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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 2 of 4) Page 2 of 4
Identifying a history of TBI
Screening for traumatic brain injury in prisons has been recommended as a means of informing more effective substance abuse treatment (SAMHSA, 1998b) and inmate management (Schofield et al, 2006; Kaufman, 2005) within corrections facilities.
Anecdotal reports suggest that although some prison intake interviews ask about a history of head injury or TBI, valid and reliable measures for TBI screening have not routinely been used in the prison setting (John Corrigan, PhD, Ohio State University, Personal Communication, July 2006). Results from the recent Minnesota project (see above) suggest that a routine intake question asking if the inmate ever had a head injury was inadequate in identifying head injury. Of the 998 inmates interviewed in that project, only 10 (1 percent) reported a history of head injury during the intake screening, as compared with 826 (83%) who reported having had at least one according to results from the TBIQ, a more detailed screening questionnaire. Similarly, Diamond and colleagues (2007) reported that a one-item, self-administered screener used during admission to prison detected only 19% of the TBIs identified via structured interview. Thus, detailed screening is needed to more accurately identify inmates with a history of TBI.
Some important factors must be considered, however, before screening is begun. First, a good working relationship must be established with corrections officials who initially may have little understanding of the potential importance of TBI within their inmate populations. (Kaufman, 2005) However, their concern for the health and safety of both inmates and corrections officers may be a good starting point for initiating discussions about implementing screening for TBI. Dissemination of fact sheets produced by the CDC, including one specifically aimed at educating criminal justice professionals, could be helpful. (See Sidebar). Second, identification of inmates with TBI should lead to some beneficial action, and establishment of a plan to assist screened populations ideally should be established before screening begins. Some of the potential benefits of screening for TBI among prisoners are that it could lead to improved treatment or management that takes into account the cognitive problems that interfere with the potential of inmates with TBI to adhere to rehabilitation programs designed for persons without TBI. Programs that could benefit from knowledge of a history of TBI include substance abuse treatment, training for victims of violence in strategies to decrease risk, and for perpetrators to manage aggressive behavior, and work assignments, all of which should be tailored to account for TBI-related deficits. Strategies to help victims of violence decrease their risk of re-injury could be implemented. In the long-term, successful implementation of such strategies could lead to more successful reintegration of inmates into work or school, decreased risk of homelessness, and decreased risk of recidivism. Although much more research is needed to design and validate more effective rehabilitation pro grams for inmates with TBI, successful pilot projects could help inform the development of future, more effective interventions.
Once it's decided that a screening program should be implemented, selection of the appropriate screening instrument is important. Selection of a validated screening tool will help ensure that identification is as accurate as possible and help to avoid mislabeling someone as having had a TBI (false positive), or missing a history of TBI (false negative). Two screening tools have been developed specifically for use with incarcerated populations and validation of these measures is currently in progress. First, the Traumatic Brain Injury Questionnaire (TBIQ) (Diamond et al, 2007) is an interviewer-administered instrument with three sections: Section I consists of items asking whether the respondent has ever experienced a head injury from 12 situations associated with such injuries (e.g., vehicle crashes, falls, assaults). Section II probes for details of the head injuries reported in Section I. Questions include age at the time of the injury, whether there was any loss of consciousness or post-traumatic amnesia, and what care was received. Section III assesses the frequency and severity of 15 cognitive and physical symptoms commonly found with head injury (e.g., trouble concentrating or remembering, dizziness or headaches). Of note, inmates are asked about "head injuries" rather than "brain injuries" because the developers of the instrument found that inmates did not understand the term brain injury. The Ohio State University TBI Identification Method (OSU TBI-ID; Corrigan et al, 2007) consists of two steps: Step 1 asks participants to recall any injuries involving a blow to the head or neck or high velocity forces that could have shaken the head violently. Step 2 collects more detailed information about each injury, including whether consciousness was altered, medical attention was received, and if any TBI-related symptoms were experienced after the injury. For both measures, the length of time required to administer them depends on the number of injuries reported. However, the TBIQ takes an average of 15 minutes and the OSU TBI-ID takes about 5 minutes to administer. The OSU Method is also available in a short-form version.
Though useful for identifying offenders with a history of TBI, screening measures are not designed to determine whether specific deficits in function are present. Thus, additional testing may also be needed to identify the smaller sub-sample of inmates with TBI-related deficits who are in greatest need of attention or intervention. For this reason, the Minnesota project is conducting additional testing of inmates who screened positive for a history of TBI using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). The RBANS is a brief screen for assessment of cognitive deficits that has been shown to be useful in evaluating cognitive problems associated with TBI (McKay et al, 2007). With further validation, it is hoped that the OSU method will also provide information that can be used to identify particular characteristics of a history of TBI (severity, age at injury, etc.) that will help identify the inmates who are most in need of intervention. Administration of more detailed neuropsychological batteries may also be needed and helpful if resources are available.
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.