Huw Williams Giray Cordan, Avril Mewse, Sarah Mills, Cris Burgess, James Tonks, Alex Haslam *School of Psychology Univer

1. Traumatic Brain Injury & Offending: A modifiable factor for reducing crime? Huw Williams Giray Cordan, Avril Mewse, Sarah Mills, Cris Burgess, James Tonks, Alex Haslam *School of Psychology University of Exeter & *Emergency Department Royal Devon & Exeter Hospital w.h.williams@exeter.ac.uk UK Brain Injury Forum / Big Lottery Centre for Clinical Neuropsychological Research (CCNR) NHS Building the bridge between academic and clinical neuropsychology

2. Need for new policies to influence practice re: TBI in prison populations • mental health & drug/alcohol problems identified • “relative to general population, [prisoners]…experience poorer physical, mental, and social health…[more] mental illness and disability, drug, alcohol…suicide, self harm…lower life expectance [etc.]…” Orme et al. BMJ editorial, 2005, 330. p 918 • and see Fazel & Danesh (2002a (Lancet)) • “….delivery of services to prisoners with anxiety and affective disorders, drugs and alcohol problems, brain injury, learning disability, challenging behaviour and repetitive self-harm has changed little or worsened.” Dearbhla Duffy, et al. (2003) p. 242 (our emphasis) • TBI is largely neglected from policy documents (Youth Crime Action Plan, 2008 and Bradley report 2009)

3. Brain development in children and adolescents: Insights from anatomical magnetic resonance imaging Rhoshel K. Lenroota and Jay N. Giedd (2006) • dorsolateral prefrontal cortex • late to reach adult levels of cortical thickness • circuitry sub-serving control of impulses, judgment, and decision-making. • implications of late maturation of this area have entered educational, social, political, and judicial discourse http://www.loni.ucla.edu/~thompson/DEVEL/dynamic.html Savage, 2009

4. Yates, Williams et al. 2006, JNNP: Attendance rates for moderate to severe head injury per 100 000 population for each 5 year age band by sex and area residence (GCS under 12). Nb. Rates of TBI (across all severities) in males across severities are given as between 5% to 24% 250-450 per 100,000 across all severities (US/UK) - 80% approx are MILD

5. Traumatic Brain Injury (TBI)(from: www.netmedicine.com/xray/ctscan/img_ct) • Traumatic brain injuries: Penetrating injury • Closed Injury

6. Brain Areas that typically Injured… • frontal-tempo-limbic systems are crucial for Monitoring arousal level & control of behaviour towards “goal states” • Moderate to Severe TBI • Neuropsychological deficits, behavioural problems and poor social outcomes (Stambrook, Moore , Peters ‌, Deviaene ‌, & Hawryluk, 1990). • poor planning and inflexibility (Milders, Fuchs & Crawford, 2003) “poor anger management (irritability and impulse control are common” (Hawley et al. 2003) • Nb. Limbic systems more vulnerable in children • Mild TBI • When “complicated”, or cumulative, there can be neuropsychological sequelae (15%?), esp. attention and executive systems (Williams, Potter & Ryland, 2010).

7. Childhood Brain Injury: long term effects Problems: Attention, working memory, executive control disinhibition etc. lack of “moral” reasoning. (Damasio 1996; Anderson, Bechara, Damasio, Tranel, & Damasio, 1999; Hanks, Temkin, Machamer & Dikmen 1999; Levin & Hanten, Powell, 2004). Often there is inappropriate social behaviour the most common and disruptive issue (Henry, Phillips, Crawford, Theodorou & Summers, 2006). may not be evident until adolescence (Lishman, 1998; Teichner & Golden, 2000) point at which ‘delayed costs’ of earlier ABI are expressed (see Anderson 2008 re: neuroplasticity & crowding effects) may occur in isolation from cognitive deficits (Anderson, Northam, Hendy & Wrennall, 2001 persisting personality and emotional deficits – due to de-coupling of cognition and emotion - has been described by Damasio (1994), as “acquired sociopathy”” – Max et al, 2001: prospective study of 94 children with TBI aged 9 at time of injury OPC in 57% of severe TBI sample (22/37) & 5% mTBI (3/57) labile and aggressive OPC subtypes most common - 3-4 x more

8. Problems MIGHT also occur post MTBI Wrightson, McGinn and Gronwall (1995) • pre-school children - MTBI tested after injury and then at 6 months and a year (V. orthopdeic control group). • no differences after injury on a range of cognitive tasks. • But, at 6 months and then at 1 year, the MTBI children less good on visual problem solving and association with further injury. Limond et al. 2009 follow up of moderate-severe and (mostly) complicated MTBI showed persisting disabilities at 1 year – >lack of pro-social behaviour and emotional symptoms

9. Prevalence studies of TBI in adult offender groups • Self-report prevalence studies of TBI - with 25% to 87% of inmates reportedly experiencing a head injury (Schofield et al., 2006; Slaughter, Fann and Ehde, 2003; Morrell et al., 1998). • Slaughter et al (2003) - TBI in inmates in a county jail in the USA. • 87% lifetime prevalence and 36% in the previous year. • TBI in the previous year had worse anger and higher psychiatric disturbance. • Barnfield and Leathem (1998) New Zealand, had 118 respondents • 86.4% reported some form of “head injury” with 56.7% reporting more than one blow to the head. • concomitant reports of difficulties with memory and socialization. • Analysis of medical records. • De Souza (2003) Brazil - • Of 3233 offenders there were 133 cases of TBI reported (39 “mild” and 94 “moderate or severe”). • In the majority (111 cases) there was no account taken of the injury by service providers.

10. Prevalence studies of TBI in young offender groups • Huxx, Bong, Skinner, Belau, & Sanger (1998) • TBI in offending and non-offending youths (50% versus 40%) • greater biomechanical forces - such as fights and road accidents versus sports injury • higher levels of immediate symptoms, such as headaches, dizziness and losses of consciousness. • Perron and Howard (2008) • period prevalence and correlates of TBI – with a LOC of 20 minutes or more - in 720 youth offenders. • 18.3% reported such a head injury. • Male gender, co-morbid psychiatric diagnosis, earlier onset of criminal behaviour and substance use were associated with TBI.

11. TBI a risk factor for crime??... • Timonen et al (2002) • population based cohort study in Finland involving more than 12,000 subjects • TBI during childhood or adolescence associated with • fourfold increased risk of developing later mental disorder with coexisting offending in adult (aged 31) male cohort members (OR 4.1) • TBI might have been a result of high novelty seeking and low harm avoidance in people susceptible (for issues of genetics, family background, social forces etc.) to risky behaviours – coincidental to crime….BUT • TBI earlier than age 12 were found to have committed crimes significantly earlier than those who had a head injury later • Therefore - temporal congruency suggests a causal link • Fazel, Philipson, Gardiner, et al. 2009 • meta-analysis of studies relating to violence and neurological conditions indicated that TBI was a moderate risk factor for violence whereas epilepsy was inversely correlated with risk

12. McKinlay A., et al.“Are children who experience Traumatic Brain Injury more likely to engage in criminal behaviour during their adult lives?” 33rd ASSBI(Abstract) Brain Impairment. 2010 • longitudinal epidemiological study of a birth cohort of 1265 children born in Christchurch (New Zealand) urban region in mid-1977. • Groups: MTBI “hospitalised” “Not hospitalised” and “No-Injury” • Outcomes - ages 21-25 - self-reported arrests, violent offences and property offences. • adjustment for gender, SES...(BUT ?? Family issues) • Adjusted rates - compared to non-injured individuals, both TBI groups were more likely to be arrested (relative risk (RR)=2.03 and RR=1.68), involved in property offences (RR=2.08 and RR=1.54) and violent offences (RR=1.35 and RR=2.29) (all p<0.01). • “clear evidence of ongoing problems for individuals who had experienced a TBI compared to their non injured counterparts”.

13. Associations between TBI & Crime • Blake, Pincus and Buckner (1995) • assessed thirty-one individuals awaiting trial or sentencing for murder, and found evidence of ``frontal'' dysfunction in 20 (64.5%). • Vietnam Head Injury Study (VHIS) (Grafman et al 1996) • rate of 14% for fighting and property damage in head injured veterans compared to 4% in non-head injured controls.

14. TBI & Crime: Coincidence or causal? • Turkstra et al. (2003) • offenders with TBI against “true peers” without TBI • 20 individuals convicted of violent crime compared to 20 non convicted controls (matched for education, age and employment). • TBI NOT more common in the offender group BUT there was variance on severity of injury • non-offending group– typically – Milder TBI from (eg sports). • offending group injuries • More assaults (with probable longer lasting changes in behaviour). • had more issue related to anger control. • TBI is not necessary for crime, but that TBI may contribute to “expression of violence” - increase the risk “threshold” in vulnerable people.

15. Rates of Mild – Severe TBI in Prisoners Williams et al (2010) Brain Injury 453 males held in HMP Exeter Pps: 196 aged between 18 and 54 years (43% response rate) sentenced or remanded

16. Percentage of population reporting TBI & type & TIME of injury (Williams et al (2010)) • we estimate that • 65% may have had a TBI. • 10% Severe • 5.6 % Moderate • 49.4% Mild Average age at 1st imprisonment: 21 Years – Non-TBI 16 years - TBI “Any tbi?” No 39.6 % Yes 60.4%

17. Any TBI? 150 No Yes Bars show counts 100 Count 50 0 No Yes Is this the first time in prison? Re-offending The number of participants that were re-offenders differed significantly according to whether they had reported “head injuries” [Chi squ (1, N=195)=11.98, p = .001].

18. Young Offenders & brain injury 192 young male offenders ranging from 11 to 19 years of age (M = 16.63, SD = 1.07 years) (response rate of 98%). The mean number of convictions 6.95 (SD 4.56). Offences of violence accounted: 27.1% shoplifting, theft, and robbery: 25.5% Burglary: 18.2% “joyriding”: 14.7% drug offences: 11.6% Fraud: 2.5% Offences: 0.4% Williams, Cordan et al (in press, Neuropsychological Rehabilitation):

19. Young offender population and TBI 65% reported a history of “head injury” main category of injury was violence (57.6%) With falls “on drugs” being second most common “criminal cause”. MTBI with a LOC of up to 10 minutes & Moderate - severe TBI made up 46% of the overall sample. Repeated MTBI were also very frequent nearly twice as many multiple MTBI compared to single MTBIs

20. Conviction profiles • Participants w/ TBIs • had an average of 2 more convictions (M = 7.23) compared to non-TBI (sig. after age effects etc.) • Those with x3+ TBI with greater violence

21. Young Offenders, TBI and Drugs Frequency of cannabis use – (once a month –to – everyday)

22. TBI in Prisoners: Childhood injury and rehabilitation • Leon-Carrion J, Ramos FJ. (2003) (BI) • Retrospective factor analytic study of links between head injuries (in childhood and adolescence) in adult violent and non-violent prisoners. • subjects in both groups had a history of academic difficulties. • Trend for both groups to have had behavioural and academic problems at school • Head injury in addition to prior learning disability/school problems increases chances of having a violent offending profile • Violent offending (noted) to be “associated with non-treated brain injury” • ? rehabilitation of head injury may be a measure of crime prevention

23. TBI and Crime – causal or co-incidental? • The evidence is not clear cut • there are many confounding factors within the relationships between injury and later offending • the link between crime and TBI may be an epiphenomenon– whereby TBI is “marker” for of various contextual factors associated with crime - indeed • criminal behaviour “particularly violent crime, is likely to result from complex interaction of factors such as genetic pre-disposition, emotional stress, poverty, substance abuse and child abuse” • Turkstra, 2004 (P 40).

24. Screening & enhancing rehabilitation • better screening for head injury at pre-sentencing and on admission to prison/custodial services – • for better understanding of risk, and for rehabilitative purposes • Esp. those with executive & socio-affective difficulties who may have difficulty in changing behaviour patterns in response to contingencies • “The person at risk of violence needs to recognise his risk and take preventative steps…but [those with]…damage to…prefrontal cortex…may not be able to reflect on their behaviour and take responsibility…[as their] internal soul-searching [is] damaged…” Raine (2002) • rehabilitation interventions in custodial systems – Targeted at impulse control/socio-emotional processing (esp. ToM/Empathy etc.)

25. Service development and community involvement • Services – as NHS provision is moving “into” prison groups: • Would also be helpful to have TBI reported as a chronic condition for which offenders within and outside custodial systems would have support for managing consequences of injury • e.g. in line with Bradley report - via Primary care – Poly-clinics – linked to specialist support in Neuro-rehabilitation centres • Community level • Policing of “at risk” groups in community (Youth Crime Action Plan, 2008) • Eg role of Police Community Support Officers & inter-agency working • Esp. with early & intensive family interventions • Alternatives to custody – eg. restorative justice re: improving empathy

26. What can be done: Younger groups children are most likely to be injured & least likely to get support EVEN if TBI is a marker, it may be an important one to pick up! Systematic neuro-rehabilitation MAY BE A MEASURE OF CRIME PREVENTION IN IN ITSELF… “sleeper effects” (“crowding” as part of neurplasticity)– esp. relevant to socio-emotional functions at transition to adolescence – important to monitor The delivery of services to such groups would therefore require close cooperation between health, social and educational systems. Particularly focus on parenting of at risk children - http://www.scmh.org.uk/pdfs/chance_of_a_lifetime.pdf http://www.incredibleyearswales.co.uk/ & see Gardner, Hutchings, Bywater & Whitaker, 2010 J. Clin Child & Adol Psych. – use of <: in multi agency work

27. Conclusions • Deputy Prime Minister Nick Clegg recently noted that the nation was "criminalising far too many young children". http://news.bbc.co.uk/1/hi/uk/8565619.stm • Public safety and long term economic advantage could be gained by better, earlier, targeted interventions to: • prevent injury • reduce impact of injury • enhance outcomes • May be complicated to deliver – BUT: “pessimist sees the difficulty in every opportunity; an optimist sees the opportunity in every difficulty” W. Churchill

28. The brain NEEDS to be socialised... • Children’s brain need to be IN Society to be SOCIALISED… (as Vygotsky may have said) • “We have to understand the brain as part of a socio-cultural environment. Our brain is shaped by … interaction with other brains. The brain is essentially a social organ that we can not understand isolated from its environment.” • Wolf Singer (in Die Zeit, May 2008) • "Brains become minds when they learn to dance with other brains" W.J. Freeman

29. Turkstra, L., Williams, W.H, Tonks, J and Frampton, I. (in press): Measuring Social Cognition in Adolescents: Implications for Students with TBI Returning to School. NeuroRehabilitation. • Wall, S., Williams, W.H., Morris, R. and Bramham, J. (in press): The Development of a New Measure of Social-Emotional Functioning for Young Adolescents. Clinical Child Psychology and Psychiatry • Tonks. J, Williams H. et al. (2009): The development of emotion and empathy skills after childhood brain injury." Developmental Medicine and Child Neurology. (2.4) • Tonks, J., Williams, W. H., Frampton, I., Yates, P., Slater, A. & Wall, S. (2008) Reading emotions after childhood brain injury: Case series evidence of dissociation between cognitive abilities and emotional expression processing skills. Brain Injury. • Hooper, Williams, et al. (2007). Stress, parental style and coping in parents of children with encephalitis. Neuropsychological Rehabilitation.(1.0) • Tonks, J., Williams, W.H., Frampton, I.J. and Slater, A. (2007): Assessing emotion recognition in 9- to 15-year olds: preliminary analysis of abilities in reading emotion from faces, voices and eyes. Brain Injury (1.2) • Yates, P.J, Williams, W.H., Round, A., Jenkins, R. & Harris, A (2006) An epidemiological study of head injuries in a UK population attending an Emergency Department. Journal of Neurology, Neurosurgery and Psychiatry.(3.6) • Wall, SE, Williams, W.H., Cartwright-Hatton, S., Kelly, T.P., Murray, J., Murray, M., Owen, A. & Turner, M. (2006). Neuropsychological dysfunction following repeat concussions in jockeys. Journal of Neurology, Neurosurgery and Psychiatry. • Williams et al (In press) Traumatic Brain Injury in young offenders: a modifiable risk factor for re-offending, poor mental health and violence. Neuropsychological Rehabilitation • Williams, Mewse…et al. (in press) Traumatic Brain injury in a Prison Population: Prevalence, and Risk for Re-Offending, Brain Injury. • Williams WH,PotterS and Ryland H (2010): Mild Traumatic Brain Injury and Post Concussion Symptoms: a Neuropsychological Perspective. Journal of neurology, Neurosurgery and Psychiatry,0:200817129 doi: 10.1136/jnnp.2008.171298 •  James Tonks*, Phil Yates, W. Huw Williams, Ian Frampton, and Alan Slater (pbl Online First): Peer-relationship difficulties in children with brain injuries: comparisons with children in mental health services and healthy controls. Neuropsychological Rehabilitation. • Williams, WH (2010) Editorial: Advances in measuring outcome for Children and Adolescents with Brain Injury. Brain Impairment.