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Marlena M. Wald, MPH, MLS — Sharyl R. Helgeson, RN, BAN, PHN — Jean A. Langlois, ScD, MPH, Brain Injury Professional magazine (page 1 of 4) Page 1 of 4
Acknowledgments
The authors thank Heather Day and Jon Roesler from the Minnesota Department of Health for their assistance in analyzing the data, and Steven Allen and Ken Carlson of the Minnesota Department of Corrections, John Corrigan, and Pamela Diamond for their contributions to this work.
Disclaimer
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Background
Approximately 2.2 million people are currently in US prisons and jails (DOJ 2006). Although women account for about 8% of those incarcerated (DOJ 2006), from 1990 to 2000 the number of women in prisons and jails more than doubled (DOJ 2006). Ensuring the successful community re-integration of prisoners is of concern since approximately 95% of people incarcerated in jail or prison will be released at some point (Commission Report, 2006).
Prevalence and causes of TBI among prisoners
The impact of traumatic brain injury (TBI) in the prison setting has not been well-recognized but is potentially quite great. Previous studies suggest that a history of TBI is common among inmates, including women, occurring among an estimated 25-87% of the jail and prison population (Figure 1). In contrast, it is estimated that 8.5% of non-incarcerated adults report a history of TBI (Silver et al, 2001). These data suggest that the prevalence of a TBI history may be as high as 10 times that of the general population.
Some more recent findings shed new light on the epidemiology of TBI among prisoners. In a recent survey conducted among male state prisoners in Minnesota, a history of having head injury was assessed using the Traumatic Brain Injury Questionnaire (TBIQ) (Diamond et al., 2007). Of the 998 inmates assessed, 82.8% reported having had one or more head injuries during their lifetime, which is consistent with a previous study (Slaughter et al., 2003). The majority were reportedly caused by assaults, followed by automobile crashes and sports (Figure 2). Of note, some of the specific causes of assault-related TBI among prisoners are unique. For example, in the Minnesota project, some of the reported head injuries among incarcerated gang members were the result of a gang initiation procedure called "pumpkinhead" in which new gang members are beaten until their heads swell "like pumpkins." Also, anecdotal reports from corrections officials in South Carolina indicate that self-inflicted TBIs occur when inmates purposely knock their heads against the bars or the cell floor until they become unconscious. This usually happens when inmates are moved to isolated cells (Anbesaw Selassie, DrPH, Medical University of South Carolina, Personal Communication, November 2007).
As an example of how common TBIs are among prisoners, in a recent study of TBI among federal prison inmates, a high percentage of women reported a history of TBI, especially multiple concussions, often totaling 10 or more, and these were usually associated with interpersonal violence (Pamela Diamond, PhD, University of Texas-Houston, Personal Communication, October 2007). One subject in this study estimated that she had been hit in the head and often knocked unconscious by her boyfriend nearly every weekend during a three year period prior to entering prison. According to the study interviewers, many of the women seemed to describe the experience of multiple concussions in a matter-of-fact way, as though they were an expected part of life.
TBI-related secondary conditions
Although a history of TBI is quite common among the offender population, not all TBIs result in long-term disability. The prevalence of long-term problems resulting from these injuries has not been established. However, traumatic brain injury among prisoners is of particular concern because it often results in cognitive, social, emotional, and behavioral problems, including aggressive behavior (NIH Consensus Conference, 1998), and secondary conditions such as substance abuse that can greatly affect their ability to function both while they are in prison and after they return to the community. (Coid, 2005; Merbitz et al., 1995) Knowledge that these problems are related to TBI as opposed to other etiologies would help inform the implementation of TBI-specific interventions, resulting in more effective management and rehabilitation and ensuring greater potential for successful community reintegration.
Individuals with a history of TBI are significantly more likely to have problems with alcohol or other substance abuse (SA) compared with persons without TBI (Silver et al., 2001). However, the relationship between TBI and substance abuse problems among prisoners has not been well-studied. The limited literature to date suggests that cognitive problems associated with a past history of traumatic brain injury (TBI) may affect inmates' potential to succeed in rehabilitation (Valliant, et al, 2003; Corrigan, 1995), including SA treatment (SAMHSA, 1998a).
TBI can result in irritability or aggressiveness, including explosive outbursts, which can be set off by minimal provocation or occur without warning (Silver et al, 2005). Among male prisoners, a history of TBI is strongly associated with perpetration of domestic violence (Cohen et al, 1999), and female prisoners who are convicted of a violent crime are more likely to have had a pre-crime TBI and/or some other form of physical abuse (Brewer-Smyth, 2004). In the prison setting, such aggression and other behavioral disturbances can lead to further injury for the prisoner or others (DOJ 2001; Maryland Police, 2001) and affect corrections center management (Schofield et al, 2006; Merbitz et al, 1995). Aggressive or violent behavior is also associated with recidivism (Coid, 2005). Thus, screening for TBI within the prison setting has been recommended to identify inmates with TBI-related behavior problems and help inform improved inmate safety and management (Schofield et al., 2006). Offenders exhibiting TBI-related aggression might also be taught behavioral and cognitive strategies to inhibit aggressive behaviors (Cohen et al., 1999), although to our knowledge this has not been demonstrated in a prison population.
Although few studies have investigated the topic, homeless-ness has been found to be associated with both imprisonment (Kushel et al., 2005) and with a history of head injury (Bremner et al., 2005), but the role of head injury (or TBI) as a risk factor has not been well described.
From Brain Injury Professional, The official publication of the North American Brain Injury Association, Vol.5, Issue 1. Copyright 2008. NABIS/HDI Publishers. Reprinted with permission. All rights reserved.
