1. Durc Fahrenhorst-Jones
Assault-related traumatic brain injuries: Factors related to stress, depression and anxiety
Lyndel Bates
School of Criminology and Criminal Justice and Griffith Institute for Criminology, Griffith University
Annerley Bates
Brain Injury Rehabilitation Service, Princess Alexandra Hospital, Queensland Health and Menzies Health Institute Queensland
Durc Fahrenhorst-Jones
Road policing used to change driver behaviour and improve road safety (Bates, Soole & Watson, 2012)
Law Enforcement and Public Health Conference, Toronto, October 2018

2. Acknowledgements
We thank the Brain Injury Rehabilitation Service and the Social Work Department at the Princess Alexandra Hospital, Queensland Health for their assistance with this study.

3. Background
Violence has been described as public health concern causing disability, injury and death (Krug, Mercy, Dahlberg, & Zwi, 2002)
Violence related TBIs, as a proportion of all TBIs range from 6% to 26% (Bates, Matthews, Simpson & Bates, 2016)
Individuals with violence-related TBIs comprise of a distinct clinical subgroup (Gerhart, Mellick, & Weintraub, 2003)
Informal caregivers are vital to the rehabilitative process (Foster et al., 2012)
1: Violence has been identified as a public health concern, with consequences including injury, disability and death.
2: One injury caused from violence is a TBI. With a large minority of people with TBIs having the cause being assault.
3: Those with violence-related TBIs comprise of a distinct clinical subgroup, often reporting lower levels in lower levels of productivity, social integration and recreation (Gerhart, Mellick, & Weintraub, 2003).
4: Because of this, these individuals often require rehabilitation. Vital to individuals rehabilitative journey are the injureds’ family. Family members, or informal caregivers often drive the rehabilitative process with past study's suggesting family engagement in the rehabilative process is associated with more positive outcomes for the injured person.

4. Background
Rehabilitation is imperative for positive outcomes post-injury (Khan, Baguley, & Cameron, 2003)
Persons with violence-related TBIs may encounter challenges when accessing rehabilitation and long-term supports needs in the health system (Esselman et al., 2004)
Those with assault-related TBIs may have to navigate the criminal justice (Bates, Matthews, Simpsons & Bates, 2016)
1: Individuals with violence-related TBIs often receive treatment from the HS (Esselman, Dikmen, Bell, & Temkin, 2004).
2: Although rehabilitation is imperative for positive outcomes post-injury (Khan, Baguley, & Cameron, 2003), persons with violence-related TBIs may encounter challenges when accessing rehabilitation and long-term supports needs (Esselman et al., 2004). This may be due to unique rehabilitative issues surrounding these individuals (Esselman et al., 2004).
3: Moreover, as individuals’ injuries are caused by assault, they may enter the CJS, alongside their informal caregiver. This navigation of the CJS and HS may complicate the rehabilitative process further, for example, hindering positive outcomes for injured persons and negatively impacting the well-being of informal caregivers.

5. Brain Injury Rehabilitation Service
Queensland-wide service
In patient and out patient
Must be an adult

6. Australia is about the same size as Canada
Approximately 4.5 million people in Queensland but very focussed on the coast

7. BIRS Social Work Database
Participants
BIRS Social Work Database
Hospital records
DASS21 scores
n = 19
BIRS Social work kept a database with the intake details of all individuals who had either an ABI or a TBI and were treated by the BIRS social work team between 2011 and 2015.
Database included information such as age, gender, geographic location, type of brain injury, reason for injury and referral information
467 people received a brain injury during this period
Because this research is part of a larger project looking at the psycho-social impacts on informal caregivers, we excluded anyone who received their injury as the result of domestic violence.
84 (18%) had their injury as the result of an assault which is consistent with the findings in the literature
We were able to access the hospital records of 65 individuals. The others weren’t available because the person may be in hospital etc.
Of the 65, 19 had DASS21 scores – instantly realised that more patients should be completing the DASS assessment.
As well as the DASS scores, we included information regarding the amount of social support, whether they were the victim or perpetrator as well as the involvement of alcohol or weapons

8. 89.5% identified as victims
Mean age = (sd = 11.34)

78.9% males
Who were our participants and how were they injured?
26.3% involved alcohol
17.6% involved weapons
89.5% identified as victims

9. Mean DASS21 scores
Depression, stress and anxiety was measured using the DASS21. This is a clinical instrument used to assess these related states. The DASS21 has 21 questions that are answered on a scale of 0 ‘Does not apply to me at all’ to 3 ‘Applied to me very much, or most of the time’. The instrument takes approximately 5 minutes to complete. The BIRS Hospital Records Database did not record the individual answer to each question but rather the score that each person had received for each of the three states.

10. Contact with criminal justice system
12 participants had contact with the criminal justice system

11. Relationship between CJS and DASS
Agency
Depression
Stress
Anxiety
Police  ?
Corrections
Courts
Victim Support Services
Criminal Justice Agencies
Did Mann-Whitney U tests to look at relationship between criminal justice system and DASS
Individuals who had dealings with police were more likely to be stressed
Approached significance for anxiety and police (.07) and anxiety and victim support services (.06)

12. Social support Looked at two measures of social support
Felt socially supported by informal caregivers
Married at time of injury

13. Relationship between social support and DASS
Depression
Stress
Anxiety
Felt socially supported outside the hospital
(n = 13) 
Married
(n = 4 married;
n = 11 not married)

14. Implications and recommendations
Measure depression, stress and anxiety for BI patients
Ensure rehabilitation professionals are able to provide mental health support as well
Benefits in having qualified mental health professionals in some criminal justice agencies (e.g. police, victim support services)
Encourage family members and others to support the injured person
Provide support to family members as well
May need more resources to do this

15. Limitations and future research
Small sample size
One hospital site (although service covers the entire state)
Future research
Use different methodologies to explore issues in-depth (semi-structured interviews)
Examine if informal support networks facilitate contact with criminal justice system

16. References
Bates, A., Matthews, S., Simpson, G., & Bates, L. (2016). Brain injury as the result of violence: A systematic scoping review. Journal of Social Work in Disability & Rehabilitation, 15(3-4), Esselman, P. C., Dikmen, S. S., Bell, K., & Temkin, N. R. (2004). Access to inpatient rehabilitation after violence-related traumatic brain injury. Archives of Physical Medicine and Rehabilitation, 85(9), Foster, A. M., Armstrong, J., Buckley, A., Sherry, J., Young, T., Foliaki, S., McPherson, K. M. (2012). Encouraging family engagement in the rehabilitation process: A rehabilitation provider’s development of support strategies for family members of people with traumatic brain injury. Disability and Rehabilitation, 34(22), Gerhart, K. A., Mellick, D. C., & Weintraub, A. H. (2003). Violence-related traumatic brain injury: A population-based study. Journal of Trauma and Acute Care Surgery, 55(6), Khan, F., Baguley, I. J., & Cameron, I. D. (2003). Rehabilitation after traumatic brain injury. Medical Journal of Australia, 178(6), Krug, E. G., Mercy, J. A., Dahlberg, L. L., & Zwi, A. B. (2002). The world report on violence and health. The Lancet, 360(9339),

17. Questions? L.Bates@griffith.edu.au
@DrLyndelBates