Monday October 22 2012
A survey estimated that 60% of adult male prisoners have a history of brain injury
What is the news behind the headlines?
A new report on the impact of acquired brain injuries on young people, and the potential link between such injuries and crime, was featured in the papers today.
An acquired brain injury (ABI), is a form of brain damage that is associated with an external cause, such as a severe head injury, as opposed to congenital factors (such as genetic conditions).
The Daily Mail claimed that young people who sustain brain injuries are more likely to end up in prison.
The report, from the University of Exeter, quotes research which found that 60% of young people in custody report having experienced some kind of traumatic brain injury.
It is thought that brain injuries from accidents such as falls, sporting injuries and car accidents, can lead immature brains to “misfire” and can interrupt the development of young peoples’ ability to restrain their impulses and actions.
These types of injuries are thought to be common in teenagers due to a potentially dangerous ‘cocktail’ of general youthful recklessness, alcohol misuse, and increased risk of being the victim of a physical assault – the classic Friday night city-centre drunken brawl amongst young men (and to a lesser extent, young women).
Brain injuries can also occur due to more wholesome pursuits, for instance, head injuries that occur during sporting activities such as football, rugby, cycling and skateboarding.
If left undetected and untreated, these types of injuries can increase the risk of young people offending.
The report calls for early intervention to identify and manage brain injuries, to ensure young people receive the right support and rehabilitation, and for greater awareness of brain injuries in the criminal justice system.
Who produced the report?
The report is by Hugh Williams, associate professor of clinical neuropsychology at the University of Exeter. It was commissioned by the Barrow Cadbury Trust as part of its work to support the Transition to Adulthood Alliance, a coalition of 12 organisations in the criminal justice, youth and health sectors.
The Alliance, formed in 2008, aims to develop a more effective approach for young people in the transition to adulthood, throughout the criminal justice system.
What is known about teenage brain development?
Many people have the mistaken impression that the human brain becomes fully developed in early childhood, in the same way as the heart or lungs.
In fact, the human brain is subject to a high degree of what neurologists have termed ‘plasticity’.
Plasticity means that the neural pathways that make up our brain, and allow us to think, are constantly evolving throughout childhood.
The report points out that the human brain is not fully developed or adult until the early or even mid-20s.
Aspects such as impulse control and forward planning are the last elements in the brain to develop, which corresponds to reckless and short-sighted behaviours that are common in those difficult teenage years.
The report highlights that the young brain, as a “work in progress”, is more prone to risk taking and more vulnerable to being injured in the first place, and also to suffering problems with attention, concentration, and managing mood and behaviour.
The report says that brain development during childhood and adolescence is complex, involving networks of billions of brain cells and several different systems – from those responsible for breathing and heartbeat, through to those enabling complex decision making.
The teenage brain has an adult-like ability to reason, which appears to be well formed at age 16. However, the system which enables adults to balance long-term consequences against short-term rewards, is not yet fully developed.
Also, in adolescents there is a heightened need for “basic reward”, with an increase in reward-seeking behaviour. This can lead to patterns of abuse involving alcohol and drugs.
What is a traumatic brain injury?
Traumatic brain injury (TBI) is the most common and most damaging form of acquired brain injury (which can also have other causes, including stroke and infection), and is considered a “silent epidemic” by the report. It most frequently occurs in young people, is caused predominantly by falls, sporting injuries, fights and road accidents, and is the major cause of death and disability within this group.
There are two main types of TBI:
- an “open” injury, where the skull is penetrated and the brain exposed, such as from a knife wound – which is thought to be least common, which typically leads to injury to a specific area of the brain
- the more common “closed” TBI, where there is an injury to the brain from an external force, but it is not penetrated; for example, by a blow to the head, or a car coming to a sudden halt in a crash
These last injuries lead to lacerations and bruising of brain structures, especially if the brain hits the inside of the skull. Internal bleeding can lead to further injury from compression and loss of oxygen to areas of the brain.
“Closed” TBIs may appear to be less dramatic, but they also lead to widespread injury across the brain, these are classified from mild through to severe.
The consequences include loss of memory and concentration, reduced awareness of one’s own and others’ emotions, poor impulse control and poor social judgement. Behavioural problems such as conduct disorder, increased aggression, attention problems and impulse control problems are all prevalent in people with brain injury.
TBI is the most prevalent form of brain injury, affecting about 8.5% of the population. Adolescents and young adults are the most at risk group, with males at far greater risk than females (because young men are more likely to be involved in physical violence).
What does the evidence suggest about the effects of a TBI on brain development?
The report says that the outcomes after brain injury in children and young people are hard to predict because their brains are undergoing dynamic change. However, an injury to the brain before certain areas have fully developed may mean they never fully mature, or to “misfire”, with recent work showing that the skills developing at the time of the injury may be the most vulnerable to being disrupted.
An injury to the parts of the brain responsible for impulse control during development can result in long term problems with impulse control and decision-making. Both of which are associated with anti social and violent behaviour.
Consequently, while young people without a brain injury are likely to grow out of immature and antisocial behaviour by their mid 20s, those with a TBI “are likely to grapple with these issues throughout young adulthood and beyond”.
What are the links between TBI and criminal behaviour?
The report includes a review of national and international research on both the links between brain injury and offending, and the prevalence of brain injury among people in custody.
Overall, it says studies from around the world have typically shown that experience of head injury in offenders is between 50-80% compared to less than 10% in the general population. One recent study in England showed that 60% of young people in custody reported experiencing a TBI. Those who reported TBI were on average five years younger at age of first prison sentence than those who did not.
Also, a range of studies has indicated possible links between brain injury and later offending. For example, a US study of Vietnam veterans indicated that brain injury could put survivors at risk of crime, while a recent study of hospital records from Sweden found that of brain-injured patients, 8.8% committed violent crime compared with 3% in population controls. This association appears for TBI in general, including mild TBI.
A number of studies indicate that TBI is a particular concern among youth who offend with prevalence rates between 50% and 90%. TBI may also be associated with other problems found to be more prevalent among offenders, including mental health problems, drug and alcohol misuse and learning difficulties.
What are the recommendations of the report?
The report says that brain injury should be recognised as a chronic health condition with ongoing symptoms. It recommends early intervention to identify and manage brain injuries, improved monitoring of symptoms of brain injuries among children and young people, and training for education staff to raise general awareness of brain injury.
The report also calls for increased awareness of brain injuries throughout the criminal justice system, including standard screening of young people when they come into contact with the criminal justice process. It also argues that there should be increased awareness among criminal justice professionals about the prevalence of brain injury among offenders and an understanding of the need for assessment and management within the justice system.
Furthermore, brain injury history should be included in pre-sentence reports and considered as a factor in decision making, in the same way that maturity and mental health issues are already considered.
This report does raise the possibility that, with greater awareness of the role of TBIs in anti-social behaviour, we might be able to screen at-risk individuals and then provide them with appropriate treatment.
This would be of benefit to all, as it could well lead to a reduction in crime figures. To quote the researchers, ‘There may well be critical ‘windows’ of opportunity that may be targeted for diverting those with brain injuries at risk of greater offending into non-offending lives, but those at most risk of injury are often those that are furthest from appropriate support. The delivery of services to these groups will therefore require close cooperation between criminal justice, health, social, and educational systems and, in working together, shattered lives can be repaired’.
Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on twitter.