Practice note: Identifying and managing the effects of traumatic brain injury

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Issued by: Chief Psychologists’ Office, Department of Corrections

Introduction

This practice note is intended as advice to frontline staff to help identify and manage the possible effects of traumatic brain injury (TBI) among offenders. It is common for TBIs to go unreported and to escape medical attention at the time of occurrence, especially if they occurred during illegal activity. Such injuries have the potential to widely impact upon individuals’ wellbeing and behaviour. In a Corrections environment, the impact of TBIs can present in behavioural and management issues that require an informed approach.

The imprisoned population has a higher incidence of TBI than the general population (Farrer & Hedges, 2011). Research has identified that 63.8% of New Zealand male offenders have sustained a TBI across their lifetime, with 32.5% of these having experienced multiple injuries (Mitchell, Theadom and Du Preez, 2017). Sustaining a TBI in childhood has been shown to increase the possibility of imprisonment in adulthood (Schofield et al., 2015). This relationship indicates that, for a number of offenders, a TBI will have preceded their sentence.

The Department is working closely with the Accident Compensation Corporation (ACC) and the Ministry of Health (MoH) as part of the Traumatic Brain Injury Strategy and Action Plan 2017 – 2021.  This future work will include increasing understanding of the prevalence of TBI in the offender population, and developing strategies to identify and treat offenders with TBI.

Alongside the close working relationship with ACC and MoH, the Laura Fergusson Trust has been running a pilot programme at the Christchurch Men’s Prison Youth Unit since November 2017 to identify young men coming into the youth unit with a suspected history of head injury.  The Trust’s project aims to determine whether each young person is registered with ACC, and to consider what formal support would assist youth with a history of head injury to manage this injury.  This support may include trying to become registered with ACC if they are not already.  Laura Fergusson Trust will be providing an evaluation of their work at the end of the pilot scheduled for June 2018.

How traumatic brain injury may affect the behaviour of offenders

The behavioural changes associated with a TBI are varied and will depend on the site, cause, intensity (e.g. open vs. closed head trauma), frequency, and duration of the injury (Maas et al., 2017). The male prison population aged from 15-34 years, as well as the elderly (65 or older), are most likely to have suffered a TBI, with even greater rates observed among Māori (Feigin et al., 2013). Traumatic brain injury has been associated with higher rates of violent behaviours (Williams, Cordan, Mewse, Tonks & Burgess, 2010), younger age of offending and a greater likelihood of re-offending (Williams et al., 2010). However, TBIs often go unrecognised by sufferers, and offenders are unlikely to have presented to emergency departments at the time of the injury (Haines, 2016).

Given that offenders may be imprisoned well after sustaining a TBI, it is particularly important to be aware of the long-term effects. The following points highlight some of the changes that may be seen (Schoenberg & Scott, 2011). These changes may negatively impact on an offender’s capacity to engage in programmes, and to self-manage their behaviour appropriately within a correctional environment.

Generalised impairments

Generalised impairment (difficulties that affect a range of brain functions) is commonly associated with blunt force trauma to the head. Injury is most commonly of a mild form that shows up in both acute and chronic symptoms. A mild injury is sometimes referred to as “concussion”. Concussion symptoms include headache, nausea, inability to concentrate, low mood, fatigue, and irritability. To be diagnosed with concussion (technically known as “acute mild-traumatic brain injury”), the individual also needs to have experienced around the time of injury: (1) loss of consciousness; (2) loss of memory before or after the trauma; and/or (3) a change in mental state (i.e. dazed, confused, disorientated). It is possible for a person to have experienced a brain injury even if they did not lose consciousness.

Some individuals experience generalised symptoms for a long period of time, developing what is known as post-concussion syndrome. This is also known as chronic mild-traumatic brain injury. It is most common in the year following the injury but can persist longer – particularly when multiple injuries have been experienced over time. Long term symptoms can include difficulties with attention, memory, learning, fatigue, depression, anxiety, sensitivity to light and noise, dizziness, and headaches.

A decline in memory and learning capacities can show up as difficulties engaging in programmes, or difficulties consolidating the skills taught in programmes. Ultimately this can contribute toward an apparent lack of behavioural improvement or change and/or generalisation of skills. Difficulties with attention and concentration can impact upon an individual’s ability to maintain focus on a task; this may be conceived as the offender being deliberately defiant and unwilling to comply with instructions and/or a lack of achievement within and after programmes.

Specific impairments

The front and side parts of the brain are particularly vulnerable to injury, which will produce specific difficulties, namely:

  • Hearing impairments resulting in difficulties hearing instructions.
  • Language difficulties resulting in difficulties finding words, comprehending what others are saying or meaning, and expressing what they want to say.
  • Slowed processing speed with information resulting in delayed understanding and reaction to information (e.g. being spoken to and reacting).
  • Emotional regulation difficulties which may be observed in fluctuating moods, such as irritability, acting childish,  or showing little emotion.
  • Behavioural regulation difficulties resulting in impulsive behaviours, being socially inappropriate, having difficulty shifting their thinking or “letting go” of an issue, and over-reacting – sometimes aggressively.
  • Disorganised thoughts and behaviours resulting in difficulties planning, talking about those plans, and acting in a logical manner. They may appear “all over the place”.
  • Apathy resulting in a lack of drive or enthusiasm which may also impact on willingness to engage in programmes, and poor awareness of the needs and feelings of others.

Identifying offenders with traumatic brain injury

Consider the possibility that an offender may be experiencing the ongoing impacts of a traumatic brain injury if the symptoms listed above have been observed. This is particularly the case if there is a reported history of head trauma or diagnosis of traumatic brain injury on file. Self-reported history, information on file, or even a positive response to the question “Have you suffered a head injury that put you in hospital?” on the SDAC-21 can be indicators that traumatic brain injury may be contributing to the observed behaviour.

Practical accommodations for offenders with traumatic brain injury

Mild symptoms may be adequately supported within the structured and consistent prison environment (most recover within six months). Severe symptoms, such as behaviour disinhibition, can be more difficult to understand and manage appropriately (Haines, 2016).

Tips to assist frontline staff in managing offenders with traumatic brain injury:

  • If attention and processing speed difficulties seem to be an issue, be aware that the person can become overwhelmed with information quickly – particularly in a pressured or stressful situation. Present single instructions in a simple form and allow offenders sufficient time to process information before giving further information.
  • For memory and learning difficulties, repeat information frequently, provide reminders, encourage offenders to ask questions. Write down routines and instructions and if you note that an offender is having difficulty remembering, provide the answer before they give the wrong answer. This can also help offenders to retain information in programmes.
  • When approaching an offender presenting as aggressive/irritable, communicate the rules in a clear and direct manner, avoid evoking conflict, and break down instructions into single clear statements.
  • For ongoing fatigue and other physical symptoms, encourage offenders to communicate their needs, keep to a schedule, and to take opportunities for short periods of rest and sleep during the day.
  • Encourage the offender to learn the signs of needing to slow down (e.g. feeling overwhelmed, frustrated/irritable, angry, tired etc), to identify what they need (e.g. clearer or written instructions, a rest), and to adapt their daily routine if possible.

Further information is available from a range of providers

There are a number of resources available that provide more information about brain injury. These resources also include information about helping individuals with brain injury manage their symptoms, and how to respond to difficult symptoms and behaviours. Two major New Zealand resources can be accessed through the following links:

Brain Injury Association: https://www.brain-injury.nz/resources-links

Accident Compensation Association: https://www.acc.co.nz/preventing-injury/traumatic-brain-injury-tbi

Additional information is also available by accessing the resources in the references section.

References

Accident Compensation Corporation. (2017). Traumatic brain injury strategy and action plan (2017-2021). Wellington, NZ: Author. Accessible at: https://www.acc.co.nz/assets/provider/tbi-strategy-action-plan.pdf

Bowman, J. (2016). Comorbid substance use disorder and mental health disorder amongst New Zealand prisoners. Practice: The New Zealand Corrections Journal, 4, 15-20.

Diamond, P. M., Harzke, A., Magaletta, P. R., Cummins, A, G., & Frankowski, R. (2007). Screening for traumatic brain injury in an offender sample: A first look at the reliability and validity of the Traumatic Brain Injury Questionnaire. Head Trauma Rehabilitation, 22, 330-338. doi: 10.1097/01.HTR.0000300228.05867.5c

Farrer, T., & Hedges, D. (2011). Prevalence of traumatic brain injury in incarcerated groups compared to the general population: A meta-analysis. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 35, 390-394. doi: 10.1016/j.pnpbp.2011.01.007

Feigin, V. L., Theadom, A., Barker-Collo, S., Starkey, N. J., McPherson, K., Kahan, M., … Ameratunga, S. (2013). Incidence of traumatic brain injury in New Zealand: A population-based study. The Lancet, 12(1), 53-64. doi: 10.1016/S1474-4422(12)70262-4

Friedland, D., & Hutchinson, P. (27 July 2013). Classification of traumatic brain injury. Advances in Clinical Neuroscience & Rehabilitation, 13(4). Accessed 23 April 2018 from http://www.acnr.co.uk/wp-content/uploads/2013/07/ACNRJA13_rehab1.pdf

Haines, S. (2016). Traumatic Brain Injury in Offenders: Impact on Offending and Management of Offenders in Prison. Unpublished research report. Wellington, NZ: Department of Corrections.

Maas, A., Menon, D. K., Adelson, P. D., Andelic, N., Bell, M. J., Belli, A., … Zumbo, F. (2017). Traumatic brain injury: Integrated approaches to improve prevention, clinical care, and research. The Lancet, 16, 987-1048. doi: 10.1016/S1474-4422(17)30371-X

Mitchell, T., Theadom, A., & Du Preez, E. (2017). Prevalence of traumatic brain injury in a male adult prison population and links with offence type. Neuroepidemiology, 48, 164-170. doi: 10.1159/000479520

Schoenberg, M., & Scott, J. (Eds.) (2011). The Little Black Book of Neuropsychology: A Syndrome-Based Approach. New York, NY: Springer. doi: 10.1007/978-0-387-76978-3

Schofield, P. W.. Malacova, E., Preen, D. B., D’Este, C., Tate, R., Reekie, J., … Butler, T. (2015). Does traumatic brain injury lead to criminality? A whole-population retrospective cohort study using linked data. PLoS One, 10, 1-12. doi: 10.1371/journal.pone.0132558

Williams, W., Cordan, G., Mewse, A., Tonks, J., & Burgess, C. (2010). Self-reported traumatic brain injury in male young offenders: A risk factor for re-offending, poor mental health and violence? Neuropsychological Rehabilitation, 20, 801-812. doi: 10.1080/09602011.2010.519613

Williams, W., Mewse, A. J., Tonks, J., Mills, S., Burgess, C. N. W., & Cordan, G. (2010). Traumatic brain Injury in a prison population: Prevalence and risk of re-offending. Brain Injury, 24, 1184-1188. doi: 10.3109/02699052.2010.495697