139 (Eglin, n = 42; Hurlburt, n = 28; Hickam, n = 11; Wright-Patterson, n = 50; Tinker, n = 6; unknown, n = 2). USA, N = 224 (Fort Campbell, n = 123; Fort Knox, n = 44; Fort Drum, n = 57). USMC SPAs, N = 131 (Camp Lejeune, n = 69; Camp Pendleton, n = 62). USN SPAs, N = 90 (Great Lakes, n = 68; Pearl Harbor, n = 22). Since the base rates for repeat incidences in the official registry was small, FAP staff were asked to complete a Repeat Incident Form, so that the predictive validity of the risk items could be determined. Project Background continued. Data obtained in the first two phases of the project were used to determine the appropriateness of developing a single instrument to be used in all four services (i.e., a Purple Risk Assessment Tool). Army/Air Force (Phase I) All Four Services (Phase II) 67% of offenders male 87% of offenders male Offender age = 27.4 years Victim age = 26.8 years Offender age = 26.8 years Victim age = 26.5 years Offender AD = 65.5% Offender AD 63.8% Project Background continued. In addition, with few exceptions cases, the risk factors were present at similar rates. Thus, although there had been concerns the tool might not be relevant for all services, Phase I and Phase II research indicated that, in general, the risk factors did not vary across military branches. However, in Phase II of the project, only a few (n = 17) Repeat Incident Forms were completed by the clinicians. Thus, data were not available to estimate the predictive validity of the SPA survey items. Project Background continued. When a decision was made to conduct a study of the predictive validity of the SPA items (Phase III), several additional changes were made in the SPA items by the working group. First, since the initial development of the SPA survey, the military environment had changed because of involvement in wars in Iraq and Afghanistan, four items were added that were specific to combat experience: 1. Experienced a traumatic event during deployment. 2. Has a traumatic brain injury. 3. Exhibits symptoms of PTSD. 4. Significant deployment-related stress in relationship.

4 Project Background continued. Items also were combined to reduce the number of items in the SPA survey. The 56 item version included Victim has access to firearms and Offender has access to firearms. These items were merged to Presence of a firearm in the home. Two victim items, Doesn t have/won t use informal support system and Willing to use formal support system were merged to Dissatisfied with available social support. Results: The final version of the SPA survey included 58 risk items. In addition, a new Repeat Incident Form that used DOD IPV definitions and involved victim self-report (via a telephone interview) of maltreatment following an initial incident report was developed for use in the predictive validity study. Study Materials/Procedures Spouse Physical Abuse (SPA) Survey (includes 58 risk items [with definitions]) Repeat Incident Survey (RIS) Protocol (includes all DOD IPV Definitions for different types of IPV). Automated Telephonic Data Collection (ATDC) system (also called Interactive Voice Recognition [IVR] system) Using the ATDC system, all RIS items were provided by a pre-recorded voice that read the items. Except for the password item, the response format for the SPA survey items was yes (participants were asked to press the number 1 on their telephone dial for a yes response) or no (participants were asked to press the number 2 on their telephone dial for a no response). ATDC System (located at the Center for the Study of Family Violence). The ATDC system provides a number of advantages over other data collection methods. The system provides participants a higher level of privacy and convenience than other approaches, such as interviews, including participants being able to provide data from any telephone at a time and place of their choosing. Use of the participant call-in system prevents participants from being called at a bad time (e.g., when the caller s children or the alleged offender might be home). Participants enter their responses using the telephone keypad, so no verbalizations are required. The elimination of written forms helped insure information is seen by others. The system allowed questions to be presented in a standardized format that do not vary from participant to participant, thereby reducing one source of error common in structured interviews. Unlike paper and pencil questionnaires, participants responding to the ATDC system do not need to be literate to understand and respond to the questions. The ATDC system records data into a database, eliminating data entry labor and data entry errors. Rosenbaum, Rabenhorst, Reddy, Fleming and Howells (2006) found that rates of self-disclosed perpetration and receipt of IPV did not vary across three data collection procedures (ATDC, faceto-face interview, and written questionnaire) and the ATDC system generated higher participation rates compared to face-to-face interviews or written questionnaires. Table. Total RIS Call Frequencies, N = 199. Number Number of Percentage Cumulative/ of calls participants descending* percentages / / / / / / / / / / / / / / /0.5 *Percentage of calls at indicated call frequency (number of calls) or above. Notes. Total number of participant calls = 1,082. Mean number of participant calls = Median number of participant calls = Number of participant calls at the initial call date (7 days) = 183 or 92.0%.

5 Table. Clinician judgments about the likelihood of future spouse maltreatment. Table. After Entry into the Study, the Self-Reported Intimate Partner Maltreatment Percentages (RIS data) for Alleged Victims who had at Least One Contact with their Partner, N =183 Type of Maltreatment Percentage indicating Maltreatment Any Maltreatment (RIS items 8-15) 140/183 = 76.5% Any Maltreatment (RIS items 9-15) 134/183 = 73.2% Physical Injury (RIS item #14) 68/183 = 37.2% Physical Injury Req. Med. Care (RIS item #15) 32/182 = 17.5% SPA item Low Medium High 59. What is the likelihood of any spouse maltreatment? a. within the next 7 days? 80.6% 16.9% 2.5% b. within the next month? 72.3% 23.2% 2.5% c. within the next 6 months 63.8% 30.2% 6.0% 60. What is the likelihood of physical spouse maltreatment? a. within the next 7 days? 86.5% 11.8% 1.7% b. within the next month? 80.0% 18.2% 1.8% c. within the next 6 months? 70.4% 25.3% 4.3% 61. What is the likelihood of severe physical spouse maltreatment? a. within the next 7 days? 90.4% 8.1% 1.5% b. within the next month? 87.5% 11.0% 1.5% c. within the next 6 months? 83.4% 13.8% 2.8% Table. 15 -Item Intimate Partner Physical Injury (IPPI): Risk Assessment Tool (RAT) Offender items 01. Caused minor injury (not requiring medical care) in incident. 02. Denies incident occurred. 03. Blames others for incident. 04. Physically aggressive toward partner prior to incident. 05. Increased frequency or severity of violence toward partner. 06. Ever used or threatened to use weapons against partner. 07. Emotionally abusive towards partner. 08. Ever choked or strangled partner. 09. Feels desperate about relationship. 10. Attempts to control partner s access to friends/family/resources. 11. Holds unrealistic expectations of partner. 12. Expresses ideas or opinions that justify violence towards partner. Victim items 13. Fears for self or children or pets. 14. Attempting to leave relationship. 15. Dissatisfied with military lifestyle. Best 15 physical injury risk assessment items (includes both static and dynamic items). Scoring: Assign one point for each yes response and sum the points for a total score (max. 15 points). Table. Classification Rates for each of the Total Risk Scale Scores for the 15-item IPPI: RAT for the Physical Injury Group and the All Others Group (non-contact and risk scales with missing item data excluded), N =142. Physical injury group n = 54 All others n = 88 Overall Total Un- Risk Weighted Score Frequency True positives Frequency True negatives Means False negatives False positives % 0.0% % 85.2% 57.4% % 3.7% % 71.6% 62.4% 2 3(2) 90.7% 9.3% % 65.9% 62.4% 3 1(1) 88.9% 11.1% % 51.1% 68.9% % 16.7% % 39.8% 72.8% 5 2(2) 79.6% 20.4% % 26.1% 76.8% 6 6(4) 68.5% 31.5% % 22.7% 72.9% 7 10(4) 50.0% 50.0% % 19.3% 65.4% 9 6(4) 27.8% 72.2% % 5.7% 63.2% 10 4(2) 20.4% 79.6% % 3.4% 61.0% 11 4(2) 13.0% 87.0% % 2.3% 58.5% 12 5(1) 3.7% 96.3% % 1.1% 51.3% 13 2(1) 0.0% 100.0% % 0.0% 50.0% Risk Score M (SD) = 7.61 (3.10) Risk Score M (SD) = 4.06 (3.24) F = 41.58, df = 1, 140, p <.0001 d = 1.115, 95% CI [.7520, 1.477] r =.4756, 95% CI [.2674,.5202] The numbers in the curved brackets ( ) indicate the number of victims who reported future physical injury severe enough that they should have received medical attention; 80% of this group was above the cut score of 5.

6 Table. Classification Terms and Definitions. Actual Condition Definitions of Classification Terms Positive Negative Sensitivity: the probably that when a test score is above the cut score that an injury will be present (true positive rate). Test Score Positive True Positives False Positives (Type I error) Positive Predictive Value (PPV) Specificity: the probably that when a test score is below the cut score that an injury will not be present (true negative rate). Negative False Negatives (Type II error) True Negatives Negative Predictive Value (NPV) Positive Predictive Value (PPV): Positive predictive value: probability that the disease is present when the test is positive = a/(a+c) Sensitivity Specificity Negative Predictive Value (NPV): Negative predictive value: probability that the disease is not present when the test is negative = d/(b+d) Sensitivity = number of true positives/number of true positives + number of false negatives Specificity = number of true negatives/number of true negatives + number of false positives PPV = number of true positives/number of true positives + number of false positives NPV = number of true negatives/number of true negatives + number of false negatives Positive Likelihood Ratio: ratio between the probability of a positive test result given the presence of the disease and the probability of a positive test result given the absence of the disease. Negative Likelihood Ratio: ratio between the probability of a negative test result given the presence of the disease and the probability of a negative test result given the absence of the disease. Table. Classification Terms for the 15-item IPPI: RAT, N = 142. Test Injury present Injury absent Total Positive True Positives (a = 43) False Positives (c = 23) a + b = 66 Negative False Negatives (b = 11) True Negatives (d = 65) b + d = 76 Total a + b = 54 c + d = 88 Injury prevalence a + b/a + b + c + d = 38.03% Sensitivity (a/a+ b) = 79.63% CI = 66.47% to 89.35% Specificity (d/c + d) = 73.86% CI = 63.41% to 82.65% Positive Predictive Value (PPV) (a/[a + c]) = 65.15% CI = 52.42% to 76.47% Negative Predictive Value (NPV) (d/[b + d]) = 85.15% CI = 75.57% to 92.54% Positive Likelihood Ratio (Sensitivity/[100 Specificity]) = 3.05 CI = 2.09 to 4.44 Negative Likelihood Ratio (100 - Sensitivity/[Specificity]) = 0.28 CI = 0.16 to 0.47 Note. The Confidence Intervals (CIs) were calculated using a procedure developed by Wilson (1927) that contains a correction for continuity. Note. Internal consistency (Cronbach s Alpha) =.816, 95% CI [.769,.857] Table. Classification Rates for each of the Total Risk Scale Scores for the 15-item IPPI: RAT for the Physical Injury Group and the All Others Group (non-contact and risk scales with missing item data excluded), N =142. Physical injury group n = 54 All others n = 88 Overall Total Un- Risk Weighted Score Frequency True positives Frequency True negatives Means False negatives False positives % 0.0% % 85.2% 57.4% % 3.7% % 71.6% 62.4% 2 3(2) 90.7% 9.3% % 65.9% 62.4% 3 1(1) 88.9% 11.1% % 51.1% 68.9% % 16.7% % 39.8% 72.8% 5 2(2) 79.6% 20.4% % 26.1% 76.8% 6 6(4) 68.5% 31.5% % 22.7% 72.9% 7 10(4) 50.0% 50.0% % 19.3% 65.4% 9 6(4) 27.8% 72.2% % 5.7% 63.2% 10 4(2) 20.4% 79.6% % 3.4% 61.0% 11 4(2) 13.0% 87.0% % 2.3% 58.5% 12 5(1) 3.7% 96.3% % 1.1% 51.3% 13 2(1) 0.0% 100.0% % 0.0% 50.0% Risk Score M (SD) = 7.61 (3.10) Risk Score M (SD) = 4.06 (3.24) F = 41.58, df = 1, 140, p <.0001 d = 1.115, 95% CI [.7520, 1.477] r =.4756, 95% CI [.2674,.5202] The numbers in the curved brackets ( ) indicate the number of victims who reported future physical injury sever enough that they should have received medical attention; 80% of this group was above the cut score of 5.

7 % Misclassifications Figure. Decision Plot for the 15-item IPPI: RAT, N = 142. Figure. ROC for the 15-item IPPI: RAT, N = 142, AUC =.783 (99%, LL =.707, UL =.860) Comparison Group Physical Injury Group Total Risk Score Table. Meta-Analysis of Area Under the Curve (AUC) Values for IPV Risk Assessment Tools IPV Assessment Tool k Total N Weighted Mean AUC Value 95% CI DA 6 3, DVSI 3 3, K-SID 2 1, ODARA 6 1, SARA 7 2, Victim Assessment 2 1, B-SAFER % CI IPPI-RAT Table. Score ranges for the 15-item IPPI:RAT, N =142. Score range Injury percentage in range Confidence Interval to 5 points 14.5% (11/76) 8.28%-24.08% 6+ points 65.2% (43/66) 53.11%-75.52% Mild Risk: 0-1 points 7.4% (2/27) 2.06%-23.37% Moderate Risk: 2-5 points 18.4% (9/49) 9.98%-31.36% High Risk: 6-10 points 61.5% (32/52) 47.96%-73.53% Very High Risk: 11 & above pts 78.6% (11/14) 52.41%-92.43% Note. DA = Danger Assessment; DVSI = Domestic Violence Screening Inventory; K-SID = Kingston Screening Instrument for Domestic Violence; ODARA = Ontario Domestic Assault Risk Assessment SARA = Spousal Assault Risk Assessment; B-SAFER = Brief Spousal Form for the Evaluation of Risk; IPPI-RAT = Intimate Partner Physical Injury-Risk Assessment Tool.

8 Table. Score ranges for the 15-item IPPI: RAT, N =142. Score range Injury percentage in range Confidence Interval* Mild Risk: 0-1 points 7.4% (2/27) 2.06%-23.37% Moderate Risk: 2-5 points 18.4% (9/49) 9.98%-31.36% High Risk: 6-10 points 61.5% (32/52) 47.96%-73.53% Very High Risk: 11 & above pts 78.6% (11/14) 52.41%-92.43% Moderate Risk: 0-1 points 7.4% (2/27) 2.06%-23.37% High Risk: 2-7 points 35.2% (25/71) 25.12%-46.82% Very High Risk: 8 & above pts 61.4% (27/44) 46.62%-74.28% *The test for significant differences in the two risk score ranges and the three risk score ranges are provided in the following notes. Note 1. Test for difference between the two risk ranges (0-5 and 6 & above points) at the 95% level: Groups 1 and 2, 40.7% difference score, 95% CI [35.3%, 62.8%] Note 2. Test for difference between the two risk ranges (0-5 and 6 & above points) at the 99% level: Groups 1 and 2, 40.7% difference score, 99% CI [30.0%, 65.8%] Note 3. Tests for differences between the three risk ranges (0-1, 2-7, and 8 & above points) at the 95% level: Groups 1 and 2, 27.8% difference score, 95% CI [8.9%, 40.6%] Groups 1 and 3, 54.0% difference score, 95% CI [32.2%, 67.9%] Groups 2 and 3, 26.2% difference score, 95% CI [7.4%, 42.5%] Note 4. Tests for differences between the three risk ranges (0-1, 2-7, and 8 & above points) at the 99% level: Groups 1 and 2, 27.8% difference score, 99% CI [1.7%, 44.2%] Groups 1 and 3, 54.0% difference score, 99% CI [24.2%, 71.2%] Groups 2 and 3, 26.2% difference score, 99% CI [1.6%, 46.8%] *These confidence intervals (CIs) are the CIs for the injury percentages representing the range. They should not be used for a test of the significance of differences between ranges (see Cummings, 2005; Cumming & Finch, 1995; Newcombe & Altman, 2000). Table. Intimate Partner Physical Injury IPPI: RAT Offender items Alleged Offender Gender About 15% of the alleged offenders in the present study were females. For the alleged male offenders the overall correct classification rate was 76.2%. For the alleged female offenders the overall correct classification rate was 82.4%. Although the overall correct classification rate for alleged female offenders was higher than the overall correct classification rate for alleged male offenders, the difference between the gender classification rates was not significant (Fisher s Exact test p =.286). 01. Caused minor injury (not requiring medical care) in incident. 02. Denies incident occurred. 03. Blames others for incident. 04. Physically aggressive toward partner prior to incident. 05. Increased frequency or severity of violence toward partner. 06. Ever used or threatened to use weapons against partner. 07. Emotionally abusive towards partner. 08. Ever choked or strangled partner. 09. Feels desperate about relationship. 10. Attempts to control partner s access to friends/family/resources. 11. Holds unrealistic expectations of partner. 12. Expresses ideas or opinions that justify violence towards partner. Victim items 13. Fears for self or children or pets. 14. Attempting to leave relationship. 15. Dissatisfied with military lifestyle. Best 15 physical injury risk assessment items (includes both static and dynamic items). Scoring: Assign one point for each yes response and sum the points for a total score.

9 % Misclasifications Table. Four Items from the 15-Item IPPI: RAT that Significantly and Uniquely Discriminated between Alleged Victims Who Self-reported Future Physical Injury and All Others in a Regression Analysis, N =166. O/01. Caused minor injury (not requiring medical care) in incident. O/03. Denies incident occurred. O/11. Ever choked or strangled partner. V/46. Fears for self or children or pets. Note. O = alleged offender; V = alleged victim. Table. Classification Rates for each of the Total Risk Scale Scores for the 4-item IPPI: RAT for the Physical Injury Group and the All Others Group (non-contact and risk scales with missing item data excluded), N = 166. Physical Injury Group n = 62(29) All Others n = 104 Overall Total Un-weighted Risk Means Score Frequency True Positives Frequency True Positives False Negatives False Negatives 0 4(1) 93.5% 6.5% % 27.9% 60.7% 1 12(6) 74.2% 25.8% % 30.8% 71.7% 2 20(9) 41.9% 58.1% % 8.7% 66.6% 3 19(11) 13.3% 88.7% % 1.9% 54.7% 4 7(2) 0.0% 100.0% % 0.0% 50.0% Risk Score M (SD) = 2.21 (1.09) Risk Score M (SD) = 1.13 (0.97) Note. The frequencies in the curved brackets ( ) indicate the number of alleged victims who reported future physical injury severe enough that they should have received medical attention (RIS survey item #15); 75.9% of this group was above the cut-off score of one. F = 43.72, df = 1, 164, p <.0001 d = 1.061, 95% CI [.726, 1.395] r =.4566, 95% CI [.3201,.5745] Table. Classification Terms for the 4-item IPPI: RAT, N = 166. Test Injury present Injury absent Total Positive True Positives (a = 46) False Positives (c = 32) a + c = 78 Negative False Negatives (b = 16) True Negatives (d = 72) b + d = 88 Total a + b = 62 c + d = 104 Injury prevalence (a + b/a + b + c + d) = 37.35% Sensitivity (a/a+ b) = 74.19%, 95% CI [61.26%, 84.10%] Specificity (d/c + d) = 69.23%, 95% CI [59.31%, 77.71%] Positive Predictive Value (PPV) (a/[a + c]) = 58.97%, 95% CI [47.25%, 69.80%] Negative Predictive Value (NPV) (d/[b + d]) = 81.82%, 95% CI [71.85%, 88,94%] Figure. Decision Plot for the 4-item IPPI: RAT, N Comparison Group Physical Injury Group Positive Likelihood Ratio (Sensitivity/[100 Specificity]) = 2.41, 95% CI [1.74, 3.33] Negative Likelihood Ratio (100 - Sensitivity/[Specificity]) = 0.37, 95% CI [0.24, 0.57] Note. The Confidence Intervals (CIs) were calculated using a procedure developed by Wilson (1927) that contains a correction for continuity. Note. Internal consistency (Cronbach s Alpha) =.430, 95% CI [.297,.547] Total Risk Score

10 Figure. ROC for the 4-item IPPI: RAT, N = 166, AUC =.764 (99%, LL =.688, UL =.840) Alleged Offender Gender Recall that almost 15% of the alleged offenders in the present study were females. For the alleged male offenders, the overall correct classification rate was 70.2%. For the alleged female offenders, the overall correct classification rate was 82.4%. Additional analysis revealed that the overall correct classification rate for the alleged female offenders was significantly higher than the overall correct classification rate for alleged male victims, Fisher s Exact test p =.041. Included in the User s manual World-Wide Roll Out Activities Two Technical Manuals Two Users Manuals (developed with multiple field tests) Training Videos (developed following multiple field tests) Discussion of risk assessment in the context of risk management. Issues related to using the IPPI-RAT Interviewing: alleged victim, alleged offender and others (command, hospital staff, police) Determining the presence/absence of the 15 IPPI-RAT risk factors, (includes discussion of fist factor definitions and how to ask risk factor related questions). Computing the total IPPI-RAT score Determining level of risk (including when to override) Strategies for managing risk Communicating findings to victim, alleged victim, commander, etc.

11 Discussion/Questions? Next Research Project Table. Intimate Partner Physical Injury IPPI: RAT Offender items 01. Caused minor injury (not requiring medical care) in incident. 02. Denies incident occurred. 03. Blames others for incident. 04. Physically aggressive toward partner prior to incident. 05. Increased frequency or severity of violence toward partner. 06. Ever used or threatened to use weapons against partner. 07. Emotionally abusive towards partner. 08. Ever choked or strangled partner. 09. Feels desperate about relationship. 10. Attempts to control partner s access to friends/family/resources. 11. Holds unrealistic expectations of partner. 12. Expresses ideas or opinions that justify violence towards partner. Victim items 13. Fears for self or children or pets. 14. Attempting to leave relationship. 15. Dissatisfied with military lifestyle. Best 15 physical injury risk assessment items (includes both static and dynamic items). Scoring: Assign one point for each yes response and sum the points for a total score. Table. Intimate Partner Physical Injury IPPI: RAT Offender items 01. Caused minor injury (not requiring medical care) in incident. 02. Denies incident occurred. 03. Blames others for incident. 04. Physically aggressive toward partner prior to incident. 05. Increased frequency or severity of violence toward partner. 06. Ever used or threatened to use weapons against partner. 07. Emotionally abusive towards partner. 08. Ever choked or strangled partner. 09. Feels desperate about relationship. 10. Attempts to control partner s access to friends/family/resources. 11. Holds unrealistic expectations of partner. 12. Expresses ideas or opinions that justify violence towards partner. Victim items 13. Fears for self or children or pets. 14. Attempting to leave relationship. 15. Dissatisfied with military lifestyle V/50. Dissatisfied with available social support. V/45. Has anger/hostility toward partner. V/42. Overlooks or easily forgives partner aggression. R/53. Ongoing pattern of marital discord. O/28. Has anger/hostility toward partner.

12 % Classifications Table. 15-Dynamic Items IPPI: RAT Offender items 1. Denies incident occurred. 2. Blames others for incident. 3. Emotionally abusive towards partner. 4. Feels desperate about relationship. 5. Has anger/hostility toward partner. 6. Attempts to control partner s access to friends/family/resources. 7. Holds unrealistic expectations of partner. 8. Expresses ideas or opinions that justify violence towards partner. Victim items 9. Fears for self or children or pets. 10. Attempting to leave relationship. 11. Dissatisfied with military lifestyle. 12. Overlooks or easily forgives partner aggression. 13. Has anger/hostility toward partner. 14. Dissatisfied with available social support. Relationship item 15. Ongoing pattern of marital discord. Table. Cut-off Score Classification Rates for each of the Total Risk Scale Scores for the Fifteen Dynamic Item Risk Scale for the Physical Injury Group and the All Others Group (non- contact and risk scales with missing item data excluded), N = 144. Physical Injury Group n = 55(26) All Others n = 89 Total Overall Risk Un- Score Frequency True Positives Frequency True Negatives Weighted False Negatives False Positives Means % 0.0% % 88.8% 55.6% % 0.0% % 80.9% 59.6% % 3.6% % 71.9% 62.2% % 10.9% % 65.2% 62.0% % 16.4% % 53.9% 64.8% % 20.0% % 41.6% 69.2% % 30.1% % 34.8% 67.6% % 45.5% % 25.8% 64.4% % 47.3% % 20.2% 66.2% % 70.1% % 16.9% 56.5% % 83.6% % 12.4% 52.0% % 92.7% % 5.6% 50.8% % 98.2% % 3.4% 49.2% % 98.2% % 1.1% 50.4% % 100.0% % 0.0% 50.0% Risk Score M (SD) = 7.82 (2.85) Risk Score M (SD) = 5.23 (3.72) F = 19.61, df = 1, 142, p <.0001 d = 0.760, 95% CI [.412, 1.107] r = 0.355, 95% CI [.190, 0.484] Table. Classification Terms for the 15Dynamic-Item IPPI: RAT, N = 144. Figure. Decision Plot for the 15-Dynamic item IPPI: RAT, N Test Injury present Injury absent Total Positive True Positives (a = 44) False Positives (c = 37) a + c = 81 Negative False Negatives (b = 11) True Negatives (d = 52) b + d = 63 Total a + b = 55 c + d = 89 Injury prevalence (a + b/a + b + c + d) = 38.19% Sensitivity (a/a+ b) = 80.00%, 95% CI [66.63%, 89.13%] Specificity (d/c + d) = 58.43%, 95% CI [47.49%, 68.63%] Positive Predictive Value (PPV) (a/[a + c]) = 56.25%, 95% CI [47.74%, 66.42%] Negative Predictive Value (NPV) (d/[b + d]) = 43.75%, 95% CI [35.59%, 52.26%] Positive Likelihood Ratio (Sensitivity/[100 Specificity]) = 1.92, 95% CI [1.45, 2.54] Negative Likelihood Ratio (100 - Sensitivity/[Specificity]) = 0.34, 95% CI [0.19, 0.59] Note. The Confidence Intervals (CIs) were calculated using a procedure developed by Wilson (1927) that contains a correction for continuity. Note. Internal consistency (Cronbach s Alpha) =.814, 95% CI [.766,.855] Total Risk Score Comparison Group Physical Injury Group

13 Figure. ROC for the 4-item IPPI: RAT, N = 166, AUC =.764 (99%, LL =.688, UL =.840) Table. Classification Rates for Different Score Ranges for the 15 Dynamic Item IPPI: RAT, N = 144. Total score range Injury percentage in range to 5 points 17.5% (11/63) 6 & above points 54.3% (44/81) Moderate Risk: 0-1 points 0.0% (0/17) High Risk: 2-7 points 33.8% (25/74) Very High Risk: 8 & above points 56.6% (30/53) The test for significant differences in the two risk score ranges and the three risk score ranges are provided in the following notes. Note 1. Test for difference between the two risk ranges (0-5 and 6 & above points) at the 95% level: Groups 1 and 2, 36.8% difference score 95% CI [.213,.496] Note 2. Test for difference between the two risk ranges (0-5 and 6 & above points) at the 99% level: Groups 1 and 2, 36.8% difference score 99% CI [.162,.530] Note 3. Tests for differences between the three risk ranges (0-1, 2-7, and 8 & above points) at the 95% level: Groups 1 and 2, 33.8% difference score 95% CI [.129,.451] Groups 1 and 3, 56.6% difference score 95% CI [.339,.690] Groups 2 and 3, 22.8% difference score 95% CI [.053,.386] Note 4. Tests for differences between the three risk ranges (0-1, 2-7, and 8 & above points) at the 99% level: Groups 1 and 2, 33.8% difference score 99% CI [.031,.488] Groups 1 and 3, 56.6% difference score 99% CI [.296,.724] Groups 2 and 3, 22.8% difference score 99% CI [.000,.429] Alleged Offender Gender Recall that almost 15% of the alleged offenders in the present study were females. In the presentation of the predictive validity data for the 15 dynamic item IPPI: RAT, no adjustments were made for gender of the alleged offender. To determine if gender of the alleged offender moderated the overall prediction rate of the 15 dynamic item IPPI: RAT, additional analyses were conducted. Using a cut-score of 5 (the best cut-score with respect to the overall correct classification rate for the total sample), the overall correct classification rates for the 15 dynamic item IPPI: RAT were determined for the alleged male offenders and for the alleged female offenders. For the alleged male offenders the overall correct classification rate was 69.8% (un-weighted mean; 67.2% weighted mean). For the alleged female offenders, the overall correct classification rate was 71.4% (un-weighted mean; 66.7% weighted mean). Follow-up analysis revealed that there was no significant gender difference in the overall correct classification rates, Fisher s Exact test p = Planned Research Primary study Goals: To determine if the 15-item dynamic IPPI-RAT shows changes in closed IPV cases where treatment is deemed successful. Compare clinicians risk assessments and dynamic IPPI-RAT scores and self-reported recidivism. Embedded study Goal: To replicate the initial predictive study.

14 Additional Discussion/Questions?