Acquired brain injury (ABI) is often associated with concussions among athletes and exposure to explosives among military personnel, but within the criminal justice system, up to 85 percent of adults and as many as 95 percent of women screen positive for a history of ABI, compared to less than 10 percent of the general population. “ABI” refers to traumatic or nontraumatic brain injury that occurs after birth (see Figure 1).

Judy Dettmer, director of technical assistance and special projects at the National Association of State Head Injury Administrators (NASHIA), explains, “Differentiating a brain injury as traumatic or nontraumatic is somewhat limiting. For example, a woman who experiences intimate partner violence through strangulation may be deprived of oxygen, which is technically a nontraumatic cause of brain injury. At the same time, she may have been punched in the head or slammed against a wall, which is a traumatic cause. Moreover, many people in jail or prison have experienced an overdose from drug use, which led to a lack of oxygen to the brain. Some people might not think of this as a brain injury, but it is a cause of nontraumatic brain injury. Using ‘ABI’ as an umbrella term captures the nuances of all brain injuries.”

Figure 1: Causes of Acquired Brain Injury

Traumatic

  • Car accidents
  • Falls
  • External blows to the head

Nontraumatic

  • Infections
  • Anoxia (absence of oxygen)
  • Stroke
  • Brain cancers

ABIs can be mild, moderate, or severe, but these classifications are assigned at the time of injury based on the duration of the altered mental status and are not related to post-injury functioning. For example, “mild” refers to an altered mind status for up to 30 minutes, with or without loss of consciousness. As Dettmer describes in a webinar on addressing the needs of people with brain injuries in the criminal justice system, even mild ABIs can have long-term effects, particularly when individuals experience multiple brain injuries or have co-occurring substance use disorders and mental health conditions.

The physical, emotional, and cognitive changes associated with ABI have ramifications throughout all phases of involvement with the criminal justice system, such as the following examples:

  • If an individual has an unsteady gait or slurred speech, that may suggest to a responding officer that substance use has occurred.
  • An incarcerated person’s irritability or hypervigilance may prompt disciplinary action to maintain safety in a correctional unit. Their cognitive processing delays may be misinterpreted as an unwillingness to follow directions.
  • Memory issues and executive functioning difficulties may thwart an individual’s ability to carry out probationary requirements, such as going to substance use disorder treatment appointments, and may hinder their ability to secure the resources necessary for successful reentry to the community, such as housing and employment.

Establishing ABI as a contributing factor to a person’s behavior not only provides insight into how to interact with them appropriately but can also facilitate treatment for mental health conditions and substance use disorders by accommodating skill deficits that the brain injury has caused.

Responding to ABI

A review of rehabilitation among individuals with brain injury who intersect with the criminal justice system identifies three strategies as key to addressing the needs of this often overlooked population: screening, education, and direct support.

Screening

The ideal protocol involves screening for both lifetime history of brain injury and current impairment. Dettmer explains, “Often people aren’t aware that multiple mild brain injuries can be part of why they struggle. It’s important to ask screening questions in easily understood language, such as, ‘Have you ever been hit in the head or neck?’ rather than, ‘Did you have a traumatic brain injury?’ Once that is established, looking at current functioning helps target interventions or compensatory strategies to meet their needs.”

The MINDSOURCE Brain Injury Network, housed within the Colorado Department of Human Services, has developed the Colorado Brain Injury Model for screening, supporting, and referring individuals involved with the criminal justice system. The model includes both a modified version of the Ohio State University Traumatic Brain Injury Identification Method and a self-reporting Symptoms Questionnaire. Russha Knauer, MINDSOURCE director, says, “We are committed to identifying individuals who may have experienced ABI and providing the service and support they need; to that end, we make all of our tools available as open-source materials.”

NASHIA’s Online Brain Injury Screening and Support System incorporates both the Brain Injury Identification Model and the Symptoms Questionnaire in an online, self-administered platform that, when completed, automatically generates tip sheets for an individual with a brain injury and guidance for the professional who referred them based on the areas of challenges that the individual indicated.

Education

Promoting awareness of ABI sheds light on the possibility of a physical cause for the manifestation of behavioral health symptoms and cognitive impairments, a recognition beneficial to not only the individual with ABI but also to corrections staff and leadership. Recognizing the need for facility-wide engagement, the University of Washington developed an online course as one of the first activities of its pilot project to integrate research-based evidence about traumatic brain injury (TBI) into practice within the Washington State Department of Corrections. Nearly all of the frontline staff—correctional officers, health services, classification providers, community corrections—completed the training on brain injury, why it matters to their job, and how to approach someone who might have TBI. Advanced training was then provided to all executive staff and facility-level coordinators of the Americans with Disability Act, reinforcing the corrections system’s responsibility to provide accommodations for individuals with disabilities, which may include those with ABI.

Direct Support

Navigating correctional facilities while in custody and reentering the community upon release can be equally challenging, particularly for anyone with processing, memory, attention, inhibition, and organizational problems. Providing direct support facilitates success in both situations. One such source of support is NeuroResource Facilitation (NRF), which identifies resources and provides hands-on ongoing support to individuals throughout their time in custody and up to 6 months after release. In previous research, the NRF intervention resulted in a seven-fold increase in productive work outcomes compared with those who did not receive the intervention. The Brain Injury Association of Pennsylvania (BIAPA) is currently working with the Icahn School of Medicine at Mount Sinai to research the impact of NRF on recidivism and productive activity. MJ Schmidt, BIAPA training and outreach coordinator, points out, “Someone with a brain injury is less likely to make parole and more likely to recidivate. Our NeuroResource facilitators set them up for success, whether that means helping them to get organized about what they want to convey at their parole hearing, make reentry plans with definitive steps, or even problem-solve getting to work when there is no money for the bus.”

Conclusion

Colorado, Washington, and Pennsylvania have all tailored critical strategies for addressing ABI to meet the needs of individuals in custody, maintain the safety of correctional facilities, and support successful reintegration into the community. The states’ collective frontline experience, scientific research, and dedication to translating research to practice has generated workable models for jurisdictions across the country. NASHIA is leading efforts to educate federal partners about the intersection of brain injury and the criminal justice system and provides technical assistance to states to develop screening, support, and referral protocols across the sequential intercepts of the criminal justice system.

Additional Resources

For more information on NASHIA, contact Dettmer (jdettmer@nashia.org).

For more information on the Colorado Brain Injury Model, contact Knauer (russha.knauer@state.co.us).

For more information on the University of Washington’s pilot TBI project, email tbicorr@uw.edu.

For more information on Pennsylvania’s Brain Injury REACH (Re-Entry Assistance from Corrections to Home), contact Schmidt at schmidt@biapa.org.

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