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      Fitness to plead: Development and validation of a standardised assessment instrument

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          Abstract

          The ability of an individual to participate in courtroom proceedings is assessed by clinicians using legal ‘fitness to plead’ criteria. Findings of ‘unfitness’ are so rare that there is considerable professional unease concerning the utility of the current subjective assessment process. As a result, mentally disordered defendants may be subjected unfairly to criminal trials. The Law Commission in England and Wales has proposed legal reform, as well as the utilisation of a defined psychiatric instrument to assist in fitness to plead assessments. Similar legal reforms are occurring in other jurisdictions. Our objective was to produce and validate a standardised assessment instrument of fitness to plead employing a filmed vignette of criminal proceedings. The instrument was developed in consultation with legal and clinical professionals, and was refined using standard item reduction methods in two initial rounds of testing (n = 212). The factorial structure, test-retest reliability and convergent validity of the resultant instrument were assessed in a further round (n = 160). As a result of this iterative process a 25-item scale was produced, with an underlying two-factor structure representing the foundational and decision-making abilities underpinning fitness to plead. The sub-scales demonstrate good internal consistency (factor 1: 0·76; factor 2: 0·65) and test-retest stability (0·7) as well as excellent convergent validity with scores of intelligence, executive function and mentalising abilities (p≤0·01 in all domains). Overall the standardised Fitness to Plead Assessment instrument has good psychometric properties. It has the potential to ensure that the significant numbers of mentally ill and cognitively impaired individuals who face trial are objectively assessed, and the courtroom process critically informed.

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          Most cited references30

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          SCAN. Schedules for Clinical Assessment in Neuropsychiatry.

          After more than 12 years of development, the ninth edition of the Present State Examination (PSE-9) was published, together with associated instruments and computer algorithm, in 1974. The system has now been expanded, in the framework of the World Health Organization/Alcohol, Drug Abuse, and Mental Health Administration Joint Project on Standardization of Diagnosis and Classification, and is being tested with the aim of developing a comprehensive procedure for clinical examination that is also capable of generating many of the categories of the International Classification of Diseases, 10th edition, and the Diagnostic and Statistical Manual of Mental Disorders, revised third edition. The new system is known as SCAN (Schedules for Clinical Assessment in Neuropsychiatry). It includes the 10th edition of the PSE as one of its core schedules, preliminary tests of which have suggested that reliability is similar to that of PSE-9. SCAN is being field tested in 20 centers in 11 countries. A final version is expected to be available in January 1990.
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            Evaluation of outcomes in chronic venous disorders of the leg: development of a scientifically rigorous, patient-reported measure of symptoms and quality of life.

            The purpose of this study was to develop a practical and scientifically rigorous, patient-reported outcome measure to evaluate quality of life and symptoms across the range of conditions (eg, telangiectasias, varicose veins, edema, skin changes, leg ulcers) in chronic venous disorders of the leg (CVDL). This study was a psychometric study within the VEnous INsufficiency Epidemiological and Economic Study (VEINES), an international, prospective cohort study to evaluate clinical outcomes, quality of life, costs, and use of health services in CVDL. The study was set in the 166 general practices and 116 specialist clinics in Belgium, France, Italy, and Canada (Quebec) that participated in the VEINES study plus in additional specialist clinics in Ottawa and Montreal. Field testing was carried out in three samples of patients in four countries (Belgium, France, Italy, Canada), including participants in the VEINES study (n dagger 1531) and patients recruited in additional samples of 88 English-speaking patients (Canada) and 53 French-speaking patients (Belgium, France). The reliability and validity sample (n = 615) included 527 VEINES patients and 88 patients from the supplementary English-speaking sample. The test-retest sample (n = 135) included 53 French-speaking and 82 English-speaking patients from the supplementary samples. The responsiveness sample included 1516 VEINES patients. The 26-item VEINES-QOL/Sym is a new, patient-reported questionnaire to evaluate symptoms and quality of life and is available in four language versions (English, French, Italian, French Canadian). Standard psychometric tests confirmed the acceptability (missing data, item endorsement frequencies, floor and ceiling effects), reliability (internal consistency, item-total, inter-item correlations) and validity (content, construct, convergent, discriminant, known groups) of the four language versions of the VEINES-QOL/Sym and the test-retest reliability of the English and French versions and provided preliminary evidence of responsiveness in a pooled language sample. The VEINES-QOL/Sym is a practical and scientifically sound, patient-reported measure of outcomes in CVDL that has been developed with rigorous methods. As the only fully validated measure of quality of life and symptoms that is appropriate for use across the full spectrum of CVDL-related conditions, that is quick and easy to administer, and that is available in four languages, the VEINES-QOL/Sym provides a rigorous tool for improving the evaluation of outcomes in clinical trials, epidemiologic studies, and audit.
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              Exploring 'theory of mind' in people with schizophrenia.

              Mentalizing ability was studied in 46 symptomatic schizophrenic patients and 44 non-symptomatic controls. Subjects heard six stories and simultaneously were shown simple cartoon pictures depicting the action sequencing occurring in the stories. All the stories involved false belief or deception, so that it was necessary to infer the mental states of the characters in order to understand their behaviour. After each story, subjects were asked one memory/reality question (concerning an event in the story) and one question that depended on the ability to infer the mental state of one of the characters. Patients with paranoid delusions were impaired on the questions concerning mental states. Patients with behavioural signs (i.e. negative features or incoherence) were also impaired on the mental state questions, but this difficulty was associated with memory impairments. Patients with symptoms of passivity (e.g. delusions of control) and patients in remission did not differ from normal controls. These results are consistent with the hypothesis that certain of the positive symptoms of schizophrenia reflect an impairment in the ability to infer the mental states of others.
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                Author and article information

                Contributors
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                26 April 2018
                2018
                : 13
                : 4
                : e0194332
                Affiliations
                [1 ] Department of Forensic and Neurodevelopmental Sciences, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
                [2 ] Department of Biostatistics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
                [3 ] Department of Clinical, Educational and Health Psychology, University College London, London, United Kingdom
                [4 ] Department of Law, London School of Economics, London, United Kingdom
                Grand Valley State University, UNITED STATES
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                • Conceptualization: NB JP MW.

                • Data curation: RB EAK PB.

                • Formal analysis: PB EAK DS.

                • Funding acquisition: NB JP MW.

                • Investigation: PB EAK RB.

                • Methodology: NB MW.

                • Project administration: NB PB RB EAK.

                • Resources: RB EAK PB MW.

                • Supervision: NB.

                • Validation: PB DS.

                • Visualization: PB.

                • Writing – original draft: PB EAK NB.

                • Writing – review & editing: PB DS EAK RB MW JP NB.

                Author information
                http://orcid.org/0000-0001-8487-7106
                Article
                PONE-D-17-20942
                10.1371/journal.pone.0194332
                5919482
                29698396
                7b551b02-7e3f-4cbe-810e-a74b46ac16f1
                © 2018 Brown et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 1 June 2017
                : 15 February 2018
                Page count
                Figures: 0, Tables: 4, Pages: 13
                Funding
                Funded by: funder-id http://dx.doi.org/10.13039/501100000279, Nuffield Foundation;
                Award Recipient :
                Funded by: funder-id http://dx.doi.org/10.13039/100004440, Wellcome Trust;
                Award Recipient :
                E A-K, RB, MW, JP and NB were supported by a Nuffield Trust Access to Justice programme grant (AJU/35238). PB is funded by the Wellcome Trust (099009/Z/12/Z). This study was funded by the Nuffield Trust. DS was part funded by the National Institute for Health Research (NIHR) Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King’s College London. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. The funders had no role in the study design; the collection, analysis or interpretation of the data; the writing of the report; or in the decision to submit the paper for publication. The researchers are independent from the funders and the sponsors.
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