traumatic brain injury and the criminal justice system · 2019-12-12 · 15 \⠀䬀愀琀攠ᤀ猀...

$: Traumatic Brain Injury and the Criminal Justice System · 2019-12-12 · 15 \⠀䬀愀琀攠ᤀ猀猀氀椀搀攀尩 I’ll describe the signs and symptoms of traumatic brain injury$
Traumatic Brain Injury and the Criminal Justice System

Wednesday January 20th, 2016

@HSJCC

Heather Lumley, South West Regional HSJCC

HSJCC Webinar

• We will have a Q&A period at the end of our webinar. To ask a question, please type your question in the chat box.

• Power-point presentation will be emailed to you following the webinar.

• Please complete the brief evaluation survey following the webinar.

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Presenters

• Flora Matheson Research Scientist at the

Centre for Research on Inner City Health, St. Michael's Hospital

• Kathryn McIsaac, Social Epidemiologist & Postdoctoral Fellow at the Centre for Research on Inner City Health, St. Michael's Hospital

• Kate Moore, Manager of Toronto-West Clinical Services at COTA

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Defining Traumatic Brain Injury (TBI)

A disruption in the normal function of the brain caused by a blow or jolt to the head or a penetrating head injury. Although blows and jolts to the head don't always result in TBI, brain injury can range in severity from mild — marked by a change in mental status — to severe, which may include an extended period of unconsciousness or amnesia after injury.

Centers for Disease Control and Prevention (CDC). (2008) http://www.cdc.gov/ncipc/tbi/TBI.htm

Traumatic brain injury in prison populations

http://www.cdc.gov/ncipc/tbi/TBI.htm

Estimates of the burden of people living with traumatic brain injury-caused disability


Roozenbeek, B. et al. (2013) Changing patterns in the epidemiology of traumatic brain injury Nat. Rev. Neurol. doi:10.1038/nrneurol.2013.22

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EU USA Canada Australia

Num

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Cost of the Problem


Chen et al. BMC Neurology 2012; 12:76

Direct Costs $32 132 for average TBI care in the first year after injury

$120.7 million in Ontario (2008-2009) Indirect Costs $1 billion in Ontario and $3 billion in Canada per year

Risk Factors for TBI


Socio-demographic Age: Young children (<15); young adults (15-24); seniors 65+ Sex: Male Race/Ethnicity: Aboriginal Place: Rural

Health related Substance use Mental Illness

Prevalence of TBI in persons with history of criminal justice involvement


Author, year Population N

Prevalence

Shiroma, 2010 Adults 20 60.2 Farrer, 2011 Youth + Adults 26 41.4

51.0 Farrer, 2013 Youth 9 30.6 Colantonio, 2014 Adults 270 41.2

TBI and risk of incarceration


People with TBI were more likely to be involved in the criminal justice system than those without TBI (Risk: 1.5 to 3 times greater)

Timonen et al 2002; Fazel et al 2011; Schofield et al 2015; McKinley et al 2015

TBI and impacts while incarcerated

Men with TBI had 1.9 times higher risk of behavioural infraction

Women with TBI had a 2.4 times higher risk of behavioural infraction

Shiroma et al. J Correct Health Care 2010; 16: 273-86.

Women with TBI who are Incarcerated


More likely to report history of physical abuse

More likely to report history of sexual abuse

Colantonio et al. J Correctional Health Care 2014; 20: 4: 271-279

TBI co-exists with other concerns: Men with TBI who are Incarcerated

More likely to be involved with drugs/alcohol at an early age

More likely to report family history of substance abuse

Awareness of TBI


Persons incarcerated

Many have not sought medical attention for TBI 16-18% Canada and 60% in USA

Research community

Underdeveloped area of research 3 studies on TBI in prison in Canada

Colantonio et al. J Correctional Health Care 2014; 20: 4: 271-279,, Kouyoumdjian et al. BMC Public Health 2015: 15: 419;

Correctional health care staff

Underestimate extent of TBI in prisons

Have misconceptions of TBI and its symptoms

Do not feel adequately trained to work with TBI

Awareness of TBI

Diamond et al. J Head Trauma Rehabil 2007; 33: 330-338


Awareness of TBI


In the United States: some routine screening South Carolina (Ohio State) Minnesota (TBI-questionnaire)

In Canada: (CSC) screens for TBI using a single question

Screening for TBI in correctional institutions

TBI in the Justice System: Screening and Support

Presenter

Presentation Notes

(Kate introduces herself and Pam)

Outline:

1. Signs and symptoms of TBI

2. Strategies to work with individuals with TBI

3. Introduction to a TBI Screener

4. Case scenarios for small group discussion

5. Review of group findings and summary

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Presenter

Presentation Notes

(Kate’s slide) I’ll describe the signs and symptoms of traumatic brain injury and provide some strategies to manage specific cognitive deficits and behavioural challenges. Pam will introduce a screening tool that helps to determine if the person you’re working with is likely to have a history of TBI. Then I’ll walk you through 2 case scenarios and we’ll break into small groups for you to answer a few questions. Some groups will be working on Scenario 1 and others will have Scenario 2. Then we’re going to come back together as a larger group to gather your findings and summarize our learnings.

TBI Changes Individuals

• TBI can result in significant cognitive, behavioural, physical and emotional changes to an individual

• TBI is often referred to as an “invisible” disability because there may be no obvious/outward signs of the disability, and the symptoms may be seen as other illnesses or character traits

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Presenter

Presentation Notes

(Kate)

Memory

• Memory is one of the most common cognitive deficits where the brain takes in, stores, recalls and uses information. A brain injury can affect any of these areas of memory.

• Signs of a possible memory impairment: Difficulty recalling information Having to repeat important information to the person Lack of memory of important events Difficulty following instructions

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Presenter

Presentation Notes

(Kate) Encoding- the brain’s ability to interpret information and create proper encoding in the brain Storage- The brain’s ability to store and retain the information Retrieval- being able to find and recall information that has been stored.

Strategies for Memory Impairment

Some strategies for an individual with memory impairment include: Written or verbal reminders Setting alarms for important tasks (e.g. Meds) Blister packs Developing routines Repetition and practice of important activities or tasks Use of a calendar, planner or smart phone to track

important appointments

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Presenter

Presentation Notes

(Kate) These memory strategies are assistive devices that work in place of their deficit in memory.

Attention

Signs of Attention Deficits:

Problems with staying on task Lack of retention of information Easily distracted Confusion

Attention Deficits can be confused with the following issues: Memory problems Defiance or stubborn behaviour

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Presenter

Presentation Notes

(Kate) Attention is the ability to focus on a task or a thought. It allows us to multi task and focus on important information. Selective attention: is the ability to quickly sort through incoming information and stay focused on one thing in spite of distractions Sustained attention: staying focused on a task for a period of time. Divided attention: the ability to multi task

Strategies for Attention Deficits

Decrease external distractions

Avoid fatigue, as it worsens attention problems

Have individual repeat back important information to check for understanding and retention

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Presenter

Presentation Notes

(Kate) Fatigue Give frequent breaks to avoid fatigue Schedule important tasks earlier in the day

Behavioural Changes

• People with TBI are likely to experience changes in their behaviour. Family members report that the individual “isn’t the same person” they once were.

• The following behavioural challenges can occur after TBI:

Lack of empathy Rigid and inflexible Lack of initiative or motivation, apathy Poor judgement and disinhibition Impulsive behaviour Aggressive behaviours

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Presenter

Presentation Notes

(Kate) Talking more about aggressive and impulsive behaviours on the next few slides

Aggressive Behaviours

• Aggressive behaviour is more likely to occur after a brain injury due to frontal lobe damage that can affect a person’s ability to control their behaviour and emotions

• Their reactions may be more intense through verbal and/or physical outbursts

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Presenter

Presentation Notes

(Kate) Our frontal lobes act as our filter and our emotional “breaking system”. Suddenly individuals with a brain injury will experience lack of control over their anger and find themselves acting out more readily. A person may have an extreme reaction when they feel themselves getting angry. Going from 0 to 60 in an argument or disagreement. They may be more likely to scream yell punch walls, throw things or become physically aggressive. This can be particularly challenging for people already involved in the justice system and they can continue to reoffend. Immediately: give the person space to calm The individual needs to be able to regain control of their behaviour or emotions. You cannot reason or rationalize with someone when they are out of control and trying to do so may only intensify their behaviour. Allow them to step away.

Strategies for Aggressive Behaviour

Strategies to support someone with aggressive behaviours due to TBI:

• Immediately- give the person space to calm down, if possible

• Once the person is calm - Offer feedback after the event Help them identify possible triggers Help identify signs of anger and develop plans for how to manage

that anger Support groups/behaviour therapy

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Presenter

Presentation Notes

(Kate)

Impulsive Behaviour and Disinhibition

• A person with TBI may engage in impulsive behaviour or experience disinhibition, reacting quickly without stopping to think about the consequences and saying exactly what they are thinking without “filtering” their thoughts.

• Strategies to assist someone with these problems:

Give feedback about the behaviour immediately in the moment Problem-solve and talk through potential problems Involve a Behaviour Therapist in treatment of these behaviours.

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Presenter

Presentation Notes

(Kate – Pam starts on the next slide) Describe how to access behaviour therapy at the end of slide Stealing, inappropriate sexual behaviours, making inappropriate comments

TBI Screener

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Presenter

Presentation Notes

(Pam) We want to introduce a quick TBI Screener that takes just a few minutes to complete. It’s a structured interview that asks a person about their lifetime history of TBI. The screener’s recommended for use by professionals working in social services and health care. It’s important to note that it’s an assessment tool that helps us gather history and interpret findings but we’re not able to use it to diagnose. Only a physician or psychologist is qualified to make a TBI diagnosis. This slide shows an online tutorial about the screener and you’ll find the link to this really helpful website at the end of our presentation.

Screening for TBI

Why is screening important?

• The effects of TBI can significantly impact the individual’s responsiveness to your services/treatment

• Some people don’t know they’ve had a TBI and there may be no documentation of it in their medical records

• You can use a person’s head injury history to assess their current presentation (cognitive, behavioural and emotional)

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Presenter

Presentation Notes

TBI has been called an invisible disability that impacts a person’s ability to cope with stress or adapt to new situations. And the TBI can affect their ability to respond to your services or treatment. The person might not even realize they’ve ever had a head injury. By using the screener, you’re able to ask questions that help the person speak about their history of injuries.

Case Scenario Jane Doe

• 59 year old female - Homeless in community moving between different women’s shelters and on the streets. Charged with theft and on probation

• You are her probation officer

• Client is panhandling, getting into fights and often barred from drop-ins and shelters.

• Missing her appointments with PO on a regular basis. Losing temper in meetings with PO and walking out before it’s over, yelling and swearing. Verbally abusive to office staff and does not want to wait. Often intoxicated from alcohol use.

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Presenter

Presentation Notes

(Kate) This is Jane Doe (read the slide)

Answers to questions on screener

• In asking the question on the screener you find out that the client had the following incidents in her life

• a fall off of her bike when she was 12 years old where she was left dazed but did not lose consciousness

• a fall down a flight of stairs at 25 where she lost consciousness for more than 30 minutes and was hospitalized

• had been in several fights between 45 and 50 yrs old where she was left dazed.

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Presenter

Presentation Notes

This slide shows the screener with its 3 steps outlined across the top.. In the step one box you would write Fall off bike check off no LOC then Yes to dazed and enter the age of 12 in the last box on the right. Then on the next line you would write fall down stairs and 30mins to 24 hours and then no and then age 25 Fights yes dazed and then Fights (multiple) no LOC yes to dazed and age 45 to 50yrs old.

Step 1: Record the Cause of Each Injury

5 Questions:

The goal of these questions is to help recall injuries to the head or neck by reminding the respondent about hospital visits and probing for common causes of TBI.

Don’t be concerned about whether a TBI occurred, only if it was possible.

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Presenter

Presentation Notes

In Step 1 you’ll ask the 5 questions on the left side of the page. These questions are intended to help the person recall past head or neck injuries. Check off “yes” or “no” to each of the questions. If the answer is “No” to all 5 questions then you can end the interview and assume there is no TBI. But if they answer yes, write down the cause of each injury separately in the blank column called Step 1 in the middle of the page. For the case scenario I provided you would have answered yes to the first question, no to the second question, yes to the 3rd question, yes to the 4th question and no to the 5th question. Then each question prompts you to record it in the cart of the answer is yes.

Step 2: Determine if TBI Occurred

In Step 2, you’ll ask the following questions to explore details about each injury identified in Step 1:

1. “Were you knocked out or did you lose consciousness (LOC)?”

• If yes: “How long?” • If no: “Were you dazed or did you have a gap in your memory from the injury?”

2. “How old were you?”

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Presenter

Presentation Notes

In Step 2 you’re probing and writing down details about the person’s age and if they had a loss of consciousness or memory gap. You’ll repeat these questions in Step 2 for each of the injuries. The answers will all be recorded in the form.

Step 3: Determine if History of Multiple Blows to Head

In Step 3, you’ll ask about any period of time when they may have sustained multiple blows to the head:

1. “Have you ever had a period of time in which you experienced multiple, repeated impacts to your head (e.g., history of abuse, contact sports, military duty)? If yes: • “What was the typical or usual effect––were you knocked out (LOC)?” • If no LOC, “Were you dazed or did you have a gap in your memory from the injury?”

2. “What was the most severe effect?” 3. “How old were you?”

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Presenter

Presentation Notes

In Step 3, we’re determining if the individual has any history of repeated blows to the head that they might not even realize were injuries. These might have resulted from contact sports, physical fights, abuse or military duty. In our case the individual did have repeated fights and blows to the head. You can record that in step 3.

Step 4: Interpreting the Results

A person may be more likely to have ongoing problems if they have ANY of the following:

Worst – one moderate or severe TBI

First – TBI with loss of consciousness before age 15

Multiple – 2 or more TBIs close together, including period of time when they experienced multiple blows to head

Recent – A mild TBI in recent weeks or a more severe TBI in recent months

Other sources – Any TBI combined with another way that their brain has been impaired (e.g., stroke)

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Presenter

Presentation Notes

Now let’s turn to Step 4. Please turn to the 2nd page of your screener and you’ll find a checklist on the right side of the 2nd page. You’ll use this checklist once you’ve completed the screener interview. This helps you determine if there’s a likelihood of a TBI. If you can answer “yes” to just one item on the list, then the person is more likely to be having ongoing problems. You’re thinking about whether the person reported at least one moderate or severe TBI. Did this occur before age 15? Did they have 2 or more TBIs close together? Did it happen recently? And have there been other significant events causing brain impairment, such as a stroke or drug overdose? So though we can’t diagnose a TBI, we can use this information to help us tailor our approach.

5 Scenario Questions and answers

Questions 1. Do you think the individual is likely to have a TBI with

ongoing problems related to his/her injuries? Although this is not a diagnostic tool it does give us an idea that she may have a brain injury due to the fall down the stairs, the bike accident and the fights that resulted in blows the head. 2. What symptoms or signs of TBI might he/she be presenting? Memory impairment. Aggressive behaviour Impulsivity impaired sustained attention

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Presenter

Presentation Notes

Question1. LOC and memory gap can be an indication of an ABI Question 2.Memory impairment- client is missing appointments Aggressive behaviour- yelling and wearing Impulsivity difficulty waiting for meeting Sustained attention- getting frustrated before the end of the meeting and walking out

5 Scenario Questions and Answers

3. For every sign or symptom listed above what can the worker do to support this client to be more successful in their environment? Memory- teach use of memory aid, reminder calls Aggressive behaviour- Space (in the moment) – feedback after calm, help identify triggers. Impulsivity- problem solve before she becomes impatient offering choices. Attention- make meeting time shorter or give breaks throughout.

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Presenter

Presentation Notes

Memory- Find a memory aid that she would find most useful. Those with homes and who spend a lot of time at home prefer a monthly wall calendar with their appointments on it, Some with phones and technology might prefer to use their phone to track appointments, many of those who live in shelters tend to prefer those small pocket calendars from the dollar store that can be kept discreetly in a jacket pocket and easily replaced of lost or stolen. Aggressive behaviour- find a quiet space if possible for her to calm once she has become aggressive and do not engage until she has calmed. Afterwards providing feedback on the event and finding out what caused her to become aggressive. How can she help manage that in the future. Practice is important. Impulsivity- When she arrives the PO could tell the person how long the wait will be. Offer for her to take a break before the meeting starts. Remind her of expectations in the office before she arrives. If client appears to have difficulty with sustaining her attention through the entire meeting you might have shorter meetings more frequently or build in some breaks where she can go outside and smoke, have a short walk or even a quiet moment to reset.

5 Scenario Questions and Answers

4. What aspects of their environment might make their possible symptoms worse? -multiple distractions of a busy office, stress of topic of meetings, having to wait for an appointment, etc. 5. Without use of the screener how might these symptoms be interpreted? - Individuals with these types of impairments can be interpreted as being purposely difficult, being angry and dangerous, frustrated and frustrating to work with.

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TBI Resources

Information: • Brainline - TBI info online www.brainline.org • Ontario Brain Injury Association www.obia.ca

Referrals: • In Toronto - Toronto ABI Network at www.abinetwork.ca (e.g., day programs, case

management, housing, Behaviour Therapy and specialists) • Outside Toronto visit www.obia.ca for a directory of local ABI services • Brain Injury Society of Toronto (BIST) www.bist.ca (support groups and social activities for

people with brain injuries)

TBI Screener: • Template is available at:

http://www.brainline.org/multimedia/presentations/OSU/includes/pdf/OSU_TBIform_July2013.pdf

• Screener tutorial - http://ohiovalley.org/tbi-id-method/

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Presenter

Presentation Notes

We’ve given you with a copy of our slides which includes this TBI resource list. Here you’ll find websites for the screener and referral information. Thank you.

http://www.brainline.org/

http://www.obia.ca/

http://www.abinetwork.ca/

http://www.obia.ca/

http://www.bist.ca/



http://ohiovalley.org/tbi-id-method/

Questions? Comments? Contact information of the speakers:

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Kate Moore: [email protected] Flora Matheson: [email protected] Kathryn McIsaac: [email protected]

Thank you for listening!

For more information about the Provincial HSJCC and to join the mailing list, visit: www.hsjcc.on.ca

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traumatic brain injury and the criminal justice system · 2019-12-12 · 15 \⠀䬀愀琀攠ᤀ猀...

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