A silent epidemic
Last Friday (13 August 2021), Her Majesty’s Inspectorate of Probation published the latest in its Academic Insights series in which leading academics summarise key criminal justice topics and draw out lessons for practitioners. This edition was written by Hope Kent and Professor Huw Williams and highlights the prevalence of traumatic brain injury among children and adults in contact with the justice system, and its links with offending. The authors start by saying that Traumatic Brain Injury (TBI) is a ‘silent epidemic’ among people in contact with the law. TBI leads to impairments in memory, cognitive ability, social communication, and the regulation of emotion and behaviour. It has been consistently linked with earlier, more frequent, and more violent offending, and is a barrier to engagement with rehabilitation when services are not designed to account for the impact of TBI.
The authors summarise the main impact of traumatic brain injuries which lead to functional difficulties across cognition, memory, social communication, and self-regulation of emotions and behaviours. This frequently leads to problems with increased irritability, frustration, and agitation, and can cause stress and anxiety, and mean that de-escalating potentially confrontational situations can be difficult. Research has found that people with TBI are also often vulnerable to substance misuse, as they have poorer judgement of the consequences of actions, and higher levels of sensation or thrill seeking. There is also evidence that people who misuse substances are also at high risk of TBI due to falls, fights, and antisocial behaviour.
TBI is also linked to behaviours which are related to factors which make people vulnerable to becoming involved in the criminal justice system including problems with social isolation, poor engagement with education or work, and problems with close personal or family relationships can create barriers for successful living (or reintegration) in society.
Prevalence among people in contact with the CJS
The authors report “compelling evidence” that people in custody have far higher levels of TBI than the general population. They cite a UK study of 200 adult male prisoners in which 60% reported that they had experienced a TBI of some kind and around 15% had had a moderate to severe TBI. In a Scottish study published this year, 78% of women in prison had experienced a significant TBI, and 40% of these women had associated disability. Many of these women had experienced multiple TBIs. Domestic violence was the cause of 89% of those injuries.
The authors cite some of the common problems for people with TBI in contact with the CJS:
“Cognitive impairments as a result of TBI can make it particularly hard for someone to navigate the justice system. Understanding legal proceedings, engaging with rehabilitation services, remembering appointments, and understanding rules about orders can be problematic for someone with TBI. Memory problems and social communication problems mean that, when TBI has not been identified, repeatedly forgetting appointments, or appearing to not be listening, or not following rules, can be seen as defiant or obstinate behaviour.”
In terms of improving our work with people with TBI who are in contact with the criminal justice system, the authors advocate screening and identification and provide information about a number of brief screening tools which can be used by police, probation and prison staff. The also advocate the introduction of TBI “linkworker” schemes of which two have been trialled in the UK.
In one of these schemes a specialist linkworker was based in custodial establishments where they screen and identified people with brain injuries before developing tailored support plans to address functional problems. The scheme also promoted interdisciplinary working with, for example, substance use teams, social services, and neurorehabilitation services. Linkworkers also prepared discharge reports and supported community integration and transition after release. Outcomes were reported as being excellent, with very high demand for this specialist service.
The report makes three main recommendations:
- TBI training for staff working in youth justice, probation and prison services.
- Promoting increased awareness and understanding of the effects of TBI.
- The implementation of more linkworker schemes.