Studies have shown that the prevalence of traumatic brain injury (TBI) among adult prisoners is more than seven times higher than among non-incarcerated adults.
Traumatic brain injury occurs when a person suffers a disruption of brain function due to an injury – such as an impact from an accident, playing sports or an assault. The most common form of TBI is a concussion.
Medical researchers have discovered that minor TBIs, previously believed to be inconsequential and transient, can result in lasting disabilities. They also discovered that the injuries caused by TBIs are cumulative, in that a series of minor TBIs can lead to major impairment.
Most people who suffer the most minor form of TBI, a concussion, will recover more or less fully within a year. For the 15% who do not, persistent symptoms may include headaches or increased irritability that interferes with everyday functioning.
Sometimes TBI results in behavioral issues that are a direct consequence of the impact that caused the injury. For example, in a vehicle accident or assault, the impact is often to the top front of the head just above the frontal lobes, which regulate behavior. Frontal lobe TBI also can be caused by the brain impacting the skull inside the head, such as during a sudden acceleration or deceleration. This type of injury can result even when the head is not hit directly.
Around 8.5% of the non-incarcerated adult population in the United States has suffered a traumatic brain injury; 2% currently suffer from some form of disability due to past TBI.
Among adult prisoners, an estimated 60% have had at least one TBI and some prison systems report an even higher rate of traumatic brain injury.
According to the Centers for Disease Control (CDC), “Many people in prisons and jails are living with traumatic brain injury (TBI)-related problems that complicate their management and treatment while they are incarcerated. Because most prisoners will be released, these problems will also pose challenges when they return to the community.”
The CDC recognizes TBI in prisons and jails as “an important public health problem,” and notes that TBI may result in memory problems and inability to follow directions, irritability or anger that is difficult to control, slowed verbal and physical responses, and impulsive behavior – all of which can cause problems in a correctional setting.
A study by the New York Department of Health and Mental Hygiene, conducted in 2012, found that 50% of male juvenile offenders at the Rikers Island jail complex had experienced TBI. The rate for female juveniles was 65%.
“This shows us that we have a real serious organic medical problem among the adolescents,” said Dr. Homer Venters, assistant commissioner of New York City’s Correctional Health Services. “We often end up giving someone a mental health diagnosis, who does not have a mental health problem, but rather TBI.”
South Carolina and Minnesota have also studied the prevalence of TBI among prisoners.
“If we don’t help individuals specifically who have significant brain injuries that have impacted their criminal behavior, then we’re missing an opportunity to short-circuit a cycle [of incarceration and recidivism],” according to Peter Klinkhammer, associate director of services at the Brain Injury Association (BIA) of Minnesota.
Complicating the issue is the difficulty in diagnosing and understanding brain injuries.
“Two people can have the same injury and have a totally different set of impairments,” said Wayne Gordon, director of the Brain Injury Research Center of Mount Sinai. “One can be fine, and one can be not so fine – but we don’t know why that is yet,” he stated, suggesting that numerous variables could account for differences in the severity of TBI.
A South Carolina study found that 65% of male prisoners and 73% of female prisoners reported having TBIs. Researchers believe those rates might be low as they may not include unremembered injuries sustained as an infant or young child, or even adult injuries that affected short-term memory. Adding to the problem is the fact that minor TBIs are often not reported to or treated by medical personnel.
For some prisoners, TBI may lead to longer incarceration if the resulting behavioral issues cause them to have difficulty following prison rules or delay their responses to orders by prison staff that are misinterpreted as defiance or resistance. Such incidents can lead to additional TBI if staff respond with force, such as violent cell extractions.
Traumatic brain injury is also associated with substance abuse and may cause treatment programs to be less effective for people with TBI. Thus, it can increase the likelihood of released prisoners relapsing and returning to prison.
Cognitive Rehabilitation Therapy (CRT) is often used to treat TBI in the broader adult population. With CRT, patients are educated about traumatic brain injuries and given exercises to help them improve their memory and make better-informed choices. CRT may work in the prison environment; however, prisons offer a unique set of challenges for those who suffer from TBI.
The first problem is a lack of diagnosis. Prisoners are rarely screened for TBI by medical personnel, and guards are more likely to misinterpret TBI-related symptoms as defiance or stubbornness. There is even a disincentive to identifying TBI among prisoners in an era of shrinking budgets because, once diagnosed, the prison system is obligated to provide treatment or accommodations for prisoners with TBI.
“It’s cheaper to just lock them up,” observed Medical University of South Carolina Associate Professor Elisabeth Pickelsimer.
While that approach may be cheaper in the short-term, at an average annual cost of approximately $31,200 per prisoner (according to a 2012 report by the Vera Institute of Justice), it would be less expensive in the long run to identify people with TBI and provide treatment that helps keep them out of prison.
The BIA has been working with prisoners, their families, probation officers and outside support services to assist prisoners with TBI who are about to be released. Klinkhammer explains that this is important because TBI victims can become distressed by the broad array of choices and information they face when they leave prison.
“It can be very overwhelming, and it could result in one more reason for a person to ‘recidivize’ – do something that will land them back in jail, even if they had no intention of breaking the law,” said Klinkhammer.
Officials in El Paso, Texas tried an experimental project in which they used an adapted cognitive treatment program on juvenile offenders and experienced a fivefold reduction in recidivism. While El Paso did not screen for TBI, the results imply a high rate of TBI among the juveniles who participated in the program.
The Traumatic Brain Injury Act of 1996 and its later amendments were designed to foster the study, prevention and treatment of TBI. However, relatively few studies have been forthcoming. The 2008 reauthorization of the Traumatic Brain Injury Act expanded certain sections of the law and directed the CDC to determine the incidence and prevalence of TBI in the general population of the U.S., including institutional settings such as prisons and jails.
Hopefully this means that additional resources, and treatment, will be made available to prisoners who suffer from TBI.