The START:AV is a structured risk assessment tool designed to assess and manage short-term (i.e., 3 months) risk of multiple adverse outcomes among male and female adolescents in mental health and/or criminal justice settings. Adverse outcomes included within the START:AV are categorized into two broad domains: Harm to Others and Rule Violations (i.e., violence, nonviolent offenses, substance abuse, and unauthorized absences) and Harm to the Adolescent (i.e., suicide, non-suicidal self-injury, victimization, and health neglect). The START:AV adheres to the structured professional judgment model of risk assessment and is an adapted version of the Short-Term Assessment of Risk and Treatability designed for use with adult psychiatric populations. The START:AV is relevant to correctional psychology, as it not only helps to guide the assessment and management of risk of violent and nonviolent offending but also provides a comprehensive assessment of other adverse outcomes that are considered critical to an adolescent offender’s well-being. The current entry describes the START:AV and discusses its purpose and development and provides a brief overview of the empirical findings regarding its reliability and validity.
Description and Purpose of the START:AV
The START:AV comprises 25 items, 24 of which fall into three clusters: Individual Adolescent, Relationships and Environment, and Response to Interventions (see Table 1 for a list of the items by cluster). Embedded within the START:AV is an additional case-specific item (i.e., Item 25) that allows for the assessor to incorporate any information pertinent to the assessment that is not otherwise captured by the other 24 items (e.g., culture). All items of the START:AV are considered modifiable (i.e., dynamic in nature), and unlike other contemporary risk assessment tools such as the Structured Assessment of Violence Risk in Youth, the START:AV does not separate items based on whether they are risk or protective factors; rather, each item is simultaneously rated as both a Strength (i.e., a feature or characteristic that decreases risk of an adverse outcome) and a Vulnerability (i.e., a feature or characteristic that increases risk of an adverse outcome). For example, an adolescent can display both strengths and vulnerabilities within a single area such as a youth who primarily associates with antisocial peers, yet maintains contact with some prosocial peers (e.g., Item 17: Peers). As such, ratings of Strengths and Vulnerabilities may or may not correspond with each other. Each item is rated as low, moderate, or high based on whether an adolescent has displayed minimal, some, or substantial Strengths or Vulnerabilities within a specific area over the past 3 months. In rating the items, assessors are to use adolescents who are of a similar age in the general population as a reference for comparison.
After each individual item is rated, Key Strengths (i.e., items that are considered to be instrumental in decreasing or buffering a youth’s risk) and Critical Vulnerabilities (i.e., items that are considered to be instrumental in increasing or driving a youth’s risk) are identified. However, not every Strength or Vulnerability rated as high need be identified as a Key Strength or Critical Vulnerability, respectively. Moreover, items rated as low or moderate may be considered a Key Strength or Critical Vulnerability as long as the item is judged as playing an instrumental role in a youth’s risk of an adverse outcome. Before rendering a final risk estimate for the various adverse outcomes, assessors are to rate whether a youth has experienced an adverse outcome at any time prior to the past 3 months (i.e., Prior History) or within the past 3 months (i.e., Recent History). In adherence with the principles of structured professional judgment, the final risk estimate is not based on any total score or algorithm; rather, the assessor rates the adolescent’s short-term risk by incorporating information gathered through the START:AV assessment in combination with his or her own professional judgment. In addition, assessors can include an additional case-specific adverse outcome that is not better addressed by the remaining eight adverse outcomes outlined within the START:AV manual (e.g., homelessness, prostitution).
Lastly, assessors have the option of flagging whether or not the youth poses an imminent risk of serious harm to themselves or others and requires immediate action. This is referred to within the START:AV manual as T.H.R.E.A.T., an acronym that stands for threat of harm that is real, enactable, acute, and targeted. Assessors are encouraged to determine whether a T.H.R.E.A.T. is present or absent for four of the adverse outcomes (i.e., violence, suicide, non-suicidal self-injury, and victimization). Upon completion of the START:AV, the assessor is encouraged to use the information gathered to inform intervention planning through risk formulation and identification of risk-related scenarios. To assist in monitoring treatment response and changes in risk level or risk-related scenarios (particularly if a youth experiences a major life event), it is recommended that reassessment with the START:AV be conducted at least every 3 months.
Development of the START:AV
Development of the START:AV was achieved through a multistep process. First was the establishment of a core team of researchers and clinicians with expertise in adolescent populations (including authors of the START) in conjunction with consultation with other professionals and experts in the field. Second, a review of the literature was undertaken to determine whether an adolescent version of the START would address various gaps in adolescent risk assessment. Third, the developers of the START:AV established a set of developmentally informed principles to guide the adaptation of the START to adolescent populations by reviewing the developmental psychopathology and criminology literature and approaches taken by other test developers. Fourth, each of the START items was reviewed to determine whether they had demonstrated empirical support in adolescent populations of which all items were found to have support. Fifth, while the START:AV retained all of the original items of the START, several important changes were made to ensure that items were developmentally relevant. This included adjustments to item anchors, revisions to coding instructions to account for the ways in which risk and protective factors manifest in adolescents, introduction of new items (i.e., Parenting and Parental Functioning), and splitting of other items into subitems to emphasize the relationships that adolescents have with their peers and caretakers (i.e., Relationships and Social Support). Moreover, nonviolent offending was added as an adverse outcome given the overlap between risk factors with violent offending, and adverse outcomes such as victimization were revised to account for abuse perpetrated both by peers and adults (e.g., caretakers). Further development of the START:AV consisted of pilot implementation and testing of an earlier iteration of the tool in Canada, the United States, and the United Kingdom.
Reliability and Validity of the START:AV
Although there is a limited amount of research examining the START:AV, much of the research on the START:AV has been conducted using mixed samples of male and female adolescent offenders and forensic psychiatric patients, and preliminary findings are promising regarding its reliability and validity. Despite a final risk score not being produced in practice, much of the research conducted with the START:AV has used total scores derived by summing the items to produce a Strength and Vulnerability total score. With respect to reliability, the START:AV (including an earlier iteration of the tool) has demonstrated high internal consistency among the Strength and Vulnerability total scores. Likewise, there has been good to excellent interrater agreement across the Strength and Vulnerability total scores and structured risk estimates, although the level of interrater agreement has typically been higher among the total scores.
Moreover, the START:AV has demonstrated strong concurrent validity with other established risk assessment tools such as the Structured Assessment of Violence Risk in Youth, and the associations between risk and protective factors and Vulnerability and Strength total scores have been within the expected directions. With respect to predictive validity, the START:AV has shown significant predictive utility across shorter term (i.e., 3 months) and longer term (i.e., 3 years) follow-up periods in predicting multiple adverse outcomes (e.g., violence, any offending, substance use, street drug use, any victimization, and non-suicidal self-injury). However, while the various structured risk estimates and Vulnerability total score have generally demonstrated moderate to large associations with outcome, results for the Strength total score have been somewhat mixed.
In addition, research has demonstrated that items on the START:AV can reliably change over time, thus providing support for their dynamic nature. There is some evidence for the utility of the START:AV in risk management. In particular, one study found that when interventions targeted youths’ Critical Vulnerabilities and leveraged youths’ Key Strengths, the occurrence of externalizing behaviors such as aggression was reduced. However, despite this preliminary support for the START:AV, there is need for further research, particularly on its utility in managing risk and its relevance across gender and across ethnic, racial, and cultural groups.
Final Thoughts
Given its focus on strengths and vulnerabilities, the reassessment of dynamic risk, short-term prediction, and multiple adverse outcomes, the START:AV is a unique addition to the adolescent risk assessment and risk management field. As adolescent offenders not only can pose a risk of harm to others (e.g., violence) but also are vulnerable to being harmed themselves (e.g., victimization, suicide), the START:AV aims to provide an integrated assessment of multiple adverse outcomes that are relevant to adolescent offenders. While further research is needed, preliminary findings are promising and interest in the tool continues to increase. Moreover, several accompanying resources are available to users of the START:AV, such as the START:AV Annotated Bibliography, which provides an up-to-date overview of published and unpublished research conducted with the tool, and the START:AV Knowledge Guide, which provides a comprehensive review of the empirical research for each of the individual items.
References:
- Bhanwer, A., Shaffer, C., & Viljoen, J. L. (2016). START:AV annotated bibliography: A summary of research on the START:AV. Burnaby, Canada: Simon Fraser University.
- Desmarais, S. L., Sellers, B. G., Viljoen, J. L., Cruise, K. R., Nicholls, T. L., & Dvoskin, J. A. (2012). Pilot implementation and preliminary evaluation of START:AV assessments in secure juvenile correctional facilities. International Journal of Forensic Mental Health, 11, 150–164. doi:10.1080/14999013.2012.737405
- Singh, J. P., Desmarais, S. L., Sellers, B. G., Hylton, T., Tirotti, M., & Van Dorn, R. A. (2014). From risk assessment to risk management: Matching interventions to adolescent offenders’ strengths and vulnerabilities. Children and Youth Services Review, 47(1), 1–9. doi:10.1016/j.childyouth.2013.09.015
- Viljoen, J. L., Beneteau, J. L., Gulbransen, E., Brodersen, E., Desmarais, S. L., Nicholls, T. L., & Cruise, K. R. (2012). Assessment of multiple risk outcomes, strengths, and change with the START:AV: A short-term prospective study with adolescent offenders. International Journal of Forensic Mental Health, 11, 165–180. doi:10.1080/14999013.2012.737407
- Viljoen, J. L., Cruise, K. R., Nicholls, T. L., Desmarais, S. L., & Webster, C. D. (2012). Taking stock and taking steps: The case for an adolescent version of the Short-Term Assessment of Risk and Treatability. International Journal of Forensic Mental Health, 11, 135–149. doi:10.1080/14999013.2012.737406
- Viljoen, J. L., Gray, A. L., & Barone, C. (2016). Assessing risk for violence and offending in adolescents. In R. Jackson & R. Roesch (Eds.), Learning forensic assessment: Research and practice (2nd ed., pp. 357–388). New York, NY: Routledge/Taylor & Francis Group.
- Viljoen, J. L., Nicholls, T. L., Cruise, K. R., Beneteau Douglas, J., Desmarais, S. L., Barone, C. C., . . . Webster, C. D. (2016). START:AV knowledge guide: A research compendium on the START:AV Strength and Vulnerability items. Burnaby, Canada: Simon Fraser University.