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Over-Representation of Brain Injury in Adult and Juvenile Criminal Justice Populations

Categories: ACBIS Insider

By Drew Nagele

The prevalence of brain injury (BI) is significantly greater in justice-involved populations, and there is an over-representation of prisoners that have likely experienced a BI during their lifetime.1  The Centers for Disease Control and Prevention is acknowledging that this as an unrecognized problem because the majority of these justice-involved individuals are not diagnosed with brain injury and have not had access to neurorehabilitation, which could have helped them improve their functioning.2 Having a history of BI is statistically significantly associated with increased use of correctional, medical, and psychological services including crisis intervention;3,4 an increased frequency of institutional misconducts;4,5,6 and higher recidivism rates4,7.

Evidence for this disproportionate over-representation of brain injury in the juvenile justice population comes from recent studies in New York and Texas showing as high as 67% of detained youth with history of brain injury,8,9  where the majority of injuries occurred prior to the adolescents’ criminal offenses. Farrer and colleagues (2013) found juvenile offenders to be 3.38 times more likely to have had a TBI than adolescents not involved in the justice system.10 Brain injury among justice-involved youth is associated with prominent, empirically supported risk factors, and is correlated with a subsequent decrease in impulse control among a sample of previously adjudicated males, increasing risk of justice involvement.11 Other studies link TBI in adolescents with substance misuse, violent behavior, and mental health problems, including suicidality12,13 .

Identifying the brain injury, and then helping the ex-offender to get brain injury specialized services and supports, has shown promise as a way to help ex-offenders chart a different course for their life. NeuroResource Facilitation or NRF (also called Resource Facilitation, or RF in other research) has been demonstrated as effective and has been replicated in large scale RCT studies in the BI population conducted by Trexler and colleagues. The initial study14 demonstrated significant effects for the RF group for return to work, and participation in the community and at home. These findings were replicated in the subsequent larger study15 where the RF group demonstrated a seven times higher odds of participating in productive community-based work relative to control participants. This approach has even greater potential when used in a corrections population.

Preliminary work done by Nagele and colleagues in Pennsylvania16, 17 has demonstrated that identifying offenders in both adult and juvenile corrections populations who have BI through screening and neurocognitive assessment, developing specialized treatment groups and individualized approaches that takes into account their cognitive strengths/weaknesses, and providing the specialized care management called NRF can be more effective than traditional approaches and supports. In the initial pilot study16, 158 men from a maximum security prison in Pennsylvania (PA) were screened for BI as they approached release from prison, either through parole or as a result of having served their maximum sentences. Three quarters (75%) of those screened reported a lifetime history of BI before their offense, and 74% of those with a BI demonstrated significant cognitive impairments, which would have likely made their re-entry to the community difficult and increased their risk of recidivism. Ex-offenders were followed into the community after release, getting specialized help through NRF, which included assisting the offenders with applying for and getting into specialized BI rehabilitation services and supports. After receiving NRF, nearly two thirds of the ex-offenders became involved in productive activity, either competitive employment, volunteering, or job training. A much lower rate of reincarceration was observed during the time they were followed, with only 5% incurring new charges, and 12% being re-arrested on parole violations.

In the Pennsylvania juvenile justice pilot17 a similar strategy was used to identify youth with history of brain injury, determine their neurocognitive barriers to successful re-entry, and create release plans including connections to appropriate resources. Four-hundred and eighty-nine youth participated. They were screened for brain injury utilizing the Ohio State University Traumatic Brain Injury Identification Method, and those who screened positive, were assessed utilizing standardized measures of memory and executive functioning. Results indicated that 49% had history of brain injury with an average of 2.59 injuries per youth, 62% of injuries did not involve a loss of consciousness, and two-thirds never sought treatment for their injury. A history of repetitive blows to the head was also common and often caused by violence. Of this group, 147 youth were subsequently evaluated for cognitive impairment, and 57% showed evidence of significant cognitive impairment, with the most common impairments being working memory, behavioral regulation, and delayed recall of novel information. Resources included referrals to brain injury school re-entry programs, vocational rehabilitation, and medical rehabilitation.

These pilot studies showed promise that identifying BI and utilizing NRF can lead ex-offenders to new resources that can help them to more effectively complete school, obtain and keep jobs, and become productive in their lives in the community. In order to change policy to get these brain injury specific practices memorialized in our juvenile and adult corrections systems, it is necessary to develop evidence from randomized control trials (RCT) where brain injury is identified, one group gets the brain injury specific practices, the other group gets standard of care, and their outcomes are compared in terms of getting jobs or other productive activities and examining recidivism. Two such research projects are currently underway.

Funded by the National Institute of Justice, and in partnership with the Icahn School of Medicine at Mount Sinai, the Brain Injury Association of Pennsylvania, and the Pennsylvania Department of Corrections, the first project is implementing a randomized clinical trial to determine if the care management intervention NRF is effective in reducing recidivism by 10% in offenders with acquired BI. Offenders in four Pennsylvania prisons are being screened for BI and those who screen positive are being randomized to receive the intervention or to receive standard of care (SoC). Two thirds of those randomized will receive the intervention and the remaining one third will serve as controls. All participants will be followed for up to three years following their release to examine the immediate and long-term reduction in recidivism. The primary research hypothesis is that individuals with BI and cognitive impairment who are provided NRF prior to and following release will show a significantly lower rate of recidivism in the three years following release compared to individuals with BI and cognitive impairment who are provided Standard of Care following release. Secondary outcomes, such as Productive Activities, Engagement with Services, Community Support, and Parole Obligations, along with demographic and offense characteristics, will also be studied to examine and control their effect on the model. Evaluating the efficacy of the NRF intervention through this rigorous study will help relevant stakeholders gain knowledge regarding the efficacy of innovative reentry interventions such as NRF and contribute to policy and best practices for programming at the institutional and community level and addressing offenders’ criminogenic risks and needs.

The second project underway is funded by the federal Office on Juvenile Justice and Delinquency Prevention (OJJDP). This is a collaborative effort between the Florida Department of Juvenile Justice (FDJJ), University of South Florida (USF) Rehabilitation & Mental Health Counseling Program, Youth Opportunity Foundation (YOF) brain injury expert practitioners and researchers, a direct service provider of juvenile justice residential services, and the Florida Division of Vocational Rehabilitation. This project is screening juvenile offenders for a lifetime history of TBI at four residential treatment program sites. Those screening positive for TBI receive a battery of neurocognitive assessments to establish the presence of moderate to severe cognitive impairment. Youth with brain injury and cognitive impairment returning to project catchment areas throughout Florida will be provided the brain injury-specific care management intervention called Resource Facilitation (RF). See Project Design in Figure 1.

 

A diagram of Juvenile Justice Project Design.

Juvenile Justice Project Design

 

RF begins during residential placement and continues post-reentry in the youth’s home community and provides an opportunity for these identified youth to have their reentry needs identified and acted on proactively so that they become connected to appropriate neurorehabilitation services/supports available in their home communities, including Pre-Employment Transition Services (Pre-ETS). The proposed project will provide an understanding of the prevalence of both lifetime TBI and cognitive impairment among the highest-risk most policy-relevant juvenile offenders: those in residential placement. Additionally, analyses will use propensity score matching to compare post-release recidivism between those youth with TBI and cognitive impairment returning to project catchment areas and those with TBI and cognitive impairment returning to non-catchment Florida areas who were not provided Resource Facilitation. Outcomes will be analyzed in terms of re-arrest, re-adjudication, and re-incarceration, school participation, use of free time, peer associations, family, substance use, mental health, attitudes, aggression, and social skills. The project is expected to contribute to an enhanced understanding of TBI among youth in residential placement and the efficacy of Resource Facilitation, as a recidivism reduction reentry tool. 

The Academy of Certified Brain Injury Specialists strives to improve the quality of care for individuals with brain injury. Are you interested in becoming certified as a brain injury specialist? Learn more.

References

  1. Shiroma, E. J., Ferguson, P. L., & Pickelsimer, E. E. (2012). Prevalence of traumatic brain injury in an offender population: A meta-analysis. The Journal of Head Trauma Rehabilitation, 27(3), E1-E10.
  2. Centers for Disease Control and Prevention (CDC). Traumatic Brain Injury in Prisons and Jails: An Unrecognized Problem. Accessed on-line August 2022 at https://www.cdc.gov/traumaticbraininjury/pdf/prisoner_tbi_prof-a.pdf.
  3. Kaba, F., Diamond, P., Haque, A., MacDonald, R., & Venters, H. (2014). Traumatic brain injury among newly admitted adolescents in the New York City jail system. Journal of Adolescent Health, 54(5), 615-617.
  4. Piccolino, A.L., & Solberg, K.B. (2014). The impact of traumatic brain injury on prison health services and offender management. Journal of Correctional Health Care, 20(3), 203-212.
  5. Merbitz, C., Jain, S., Good, G.L., & Jain, A. (1995). Reported head injury and disciplinary rule infractions in prison. Journal of Offender Rehabilitation, 22(3-4), 11-19.
  6. Shiroma, E.J., Pickelsimer, E.E., Ferguson, P.L., Gebregziabher, M., Lattimore, P.K., Nicholas, J.S., … & Hunt, K.J. (2010). Association of medically attended traumatic brain injury and in-prison behavioral infractions: A statewide longitudinal study. Journal of Correctional Health Care, 16(4), 273-286.
  7. Ray, B., & Richardson, N. J. (2017). Traumatic brain injury and recidivism among returning Criminal Justice and Behavior, 44(3), 472-486.
  8. Kaba, F., Diamond, P., Haque, A., MacDonald, R., Venters, H. (2014). Traumatic brain injury among newly admitted adolescents in the New York City jail system. Journal of Adolescent Health 54(5), 615-617.
  9. Gordon, W. A., Spielman, L. A., Hahn-Ketter, A. E., Sy, K. T. L. (2017). The relationship between traumatic brain injury and criminality in juvenile offenders. Journal of Head Trauma Rehabilitation, 32(6), 393-403.
  10. Farrer, T. J., Frost, R. B., & Hedges, D. W. (2013). Prevalence of traumatic brain injury in juvenile offenders: A meta-analysis. Child Neuropsychology, 19(3), 225-234.
  11. Schwartz, J. A., Connolly, E. J., & Valgardson, B. A. (2018). An evaluation of the directional relationship between head injuries and subsequent changes in impulse control and delinquency in a sample of previously adjudicated males. Journal of Criminal Justice, 56, 70-80.
  12. Buckley, L., & Chapman, R. L. (2017). Associations between self-reported concussion with later violence injury among Australian early adolescents. Journal of Public Health, 39(1), 52-57.
  13. Perron, B. E., & Howard, M. O. (2008). Prevalence and correlates of traumatic brain injury among delinquent youths. Criminal Behaviour and Mental Health, 18(4), 243-255.
  14. Trexler, L.E., Trexler, L.C., Malec, J.F., Klyce, D., & Parrott, D. (2010). Prospectiverandomized controlled trial of resource facilitation on community participation and vocational outcome following brain injury. The Journal of Head Trauma Rehabilitation, 25(6), 440-446.
  15. Trexler, L.E., Parrott, D. R., & Malec, J.F. (2016). Replication of a prospective randomized controlled trial of resource facilitation to improve return to work and school after brain injury. Archives of Physical Medicine and Rehabilitation, 97(2), 204-210.
  16. Nagele, D., Vaccaro, M., Schmidt, M. J., & Keating, D. (2018). Brain injury in an offender population: Implications for reentry and community transition. Journal of Offender Rehabilitation, 57(8), 562-585.
  17. Nagele, D., Vaccaro M, Schmidt, MJ, and Myers, J. Brain injury in justice-involved youth: Findings and implications for juvenile service professionals. Journal of Applied Juvenile Justice Services. 2021, (April) 73-88. DOI: 52935/21.1417512.06