1. Traumatic Brain Injury in a Forensic Intellectual Disability Population Verity Chester, Ginny Painter, Lucy Ryan, Jason Popple, Kudzanai Chikodzi & Regi T Alexander

2.  Brain injury caused by trauma to the head  This can happen as a result of: 1.the head being struck, 2.the head striking an object 3.the brain undergoing an acceleration/deceleration movement (i.e., whiplash) without direct external trauma to the head. Traumatic Brain Injury

3. 1.4 million patients per year in the UK (Moppett, 2007) Majority are young - Peak - 0 to 4yrs and 15 to 19yrs 1.5 x more likely in Males Most common causes of TBI: Falls Assaults Motorcycle / car / cycling accidents Workplace injuries Sports Prevalence and Causes of TBI

4. Severity Classification TypeGlasgow Coma Scale Loss of ConsciousnessPost Trauma Amnesia Mild13-1530mins or less< 1 hour Moderate9-1230mins to 24hrs1-24hrs Severe≤ 8> 24hrs 80% of the brain injuries are of mild degree

5. Prognosis and Effects of TBI SeverityPrognosis MildVast majority make a full recovery, usually after 3-4 months. However there is a very small sub-group whose recovery is not so good. Moderate Likely to suffer from a number of residual symptoms, e.g. tiredness, headaches and dizziness, difficulties with thinking, attention, memory planning, organising, concentration and word-finding problems, and irritability. These symptoms are often accompanied by worry and anxiety. For the majority of people these residual symptoms gradually improve, although this can sometimes take 6 to 9 months. Severe As above, but the longer the length of coma and amnesia, the poorer the outcome. However, there are exceptions to this rule and, there is a small group of individuals who do exceptionally well.

7.  TBI frequently results in significant long-term, cognitive, behavioural and social changes in the affected person (Colantonio et al., 2007), including:  Increased agitation and aggression (Fleminger et al., 2008)  Increased irritability  Inappropriate social and sexual behaviours Effects of TBI

8. TBI and Offending Populations

9.  There is an association between TBI and involvement in criminal behaviour (Colantonio et al., 2007).  Recent studies suggest TBI highly prevalent in forensic populations:  Pitman et al. screened for TBI among 613 male prisoners, 47% had a history of TBI.  Williams et al. (2010) investigated rates of TBI in a sample of 196 adult offenders. 60% had a history of head injury.  Of offenders with TBI, almost 75% sustained their first injury before their first offence (Pitman). TBI and Offending Populations

10.  TBI associated with specific offence profiles and poorer outcomes.  Younger at entry into custodial systems  Higher number of previous convictions  More likely to have a violent index offence, sexual offences less common  Restriction orders and criminal sections more common (Hawley & Maden, 2003)  Perceived by clinicians as high risk to others  Problems with aggression continue for many years  4x more difficult to discharge  Longer lengths of time spent in secure settings  Higher rates of reoffending (Williams et al., 2010) TBI and Offending Populations

11.  Studies have recommended that forensic services should be routinely screening for brain injury on admission (Colantonio et al., 2007; Williams et al., 2010).  Screening should involve (Colantonio et al., 2007): 1.Asking: “Have you ever had an injury to the head which knocked you out or left you dazed, confused or disoriented? 2.Recording: The date of, or age at injury 3.Recording: The length of unconsciousness 4.Recording: Whether hospitalised and length of hospitalisation  Despite these recommendations, brain injury screening has not been widely adopted into routine clinical practice within forensic settings. Screening for TBI

12.  Screening can…  Direct further neuropsychological assessment as required, to confirm the brain injury and identify its effect(s) (if any) on the individual.  Inform assessment and treatment pathway  Inform care staff and management approaches  Help predict length of stay and other treatment outcomes  If present, TBI will contribute to the unique clinical and forensic presentation of an individual. What is the point of screening?

13.  No published research has focused on rates of TBI among offenders with ID.  Rates likely to be equally high, if not higher:  Falls more common in those with ID (e.g. gait problems) (Finlayson et al., 2010)  Epilepsy (Finlayson et al., 2010) Offenders with Intellectual Disabilities

14.  Case note review – Case notes searched for any record of traumatic head injury, but also any acquired brain injury.  80 patients records searched.  Brain Injury Screening Questionnaire (BISQ ©, The Disabilities Trust Foundation) – A self-report tool which measures a number of widely recognised indicators of TBI. The tool establishes the history of TBI and, and provides guidance for assessing the severity of the injury as either mild, moderate or severe in nature. This assessment was offered to all patients.  66 patients agreed to be interviewed. Method

15.  Ten patients (13%) had a traumatic brain injury (TBI) documented.  Seven patients (9%) had some form of organic brain injury documented. The causes of this included temporary loss of oxygen during birth, temporal lobe epilepsy due to encephalopathy, overdoses of prescribed medication, post natal asphyxia due to mucus on the lungs, and suspected stroke.  Quality of the TBI recording was poor, often failing to report key information, such as the date of, or patients age at injury, the patients length of unconsciousness, and any treatment or hospitalisation received. Results – Prevalence from case notes

16. Results – Prevalence from interviews  Of the 66 interviewed using the BISQ, 43 (65%) reported that they had experienced at least one TBI.  Many reported experiencing more than one, with some experiencing over five. 113 TBIs were reported in total. n of TBIsn of patientsTotal injuries 118 236 3824 4520 5 or more945+ 43113+

17. Reliability of self-reports / BISQ tool BISQ tool  Didn’t ask what the injuries were (key)  Didn’t always have enough space for the number of injuries patients were reporting.  Asking patients with ID about their memory and speech, tapped more into their ID than TBI.  Terminology - unconsciousness Self reports  Under reporting  Confusion between injuries, and the treatment received for each.  One patient reported being in 6 comas.

18. Results – Severity  Of the 113 TBI’s reported:  72% were mild  7% moderate  2% severe  21% could not be classified as the patient could not remember details about their loss of consciousness.

19. Results - Treatment  The most common mode of treatment was to visit hospital (36%), see a paramedic at the accident scene (18%), or visit the GP (7%). Some received medical treatment within their inpatient service.  However, 27% did not seek any treatment, and 8% did not know what treatment they received.

20. Causes of TBI Accidents Many patients reported accidents had caused blows to their head; mostly falls (n = 14), car / motorcycle accidents (n = 11), and other accidents. One patient reported being dropped from a third floor window as a baby. Childhood physical abuse Case notes and patients described numerous incidents of physical abuse during childhood which resulted in blows to the head. Some described multiple blows to the head during one incident, e.g., being hit in the head and falling back and hitting head. Others reported regular blows to the head over the course of their childhood. AssaultMany patients reporting experiencing assault(s) throughout the course of their lifetime. Some of the assaults occurred in community settings, such as in nightclubs or in the street. Many reported that they had been assaulted in inpatient settings.

21. Causes of TBI RestraintA number reported hitting their head during restraint. Physical health One patient described collapsing, which resulted in them hitting their head, and another reported often hitting their head during epileptic seizures. Self harm / Suicidal A number reported that self harming or suicidal behaviours had caused blows to their head, e.g. jumping from a moving car, walking into traffic, and jumping from heights. However the main cause was “head banging”. Head banging behaviour was documented within the case histories of fifteen patients (19%), e.g. "he self- harmed by banging his head" and “knocked head into a prison cell door”. Some reported head banging during restraint. A number had severe and prominent facial scarring as a result.

22. Clinical VariablesTBI group n (%) Non-TBI group n (%) Statistical test Gender24(53.3)22(62.9)n.s. Psychosis 11 (24.4)9 (25.7)n.s. Bipolar disorders3(6.7)0(0)n.s. Depressive disorders6(13.3)3(8.6)n.s. Harmful use / dependence on substances25(55.6)16(45.7)n.s. Personality disorder27(60)17(48.6)n.s. Autism Spectrum Disorder19(42.2)8(22.9)n.s. ADHD10(22.2)4(11.4)n.s. Epilepsy6(13.3)4(11.4)n.s. Self-harm33(73)24(68.6)n.s. Physical abuse11(24.4)9(25.7)n.s. Sexual abuse8(17.8)8(22.9)n.s. Health related quality of life - mean.81.78 n.s. IQ - mean6262.6 n.s. Between Group Comparisons

23. Forensic VariablesTBI group n (%) Non-TBI group n (%) Statistical test Criminal detention33 (73.3)18(51.4)n.s. Violent convictions 19 (42.2)16 (45.7)n.s. Sexual convictions11 (24.4)7(20)n.s. Arson convictions10 (22.2)5(14.3)n.s. Verbal aggression 39 (86.7)33 (94.3)n.s. Aggression towards people40 (88.9)34(97)n.s. Aggression towards property34 (75.6)28(80)n.s. History of sexual aggression24 (53.3)21(60)n.s. History of fire setting24 (53.3)11(31)n.s. Between Group Comparisons

24. Treatment Outcome VariablesTBI groupNon-TBI groupStatistical test Physical Intervention1.5.8n.s. Seclusion.2.3n.s. Observation.7.4n.s. Length of Stay16511533.2n.s. Between Group Comparisons

25.  65% of patients self-reported experiencing at least one TBI during their lifetime.  This was in contrast to the 10% recorded within case notes.  And higher than rates reported in previous studies. Pitman et al. reported a 47% prevalence in 613 male prisoners, and Williams et al. (2010) reported a 60% rate in 196 adult offenders.  Many patients reported experiencing more than one TBI, with some experiencing multiple injuries. Considering severity, the vast majority of the reported injuries were of a mild nature, with only a small number classified as moderate or severe.  The most common causes of TBI were accidents, self harm, childhood physical abuse, and assaults.  Opportunity for intervention? Conclusions

26.  Treatment-seeking could be described as erratic, with 1/3 of injuries receiving no treatment. These patients are not accessing the full range of assessments, monitoring and treatments outlined in the NICE guideline (2014). Furthermore, without appropriate investigations and treatment, the long-term consequences of the TBI on affected individuals health, functioning and behaviour are immeasurable.  Results suggest TBI is highly prevalent among this population, yet under recognised. Introducing routine screening appears to be a useful way of highlighting potential TBI cases for further investigation and assessment. Conclusions

27. Thank you Any Questions? verity.chester@partnershipsincare.co.uk