Traumatic brain injury and juvenile offending: complex causal links offer multiple targets to reduce crime

The effect of a minor health shock on labor market outcomes: The case of concussions

The literature on health shocks finds that minor injuries have only short-term labor market impacts. However, mild traumatic brain injuries (mTBIs, commonly referred to as concussions) may be different as the medical literature highlights that they can have longer-term health and cognitive effects. Moreover, TBIs are one of the most common causes of disability globally, with the vast majority being mild. Thus, it is important to understand the impact of mTBIs on labor market outcomes. We use administrative data on all medically-diagnosed mild traumatic brain injuries (mTBIs) in New Zealand linked to monthly tax records to examine the labor market effects of a mTBI. We use a comparison group of those who suffer a mTBI at a later date to overcome potential endogeneity issues, and employ a doubly-robust difference-in-differences method. We find that suffering a mTBI has negative labor market effects. Rather than dissipating over time, these negative effects grow, representing a decrease in employment of 20 percentage points and earning losses of about a third after 48 months. Our results highlight the need for timely diagnosis and treatment to mitigate the effect of mTBIs to reduce economic and social costs.

Association Between Traumatic Brain Injury and Psychopathic Traits Among Justice-Involved Adolescents

Traumatic brain injury (TBI) is a global public health problem and is highly prevalent among justice-involved populations. Pediatric TBI is linked with long-term negative outcomes and is correlated with substance use, criminal behavior, psychiatric disorders, and disruptions in neurocognition. These same TBI correlates are evident among youth with psychopathic traits. Given ongoing neurobiological and social development in adolescence, understanding the link between psychopathic traits and TBI in justice-involved youth is critical. A sample of 263 male adolescents were recruited from a maximum-security juvenile justice facility. Using a structural equation modeling (SEM) framework, measurement invariance of psychopathic traits (TBI ±) was tested, and psychopathy scores were accounted for in terms of TBI variables (severity, age of first TBI, total number), participant's age, IQ, substance use, and internalizing psychopathology. There was evidence of strong invariance across TBI status and those with TBI had higher affective and impulsive lifestyle psychopathic traits than adolescents without TBI. The SEM indicated that TBI severity was associated with lower IQ scores, which in turn were associated with increased lifestyle/antisocial (Factor 2) psychopathic traits. Total number of TBIs was associated with higher substance use, which was associated with both increased interpersonal/affective (Factor 1) and Factor 2 psychopathic traits. These TBI variables also had indirect associations with psychopathic traits through IQ and substance use. The findings indicate that TBI is associated with psychopathic traits and suggest that disturbances in cognition and substance use may be treatment targets for youth with TBI and psychopathic traits.

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.

Further recommendations of the International Paediatric Brain Injury Society (IPBIS) for the post-acute rehabilitation of children with acquired brain injury

BACKGROUND

Paediatric acquired brain injury is a life-long condition which impacts on all facets of the individual's lived experience. The existing evidence base continues to expand and new fields of enquiry are established as clinicians and researchers uncover the extent of these impacts.

PRIMARY OBJECTIVE

To add to recommendations described in the International Paediatric Brain Injury Society's 2016 paper on post-acute care for children with acquired brain injury and highlight new areas of enquiry.

REVIEW OF INFORMATION

Recommendations were made based on the opinions of a group of experienced international clinicians and researchers who are current or past members of the board of directors of the International Paediatric Brain Injury Society. The importance of each recommendation was agreed upon by means of group consensus.

OUTCOMES

This update gives new consideration to areas of study including injuries which occur in pre-school children, young people in the military, medical referral, young offenders and the use of technology in rehabilitation.

Persons With Histories of Traumatic Brain Injury and Problematic Sexual Behavior: An Exploratory Analysis

Persons with traumatic brain injuries (TBI) who have engaged in problematic or illegal sexual behavior present with complex assessment and intervention needs yet remain understudied within the empirical literature. In the current exploratory analysis, important differences in adaptive and clinical functioning, adverse childhood experiences, and criminal offense history are examined in 25 persons with previous brain injury, 118 persons with intellectual disability but no known TBI, and 103 persons with no history of brain injury or intellectual disability, all of whom have engaged in problematic sexual behavior and who were residing in secure forensic inpatient care. Group differences were examined using comparisons of means and chi-squares. Results highlight important differences in education and employment experiences, diagnostic presentation, exposure to childhood maltreatment, and justice system involvement and characteristics of their sexual offense victims. Associations with prior literature and future research directions are discussed.

Mild traumatic brain injury increases engagement in criminal behaviour 10 years later: a case-control study

Introduction

Sustaining a mild traumatic brain injury (mTBI) has been linked to increased criminal behaviour in later life. However, previous studies have not controlled for the number of injuries, gender, social deprivation, impact of past behaviour, or link to offence type. This study aims to determine if people who experienced a single or multiple mTBI have increased risk of criminal behaviour 10 years post-injury than matched orthopaedic controls.

Methods

This was a case control study of adults (aged >16 years) who experienced a medically diagnosed mTBI and controls who experienced a lower limb fracture (with no TBI) over a 12-month period (01/01/2003-31/12/2003). Participants were identified within Stats New Zealand's Integrated Data Infrastructure (national database including health and justice records). Participants who experienced a subsequent TBI (post-2003), who were not resident in New Zealand, and who died by 2013 were excluded. Case and controls were matched by age, sex, ethnicity, deprivation index and pre-injury criminal history.

Results

The study included N = 6,606 mTBI cases and N = 15,771 matched trauma controls. In the 10 years after injury, people experiencing a single mTBI had significantly higher numbers of violent charges (0.26 versus 0.21, p < 0.01) and violent convictions (0.16 versus 0.13, p < 0.05) but not for all court charges and convictions. Analysis of those with a history of prior mTBIs yielded larger effects, with significantly higher numbers of violent charges (0.57 versus 0.24, p < 0.05) and violent convictions (0.34 versus 0.14, p < 0.05). For males, the single mTBI case group had a significantly higher number of violent charges (0.40 versus 0.31, p < 0.05) and violent convictions (0.24 versus 0.20, p < 0.05) but this was not observed for females or all offence types.

Discussion

Experiencing multiple mTBIs over the lifetime increases the number of subsequent violence-related charges and convictions but not for all offence types in males but not for females. These findings highlight the need for improved recognition and treatment of mTBI to prevent future engagement in antisocial behaviour.

Decision-making abilities under risk and ambiguity in adults with traumatic brain injury: what do we know so far? A systematic review and meta-analysis

Traumatic brain injury (TBI) is a major health and socio-economic problem since it is one of the major sources of death and disability worldwide. TBI patients usually show high heterogeneity in their clinical features, including both cognitive and emotional/behavioral alterations. As it specifically concerns cognitive functioning, these patients usually show decision-making (DM) deficits. DM is commonly considered a complex and multistep process that is strictly linked to both hot and cold executive functioning and is pivotal for daily life functioning and patients' autonomy. However, the results are not always in agreement, with some studies that report huge alterations in the DM processes, while others do not. The present systematic review and meta-analysis aims to integrate past literature on this topic, providing a clear and handy picture both for researchers and clinicians. Thirteen studies addressing domain-general DM abilities were included from an initial N = 968 (from three databases). Results showed low heterogeneity between the studies (I2 = 7.90, Q (12) = 13.03, p = .37) supporting the fact that, overall, TBI patients showed lower performance in DM tasks as compared to healthy controls (k = 899, g = .48, 95% CI [0.33; 0.62]) both in tasks under ambiguity and under risk. The evidence that emerged from this meta-analysis denotes a clear deficit of DM abilities in TBI patients. However, DM tasks seemed to have good sensitivity but low specificity. A detailed description of patients' performances and the role of both bottom-up, hot executive functions and top-down control functions have been further discussed. Finally, future directions and practical implications for both researchers and clinicians have been put forward.

Preliminary findings on TBI knowledge of professionals working with justice-involved youth

Professionals working with justice-involved youth (JIYs) play a critical role in identifying and providing supports and services related to traumatic brain injury (TBI). The aim of this study was to better understand the knowledge of TBI of professionals working with JIYs, a research priority identified by the National Conference of State Legislatures. Fifty employees of an urban juvenile court system completed an online survey about their TBI knowledge. Respondents scored an average of 77.31% correct, yet patterns emerged in item responses and based on participant characteristics that indicate opportunities for training and education on TBI. The results of this preliminary study provide foundational evidence on TBI knowledge of professionals working with JIYs, inform future TBI-related trainings and education provided to professionals working with JIYs, and inform other practices and policies related to JIYs with TBI.

An intervention to improve coping strategies in adult male prisoners with a history of traumatic brain injury: A pilot randomised clinical trial

OBJECTIVE

To determine whether a psychological intervention improves coping, post-concussion symptoms and decreases in-prison infractions in adult males with a history of traumatic brain injury.

DESIGN

A single centre, randomised, wait-list, pilot study.

SETTING

A high security prison in New Zealand.

SUBJECTS

Fifty-five adult male participants who had experienced at least one traumatic brain injury in their lifetime (mean age 37.29 +/-9.81 years).

INTERVENTION

A manualised ten session, in-person, group based combined Cognitive Behavioural Therapy /Mindfulness Based Stress Reduction intervention versus wait list control.

MAIN MEASURES

The Negative Affect Repair Questionnaire and Rivermead Post-concussion Symptom Questionnaire were completed at baseline, post-intervention (five weeks) and at 12 week follow up. In-prison misconduct charges and negative file notes were reviewed for the previous five weeks at each assessment time point.

RESULTS

There was an improvement in the use of calming and distraction strategies in the intervention group from baseline (x̄ = 17.38, SD = 3.57) to post-intervention (x̄ = 18.67, SD = 3.84) and 12-week follow up (x̄ = 18.13, SD = 2.63). Participants in the intervention group had significantly higher negative affect repair on the calming and distractive strategies subscale following completion of the intervention, compared to wait-list controls (F = 4.69, P = 0.04) with a moderate effect size (η_p² = 0.11). Improvements in use of calming and distractive strategies was not sustained at the twelve-week follow-up (F = 0.87, P = 0.36). There was no-significant improvement on other negative affect subscales or for post-concussion symptoms or decrease in-prison infractions.

CONCLUSION

A manualised psychological intervention may have the potential to facilitate the development of positive coping strategies in prisoners with a history of traumatic brain injury.

Executive dysfunction in children and adolescents with behavior disorders and traumatic brain injury

Traumatic brain injury (TBI) is known to contribute to deficits in executive functioning (EF). Executive functioning abilities are disrupted in adolescents with either conduct disorder or oppositional defiant disorder, collectively known as disruptive behavior disorders (DBDs). There is little research on the relationship between executive dysfunction and DBDs in a group with a confirmed history of TBI. The current study endeavored to examine EF abilities, as measured by parent report on the Behavior Rating Inventory of Executive Function (BRIEF), in four groups: (1) adolescents with a TBI history and co-occurring DBDs history, (2) adolescents with a TBI history and no DBDs history, (3) adolescents with an orthopedic injury (OI) history and co-occurring DBDs history, and (4) adolescents with an OI history and no DBDs history. Groups were matched on the basis of age at injury and estimated socioeconomic status. Participants were evaluated at five time-points throughout the study, within 1 month of injury (initial assessment), 3, 12, 18, and 24 months post-injury. Results indicated the TBI and DBDs group was not significantly different from the OI and DBDs group, and both DBDs groups suffered higher levels of executive dysfunction than the TBI only and OI only groups, which were not significantly different from each other. Results also showed across the four groups, EF deficits were significantly lower at 1 month and 24 months post-injury, suggesting a positive trajectory in EF skill development. Results are discussed in terms of the prognostic importance of EF deficits in children with DBDs.

Challenges of Conducting Research With Young Offenders With Traumatic Brain Injury

The purpose of this commentary is to highlight the challenges encountered when conducting research with young offenders. This is drawn from the first-hand experience of 3 researchers working on separate projects within this environment. Young offenders present as a complex clinical population with high levels of illiteracy, substance abuse, and mental health issues. Significant planning is therefore required before working with this group. Consideration must be given to the heterogeneity of prison populations alongside the potential limitations of datacollection methods, in particular, reliance on self-report. The capacity of young offenders to comprehend and effectively engage with research is also of concern, posing issues of both a practical and ethical nature. The absence of a consistent "research culture" within prison environments poses further practical challenges, potentially also placing significant burden on both researchers and prison resources. The challenges discussed in this article may help inform future studies in the area and emphasize the need for greater critical reflection among researchers conducting work of this type.

Traumatic brain injury: a potential cause of violent crime?

Traumatic brain injury (TBI) is the biggest cause of death and disability in children and young people. TBI compromises important neurological functions for self-regulation and social behaviour and increases risk of behavioural disorder and psychiatric morbidity. Crime in young people is a major social issue. So-called early starters often continue for a lifetime. A substantial majority of young offenders are reconvicted soon after release. Multiple factors play a role in crime. We show how TBI is a risk factor for earlier, more violent, offending. TBI is linked to poor engagement in treatment, in-custody infractions, and reconviction. Schemes to assess and manage TBI are under development. These might improve engagement of offenders in forensic psychotherapeutic rehabilitation and reduce crime.

Health-related quality of life in prisoners with attention-deficit hyperactivity disorder and head injury

BACKGROUND

Attention-deficit hyperactivity disorder (ADHD) and head injury (including traumatic brain injury (TBI)) manifest in high levels across prison samples and guidance from the National Institute for Health and Care Excellence notes that people with acquired brain injury may have increased prevalence of ADHD. We aimed to examine the association of ADHD with TBI and the impact of the association upon health-related quality of life (HRQoL) and service use among imprisoned adults.

METHODS

An observational study was performed in 2011-2013, at Porterfield Prison, Inverness, United Kingdom (UK). The all male sample included 390 adult prison inmates with capacity to consent and no history of moderate or severe intellectual disability. Head injury was measured with a series of self-reported questions, addressing history of hits to the head: frequency, severity, loss of consciousness (LOC), and sequelae. Participants were interviewed using the Diagnostic Interview for ADHD in Adults 2.0. The Health Utilities Index Mark 3 was used to measure health status, and to calculate attribute specific HRQoL and Quality-Adjusted Life Year (QALY) scores.

RESULTS

72% of prisoners sampled reported at least one head injury in their lifetime. Among those, 70% of head injuries occurred before age 16 and 70% experienced LOC. Prisoners with ADHD were nearly twice more likely to have TBI. Prisoners with ADHD-only and ADHD with co-morbid TBI had significantly lower scores in several HRQoL attributes, compared with TBI only or the absence of either condition. Adjusted logistic regression models indicated an average reduction of 0.20 QALYs in inmates with ADHD-only and 0.30 QALY loss in those with ADHD with co-morbid TBI compared with inmates with neither condition.

CONCLUSIONS

There is a robust association between ADHD and TBI, and ADHD with co-morbid TBI confers significantly greater impairment in terms of HRQoL. Managing the short and long-term consequences of TBI is essential to improving care for prisoners and to addressing the criminogenic factors related to them.

'I am not drunk, I have an ABI': findings from a qualitative study into systematic challenges in responding to people with acquired brain injuries in the justice system

The over-representation of acquired brain injury (ABI) amongst prisoner and juvenile justice populations is a significant issue across jurisdictions. This article reports on the findings of over 100 interviews conducted in Victoria, Australia with people who have an ABI, as well as key stakeholder groups who work in, or with, the justice system. The study identified systemic problems faced by people with ABI along multiple points of the justice system continuum. Improved identification and diagnosis of ABI, well-resourced support for those with the condition, comprehensive training to improve ABI literacy among all stakeholder groups, and a more appropriate and therapeutic approach to people with ABI in the justice system are all recommended.

Managing challenging behaviour in preschool children post-traumatic brain injury with online clinician support: protocol for a pilot study

BACKGROUND

Traumatic brain injury (TBI) in children is associated with a range of poor long-term outcomes, including behavioural disturbances. Parents can experience high levels of stress and injury-related burden, and evidence suggests that distressed parents are less likely to adopt positive parenting styles to manage their child's behaviour. The 'Signposts for Building Better Behaviour' program is a parenting programme that was originally developed to assist parents of children with an intellectual disability in managing their child's behaviour. More recently, it has been adapted to include a TBI module, to assist parents in managing post-TBI behaviour. However, geographical and financial barriers remain, preventing many parents from accessing the programme in the standard face-to-face modality. This project aims to investigate the feasibility and acceptability of the programme when delivered with clinician support via videoconferencing.

METHODS/DESIGN

The sample for this feasibility study will be recruited from the Royal Children's Hospital, Melbourne, and the Victorian Paediatric Rehabilitation Service. Participants will be the parents of a child who sustained a TBI between the ages of 2.0 and 6.11, within the previous 2 years. The parents of 15 children will complete the programme, with clinician support via videoconferencing, while the parents of a further 15 children will form a treatment as usual wait-list control group. Parents complete questionnaires assessing their child's behaviour, as well as assessing their own mental health, sense of parenting competency, disciplinary style, and family functioning. These will be completed upon enrolment in the study regarding their child's pre-injury behaviour and then again pre-intervention, immediately post-intervention, and 4 months post-intervention. Parents who complete the intervention will also complete questionnaires assessing their satisfaction with the programme and its delivery. Information will be collected on the feasibility, clinical practicality, and acceptability of the programme when delivered through this medium.

DISCUSSION

This study is the first to investigate the feasibility of delivering post-child TBI behavioural intervention via videoconferencing in Australia. Preliminary findings from this study may support the development of a larger randomised controlled trial. It is hoped that programme delivery through this medium would facilitate better access to the programme, enabling improved long-term outcomes for families.

TRIAL REGISTRATION

ANZCTR, ACTRN12616001574437.

Misconceptions about traumatic brain injury among probation services

PURPOSE

The prevalence of traumatic brain injury (TBI) among offender populations is significantly higher than among the general population. Despite this, no study has yet assessed the knowledge of members of the probation service surrounding TBI.

METHOD

Knowledge was assessed among members of the Probation Board for Northern Ireland (PBNI) using a cross-sectional online version of the Common Misconceptions about TBI (CM-TBI) questionnaire. Mean total misconception scores, along with scores on four subdomains (recovery, sequelae, insight, and hidden injury) were calculated. Analysis of variance was used to explore differences in misconceptions based on the collected demographic information.

RESULTS

The overall mean percentage of misconceptions for the group was 22.37%. The subdomain with the highest rate of misconceptions (38.21%) was insight into injury which covered misconceptions around offenders' self-awareness of injuries. Those who knew someone with a brain injury scored significantly higher in the CM-TBI total score, F(1,63) = 6.639, p = 0.012, the recovery subdomain, F(1,63) = 10.080, p = 0.002, and the insight subdomain, F(1,63) = 5.834, p = 0.019. Additionally, significant training deficits around TBI were observed among the probation service.

CONCLUSIONS

This study is the first of its kind to examine the level of understanding around TBI within probation services. The findings reflect potential barriers to identification and rehabilitation of TBI for offenders coming into contact with the criminal justice system. A lack of identification coupled with misconceptions about TBI could lead to inaccurate court reporting with a subsequent impact on sentencing. Implications for Rehabilitation Despite being one of the first points of contact for offenders entering the criminal justice system, members of the probation service reported having no formal training on traumatic brain injury (TBI). The subdomain with the highest rate of misconceptions (insight into injury) revealed an over-reliance on survivors of brain injury to identify, understand, and communicate the extent and severity of their injuries. Probation service personnel require training on TBI to improve awareness of the potential outcomes of the condition, ensuring injuries are identified and referred to the appropriate care pathways.

Substance use, criminal behaviour and psychiatric symptoms following childhood traumatic brain injury: findings from the ALSPAC cohort

Recent research suggests a link between traumatic brain injury (TBI) in youth and later risk behaviour. We explored the association between mild TBI and psychiatric symptoms, substance use and criminal behaviour using data from a longitudinal birth cohort. Participants with mild TBI (n = 800), orthopaedic injuries (n = 2305) and no injuries (n = 8307) were identified from self and parent reports up to age 16 years. Self-report measures of substance use (alcohol, tobacco and cannabis) and criminal behaviours, and parent-reported psychiatric symptoms were collected at age 17 years. Analyses were adjusted for pre-birth and early childhood confounders. Participants with a TBI showed increased odds of hazardous alcohol use compared to those with no injury and those with an orthopaedic injury. Relative to those with no injury, participants with a TBI showed increased odds of problematic use of tobacco and cannabis, being in trouble with the police and having more parent-reported conduct problems. Sustaining either a TBI or an orthopaedic injury increased the odds of offending behaviour compared to having no injuries. There was no clear evidence of association between orthopaedic injury and the other risk outcomes. The increased odds of risk behaviour associated with TBI relative to no injury replicated previous research. However, the inclusion of a non-brain-related injury group adds evidence for a possible causal pathway between mild TBI in youth and later hazardous alcohol use only. This highlights the importance of including an additional negative control injury group in mild TBI research.