Traumatic Brain Injury & Crime:

Huw Williams

Avril Mewse, Cris Burgess, Alex Haslam, Emma Hodges, James Tonks, Rebecca Davies, Luke Mounce, Nathan Hughes, Karen McAuliffe, Jac Dendle, Miriam Cohen, Seena Fazel, Prathiba

Chitsabesan….

**School of Psychology, University of Exeter & *Emergency School of Psychology, University of Exeter & *Emergency Dept Royal Devon & Exeter Hospital, UKDept Royal Devon & Exeter Hospital, UK

w.h.williams@exeter.ac.uk

NHS

Centre for Clinical Neuropsychological Research (CCNR)

UK Brain Injury Forum

The cost of re-offending - UK• In UK - Crime is down BUT re-offending

rates are high– 1 year post release “45%”*– 2 years post release “75%”*

• “Reoffending costs the UK somewhere between nine and 13 billion pounds a year. The taxpayer has so far got a poor return for the money invested in rehabilitation, which is why we need a new way of approaching the problem” (Secretary of State for Justice: Chris Grayling MP)

* Ministry of Justice 8/12 Analytical Services Prisoners Criminal Backgrounds and Re-offending report

Adolescence & Crime Farrington (1996)

““I would that there were I would that there were no age no age between ten and twenty three... for there between ten and twenty three... for there is nothing in between but getting is nothing in between but getting wenches with child, wronging the wenches with child, wronging the ancientry, stealing, fightingancientry, stealing, fighting...” ...” Shakespeare, The Winter’s Tale, Act III Shakespeare, The Winter’s Tale, Act III

Teenage brain – modules in a muddle

• “Such ‘peaks’ are – like iceberg tips - only a small indication of the complexity of the underlying changes happening in brain systems and their related cognitive and emotional functions.” Williams 2012

“The teenage brain- adult-like ability to reason, but with a heightened need for basic reward [MESOLIMBIC],and a lowered capacity [FRONTAL] to buffer immediate influences..POOR ON CONSIDERING CONSEQUENCES OF BEHAVIOUR (DLPFC)- risky decision-making ‘starting the engines without a skilled driver behind the wheel’.

Savage, 2009Fig. 6. gray matter maturation over the cortical surface. http://www.loni.ucla.edu/~thompson/DEVEL/dynamic.html

Emotion reading , Theory of Mind & empathy - develop across childhood into late adolescence

From birth:Intrinsic bipolar emotional related to arousal - distress and pleasure (Schaffer, 2003).

We were both, in our own way, manipulators — good at grasping

the feelings of others and instinctively playing on them. 

Tony Blair, as reported in the Guardian, 1/9/10

Six? Months:Primary emotions - surprise, interest, anger, sadness and fear

1 year (Girls): ‘empathising’ 3 years: Theory of Mind

7-9 Years: Complex theory of mind (e.g. Detecting faux pas) (see Baron-Cohen et al, 1999).

Continues to develop in late adolescence (14-17 yrs (ToM) (Dumontheil et al in press)

Development is non-linear - rapid development associated with growth of the prefrontal cortex, (see Tonks et al. 2009)

Offenders – and “Thinking” problemsOffenders cope poorly with life because they exhibit various ‘cognitive deficits’ (Ross and Fabiano, 1985, cited in Home Office, 2002).

• lack of impulse control• poor problem solving• rigid and inflexible thinking• inability to see other people’s views

__________________________________________________________________Offender Management Community Cohort Study (OMCCS): Assessment and sentence planning (Cattell et al, 2013)

• Longitudinal survey of 2,919 representative sample of offenders young adultviolence, theft, burglary… on community orders

• Over four-fifths of offenders in the cohort had problems with recognising the consequences of their actions.

Offenders:Problems of Theory of Mind & Empathy

Offender Groups:- Young offenders have been found to have less empathic responses compared Young offenders have been found to have less empathic responses compared to no-offending groups to no-offending groups (Robinson, 07).(Robinson, 07).

- Persistent offenders are described as impulsive and lacking affective empathy - Persistent offenders are described as impulsive and lacking affective empathy (see Williams et al 2010)(see Williams et al 2010)

- Harsh or inconsistent parenting , abuse “empathy poor” environments - Harsh or inconsistent parenting , abuse “empathy poor” environments (Patterson, 82,95) (Patterson, 82,95)- Angry, coercive responding role models for emotional regulation rather than - Angry, coercive responding role models for emotional regulation rather than pro-social empathic models pro-social empathic models (see Robinson 2007).(see Robinson 2007).

Psychosocial risks for poor empathic responding:sychosocial risks for poor empathic responding:

Such anti-social behaviours = rejection by peers and gravitation Such anti-social behaviours = rejection by peers and gravitation towards those with similar behaviours...towards those with similar behaviours...

Additional Additional neurological injury may contribute to poorer neurological injury may contribute to poorer functioning (*??).functioning (*??).

Rates of moderate to severe head injury:

0

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05-0

9

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30-3

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45-4

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85+

Age Group

Rat

e p

er 1

00,0

00 p

op

n

MIXED RURAL - Female URBAN - Female MIXED RURAL - Male URBAN - Male

Yates, Williams et al: Attendance rates for moderate to severe head injury per 100 000

population NOTE: AGE, GENDER, URBAN LOCATION and SOCIAL DEPRIVATION as KEY RISK FACTORS

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

Traumatic Brain Injury – Neurocognitive Impairment & Self-Regulation

Moderate to Severe TBI: Adults and Children:

- Poor planning and inflexibility (Milders, Fuchs & Crawford, 2003)

-Problems: Attention, working memory, executive control, Dis-inhibition etc. (Anderson et al 2006))

Mild - TBI – Neurocognitive Impairment & Self-Regulation

Mild TBI: Children & Adolescents

- “complicated”, or cumulative, and YOUNGER, can be neuropsychological sequelae (15%?), esp. attention and executive systems. (Williams, Potter & Ryland, 2010; Wall, Williams et al, 2006; Williams et al, in press).

- Repeated MTBI: Difficulties considering alternative behaviours or controlling impulses esp. in conflict situation. (Pontifex 2009)

Prospective study of 94 children with TBI aged 9 at time of injury showed Organic Personality Change (OPC) in 57% of severe & 5% mTBI (3/57) labile and aggressive OPC subtypes most common - 3-4 x more. (Max et al, 2001)

Neuro-metabolic cascadeDiffuse microstructural white matter changes ; Giza et al. 2001

TBI & Socio-affective processing:

Theory of Mind (ToM): Theory of Mind (ToM): To attribute mental states to othersTo attribute mental states to others

(S(See Shamay-Tsoory, 2009 - VPCee Shamay-Tsoory, 2009 - VPC))

Empathy:Empathy:To understand another's state of mind or To understand another's state of mind or emotion & “co-experience” their outlook or emotion & “co-experience” their outlook or emotions emotions within oneselfwithin oneself “ “

A pre-requisite would be to be A pre-requisite would be to be able to process another’s basic able to process another’s basic

emotionemotion

ABI groups:ABI groups:- TBI may have an impact on skills for emotional understanding of - TBI may have an impact on skills for emotional understanding of others others (ToM and Empathy) see Tonks & Williams, 2008/09/10 (ToM and Empathy) see Tonks & Williams, 2008/09/10

How ABI children perform compared to non-injured children?

Group

HealthyABI

Mea

n m

ind

in th

e ey

es te

st

70

60

50

PIAGROUP

12 Plus11 to 12up to 11

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80

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Group

ABI

Healthy

- - misperceive elements of a situationmisperceive elements of a situation (not reading emotion of others & (not reading emotion of others & perceive threat when there was none). perceive threat when there was none).

- - Make poor social judgementsMake poor social judgements (and behave inappropriately). (and behave inappropriately).

- L- Lack communication skills to negotiate out of conflictack communication skills to negotiate out of conflict

Childhood TBI and risk of crime:

Timonen et al (2002)Timonen et al (2002)- Population based cohort study in Finland.- Population based cohort study in Finland. >12,000 subject >12,000 subject Results:Results: Childhood/adolescent TBI associated with: Childhood/adolescent TBI associated with: Fourfold increased risk of developing later mental disorder with Fourfold increased risk of developing later mental disorder with coexisting offending in adult (aged 31) male cohort members coexisting offending in adult (aged 31) male cohort members (OR 4.1). (OR 4.1).

TBI result of (?): TBI result of (?): High novelty seekingHigh novelty seeking and and low harm avoidancelow harm avoidancein people susceptible to risky behaviours – coincidental to crimein people susceptible to risky behaviours – coincidental to crime

BUT…BUT…

TBI earlier than age 12 were found to have committed crimes TBI earlier than age 12 were found to have committed crimes significantly earlier than those who had a head injury later significantly earlier than those who had a head injury later

Therefore - temporal congruency Therefore - temporal congruency suggests a causal linksuggests a causal link

Risk of Crime after TBI:Fazel S, Lichtenstein P, Grann M, Langstrom N (2011) Risk of

violent crime in individuals with epilepsy and traumatic brain injury: A 35-Year Swedish Population Study. PLoS Med

8: e1001150

• Swedish population registers from 1973 to 2009, and examined associations of epilepsy (n = 22,947) and traumatic brain injury (n = 22,914) with subsequent violent crime (convictions for homicide, assault, robbery, arson, any sexual offense, or illegal threats or intimidation)”

• traumatic brain injury cases, 2,011 individuals (8.8%) committed violent crime after diagnosis, compared with population controls (n = 229,118 (5,504 controls - 2.5%)), corresponded to a substantially increased risk (adjusted odds ratio [aOR] = 3.3, 95% CI: 3.1–3.5);

• risk was attenuated when cases were compared with unaffected siblings (aOR = 2.0, 1.8–2.3)– “Among the major strengths of the study are..very large sample size…entire population of Sweden, and the

follow-up of 35 years…findings are of major public health importance and provide inspiration for further research” J Volavka (Commentary)

“Are children who experience TBI more likely to engage in criminal behaviour?”

McKinlay. A; et al (2010). Brain impairment

““clear evidence of ongoing problems for [those who] clear evidence of ongoing problems for [those who] had ...a TBI compared to their non injured counterparts”.had ...a TBI compared to their non injured counterparts”.

- Longitudinal epidemiological study of birth cohort of 1265 children born in - Longitudinal epidemiological study of birth cohort of 1265 children born in Christchurch (New Zealand) urban region in mid-1977. Christchurch (New Zealand) urban region in mid-1977.

- - Groups:Groups: 1) MTBI “hospitalised” 1) MTBI “hospitalised” 2) MTBI “Not hospitalised” 2) MTBI “Not hospitalised” 3) “No- Injury” 3) “No- Injury”

- - Outcomes:Outcomes: Ages 21-15: self-reported arrests, violent offences and property Ages 21-15: self-reported arrests, violent offences and property offences offences- Adjustment for gender, SES...(BUT ?? Family issues)- Adjustment for gender, SES...(BUT ?? Family issues)- Adjusted rates - compared to non-injured individuals,- Adjusted rates - compared to non-injured individuals, both TBI groups were both TBI groups were more likely to be arrested (relative risk (RR)=2.03 and RR=1.68), involved in 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 offencesproperty offences (RR=2.08 and RR=1.54) and violent offences (RR=1.35 and (RR=1.35 and RR=2.29) (all p<0.01). RR=2.29) (all p<0.01).

Not having a “Knock out” history being protective for life course

persistent offending• Raine (2005)

– Community sample of 325 boys• 7-17 yrs• Life-course (LC) and Adolesence Limited (AL) groups BOTH had

neurocognitive deficits (verbal, non-verbal etc.)• Attributable to range of factors (genes, family etc.) • And SIMILAR profiles • BUT

– AL had significantly less “knock out” head injuries• Therefore, ? “this [no LoC] may explain why…they

avoid a negative antisocial outcome in later life” Raine p.46 2005

Rates of Mild-Severe TBI in Adult Prisoners Williams et al (2010). Brain injury

453 males held in 453 males held in HMP Exeter HMP Exeter

Participants:Participants:196 aged between 196 aged between 18 and 54 years 18 and 54 years (43% response rate)(43% response rate)

sentenced or sentenced or remandedremanded

Other

Murder/manslaughter

Robbery

Sexual offences

Drugs offences

Fraud/deception

Driving offences

Violent offences

Shoplif ting/theft

Burglary

Missing

% of Population Reporting TBI & Type and Time of Injury

Any tbi?

YesNoMissing

Co

un

t

140

120

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80

60

40

20

0

Williams et al (2010) Brain Injury.

“Any TBI?”No 39.6 %Yes 60.4%

We estimate that:65% may have had TBI…10% Severe5.6% Moderate49.4% Mild

Average age of first imprisonment:16 Years – TBI

21 Years – non-TBI

Number of severe tbi

Number of moderate t

Number of mild tbi

Young Offenders & TBIWilliams, Cordan et al (2010, Neuropsychological Rehabilitation): http://www.informaworld.com/

The mean number of convictions 6.95 (SD 4.56).The mean number of convictions 6.95 (SD 4.56). Offences of violence accounted: 27.1%Offences of violence accounted: 27.1% shoplifting, theft, and robbery: 25.5%shoplifting, theft, and robbery: 25.5% Burglary: 18.2%Burglary: 18.2% ““joyriding”: 14.7% joyriding”: 14.7% drug offences: 11.6%drug offences: 11.6% Fraud: 2.5%Fraud: 2.5% Offences: 0.4%Offences: 0.4%

192 young male offenders ranging from 11 to 19 years of age 192 young male offenders ranging from 11 to 19 years of age (M = 16.63, SD = 1.07 years) (response rate of 98%).(M = 16.63, SD = 1.07 years) (response rate of 98%).

TBI in Young Offenders in UK

Williams, Cordan et al (2010) Structured interviews, youth offenders (YOI) (n = 192; 16 yrs)• 65% reported history of “head injury”

- Main injury category = VIOLENCE (57.6)

• MTBI with LOC up to 10minutes & moderate-severe TBI = 46% of overall sample

• Repeat injury common• Those with TBI = more convictions• X3+ TBIs = more violence• TBI = more Mental Health problems

Davies, Williams et al (2012)• 60 young offenders(similiar prison population)• 16 yrs age• 70% one head injury • post-concussion

symptoms reliably increasing with the frequency

SOCIO-EMOTIONAL PROCESSING IN YOUNG OFFENDERS WITH TBI

Substantial dosage of TBI (3 or more mildTBI, or 1 mod-severe injury) significantly impaired on the expression recognition task.

Cohen & Williams (in prep) A study of facial expression recognition in community offenders, n=27, (male = 18, female = 9), mean age = 16.3 years.

Role of parenting in TBI & CrimeHodges, Williams, Mounce, Mewse, Hinder (in prep)

and

• 91 incarcerated young men – av age 16• 75% (apx) had TBI • IQ average 85

• Measures:– Parenting experience (Alabama)– Basic empathy scale (BES) (Joliffe)– Aggression – Reactive –Impulsive (Raine)– Convictions…

Parenting and TBI…

--

Negative parenting

Lead Authors:Dr Nathan Hughes (Senior Lecturer in Social Policy, University of Birmingham)

Prof Huw Williams (Director of the Centre for Clinical Neuropsychology Research, University of Exeter)

Dr Prathiba Chitsabesan (Consultant Child and Adolescent Psychiatrist, Pennine Care NHS Foundation Trust, and member of the Offender Health Research Network, University of Manchester)

The Children’s Commissioner has a duty to promote the views and interests of all children in England “I think I must have been born bad” argued for improvements in services designed to meet the mental health needs of young people in the secure estate

Prevalence of neurodevelopmental disorders in young people in custody – systematic review

Hughes, Williams & Chitsabesan (2012)

• “astonishingly, it’s far more likely than not that if you’re a young person in custody you will have experienced a TBI” SoS- Justice Grayling

Neurodisability as ‘risk’• Criminogenic risk factors associated with neurodisability

include: - hyperactivity and impulsivity; - alienation;- cognitive and language impairment; - poor emotional regulation.

• Secondary association with other risk factors such as:-truancy and peer delinquency; - illicit drug use;

• Systemic factors may increase risk further, such as:- detachment from education; - challenges in parenting; - failure of services to recognise and meet specialist needs.

Is TBI causal or coincidental in crime?

• Although there are many confounding factors in relationship between (eg) TBI and offending:TBI = “marker” for contextual factors & a likely catalyst!

ADVERSITY BEING A KEY ISSUE

“one reason why we have been so unsuccessful in preventing adult crime is because interventions to date have systematically ignored the biological side of the biosocial equation that produces crime” p43. Raine 2002

Secretary of State for Justice, Chris Grayling MP in a speech to CIVITAS: “Astonishingly, it’s far more likely than not that if you’re a young person in custody you will have experienced a traumatic brain injury. Somewhere between 65 and 70% [65.1-72.1%]. (June 2013)”*

Structural & Functional Brain Differences Associated with Maltreatment(?):

Smaller hippocampal volume found among adults with early abuse-related PTSD (Bremner 1997, 2003a; Stein 1997).

Children with PTSD - smaller whole brain and corpus callosum volume (Carrion and Steiner 2000; De Bellis 2002)

Research Review: Eamon McCrory et al.(2010) The neurobiology and genetics of maltreatment and adversity. Journal of Child Psychology and Psychiatry. doi:10.1111/j.1469-7610.2010.02271

“reduced corpus callosum and cerebellar volume in individuals who have experienced adversity maltreatment is associated with hypo-activity in several brain regions, including certain regions of the PFC and the limbic and paralimbic systems (McCrory 2010)

used voxel-based morphometry to compare grey matter volume in a group of 18 children (mean age 12.01 years, SD = 1.4), referred to community social services, with documented and well-characterised experiences of maltreatment at home and a group of 20 nonmaltreated children (mean age 12.6 years, SD = 1.3).

Maltreated children [had] reduced grey matter in the medial orbitofrontal cortex and the left middle temporal gyrus.

Areas implicated in reinforcement-based decision-making, emotion regulation and autobiographical memory, processes that are impaired in a number of psychiatric

disturbance in these regions ..may represent a latent neurobiological risk factor for later psychopathology and heightened risk taking.

• f MRI brain scan study to investigate the impact of physical abuse and domestic violence

• exposure to family violence was associated with increased brain activity in anterior insula and the amygdala when children viewed pictures of angry faces.

• ? associated with threat detection. • ?maltreated children and soldiers may

have adapted to be ‘hyper-aware’ of danger in their environment.

• may help explain why children exposed to family violence are at greater risk of developing anxiety problems later in life.

? Early adversity - “adaptive” response of hyper-vigilance for threat in “unpredictable” home environmentsBUT may be maladaptive in life & = psychiatric vulnerability + risky

+ limit social and emotional regulation skills

Neuroplasticity: A window of OPPORTUNITYNeuroplasticity = change in neural structure and function in response to experience or environmental stimuli (Rapport & Gogtay, ’08)

- Differential potential across cognitive systems – verbal v. visio-spatial (Neville & Bavelier, 2002)

- sensitive periods (“windows”) in which complex experiencial input seem

required for change (“re-assignment”) (Knudsen, 2004; see Johnson, 2009*) REHABILITATION encourages connectivity- Sprouting – aborisation (Brs-Ramer et al. 2007); increased neurotrophic agents (Bachelor et al, 2000); re-modelling of synaptic morphology & chemistry. (n.b. Animal studies)- Positive parenting encourages brain organisation (Frye et al.2010).

BRAIN: REVIEW ARTICLE: Harnessing neuroplasticity for clinical applications, Steven C. Cramer,

TBI in Prisoners: Childhood injury and rehabilitation

Retrospective factor analysis of links between head injuries (in children and adolescents) in adult and non-violent prisoners.Leon-Carrion J, Ramos FJ (2003) (BI)

- Subjects in both groups had history of academic difficulties.- Trend for both = to have had behavioural and academic problems.- Head injury in addition, increases chances of having 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.

BRAIN BASED INTERVENTIONS WORK!

Policy and practice implications• PREVENTATIVE ACTION:

– Improved management of TBI in childhood via ED and GPS and schools• Neuro-rehabilitation for childhood TBI may assist in crime prevention

– Identification of TBI in children and young people as it may lead to problems in school and to socialisation which could lead to exclusion and social isolation.

– Awareness and training of staff in TBI (screening) in assessment and management for those involved in education/health/social

– Need to track for emerging problems in behaviour and educational engagement over time. • This is critical for when the child may be facing both a transition from structured

schooling (primary) to less structured environments (secondary). Especially as there may be an issue relating to deficits becoming more apparent over time.

See * NHS ENGLAND STRATEGY FOR ACUTE BRAIN INJURYNb: CHILD & FAMILY BILL and response from BPS VIA CJAABIG & Lord Ramsbotham

– RE SCREENING, STATEMENTING AND PROVISION FOR CHILDREN IN SCHOOLS

Justice system• Improve detection and management of TBI in justice system

– e.g. at court proceedings, sentencing and in forensic rehabilitation• Vital that probation staff record and reflect issues in court reports• That magistrates & judges can take account of TBI in sentences etc.

– At 1st and/or soon after 1st contact Importance of screening for TBI in offenders (use of CHAT. S 5)

• Prison staff liaise with health re: best management• Consider risk factors for violence in TBI persons, especially modifiable ones

(e.g. alcohol or illegal drugs)• Use of Linkworkers to enable re-settlement (eg The Disabilities Trust)• See: Healthcare Standards for Children and Young

People in Secure Settings (June 2013) Royal College of Paediatrics & Child Health re: Neurodisability

Comprehensive Health Assessment Tool (P. Chitsabesan et al – Offender Health Research Network)

Investing in development:

Children MOST most likely to be injured ARE least likely to get support.

“... To borrow an analogy from economics, by investing early and well in our children’s development, we increase the rate of return later in life and in so doing improve not only the lives of individuals but of societies as well.” Fox, 2010, p36

“Brains become minds when they learn to dance with other brains” W.J. Freeman