Implementing Interventions for Women and Youth with Traumatic Brain Injury at Transition from Custodial Settings: A Call to Action.

Traumatic brain injury (TBI) is a serious public health concern and overrepresented among justice-involved populations. An emerging area of research focuses on the complex, interrelated and unmet health and social needs of justice-involved women and youth with TBI. Evidence of these needs continues to grow, yet the health and justice systems continue to underperform in supporting the health and social care of justice-involved women and youth. This commentary is a call to action to begin to redress these gaps. We first provide an overview of the needs of women and youth with TBI that affect their transition from custody to community, including those related to victimization, trauma, mental health, substance use, and homelessness. We then highlight the current gaps in knowledge and practice with respect to interventions for women and youth with TBI at transition from custody. The available evidence for the impact of interventions on people with head injury who are justice-involved is sparse, especially studies of interventions focused on women and youth. We conclude with a call for implementation science studies to support translation from research to practice, emphasizing that researchers, practitioners, policy makers, and women and youth at transition should collaborate to develop, implement, and evaluate accommodations and interventions for TBI. To have meaningful, positive impacts on the systems that serve these women and youth, interdisciplinary service delivery approaches should aim to prevent, raise awareness, identify, and provide timely support and services for the varied needs of women and youth with TBI in transition.

Prisoner knowledge about head injury is Improved by brief psychoeducation.

INTRODUCTION: The high prevalence of head injury (HI) in prisoners and its association with offending indicates a need for interventions. However, there is little evidence and none for the effectiveness of psychoeducation in improving prisoner knowledge about HI and its effects. METHODS: Small groups of males in two Scottish prisons underwent a 1 hour psychoeducation session delivered by PowerPoint and combined with question and answer, video clips and a booklet about HI. A pre-post intervention design was used to assess knowledge about HI from vignettes. Participants indicated effects of HI using unprompted free recall and then with a questionnaire (the Symptom Checklist; SCL), pre-education (n = 34), post-education (n = 19) and at 4-week follow-up (n = 11). Free recall was scored using symptom lists from national guidelines (FR-SIGN) or the SCL (FR-SCL). Within-subject comparisons were made between pre-intervention, post-intervention and follow-up scores. RESULTS: Knowledge about HI significantly increased pre- to post-education for FR-SIGN (d = 0.91; 95% CI 0.62, 2.53) and FR-SCL (d = 0.99; 95% CI 0.95, 4.00) without decrement at follow-up (FR-SIGN d = 1.27; 95% CI 0.53, 2.56; FR-SCL r = 0.60). Scores on the SCL did not change over time (p > .05). CONCLUSION: Prisoner knowledge about HI was improved by brief psychoeducation suitable for delivery in prisons.

Associations between significant head injury and persisting disability and violent crime in women in prison in Scotland, UK: a cross-sectional study.

BACKGROUND: The prevalence of head injury is estimated to be as high as 55% in women in prison and might be a risk factor for violent offending, but evidence is equivocal. The extent of persisting disability is unknown, making decisions about service needs difficult. The UN recognises vulnerabilities in women in prison, but does not include head injury. This study aimed to investigate relationships among head injury, comorbidities, disability, and offending in women in prison. METHODS: In this cross-sectional study, women were recruited between Feb 2, 2018, and Sept 30, 2019, from four prisons across Scotland, UK: Her Majesty's Prison (HMP) Cornton Vale, Her Majesty's Young Offenders Institute Polmont, HMP Edinburgh, and HMP Greenock (detaining approximately 355 individuals at the time of recruitment). Women were included if they were aged older than 16 years, fluent in English, able to participate in face-to-face assessment and provide informed consent, and did not have a severe acute disorder of cognition or communication. Head injury, cognition, disability, mental health, and history of abuse and problematic substance use were assessed by interview. History of head injury was assessed with the Ohio State University Traumatic Brain Injury Identification method and disability was assessed with the Glasgow Outcome at Discharge Scale. Comparisons were made between women with and without a history of significant head injury. FINDINGS: We recruited 109 (31%) of the 355 women in these prisons. The sample was demographically representative of the approximately 400 individuals in women's prisons in Scotland. Significant head injury (SHI) was found in 85 (78%) of 109 women, of whom 34 (40%) had associated disability. Repeat head injury was reported in 71 (84%) of the 85 women with SHI and, in most cases, this resulted from domestic abuse that had occurred over many years. Women with a history of SHI were significantly more likely to have a history of violent offences than those without a history of SHI (66 [79%] of 85 women in the SHI group vs 13 [54%] of 24 women in the no-SHI group had committed a violent offence; odds ratio [OR] 3·1, 95% CI 1·2-8·1). This effect remained significant after adjusting for current factors (3·1, 1·1-9·0), including comorbidities associated with post-traumatic stress disorder, and was no longer statistically significant after adjusting for historical factors (3·3, 1·0-10·9), such as abuse as a child or adult. Women with SHI had spent longer in prison than women without SHI after adjustment for current (rate ratio 3·4, 1·3-8·4) or historical (3·5, 1·3-9·2) risk factors. INTERPRETATION: It is recognised that women in prison are vulnerable because of histories of abuse and problematic substance use; however, history of SHI needs to be included when developing criminal justice policy, interventions to reduce mental health morbidity, and assessment and management of risk of violent offending. FUNDING: The Scottish Government.

The association between dual-task walking and counting responses and cognitive function and disability after severe head injury: A preliminary study.

Adverse outcomes after severe head injury (SHI) can be difficult to detect in primary care and other settings where there is not specialist expertise for interpretation. Walking and counting dual-task (DT) measures are strongly associated with cognitive impairment and dementia and this preliminary study investigates whether performance on DT walking and counting tasks are associated with cognitive function and disability in 125 participants who sustained a SHI on average 26 years before. Single Task (ST) walking (speed over 6 metres) and ST counting (Serial 3s) and DT performance of concurrent walking and Serial 3s were compared with neuropsychological, wellbeing and disability tests for strength of association. The strongest correlations were between ST Correct Cognitive Responses (CCRs) and MMSE (rho = 0.435), DT CCRs and Short-term Memory Binding Tests (STMBT) binding accuracy (rho = 0,409) and DT CCRs and STROOP (rho = 0.420), but associations were less strong with disability. Developing this test, as a cost-efficient screening tool for triage to onward referral for neuropsychological assessment, holds promise, but requires further research.

In vivo detection of cerebral tau pathology in long-term survivors of traumatic brain injury.

Traumatic brain injury (TBI) can trigger progressive neurodegeneration, with tau pathology seen years after a single moderate-severe TBI. Identifying this type of posttraumatic pathology in vivo might help to understand the role of tau pathology in TBI pathophysiology. We used flortaucipir positron emission tomography (PET) to investigate whether tau pathology is present many years after a single TBI in humans. We examined PET data in relation to markers of neurodegeneration in the cerebrospinal fluid (CSF), structural magnetic resonance imaging measures, and cognitive performance. Cerebral flortaucipir binding was variable, with many participants with TBI showing increases in cortical and white matter regions. At the group level, flortaucipir binding was increased in the right occipital cortex in TBI when compared to healthy controls. Flortaucipir binding was associated with increased total tau, phosphorylated tau, and ubiquitin carboxyl-terminal hydrolase L1 CSF concentrations, as well as with reduced fractional anisotropy and white matter tissue density in TBI. Apolipoprotein E (APOE) ε4 genotype affected the relationship between flortaucipir binding and time since injury, CSF ß amyloid 1-42 (Aß42) concentration, white matter tissue density, and longitudinal Mini-Mental State Examination scores in TBI. The results demonstrate that tau PET is a promising approach to investigating progressive neurodegeneration associated with tauopathy after TBI.

The prevalence, characteristics, and impact of head injury in female prisoners: a systematic PRISMA review.

Background: Although head injury (HI) is associated with offending behavior, there has been relatively little attention to female prisoners. This systematic review considers prevalence and characteristics of females prisoners with HI, with a view towards improving understanding of service needs.Methods: Electronic databases, two meta-analyses and two systematic reviews were searched for relevant papers. Studies describing the prevalence of HI in female prisoners were included and assessed for risk of bias.Results: Twelve studies were included. Prevalence of HI ranged from 19%-95%. It was lower if using hospital records rather than self-report and generally not different by gender. Risk of bias was high overall, with little consistency in assessment methods and definition of HI. Sample sizes of female prisoners with HI were often modest and not clearly representative of the population. The experiences/needs of prisoners can differ by gender, females having a higher risk of physical and mental health problems, including psychological trauma.Conclusion: HI is prevalent in female prisoners, and their needs and experiences may differ from male prisoners with HI and female prisoners without. Future research should address methodological limitations to allow a firm, evidence base for effective services and interventions for female prisoners with HI to be developed.

Brief compassion focused imagery for treatment of severe head injury.

OBJECTIVE: To determine whether participants with severe head injury (SHI) allocated to a brief compassion focused imagery (CFI) intervention show greater change in compassion than those exposed to relaxation imagery (RI). METHOD: Participants were exposed to a preparatory video to promote engagement and then randomly allocated to intervention. Pre- and post-preparatory measures were Motivation for Intervention and Fears of Compassion Scales, State-Trait Anxiety Inventory (STAI) and PANAS. Pre- and post-intervention self-report measures were the Empathy Quotient, Self-Compassion Scale, STAI and Relaxation Scale. Heart rate variability (HRV) was monitored throughout. RESULTS: Motivation for therapy increased after the preparatory video (z = 3.44, p = 0.001). Across the intervention, group differences were not found on self-report measures or HRV changes. When CFI and RI groups were pooled, improvement in relaxation (r = .41, p < 0.01) and state anxiety (r = .29, p < 0.05) were found across the intervention; these outcomes were not associated with changes in self-compassion or HRV. CONCLUSION: Brief CFI, a central aspect of compassion focused therapy, did not produce a reliable change in people with SHI. Enhanced motivation for psychological therapy after a brief preparatory video is relevant and underlines the need to understand mechanisms of action rather than the pursuing whole protocol approaches to therapy.

Traumatic brain injury: a potential cause of violent crime?

Traumatic brain injury (TBI) is the biggest cause of death and disability in children and young people. TBI compromises important neurological functions for self-regulation and social behaviour and increases risk of behavioural disorder and psychiatric morbidity. Crime in young people is a major social issue. So-called early starters often continue for a lifetime. A substantial majority of young offenders are reconvicted soon after release. Multiple factors play a role in crime. We show how TBI is a risk factor for earlier, more violent, offending. TBI is linked to poor engagement in treatment, in-custody infractions, and reconviction. Schemes to assess and manage TBI are under development. These might improve engagement of offenders in forensic psychotherapeutic rehabilitation and reduce crime.

Prevalence of Head Injury and Associated Disability in Prison Populations: A Systematic Review.

OBJECTIVE: This review systematically assesses literature on the prevalence of head injury (HI) and associated disability in adults in prison. METHODS: Searches were carried out using electronic databases (PsycINFO, Cochrane Databases, MEDLINE, EMBASE, Web of Science). Reference lists of 2 meta-analyses were checked for relevant articles. Methods were rated for risk of bias. RESULTS: The 10 studies included report a range in prevalence of HI in prisoners from 25% to 86%. Risk of bias was high overall, probably because a range of HI definitions was used, assessments were often not validated, and samples were not or not evidenced to be representative of the prison population. There was an absence of appropriate population controls from which to compare relative risk of HI in different countries. No study reported the prevalence of disability associated with HI. CONCLUSION: The wide range in prevalence estimates of HI in prisoners is associated with high risk of bias from study design and methods. Persisting disability associated with HI was not reported and as a result the service need for prisoners with HI is unclear. Future studies should indicate that samples are representative of prison populations, use validated tools and internationally accepted definitions of HI, and link prevalence to persisting disability.

The Glasgow Outcome Scale - 40 years of application and refinement.

The Glasgow Outcome Scale (GOS) was first published in 1975 by Bryan Jennett and Michael Bond. With over 4,000 citations to the original paper, it is the most highly cited outcome measure in studies of brain injury and the second most-cited paper in clinical neurosurgery. The original GOS and the subsequently developed extended GOS (GOSE) are recommended by several national bodies as the outcome measure for major trauma and for head injury. The enduring appeal of the GOS is linked to its simplicity, short administration time, reliability and validity, stability, flexibility of administration (face-to-face, over the telephone and by post), cost-free availability and ease of access. These benefits apply to other derivatives of the scale, including the Glasgow Outcome at Discharge Scale (GODS) and the GOS paediatric revision. The GOS was devised to provide an overview of outcome and to focus on social recovery. Since the initial development of the GOS, there has been an increasing focus on the multidimensional nature of outcome after head injury. This Review charts the development of the GOS, its refinement and usage over the past 40 years, and considers its current and future roles in developing an understanding of brain injury.

Friendship, loneliness and psychosocial functioning in children with traumatic brain injury.

OBJECTIVE: This study compares friendship quality, rates of loneliness and general psychosocial functioning in children who have sustained a traumatic brain injury (TBI) with non-injured controls. METHODS: A between-subjects design with 14 participants in the TBI group and 14 in the non-injured control group, aged between 7-13 years and matched for age, gender, receptive vocabulary and socio-economic status. Children completed measures of receptive vocabulary (BPVS II), friendship quality (FQQ-R) and loneliness (LSDS). The main caregiver was asked to assess social skills and social withdrawal (PIC-2) and general psychosocial and behavioural functioning (SDQ). RESULTS: Significant differences were not found on measures completed by children or on the PIC-2. On the SDQ, total difficulties were rated as much greater by caregivers in the TBI group (z = -2.6, p = 0.009) and these were mainly associated with sub-scales relating to emotional problems and hyperactivity. CONCLUSIONS: Whilst evidence for friendship problems was not found in children with TBI, evidence for emotional and behavioural difficulties that may lead to social vulnerabilities later in life were found. This indicates a need for prospective longitudinal research to explore the complex relationship between TBI and poorer social outcomes that may not become evident until adolescence.

A systematic review of psychological interventions to alleviate cognitive and psychosocial problems in children with acquired brain injury.

AIM: It is now generally accepted that paediatric acquired brain injury (ABI) can have an impact on a child's cognitive, social, and behavioural functioning. However, the lack of guidelines on effective interventions for the affected children and their families, particularly beyond the acute recovery phase, can limit access to effective support. We provide a systematic review of the literature on the effectiveness of psychological interventions aimed at alleviating cognitive and psychosocial outcomes after paediatric ABI. METHOD: The search used the Ovid MEDLINE, Embase, Web of Knowledge, and EBSCO databases and hand searches of key journals. Nine studies met inclusion criteria: five intervention studies of cognitive outcome and four of psychosocial outcome. Effect sizes and methodological quality ratings were calculated using specific criteria. RESULTS: Only two of the nine studies were rated as high quality. There was limited evidence for effective interventions for cognitive outcomes (attention, memory, and learning difficulties). For psychosocial outcomes, there was evidence that interventions can alleviate internalizing symptoms. INTERPRETATION: Although there are some encouraging findings, there is a need for further, more rigorously designed, and better controlled research in this important area. We discuss how future research may consider issues such as age-appropriate interventions, the delivery format, and optimum post-injury timing of interventions, as well as multicentre collaborations.

Misdiagnosis of post-traumatic stress disorder following severe traumatic brain injury.

BACKGROUND: The incidence of post-traumatic stress disorder (PTSD) after traumatic brain injury is unclear. One issue involves the validity of diagnosis using self-report questionnaires. AIMS: To compare PTSD'caseness' arising from questionnaire self-report and structured interview. METHOD: Participants (n=34) with traumatic brain injury were recruited. Screening measures and self-report questionnaires were administered, followed by the structured interview. RESULTS: Using questionnaires, 59% fulfilled criteria for PTSD on the Post-traumatic Diagnostic Scale and 44% on the Impact of Events Scale, whereas using structured interview (Clinician-Administered PTSD Scale) only 3% were 'cases'. This discrepancy may arise from confusions between effects of PTSD and traumatic brain injury. CONCLUSIONS: After traumatic brain injury, PTSD self-report measures might be used for screening but not diagnosis.

Post-traumatic stress disorder and traumatic brain injury: A review of causal mechanisms, assessment,and treatment.

In this paper we explore the evidence for post-traumatic stress disorder (PTSD) after traumatic brain injury (TBI). We examine its possible mediating mechanisms after brain injury, the evidence for its occurrence, risk, and protective factors, and the implications for intervention and service demands. In the first section we review the current literature relevant to cause, maintenance, and treatment of PTSD in general, before addressing issues associated with the assessment and management of PTSD after TBI. It is argued that PTSD may occur after a brain injury, and can be, relatively, a common disorder. However, explanatory mechanisms for its occurrence may be speculative. In this context, we argue, assessment and treatment need to be carefully considered, and comprehensive.