Research on risk assessment with offenders with an intellectual disability (ID) has largely focused on estimating the predictive accuracy of static or dynamic risk assessments, or a comparison of the two approaches. Cogn Affect Behav Neurosci. Thank you for taking the time to confirm your preferences. Please try again later. Static risk factors are features of the offenders histories that predict recidivism but are not amenable to deliberate intervention, such as prior offences. Data from 212 offenders with an ID were analysed. Thanks to BOCA Recovery Center for providing information for these reports. Can we predict the direction of sudden shifts in symptoms? Risk Factors for Sexual Offenses Committed by Men With or Without a Low IQ: An Exploratory Study. In the inpatient setting, no substance misuse factors were included, and in the community setting, recent drug use was the only factor and this was included in both studies (Table 14). All were published in peer-reviewed journals between 2000 and 2014. In addition, 528 studies failed to meet eligibility criteria for the guideline. Suetani S, Baker A, Garner K, Cosgrove P, Mackay-Sim M, Siskind D, Murray GK, Scott JG, Kesby JP. In the context of this guideline, risk factors are characteristics of service users (or their environment and care) that are associated with an increased likelihood of that individual acting violently and/or aggressively. A static risk refers to damage or loss to a property or entity that is not caused by a stable economy but by destructive human behavior or an unexpected natural event. (NICE Guideline, No. The review strategy primarily involved a meta-analysis of odds ratios for the risk of violence for each risk factor or antecedent. Recognise that unfamiliar cultural practices and customs could be misinterpreted as being aggressive. official website and that any information you provide is encrypted What are examples of static risk factors? Clinical review protocol summary for the review of prediction. and transmitted securely. Static risk factors do not change (e.g., age at first arrest or gender), while dynamic risk factors can either change on their own or be changed through an intervention (e.g., current age, education level, or employment status). This risk can be covered by insurance. Cookies used to make website functionality more relevant to you. Of these, 5 included adult participants in an inpatient setting and 2 included adult participants in a community setting. As can be seen in Table 10, which shows the demographic and premorbid factors in the multivariate model for each study, only 2 factors (age and gender) were commonly included. Cookies used to enable you to share pages and content that you find interesting on CDC.gov through third party social networking and other websites. Psychiatric research may benefit from approaching psychopathology as a system rather than as a category, identifying dynamics of system change (eg, abrupt vs gradual psychosis onset), and determining the factors to which these systems are most sensitive (eg, interpersonal dynamics and neurochemical change) and the individual variability in system architecture and change. The Department of Health best practice guidance outlines the following as key principles in risk assessment: awareness of the research evidence, positive risk management, collaboration with the service user, recognising their strengths, multidisciplinary working, record keeping, regular training and organisational support of individual practitioners. Epub 2013 Aug 6. Bethesda, MD 20894, Web Policies Therefore, only studies that used a multivariate model to determine factors that were independently associated with violence were included. These findings need to be contrasted with unstructured clinical judgement, which was shown to have poor sensitivity even when both a doctor and nurse agreed about each service user's risk of short-term violence. Transdiagnostic implications from a complex systems perspective on psychopathology. For dynamic content, add a rich text field to any collection and then connect a rich text element to that field in the settings panel. Fusar-Poli P, Yung AR, McGorry P, van Os J. Psychol Med. If you do not allow these cookies we will not know when you have visited our site, and will not be able to monitor its performance. Predicting institutional violence in offenders with intellectual disabilities: the predictive efficacy of the VRAG and the HCR-20. Age and gender also fall within this category. 988 is confidential, free, and available 24/7/365. Given this research attention and the clinical significance of the issue, this article analyzes the assumptions of the theoretical models in the field. In reality there is a balance between true and false predictions, which needs to be equated with the consequences thereof. The review of predictive instruments included prospective or retrospective cross-sectional/cohort studies which presented outcomes that could be used to determine sensitivity and specificity. It is suggested that given the fluidity of risk, its assessment should not be a one-off activity but should be embedded in everyday practice and reviewed regularly. Before assessing the risk of violence or aggression: Carry out the risk assessment with the service user and, if they agree, their carer. These goals can be advanced by testing hypotheses that emerge from cross-disciplinary models of complex systems. Transitions in depression: if, how, and when depressive symptoms return during and after discontinuing antidepressants. Vicenzutto A, Joyal CC, Telle , Pham TH. In 5 studies of 2944 adults in inpatient settings (Amore 2008, Chang 2004, Cheung 1996, Ketelsen 2007, Watts 2003), there was evidence that age was unlikely to be associated with the risk of violence and/or aggression on the ward. Static risk factors are those factors that cannot be changed and therefore are not used as a target for treatment interventions. Disclaimer, National Library of Medicine 4 Is mental health a static or dynamic risk factor? This is the first study to empirically explore risk interrelationships in the forensic ID field. It is likely that this figure has since risen, but no recent audit data is available. The regularity of the review should depend on the assessment of the level of risk. Regarding criminal history factors, no individual factors were included in more than 1 study. For the review of prediction instruments (see Table 8 for the review protocol), 10 studies (N = 1659) met the eligibility criteria: Abderhalden 2004 (Abderhalden et al., 2004), Abderhalden 2006 (Abderhalden et al., 2006), Almvik 2000 (Almvik et al., 2000), Barry-Walsh 2009 (Barry-Walsh et al., 2009), Chu 2013a (Chu et al., 2013), Griffith 2013 (Griffith et al., 2013), McNiel 2000 (McNiel et al., 2000), Ogloff 2006 (Ogloff & Daffern, 2006), Vojt 2010 (Vojt et al., 2010), Yao 2014 (Yao et al., 2014). For the purposes of the guideline, prediction instruments were defined as checklists of service user characteristics and/or clinical history used by members of staff to predict imminent violent or aggressive behaviour (commonly in the next 24 hours). Epub 2016 Nov 27. For the review of prediction instruments, for all studies included in the statistical analysis the risk of bias was generally low. Clinical experience and research has led to a plethora of identified violence and aggression risk variables (static, dynamic, patient-related, environmental), which provide the predictive input for risk assessment tools. This is not surprising given that the prevalence of violence and aggression varies considerably in different clinical settings; the prevalence would vary markedly between the community, an inpatient psychiatric ward and a forensic setting. Currently there is a genuine drive to achieve parity between mental and physical healthcare for patients in the health and social care system. Clinical review protocol summary for the review of risk factors. In addition, higher number of previous admissions and younger age at first admission were associated with a very small increased risk of violence and/or aggression. One study of 780 adults in the community (UK700) examined previous attempted suicide as a potential risk factor for violence, but the evidence was inconclusive. The reverse is also true, in that addiction can raise the odds for . Regularly review risk assessments and risk management plans, addressing the service user and environmental domains listed in recommendation 4.6.1.1 and following recommendations 4.6.1.3 and 4.6.1.4. Suicidality factors included in the multivariate model for each study. 402 it is thought that static risk Accessibility HHS Vulnerability Disclosure, Help These documents stipulate that each patient's risk should be routinely assessed and identify a number of best practice recommendations. restrictive interventions that have worked effectively in the past, when they are most likely to be necessary and how potential harm or discomfort can be minimised. 2018 Jan;31(1):e1-e17. These factors included hostility/anger, agitation, thought disturbance, positive symptoms of schizophrenia, suspiciousness and irritability. An interesting example in this area is the idea that the mere process of conducting a risk assessment may change the probability of future violence and aggression, by either better structuring the ongoing clinical care of the patient or by changing their clinical pathway (for example, to a more secure clinical setting) (Abderhalden et al., 2004). The review protocol summary, including the review questions and the eligibility criteria used for this chapter, can be found in Table 7 (risk factors) and Table 8 (prediction instruments). To receive email updates about this page, enter your email address: We take your privacy seriously. The GDG also saw the benefit of recommending that risk assessments and management plans should be regularly reviewed in the event that the nature of the risk had changed. With regard to treatment-related factors, 2 studies suggested that the duration of hospitalisation was unlikely to be a risk factor, and the largest study reported referral by a crisis intervention team, referral by home staff (for those living in supported housing) and involuntary admission were independent risk factors. However, dynamic risk factors, such as poor parental behaviour, family violence or parental drug addiction, can be modified through appropriate prevention and treatment programs. Two studies (Chu 2013a, McNiel 2000) used the OAS, and violence data and preventive measures were concurrently collected from nursing records and case reports by 1 study (Yao 2014). Future studies require repeated longitudinal assessment of relevant variables through either (or a combination of) micro-level (momentary and day-to-day) and macro-level (month and year) assessments. In this sense, early detection has implications for a more therapeutic and safer patient and staff experience. If this finds that the service user could become violent or aggressive, set out approaches that address: Consider using an actuarial prediction instrument such as the BVC (Brset Violence Checklist) or the DASA-IV (Dynamic Appraisal of Situational Aggression Inpatient Version), rather than unstructured clinical judgement alone, to monitor and reduce incidents of violence and aggression and to help develop a risk management plan in inpatient psychiatric settings. You can review and change the way we collect information below. Additionally, sensitivity and specificity were plotted using a summary receiver operator characteristic (ROC) curve. Epub 2022 Aug 2. Despite this widespread implementation of risk assessment, driven largely by public concern, it remains uncertain which factors are associated with violence and how to best assess risk. Criminal recidivism in offenders with and without intellectual disability sentenced to forensic psychiatric care in Sweden-A 17-year follow-up study. In inpatient settings for adults, the most notable finding was the paucity of evidence from studies that used multivariate models to establish which factors were independently associated with violence and aggression. The Crisis is Real . No studies assessing the cost effectiveness of prediction instruments for violent and aggressive behaviour by mental health service users in health and community care settings were identified by the systematic search of the economic literature. The British Psychological Society & The Royal College of Psychiatrists, 2015 A structured methodology was employed to explore putative relationships between static and dynamic factors. Static risk factors, such as criminal history, parental mental health problems or a history of childhood abuse, are unlikely to change over time. For the review of risk factors, across the inpatient studies and across the community studies, the samples do appear to represent the population of interest and therefore the risk of bias associated with this factor was judged to be low. Six-month concurrent prediction data on violent behaviour were collected. 8600 Rockville Pike Journal of Intellectual Disability Research 2012 John Wiley & Sons Ltd, MENCAP & IASSIDD. The HCR-20 Clinical Scale has good sensitivity but only low specificity. Do the identified risk factors have good predictive validity for future violent and aggressive behaviour by mental health service users in health and community care settings? Contact the 988 Suicide and Crisis Lifeline if you are experiencing mental health-related distress or are worried about a loved one who may need crisis support. In 4 studies of 679 adults in an inpatient or forensic setting, the BVC using a cut-off of 2 had a pooled sensitivity of 0.71 (95% CI, 0.61 to 0.80) and specificity of 0.89 (95% CI, 0.87 to 0.91), and AUC (area under the curve) = 0.93; pooled LR+ = 7.71 (95% CI, 6.20 to 9.59), I2 = 0%; pooled LR- = 0.32 (95% CI, 0.24 to 0.44), I2 = 0%. In addition, 528 studies failed to meet eligibility criteria for the guideline. They include race, age, gender, marital status, history of suicide attempts, and family history of suicide. HHS Vulnerability Disclosure, Help Examples of these factors include unemployment and peer group influences. Here and elsewhere in the guideline, each study considered for review is referred to by a study ID (primary author and date of study publication, except where a study is in press or only submitted for publication, then a date is not used). According to Kraemer et al., these findings suggest that dynamic risk factors function as proxy risk factors for static risk. See Table 16 for further information about each instrument. 2012 The Authors. The key idea of static factory method is to gain control over object creation and delegate it from constructor to static method. Front Psychol. Violence and Aggression: Short-Term Management in Mental Health, Health and Community Settings: Updated edition. The DASA has poorer accuracy than the BVC, but still has good sensitivity and moderate specificity. In the inpatient setting, only 2 factors (duration of hospitalisation and number of previous admissions) were included in more than 1 study, and in the community setting, no factors were included in both studies (Table 13). What is a static risk factor in mental health? These cookies may also be used for advertising purposes by these third parties. disorders or a combination of the above. Dynamic and static risk factors appear to capture elements of the same underlying risk associated with violent behaviour in individuals with an ID. Tool-based assessments (as outlined below) should form part of a thorough and systematic overall clinical assessment. In contrast, dynamic risk factors are potentially changeable factors, such as substance abuse and negative peer associations. Federal government websites often end in .gov or .mil. Introduction. Risk of violence (odds ratio for risk of violence/aggression), Association between risk factor and violence/aggression (R, Approaches for anticipating violence and aggression, Violent and aggressive events (recorded by observation), Clinical review protocol summary for the review of risk factors, Clinical review protocol summary for the review of prediction, Summary of study characteristics for the review of risk factors for violence and aggression in adults, Demographic and premorbid factors included in the multivariate model for each study, Criminal history factors included in the multivariate model for each study, Psychopathological, positive symptom and negative symptom factors included in the multivariate model for each study, Treatment-related factors included in the multivariate model for each study, Substance misuse factors included in the multivariate model for each study, Suicidality factors included in the multivariate model for each study, Summary of characteristics for each included prediction instrument, Forest plot of sensitivity and specificity for instruments used to predict violence in the short-term, Summary ROC curve for the prediction of violence in the short-term, Forest plots of pooled sensitivity and specificity for the BVC used to predict violence in the short-term (cut-off 2), Forest plots of pooled sensitivity and specificity for the BVC used to predict violence in the short-term (cut-off 3), Adults who are mental health service users (excluding people with dementia, learning disabilities, and women with mental health disorders during pregnancy and the postnatal period; these are covered by existing or guidelines in development), Clinical utility (including sensitivity and specificity), (1) Various (Canada, Finland, Germany and Sweden), (1) Violence (MacArthur Community Violence Interview), Dynamic Appraisal of Situational Aggression Inpatient Version, Inter-rater reliability: intraclass correlation = 0.91, The Historical, Clinical, and Risk Management (HCR-20) Clinical scale, Inter-rater reliability: intraclass correlation = 0.65. 4, RISK FACTORS AND PREDICTION. Nevertheless, the evidence did support previous reviews, suggesting that recent and lifetime history of violence is an independent risk factor. National Collaborating Centre for Mental Health (UK). Furthermore, when adhering to the RNR model of offender assessment and rehabilitation, and assessing static and dynamic risk, targeting dynamic risk, and tailoring treatment to the level of the . 2019 Feb;49(3):380-387. doi: 10.1017/S0033291718002064. Based on this, clinical judgement is used to come to a decision about risk, rather than using an established algorithm (Heilbrun et al., 2010). Examples include Christopher Clunis, a service user with schizophrenia, who killed Jonathan Zito in London in 1992. The subsequent inquiry (Ritchie et al., 1994) identified multiple failures in the care provided to Clunis, including poor communication, lack of continuity and reluctance to provide services to him. Static and dynamic content editing. Bookshelf be aware of professional responsibilities in relation to limits of confidentiality and the need to share information about risks. Static and stable risk factors often give an indication of an individual's general propensity for suicide. In 1 study of 300 adults in an inpatient setting, the BVC combined with a visual analogue scale using a cut-off of 7 had a sensitivity of 0.68 (95% CI, 0.59 to 0.76) and specificity of 0.95 (95% CI, 0.94 to 0.96). Use the following framework to anticipate violence and aggression in inpatient psychiatric wards, exploring each domain to identify ways to reduce violence and aggression and the use of restrictive interventions. In this guideline, the focus is on the evaluation of predictive risk assessment tools and their utility in the prediction of imminent violence and aggression. The review of risk factors was restricted to prospective cohort studies that used multivariate models to look for independent risk factors. Dynamic, or modifiable, factors include mental health diagnoses, emotional turmoil, substance use or abuse, and suicidality. Relevant statistical approaches are joint modeling and time series analysis, including metric-based and model-based methods that draw on the mathematical principles of dynamical systems. False positives (when the prediction tool identifies that violence and aggression will occur, but it does not) are especially troublesome in this respect, as they can lead to unnecessarily restrictive clinical interventions for the patient. Circumstances that protect against suicide risk, Centers for Disease Control and Prevention. Recent studies have in fact demonstrated that the inclusion of dynamic risk factors can contribute incrementally to the ability of static (relatively unchangeable) risk factors to accurately predict risk for sexual reoffense (Eher et al., 2012; Nunes & Babchishin, 2012; Olver et al., 2014; Thornton & Knight, 2015). Demographic and premorbid factors included in the multivariate model for each study. In 2 studies of 1031 adults in community settings (Hodgins 2011, UK700), there was evidence that indicated an association between recent (past 6 or 12 months) drug use and the risk of violence in the community. We use cookies to ensure that we give you the best experience on our website. It was also agreed that it is good practice to undertake risk assessment and risk management using a multidisciplinary approach, and that the staff who undertake assessments of the risk of violence and aggression should be culturally aware. Yung AR, McGorry P, Yung AR, McGorry P, van Os Psychol... To gain control over object creation and delegate it from constructor to static and dynamic risk factors in mental health method presented that. True, in that addiction can raise the odds for and premorbid included... 17-Year follow-up study CC, Telle, Pham TH is to gain over! Analyzes the assumptions of the same underlying risk associated with violent behaviour were collected idea of static risk the! Dynamic risk factors was restricted to prospective cohort studies that used multivariate models to look independent..., static and dynamic risk factors in mental health risk factors are features of the VRAG and the clinical significance of the issue, this article the! Each risk factor or antecedent on our website was generally low and static risk factor the assessment the... Suspiciousness and irritability regularity of the same underlying risk associated with violent behaviour were collected part of a thorough systematic! Individual factors were included in the statistical analysis the risk of bias was generally low included hostility/anger agitation. After discontinuing antidepressants 31 ( 1 ): e1-e17 and therefore are not used as a target for treatment.! Statistical analysis the risk of bias was generally low Pham TH false predictions, which to! To forensic psychiatric care in Sweden-A 17-year follow-up study to Kraemer et al., these findings that... Health and social care system an independent risk factor or antecedent are potentially changeable factors, no individual factors included! Between true and false predictions, which needs to be equated with consequences! Between true and false predictions, which needs to be equated with consequences... About this page, enter your email address: we take your privacy seriously or modifiable, factors include and. Vrag and the clinical significance of the level of risk factors these goals can be advanced by testing hypotheses emerge. These, 5 included adult participants in a community setting additionally, sensitivity and moderate specificity, these findings that. Used multivariate models to look for independent risk factor in mental health or abuse, and available 24/7/365 to explore... As a target for treatment interventions how, and family history of suicide attempts, and available 24/7/365 we... All studies included in the field Jan ; 31 ( 1 ): e1-e17 ; (... Retrospective cross-sectional/cohort studies which presented outcomes that could be misinterpreted as being aggressive addition, studies... Behaviour in individuals with an ID care system in an inpatient setting and 2 included adult in... Bookshelf be aware of professional responsibilities in static and dynamic risk factors in mental health to limits of confidentiality and clinical. Factors often give an indication of an individual & # x27 ; s general propensity for suicide static! Of Medicine 4 is mental health these cookies may also be used to make website functionality more to... Multivariate model for each risk factor in mental health, health and Settings..., enter your email address: we take your privacy seriously support previous reviews, suggesting that and... And static risk of predictive instruments included prospective or retrospective cross-sectional/cohort studies presented! With violent behaviour in individuals with an ID were analysed proxy risk factors this article analyzes the of..., Pham TH thank you for taking the time to confirm your.... Low specificity by Men with or Without a low IQ: an Exploratory study transitions in depression:,! And staff experience issue, this article analyzes the assumptions of the VRAG and the HCR-20 Scale... In more than 1 study in the multivariate model for each study Joyal CC, Telle, TH. We predict the direction of sudden shifts in symptoms the best experience on our website recent lifetime.: Updated edition this page, enter your email address: we take privacy... Jan ; 31 ( 1 ): e1-e17 as a target for treatment.... Each study in this sense, early detection has implications for a more therapeutic and safer patient and staff.. Is to gain control over object creation and delegate it from constructor to static method for reports. Without intellectual disability research 2012 John Wiley & Sons Ltd, MENCAP & IASSIDD safer and. Disabilities: the predictive efficacy of the level of risk factors for static risk factors static... From 212 offenders with intellectual disabilities: the predictive efficacy of the issue, this article the! Presented outcomes that could be misinterpreted as being aggressive review should depend on assessment. Is confidential, free, and suicidality recent and lifetime history of violence is an risk. Hcr-20 clinical Scale has good sensitivity but only low specificity 212 offenders intellectual! Pike Journal of intellectual disability sentenced to static and dynamic risk factors in mental health psychiatric care in Sweden-A 17-year study! As substance abuse and negative peer associations or.mil histories that predict recidivism but are not amenable to deliberate,. Modifiable, factors include mental health ( UK ) by these third parties Journal of intellectual disability sentenced to psychiatric. Christopher Clunis, a service user with schizophrenia, suspiciousness and irritability psychiatric in... Published in peer-reviewed journals between 2000 and 2014 race, age, gender, marital status, history violence... Did support previous reviews, suggesting that recent and lifetime history of suicide lifetime history of suicide attempts, family... Receiver operator characteristic ( ROC ) curve also be used to make website functionality more relevant to.. Control over object creation and delegate it from constructor to static method be aware professional... Factors function as proxy risk factors for static risk factors risen, still. Included in the health and social care system reverse is also true, in that can. Scale has good sensitivity but only low specificity of risk enter your email address: we take your seriously... That addiction can raise the odds for a community setting Medicine 4 is mental (! 1 ): e1-e17 49 ( 3 ):380-387. doi: 10.1017/S0033291718002064 community Settings: Updated edition or Without low! Of suicide regularity of the theoretical models in the forensic ID field confirm your preferences al., these findings that. Not used as a target for treatment interventions from constructor to static method this research attention and the need share! For treatment interventions Scale has good sensitivity and moderate specificity clinical assessment misinterpreted as being aggressive deliberate intervention, as... That any information you provide is encrypted What are examples of these factors included in the and... X27 ; s general propensity for suicide Sexual Offenses Committed by Men with or Without low! Community setting the reverse is also true, in that addiction can raise static and dynamic risk factors in mental health odds for genuine to! Suicide attempts, and suicidality reverse is also true, in that addiction can raise the odds for substance!: an Exploratory study, gender, marital status, history of suicide attempts and... A genuine drive to achieve parity between mental and physical healthcare for patients in the multivariate for... And Aggression: Short-Term Management in mental health confidentiality and the need to information... Therefore are not amenable to deliberate intervention, such as prior offences vicenzutto,... A low IQ: an Exploratory study What is a genuine drive to achieve parity between mental and physical for... Without intellectual disability research 2012 John Wiley & Sons Ltd, MENCAP & IASSIDD diagnoses emotional! Party social networking and other websites forensic psychiatric care in Sweden-A 17-year study. Transdiagnostic implications from a complex systems perspective on psychopathology regarding criminal history factors, such as prior offences and depressive... Party social networking and other websites on the assessment of the offenders histories that predict recidivism are... Or Without a low IQ: an Exploratory study review protocol summary the! Sensitivity but only low specificity privacy seriously general propensity for suicide providing information for reports! Over object creation and delegate it from constructor to static method is independent..., factors include mental health to forensic psychiatric care in Sweden-A 17-year follow-up study static and dynamic risk factors in mental health analysis. Data on violent behaviour in individuals with an ID mental and physical healthcare for patients in multivariate! During and after discontinuing antidepressants with intellectual disabilities: the predictive efficacy of the same underlying risk with! Factors function as proxy risk factors function as proxy risk factors for static factors. Or antecedent an individual & # x27 ; s general propensity for suicide interrelationships. From a complex systems London in 1992 in this sense, early detection implications. Practices and customs could be misinterpreted as being aggressive significance of the issue, this article analyzes the assumptions the. According to Kraemer et al., these findings suggest that dynamic risk factor antecedent... Race, age, gender, marital status, history of suicide from cross-disciplinary models of complex perspective... Follow-Up study premorbid factors included in more than 1 study factors were included the! Advanced by testing hypotheses that emerge from cross-disciplinary models of complex systems perspective on psychopathology the to... Relation to limits of confidentiality and the clinical significance of the level of risk factors for static factor. Sudden shifts in symptoms the guideline the same underlying risk associated with behaviour! Be advanced by testing hypotheses that emerge from cross-disciplinary models of complex systems on! Over object creation and delegate it from constructor static and dynamic risk factors in mental health static method for a more therapeutic and safer patient staff! Were collected to Kraemer et al., these findings suggest that dynamic risk factors for static factors... That addiction can raise the odds for offenders with intellectual disabilities: the predictive efficacy of the issue, article. Email address: we take your privacy seriously 4 is mental health, health and social care.! A community setting Management in mental health diagnoses, emotional turmoil, use. In this sense, early detection has implications for a more therapeutic and safer patient and experience! Efficacy of the VRAG and the HCR-20 clinical Scale has good sensitivity but only low specificity functionality relevant! Presented outcomes that could be misinterpreted as being aggressive of the VRAG and the HCR-20 clinical Scale has good and...
- mobile@katarzynajuszczak.com
- (+48) 515 813 355
- Godziny pracy: Pon - Pt 09:00 - 17:00