Prevalence and assessment of traumatic brain injury in prison inmates: A systematic PRISMA review

Implementing Interventions for Women and Youth with Traumatic Brain Injury at Transition from Custodial Settings: A Call to Action

Traumatic brain injury (TBI) is a serious public health concern and overrepresented among justice-involved populations. An emerging area of research focuses on the complex, interrelated and unmet health and social needs of justice-involved women and youth with TBI. Evidence of these needs continues to grow, yet the health and justice systems continue to underperform in supporting the health and social care of justice-involved women and youth. This commentary is a call to action to begin to redress these gaps. We first provide an overview of the needs of women and youth with TBI that affect their transition from custody to community, including those related to victimization, trauma, mental health, substance use, and homelessness. We then highlight the current gaps in knowledge and practice with respect to interventions for women and youth with TBI at transition from custody. The available evidence for the impact of interventions on people with head injury who are justice-involved is sparse, especially studies of interventions focused on women and youth. We conclude with a call for implementation science studies to support translation from research to practice, emphasizing that researchers, practitioners, policy makers, and women and youth at transition should collaborate to develop, implement, and evaluate accommodations and interventions for TBI. To have meaningful, positive impacts on the systems that serve these women and youth, interdisciplinary service delivery approaches should aim to prevent, raise awareness, identify, and provide timely support and services for the varied needs of women and youth with TBI in transition.

Characteristics of forensic psychiatric patients with a neurocognitive disorder

BACKGROUND

Emotional and behavioural disturbances accompanying neurocognitive disorders may sometimes lead to a criminal offence. Our knowledge of this specific forensic subpopulation is lagging behind the knowledge on, and attention for, 'classic' psychiatric disorders in forensic populations.

AIMS

To gain knowledge on the prevalence and characteristics of individuals with neurocognitive disorders in the forensic population.

METHOD

This retrospective database study uses an anonymised data-set of the National Database of penitentiary psychiatric centres (PPC) (N = 8391), which collects data on all patients admitted to one of the four PPCs (mental health clinics within the prison system) in The Netherlands since May 2013. Inclusion criterion for this study was the presence of a Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR) or Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) diagnostic code belonging to the category of neurocognitive disorders.

RESULTS

A DSM-IV-TR or DSM-5 diagnostic code of a neurocognitive disorder was classified in 254 out of 8391 unique individuals, resulting in a prevalence of 3.0% in the total PPC population. The most prevalent diagnosis was unspecified neurocognitive disorder (59.1%). The neurocognitive disorder group significantly differed from a random control group from the database (n = 762) on demographic, clinical and criminological variables.

CONCLUSIONS

The prevalence of neurocognitive disorders in this real-world clinical sample is remarkably lower than in two earlier studies in similar populations. Also remarkable is the relatively high prevalence of an unspecified neurocognitive disorder. These findings lead us to hypothesise that neurocognitive disorders may be underdiagnosed in this population. Forensic psychiatric settings should evaluate whether they have sufficient expertise available in neuropsychological assessment.

Six-month post-release outcomes for inmates with traumatic brain injury in supported community programming

OBJECTIVE

The goal of this study is to examine the effectiveness of case management services for a population of justice-involved individuals with TBI history.

METHODS

Two thousand three hundred and eighty-nine records from statewide behavioral health and brain injury program databases were used in two studies.

RESULTS

Participants with a reported TBI history were more likely to have experienced trauma and to have a behavioral health diagnosis relative to incarcerated persons without TBI. Six months after release, 56.8% of participants with a history of TBI were still receiving community treatment, 27.8% were not in treatment, and 3.4% had completed treatment. There was a high attrition rate; 70% of people referred for case management failed to maintain contact.

CONCLUSIONS

For those that did receive services, these data suggest that it prevented an escalation of psychosocial needs. There were no differences in community participation as measured by the Mayo Portland Adaptability Index's Participation Index (M2PI) scores (t24 = .497, p = 0.624) at intake and after 6 months of case management. This study confirms that case management confers a benefit to persons with TBI who are released from the criminal justice system. Further, recidivism rates for this vulnerable group were no different from the larger population of returning citizens.

History of incarceration and age-related neurodegeneration: Testing models of genetic and environmental risks in a longitudinal panel study of older adults

History of incarceration is associated with an excess of morbidity and mortality. While the incarceration experience itself comes with substantive health risks (e.g., injury, psychological stress, exposure to infectious disease), most individuals eventually return from prison to the general population where they will be diagnosed with the same age-related conditions that drive mortality in the non-incarcerated population but at exaggerated rates. However, the interplay between history of incarceration as a risk factor and more traditional risk factors for age-related diseases (e.g., genetic risk factors) has not been studied. Here, we focus on cognitive impairment, a hallmark of neurodegenerative conditions like Alzheimer's disease, as an age-related state that may be uniquely impacted by the confluence of environmental stressors (e.g., incarceration) and genetic risk factors. Using data from the Health and Retirement Study, we found that incarceration and APOE-ε4 genotype (i.e., the chief genetic risk factor for Alzheimer's disease) both constituted substantive risk factors for cognitive impairment in terms of overall risk and earlier onset. The observed effects were mutually independent, however, suggesting that the risk conveyed by incarceration and APOE-ε4 genotype operate across different risk pathways. Our results have implications for the study of criminal-legal contact as a public health risk factor for age-related, neurodegenerative conditions.

Health status and health-care utilization among men recently released from a superjail: a matched prospective cohort study

PURPOSE

Continuity of care and access to primary care have been identified as important contributors to improved health outcomes and reduced reincarceration among people who are justice-involved. While the disproportionate burden of health concerns among incarcerated populations is well documented, less is known about their health service utilization, limiting the potential for effective improvements to current policy and practice. This study aims to examine health status and health care utilization among men recently released from a superjail in a large metropolitan area to better understand patterns of use, risk factors and facilitators.

DESIGN/METHODOLOGY/APPROACH

Participants included adult men (n = 106) matched to a general population group (n = 530) in Ontario, Canada, linked to medical records (88.5% linkage) to examine baseline health status and health utilization three-months post-release. The authors compared differences between the groups in baseline health conditions and estimated the risk of emergency department, primary care, inpatient hospitalization and specialist ambulatory care visits.

FINDINGS

Superjail participants had a significantly higher prevalence of respiratory conditions, mental illness, substance use and injuries. Substance use was a significant risk factor for all types of visits and emergency department visits were over three times higher among superjail participants.

ORIGINALITY/VALUE

This empirical case is illustrative of an emerging phenomenon in some regions of the world where emergency departments serve as de facto "walk-in clinics" for those with criminal justice involvement. Strategic approaches to health services are required to meet the complex social and health needs and disparities in access to care experienced by men released from custody.

Comparing post-concussion symptom reporting between adults with and without a TBI history within an adult male correctional facility

BACKGROUND

A higher proportion of people in prison have a history of traumatic brain injury (TBI) than the general population. However, little is known about potentially related persistent symptoms in this population.

AIMS

To compare symptom reporting in men with and without a history of TBI following admission to a correctional facility.

METHODS

All men transferred to the South Auckland Correctional Facility in New Zealand complete a lifetime TBI history and the Rivermead Post-Concussion Symptom Questionnaire (RPQ) as part of their routine health screen. Data collected between June 2020 and March 2021 were extracted and anonymised. Participants were classified as reporting at least one TBI in their lifetime or no TBI history. The underlying factor structure of the RPQ was determined using principal components analysis. Symptom scores between those with and without a TBI history were compared using Mann Whitney U tests.

RESULTS

Of the N = 363 adult male participants, 240 (66%) reported experiencing at least one TBI in their lifetime. The RPQ was found to have a two-factor structure (Factor 1: cognitive, emotional, behavioural; Factor 2: visual-ocular) explaining 61% of the variance. Men reporting a TBI history had significantly higher cognitive, emotional and behavioural (U = 50.4, p < 0.001) and visuo-ocular symptoms (U = 68.5, p < 0.001) in comparison to men reporting no TBI history.

CONCLUSION

A history of TBI was associated with higher symptom burden on admission to a correctional facility. Screening for TBI history and current symptoms on admission may assist prisoners experiencing persistent effects of TBI to access rehabilitation.

Executive functioning as mediator of the association between traumatic brain injury and prison bullying

OBJECTIVE

This study examined whether executive functioning (EF) mediated the relationship between childhood traumatic brain injury (TBI) and engaging in bullying in prison (BP).

PARTICIPANTS

A sample of male adults in custody in Uruguay (N = 236), drawn from five prisons.

METHODS

Inmates filled out self-report questionnaires examining TBI (Head Injury Questionnaire), EF (Behavior Rating Inventory of Executive Function Adult, BRIEF-A) and bullying in prison (Direct and Indirect Prisoner Behavior Checklist - revised, SCALED, DIPC-SCALED-r).

RESULTS

Findings showed that TBI was associated with prison bullying after controlling for age, level of education, socioeconomic status, and civil status. The mediation analysis indicated that the relationship between TBI and bullying was fully mediated via executive impairment, especially through the behavioral regulation component (mainly inhibition and emotional control).

CONCLUSION

These findings suggested that compensating for EF difficulties in adult inmates with brain injuries might help to decrease the bullying in prison.

Traumatic Brain Injury History Among Individuals Using Mental Health and Addictions Services: A Scoping Review

OBJECTIVE

Traumatic brain injury (TBI) has been increasingly linked in population research to psychiatric problems as well as substance use and related harms, suggesting that individuals with TBI may also present more frequently to mental health and addictions (MHA) services. Little is known, however, about TBI history among MHA service users. The objectives of this review were to understand (i) the prevalence of TBI history among MHA service users; (ii) how TBI history is identified in MHA service settings; and (iii) predictors or outcomes of TBI that have been reported in MHA service users.

METHODS

A scoping review was conducted in accordance with PRISMA Scoping Review Extension guidelines. A search for relevant literature was conducted in MEDLINE, PsycINFO, SPORTDiscus, CINAHL, and Embase as well as various gray literature sources.

RESULTS

Twenty-eight relevant studies were identified. TBI was defined and operationalized heterogeneously between studies, and TBI history prevalence rates ranged considerably among the study samples. The included studies used varied methods to identify TBI history in MHA settings, such as clinical chart audits, single-item questions, or structured questionnaires (eg, Brain Injury Screening Questionnaire or Ohio State University TBI Identification Method). TBI history was most consistently associated with indicators of more severe substance use problems and mental health symptoms as well as increased aggression or risk to others. Studies reported less consistent findings regarding the relationship of TBI to physical health, cognitive impairment, functioning, risk to self, and type of psychiatric diagnosis.

CONCLUSION

Screening for TBI history in MHA settings may contribute important information for risk assessment and care planning. However, to be clinically useful, assessment of TBI history will require consistent operationalization of TBI as well as use of validated screening methods.

The prevalence, characteristics, and psychiatric correlates of traumatic brain injury in incarcerated individuals: an examination in two independent samples

PRIMARY OBJECTIVE

Identify the prevalence, characteristics, and psychological correlates of traumatic brain injury (TBI) among incarcerated individuals.

RESEARCH DESIGN

Three aims: (1) Determine the prevalence and characteristics of TBI in 1469 adults incarcerated in Wisconsin state prisons (1064 men, 405 women); (2) Characterize the relationship between mild TBI and mental illness in a sub-sample of men and women; (3) Reproduce the findings from Aim 1 and Aim 2 in an independent sample of 1015 adults incarcerated in New Mexico state prisons (600 men, 415 women).

METHODS AND PROCEDURES

Standardized TBI assessment with structured clinical interviews and self-report questionnaires.

MAIN OUTCOMES AND RESULTS

Rates of TBI were approximately five times greater than the general population, with a substantially higher rate of TBI caused by assault. In the Wisconsin sample, mild TBI was associated with greater levels of post-traumatic stress disorder (PTSD) among women (but not among men). In the New Mexico sample, TBI of any severity was associated with greater levels of major depressive disorder (MDD) among women (but not among men).

CONCLUSIONS

This study thus provides novel data on TBI and its correlates among individuals incarcerated in state prisons, and highlights a specific treatment need within the prison population.

Neurobiology of Female Homicide Perpetrators

Neurobiology of female homicide perpetrators is not well understood. Data from private interviews and examinations of females were re-analyzed comparing those who committed homicide (n = 9); other violent crimes, no known homicide (n = 51); nonviolent crimes, no known violent convictions (n = 49); and noncriminals (n = 12). Homicide perpetrators suffered the most childhood sexual abuse (CSA); most recent abuse; had the most neurological histories, mainly traumatic brain injuries (TBIs); most health care access for abuse-related injuries; lowest AM and PM salivary cortisol; and greatest proportion who committed crime under the influence of alcohol. Only CSA, years since last abuse, TBI, neurological histories, and health care access for abuse-related injuries were significant. Those who committed homicide under the influence of alcohol suffered the most recent abuse and had the lowest AM cortisol and flattest diurnal cortisol slope (DCS) compared with others; though the n precludes determining significance. Amount of time since last abuse, AM cortisol and DCS progressively decreased as crime severity increased; other variables progressively increased as crime severity increased. These preliminary findings suggest that low AM cortisol, flat DCS, greater CSA frequency and severity, recent abuse, TBIs, and health care access for abuse-related injuries could be risk factors for females committing homicide. Further study is needed due to the small n of homicide perpetrators. Abuse victims may be at greater risk for alcohol use and cortisol dysregulation associated with perpetrating violence, especially homicide. Frontal lobe damage from TBIs may decrease ability to control behaviors associated with emotions from the limbic system. Health care providers released these women when their abuse-related injuries were not life-threatening; yet, they were life-threatening for victims of their subsequent homicides. Females accessing health care for abuse-related injuries present a critical opportunity for violent crime prevention interventions.

Associations between significant head injury and persisting disability and violent crime in women in prison in Scotland, UK: a cross-sectional study

BACKGROUND

The prevalence of head injury is estimated to be as high as 55% in women in prison and might be a risk factor for violent offending, but evidence is equivocal. The extent of persisting disability is unknown, making decisions about service needs difficult. The UN recognises vulnerabilities in women in prison, but does not include head injury. This study aimed to investigate relationships among head injury, comorbidities, disability, and offending in women in prison.

METHODS

In this cross-sectional study, women were recruited between Feb 2, 2018, and Sept 30, 2019, from four prisons across Scotland, UK: Her Majesty's Prison (HMP) Cornton Vale, Her Majesty's Young Offenders Institute Polmont, HMP Edinburgh, and HMP Greenock (detaining approximately 355 individuals at the time of recruitment). Women were included if they were aged older than 16 years, fluent in English, able to participate in face-to-face assessment and provide informed consent, and did not have a severe acute disorder of cognition or communication. Head injury, cognition, disability, mental health, and history of abuse and problematic substance use were assessed by interview. History of head injury was assessed with the Ohio State University Traumatic Brain Injury Identification method and disability was assessed with the Glasgow Outcome at Discharge Scale. Comparisons were made between women with and without a history of significant head injury.

FINDINGS

We recruited 109 (31%) of the 355 women in these prisons. The sample was demographically representative of the approximately 400 individuals in women's prisons in Scotland. Significant head injury (SHI) was found in 85 (78%) of 109 women, of whom 34 (40%) had associated disability. Repeat head injury was reported in 71 (84%) of the 85 women with SHI and, in most cases, this resulted from domestic abuse that had occurred over many years. Women with a history of SHI were significantly more likely to have a history of violent offences than those without a history of SHI (66 [79%] of 85 women in the SHI group vs 13 [54%] of 24 women in the no-SHI group had committed a violent offence; odds ratio [OR] 3·1, 95% CI 1·2-8·1). This effect remained significant after adjusting for current factors (3·1, 1·1-9·0), including comorbidities associated with post-traumatic stress disorder, and was no longer statistically significant after adjusting for historical factors (3·3, 1·0-10·9), such as abuse as a child or adult. Women with SHI had spent longer in prison than women without SHI after adjustment for current (rate ratio 3·4, 1·3-8·4) or historical (3·5, 1·3-9·2) risk factors.

INTERPRETATION

It is recognised that women in prison are vulnerable because of histories of abuse and problematic substance use; however, history of SHI needs to be included when developing criminal justice policy, interventions to reduce mental health morbidity, and assessment and management of risk of violent offending.

FUNDING

The Scottish Government.

Characteristics and neuropsychological impact of traumatic brain injury in female prisoners

Objective: To investigate the characteristics of head injury (HI) and its association with offending behaviour, psychological and neurobehavioral functioning, and cognitive performance in female prisoners.Methods: Using a cross-sectional design, female prisoners in the UK reporting a HI with a loss of consciousness (LOC) over ten minutes (n = 10) were compared with a group without a HI with LOC over ten minutes (n = 41) across a range of measures; including scores on standardized clinical questionnaires and performance-based cognitive assessments. Semi-structured clinical interviews assessed HI and forensic history, with forensic history triangulated against the prison database.Results: Domestic abuse was the most frequently reported cause of HI. The HI with LOC group had been to prison a greater number of times and had committed a greater number violent offences. No significant difference was found on self-reported psychological and neurobehavioral measures, or between the groups' cognitive functioning on neuropsychological tests.Conclusions: Psychosocial factors such as trauma may contribute to higher rates of violent offending and imprisonment in those with a HI with LOC. Domestic abuse is an important factor in HI amongst female prisoners. Forensic screening and interventions need to be designed, adapted and evaluated with consideration of trauma and HI.

Association between traumatic brain injury and prison charges: a population-based cohort study

BACKGROUND

Traumatic Brain Injury (TBI) is a serious hidden health issue disproportionately affecting people who experience incarceration.

OBJECTIVE

We examined the association between TBI and serious disciplinary charges among men and women sentenced by the courts to terms of two or more years.

METHODS

The study originated in Ontario, Canada and used linked administrative health and correctional data. The cohort included adults experiencing their first federal sentence between 1998 and 2011 (N = 12,038). We examined disciplinary charges incurred 2 years post-sentence commencement. TBI was defined using the International Classification of Diseases (ICD-9 and ICD-10) diagnostic codes. Robust Poisson regression was conducted to assess the association between TBI and disciplinary charges.

FINDINGS

The prevalence of TBI for the full sample was 13.2%. One-third of adults with a recent TBI had a serious disciplinary charge. The unadjusted risk of incurring a serious charge for those with a history of TBI was 39% higher than those with no history of TBI (CI: 1.29-1.49). The adjusted risk was 1.14 (CI: 1.06-1.22).

CONCLUSIONS

TBI is a serious health concern that makes it difficult for incarcerants to adjust to prison. Additional support/resources are needed to support those with histories of TBI.

Utility of the Brain Injury Screening Index in Identifying Female Prisoners With a Traumatic Brain Injury and Associated Cognitive Impairment

There is a high prevalence of traumatic brain injury (TBI) in prisoners, but screening tools for identifying TBI in female prisoners are not readily available. Using a cross-sectional design, the psychometric properties of the Brain Injury Screening Index (BISI) were investigated in a closed United Kingdom female prison. Purposive sampling comprised 56 females. Assessment included clinical interview, the BISI, self-report measures of mood, and a battery of measures of cognitive functioning. Seven of the 10 clinical indicators on the BISI met test-retest reliability criteria. Two of the three BISI summary variables demonstrated correlations with questionnaires in the hypothesized directions; however, only two BISI variables were associated with cognitive functioning. Findings support further investigation into the validity and reliability of the BISI with a larger sample.

Assessing aggression following Acquired Brain Injury (ABI): a systematic review of assessment measures

Objective: To conduct a systematic review to identify and examine the reliability and validity of standardized measures used to assess aggression in people with ABI. Data sources: Systematic searches of PsychInfo, Medline, Embase, PubMed and CINAHL databases along with hand searching of gray literature and review articles. Study selection: Studies were included if the sample had an ABI, and the measure included assessment of aggression. Data extraction: Sample and measure characteristics and psychometric properties were extracted. Measure quality was assessed using the COSMIN checklist. Data synthesis: Of 5,100 abstracts screened, 78 were reviewed in full against the inclusion and exclusion criteria, and 25 articles met the criteria for analysis. Included articles assessed the psychometric properties of 17 different measures of aggression in adults with ABI. Quality of evidence was often low. Four measures (MBPC-1990R, NFI, SASNOS and KSMS) demonstrated positive evidence of at least one psychometric property with good quality evidence. Conclusions: Although a large number of general measures were available, there are few measures that only assess post-ABI aggression, and many are not well-validated. Future research should assess the psychometric properties of these measures.

The Building Bridges project: Linking disconnected service networks in acquired brain injury and criminal justice

People with acquired brain injury (ABI) are overrepresented in prison populations across many countries. An effective service response to reduce this trend requires collaboration between the ABI and criminal justice (CJ) sectors. The Building Bridges project piloted a novel professional development model designed to increase cross-sectoral knowledge and collaboration between the ABI and CJ sectors. A total of 178 service providers from Victoria, Australia, participated in six professional development forums that included content about ABI, policing, disability and legal supports, and correctional/post-release services. Participants came from the disability, criminal justice, and health and community service sectors. Using a pre-test-post-test design with 6-month follow-up, data were obtained via a project-specific questionnaire evaluating knowledge and behaviour change among participants. Statistically significant gains in knowledge were shown at post-test and maintained at follow-up. Work-related behaviours addressing ABI/CJ issues had increased significantly within both sectors at follow-up compared to the 6 months prior to the forum. Carefully constructed professional forums improved cross-silo collaboration in the ABI/CJ sectors. This pilot project illustrates effective use of existing service resources, and highlights training as an important part of a raft of initiatives needed to address the overrepresentation of people with ABI in the CJ system.

Prevalence of Traumatic Brain Injury in a Male Adult Prison Population and Its Association with the Offence Type

Background: The prevalence of traumatic brain injury (TBI) in prison populations has been found to vary considerably. This study aimed to determine the prevalence of TBI in a prison population in New Zealand and to identify whether age, ethnicity, offence type, security classification and sentence length were linked to TBI prevalence. Methods: All offenders admitted to a new Corrections Facility over a 6-month period (May-November 2015) were screened to understand their history of TBI. Data was merged with demographic information, details of the offence type, sentence length and security classification from the prison database. Binary logistic regression was used to identify the contribution of predictors on TBI history. Results: Of the 1,061 eligible male prisoners, 1,054 (99.3%) completed a TBI history screen. Out of the 672 (63.7%) who had sustained at least one TBI in their lifetime, 343 (32.5%) had experienced multiple injuries. One in 5 participants experienced their first TBI injury before the age of 15 years. A regression model was able to correctly classify 66.9% of cases and revealed that belonging to Māori ethnicity or being imprisoned for violent, sexual or burglary offences were independently predictive of TBI (χ2 = 9.86, p = 0.28). Conclusions: The high prevalence of TBI within male prisoners and a high proportion of injuries sustained in childhood suggest the need for routine screening for TBI to identify prisoners at risk of persistent difficulties. Interventions to support those experiencing persistent difficulties post-TBI are needed to optimise functioning and prevent reoffending.