Confidentiality and disclosure : assessment and intervention issues

This portfolio addresses the moral, ethical and legal issues that impact upon decisions to maintain or disclose confidential communications. The tensions and moral dilemmas that are created when a conflict between these aspects arises are considered. Risk assessment procedures that inform decisions to maintain or disclose confidential information are discussed, as are issues related to the practical implementation of planned interventions. The topic is addressed by firstly reviewing professional codes of conduct and legal requirements to maintain confidentiality. The limits of confidentiality and privileged communication are then reviewed together with legal requirements of “duty to warn” or “duty of care”. These requirements are then related to risk assessment procedures and relevant interventions. Four case studies that illustrate the practical application of assessment techniques in the decision process and planned interventions are presented. They cover such diverse topics as disclosure and suicidal intent, threat of harm to a third party, risk of transmission of the AIDS virus and “duty to warn” and maintenance of a minor’s confidential communications. The ways in which these issues were addressed and the outcome is presented. NOTE: All names and details that have the potential to identify the people whose cases are presented here have been changed to protect their anonymity.

Multi-type maltreatment : relationships between familial characteristics, maltreatment and adjustment of children and adults

This thesis examines the nature, extent and impact of multiple forms of maltreatment (multi-type maltreatment) from within a developmental victimological framework. The interrelationships between sexual abuse, physical abuse, psychological maltreatment, neglect, and witnessing family violence are assessed. The role of family variables in predicting maltreatment and the relative contribution of child maltreatment and family variables to adjustment are evaluated. Risk factors for multi-type maltreatment, and the relationship between multi-type maltreatment and adjustment are explored. The major theories of child development are reviewed. As well as exploring the relevance of developmental theories to understanding the impact of child maltreatment, factors influencing the emergence of child psychopathology are reviewed from a developmental psychopathology perspective. Ecological and developmental perspectives on how child maltreatment translates into the behavioural and emotional adjustment problems of children are integrated in the Child Maltreatment: Risk and Protection Model. After exploring some of the relevant conceptual issues, the literature on the prevalence and impact of each maltreatment type is reviewed, and the literature on multi-type maltreatment critiqued. Methodological and ethical concerns with the conduct of research in the field of child maltreatment using direct assessment of children led to the need for an instrument to assess parent perceptions of each of the types of abuse and neglect, as well as adult retrospective reports. Data are presented from two cross-sectional questionnaire-based studies using the Parent and Adult versions of the Family and Life Experiences Questionnaire which was designed to assess perceptions of children's experiences of sexual abuse, physical abuse, psychological maltreatment, neglect and witnessing family violence. Problems with the isolated focus of research on single forms of child maltreatment are addressed by the inclusion of each of these forms of child maltreatment within a single research design. Respondents for both studies were volunteers recruited from counselling agencies, medical, community health, child care and fitness centres and a first year psychology course. Parents (N=50) described their perceptions of primary school children's family characteristics, experiences of maltreatment and adjustment. Children's behavioural adjustment (internalising and externalising), sexual behaviours, emotions, self-esteem, gender identity, family adaptability and cohesion, parental traditionality, parental sexual punitiveness, interparental relationship satisfaction, and demographic characteristics are assessed in the study of Parents' perceptions. A large degree of overlap between the different types of abuse and neglect was found, with a high proportion of parents describing children's experiences of multiple forms of child maltreatment. Using both maltreatment and family characteristics to predict internalising behaviour problems, neglect and family cohesion were the only unique predictors. Family adaptability and cohesion were the only unique predictors of externalising behaviour problems. Physical and sexual abuse were not predicted from family characteristics; neglect was predicted, but no variables provided unique prediction. Unique predictors of psychological maltreatment were family cohesion, parental sexual punitiveness and divorce. Divorce was the only variable with significant unique prediction of the child witnessing family violence. Family background and family functioning were found to predict some forms of maltreatment, but to also be important factors mediating the adjustment of children, independent of maltreatment. The results are interpreted within an ecological framework, integrating risk factors for maltreatment with experiences of abuse and neglect and subsequent adjustment in childhood. Retrospective reports of adults' (N=175) own childhood family characteristics, experiences of maltreatment, and reports of their current adjustment are also studied. Included with the adult version of the FLEQ were the Trauma Symptom Checklist-40, Rosenberg's Self-esteem Scale, and the Family and Adaptability and Cohesion Evaluation Scale-II. Similar results were found in the in the Adult Study. As hypothesised, adult retrospective reports of the five different types of child maltreatment were found to be highly intercorrelated. Family characteristics predicted maltreatment and adjustment scores and discriminated between single and multi-type maltreatment. Maltreatment scores also predicted adult adjustment. As the number of maltreatment types increased, there was an increase in the number of adjustment problems reported. Alternate hypotheses regarding the possible operation of mediating and moderating processes in the relationships between family characteristics, maltreatment and the adjustment of adults were assessed. Finally, the results of these investigations are discussed and interpreted in the light of extant findings previously reviewed. Data from the two major empirical studies are used to demonstrate the overlap between different child maltreatment categories, and the extent and impact of multi-type maltreatment. The results show that children are vulnerable to more than one type of maltreatment. Individuals who experience a number of different forms of maltreatment had greater adjustment problems than those experiencing only one or two different types of abuse or neglect. Dysfunctional families place children at risk of child maltreatment. Negative family characteristics lead to adjustment problems in children and adults. The type of maltreatment having the most damaging effect on children was neglect, and in the long-term, sexual abuse. A multi-dimensional approach to prevention and intervention needs to be adopted, based on the co-morbidity of maltreatment types, and the likelihood of children experiencing further abuse or neglect of a different type. Dysfunctional family dynamics which place children at risk of multi-type maltreatment, and mediate the effects of maltreatment on adjustment, need to be specifically targeted with support and family intervention strategies. Risk-assessment measures used by Child Protection workers must include adequate knowledge of the inter-relationships between maltreatment types, and the particularly negative impact on adjustment of experiencing many forms of abuse or neglect. Suggestions for future clinical and research work in the area of child maltreatment are developed. The importance of assessing all forms of maltreatment when examining the relationships of maltreatment to adjustment is emphasised. It is recommended that prevention and intervention strategies acknowledge the interrelationships between maltreatment types.

Exposure estimation, uncertainty and variability in occupational hygiene retrospective assessment

This thesis reports on a quantitative exposure assessment and on an analysis of the attributes of the data used in the estimations, in particular distinguishing between its uncertainty and variability. A retrospective assessment of exposure to benzene was carried out for a case control study of leukaemia in the Australian petroleum industry. The study used the mean of personal task-based measurements (Base Estimates) in a deterministic algorithm and applied factors to model back to places, times etc for which no exposure measurements were available. Mean daily exposures were estimated, on an individual subject basis, by summing the task-based exposures. These mean exposures were multiplied by the years spent on each job to provide exposure estimates in ppm-years. These were summed to provide a Cumulative Estimate for each subject. Validation was completed for the model and key inputs. Exposures were low, most jobs were below TWA of 5 ppm benzene. Exposures in terminals were generally higher than at refineries. Cumulative Estimates ranged from 0.005 to 50.9 ppm-years, with 84 percent less than 10 ppm-years. Exposure probability distributions were developed for tanker drivers using Monte Carlo simulation of the exposure estimation algorithm. The outcome was a lognormal distribution of exposure for each driver. These provide the basis for alternative risk assessment metrics e.g. the frequency of short but intense exposures which provided only a minimal contribution to the long-term average exposure but may increase risk of leukaemia. The effect of different inputs to the model were examined and their significance assessed using Monte Carlo simulation. The Base Estimates were the most important determinant of exposure in the model. The sources of variability in the measured data were examined, including the effect of having censored data and the between and within-worker variability. The sources of uncertainty in the exposure estimates were analysed and consequential improvements in exposure assessment identified. Monte Carlo sampling was also used to examine the uncertainties and variability associated with the tanker drivers' exposure assessment, to derive an estimate of the range and to put confidence intervals on the daily mean exposures. The identified uncertainty was less than the variability associated with the estimates. The traditional approach to exposure estimation typically derives only point estimates of mean exposure. The approach developed here allows a range of exposure estimates to be made and provides a more flexible and improved basis for risk assessment.

Safeguarding Australia from cyber-terrorism : a proposed cyber-terrorism SCADA risk framework for industry adoption

Terrorist groups are currently using information and communication technologies (ICTs) to orchestrate their conventional physical attacks. More recently, terrorists have been developing a new form of capability within the cyber-arena to  coordinate cyber-based attacks. This paper identifies that cyber-terrorism capabilities are an integral, imperative, yet under-researched component in establishing, and enhancing cyber-terrorism risk assessment models for SCADA systems.

This paper is an extension of work previously published by Beggs and Warren 2008, it presents a high level overview of a cyber-terrorism SCADA risk framework that has been adopted and validated by SCADA industry practitioners. The paper proposes a managerial framework which is designed to measure and protect SCADA systems from the threat of cyber-terrorism within Australia. The findings and results of an industry focus group is presented in support of the developed framework for SCADA industry adoption and acceptance.

General practitioners' role in health assessment of humanitarian settlers

An approach to health assessment of humanitarian settlers was developed and evaluated from the perspective of general practitioners (GPs). While conducting assessment was found to be feasible, there were significant barriers which GPs without a primary interest in refugee health and those working in private practice may find difficult to transcend.

Why is type 2 diabetes such a serious risk factor for coronary heart disease in women?

Women with type 2 diabetes were found to display an altered distribution of body fat, higher resistance to the action of insulin, highly increased levels of tryglycerides and significant elevations in the level of plasminogen activator inhibiter. Concludes that interventions which enhance the action of insulin, such as exercise or drug therapy, should lower the risk of coronary heart disease in these women.

Exploring the application of Health Impact Assessment in neighbourhood renewal

This thesis explores the role that Health Impact Assessment can play in social exclusion policy contexts focusing specifically on Victoria's Neighbourhood Renewal Scheme. The findings demonstrate that it can play an important role if due attention is given to contextual and procedural factors both within community settings and within government.

Imperatives for policy health impact assessment : perspectives, positions, power relation

The thesis disturbs the seeming secure foundations of the dominant realist tales about the imperatives for the development of Health Impact Assessment, a relatively new policy device used within governments to consider the effects of policies on health. Foucauldian genealogical approaches are used to provide alternative, non-linear and non-definitive accounts.

Ethical practice in sex offender assessment : consideration of actuarial and polygraph methods

The current generation of community protection laws represents a shift in priorities that may see the individual rights of sex offenders compromised for the goal of public safety. At the center of many judicial decisions under these laws are the risk assessment reports provided by mental health practitioners. The widespread enactment of laws allowing for additional sanctions for sex offenders, and a burgeoning research literature regarding the methods used to assess risk have served to heighten rather than resolve the ethical concerns associated with professional practice in this area. This article examines ethical issues inherent in the use of two assessment methods commonly used with sex offenders in the correctional context, focusing on actuarial measures and polygraph tests. Properly conducted and adequately reported actuarial findings are considered to provide useful information of sufficient accuracy to inform rather than mislead judicial decision makers, although careful consideration must be given to the limitations of current measures in each individual case. Despite its increasing use, polygraph testing is considered controversial, with little consensus regarding its accuracy or appropriate applications. On the basis of the current state of the professional literature regarding the polygraph, its use with sex offenders raises unresolved ethical concerns.

Does the polygraph lead to better risk prediction for sexual offenders?

The polygraph is receiving increased attention surrounding its ability to facilitate more honest disclosures from sexual offenders concerning risk-related information (e.g., historical risk factors and acute-dynamic risk factors). In addition, the polygraph has become accepted as a standard containment tool in the US, although UK professionals appear to have taken a more cautionary approach. The aim of this review is to provide a basic overview of current risk assessment procedure in the absence of the polygraph, and then to investigate studies that use the polygraph to enhance sexual offenders' risk assessments. Specifically, studies examining historical risk factors, stable-dynamic risk factors, and acute-dynamic risk factors are examined and evaluated. We conclude that there is reasonable evidence supporting polygraph use in some areas of risk assessment. However, the vast majority of studies suffers from serious confounds that should be taken into account by professionals who use the polygraph as a standard practice in sexual offender risk assessment and management. Finally, the future of the polygraph is discussed in light of the presented empirical evidence.

Incorporating a knowledge perspective into security risk assessments

Purpose – Many methodologies exist to assess the security risks associated with unauthorized leakage, modification and interruption of information used by organisations. This paper argues that these methodologies have a traditional orientation towards the identification and assessment of technical information assets. This obscures key risks associated with the cultivation and deployment of organisational knowledge. The purpose of this paper is to explore how security risk assessment methods can more effectively identify and treat the knowledge associated with business processes.

Design/methodology/approach – The argument was developed through an illustrative case study in which a well-documented traditional methodology is applied to a complex data backup process. Follow-up interviews were conducted with the organisation’s security managers to explore the results of the assessment and the nature of knowledge “assets” within a business process.

Findings – It was discovered that the backup process depended, in subtle and often informal ways, on tacit knowledge to sustain operational complexity, handle exceptions and make frequent interventions. Although typical information security methodologies identify people as critical assets, this study suggests a new approach might draw on more detailed accounts of individual knowledge, collective knowledge and their relationship to organisational processes.

Originality/value – Drawing on the knowledge management literature, the paper suggests mechanisms to incorporate these knowledge-based considerations into the scope of information security risk methodologies. A knowledge protection model is presented as a result of this research. This model outlines ways in which organisations can effectively identify and treat risks around process knowledge critical to the business.

Mental health-related risk factors for violence : using the evidence to guide mental health triage decision making

Mental health clinicians working in emergency crisis assessment teams or mental health triage roles are required to make rapid and accurate risk assessments. The assessment of violence risk at triage is particularly pertinent to the early identification and prevention of patient violence, and to enhancing the safety of clinical staff and the general public. To date, the evidence base for mental health triage violence risk assessment has been minimal. This study aimed to address this evidence gap by identifying best available evidence for mental health-related risk factors for patientinitiated violence.We conducted a systematic review based on the National Health and Medical Research Council of Australia’s methodology for systematic reviews. A total of 6847 studies were retrieved, of which 326 studies met the study inclusion criteria. Of these studies, 277 met inclusion criteria but failed the quality appraisal process, thus a total of 49 studies were included in the final review. The risk factors that achieved the highest evidence grading were predominantly related to dynamic clinical factors immediately observable in the patient’s general appearance, behaviour and speech. These factors included hostility/anger, agitation, thought disturbance, positive symptoms of schizophrenia, suspiciousness and irritability.

He did what? Well that wasn't handed over! Communicating risk in mental health

Mental health inpatient units are dynamic, complex environments that provide care for patients with heterogeneous ages, diagnoses and levels of acuity. These environments commonly expose clinicians and patients to many potential risks. Despite extensive research into risk assessment, prediction and management, no study has investigated how risk information is communicated at handover in acute mental health settings. Given the pivotal role handover plays in informing risk management, this evidence gap is significant. This paper reports on a study that investigated the practices of communicating risk at handover in an Australian acute mental health inpatient unit. The aim of this research was to identify the frequency and type of risk information communicated between nursing shifts, and the methods by which this communication was performed. A secondary aim was to identify effective and ineffective risk communication practices. This study involved an observational design method using a 14-item Clinical Audit Tool derived from handover principles outlined by World Health Organization. Five hundred occasions of patient handover were observed. Few risk information items were observed to be communicated in any method. Risk communication practice was inconsistent, and a key recommendation from the study is the use of standardized handover tools that ensures risk information is adequately reported.

Debating the evidence : oral contraceptives containing drospirenone and risk of blood clots

Skepticism is an essential quality in science. We doubt, re-examine and demand the highest quality of evidence. However, sometimes this puts us in an awkward situation. How much evidence do we need before we act? This dilemma is a constant problem in drug safety. Treatment decisions are always a balance of risks and benefits and there may be a paucity of evidence about rare or very rare adverse events.