Identifying Brain Injury in State Juvenile Justice, Corrections, and Homeless Populations Sharyl R. Helgeson, RH, PHN, Brain Injury Professional magazine Page 1 of 4

Challenges and Promising Practices

Introduction

A young man, in his mid-twenties, hospitalized in a mental health unit, was admitted with the following complaint, “There is some­thing wrong with my head and I can’t keep a job.” During a clini­cal interview, he revealed that his father had not been in his life for almost twenty years. His father had been physically abusive and he was subsequently hospitalized for broken bones. When he was school age, he was hit by a car, resulting in hospitalization for multiple injuries. He was placed in Special Education, as he had trouble learning and controlling his behavior in class. As an ado­lescent, he began using multiple drugs as well as alcohol. While still a teen, he was involved in another incident, resulting in hos­pitalization for several days. Thereafter, his ability to concentrate, remember, and control his temper became even worse.

After high school, he enlisted in the National Guard and served in Iraq for several months. He was injured in an attack, later describing this experience as ‘severe PTSD’. Once he was back in the states, he could not keep a job. His use of drugs and alcohol escalated and he was jailed for various offenses. He had nowhere to sleep except his car. A mental health crisis resulted in hospitalization. The clinician recognized the likelihood of trau­matic brain injury (TBI). Neuropsychological testing revealed to the multidisciplinary treatment team problems with his multiple conditions.

This young man was indeed a case of “Unidentified TBI”. Once brain injury was identified as a contributing factor, he was linked to appropriate services and supports and was able to get supported employment and move along with his life.

Why mix a discussion of diagnoses, of clinical conditions, with discussion of life circumstances such as homelessness or in­carceration? For those who know individuals with these very complex and multiple conditions, or who work with them as clinicians, the stories are all too familiar. In addition, state sys­tems may be designed for one purpose, such as public safety (e.g. corrections and juvenile justice systems) or treatment for one condition (e.g. alcohol/substance abuse, mental illness, or brain injury) or the lack of appropriate services will result in homeless­ness for many individuals. In addition, individuals with TBI may have overlaying mental health and substance abuse problems that complicate appropriate diagnosis, treatment and care.

While nearly every state screens for mental health problems within juvenile justice systems according to the National Cen­ter for Mental Health and Juvenile Justice, screening for TBI has not been universally adopted. Similarly, most state corrections, mental health and alcohol and substance abuse agencies collabo­rate with regard to screening and treatment programs for inmates with these problems. An emerging trend across the country is to establish veterans’ treatment courts for nonviolent offenders, rec­ognizing that veterans with mental health and substance use issues end up involved with the criminal justice system (Stateline.org). Although TBI is generally omitted from these initiatives, these collaborative efforts provide opportunities for TBI state programs to educate other systems about TBI in order to better address the needs of individuals with TBI in their systems, as well as to de­velop appropriate release planning that links individuals to TBI services and supports for those who return to the community.

The purpose of this paper is to highlight examples of state responses to the overlapping sub-populations of persons with al­cohol and substance use disorders, persons who are in or have been involved with criminal justice and corrections systems, and those who are homeless.

The Problem: Recognizing TBI

In a publication produced by the New York TBI Model System at Mt. Sinai, it was noted that TBI is often the “hidden” dis­ability that is undiagnosed, yet it can be the cause of cognitive problems, including poor judgment, poor memory, and lack of good communication skills; behavioral and personality problems and disorders; and poor social skills. As such, individuals may drop out of school, or may be unable to obtain or maintain a job or are poor risk takers resulting in incarnation in adult and juvenile correctional systems (New York Model Systems, 2006).

Unless medical documentation is available or a TBI screen­ing is in place, systems that have primary functions other than TBI, will not document TBI. In its study of TBI and residents of Missouri youth services facilities, the researchers noted limi­tations with regard to the reliance on self-reporting for deter­mining TBI, as TBI information was generally not included in medical records. Despite these limitations, the findings indi­cated that nearly one-in-five youths, 18 %, reported a lifetime TBI. These individuals were significantly more likely to be male, have received a psychiatric diagnosis, reported an earlier onset of criminal behavior/substance use and more lifetime substance use problems and past-year criminal acts, than those who did not report a TBI (Perron & Howard, 2008).

In a Wisconsin study involving 90 homeless men, 80% were found to have evidence of cognitive impairment (Solliday-McRoy, et al., 2004). The author of a monolith on homeless and TBI not­ed that with regard to the over 3,000 comprehensive psychiatric evaluations of persons experiencing homelessness performed by the author, at least half reported histories of blows to the head sus­tained as the result of childhood physical abuse or motor vehicle crashes, falls, or sporting injuries (Highley and Proffitt, 2008).

The Centers for Disease Control and Prevention (CDC) found that 25-87% of inmates report having experienced a head injury or TBI as compared to 8.5% in a general population re­porting a history of TBI. As noted in another study regarding the prevalence in correctional facilities, TBI can create challenges to offenders and to their successful community reentry upon re­lease. This study noted other articles that reported in-prison be­havior related to brain injury and associated rates of disciplinary incidents and inability to adapt to prison life and rules (Solliday-McRoy, 2004).

From Brain Injury Professional, the official publication of the North American Brain Injury Society, Vol. 7, Issue 4. Copyright 2011. Reprinted with permission of NABIS and HDI Publishers. For more information or to subscribe, visit: www.nabis.org.

Brain Injury Professional is the largest professional circulation publication on the subject of brain injury and is the official publication of the North American Brain Injury Society. Brain Injury Professional is published jointly by NABIS and HDI Publishers. Members of NABIS receive a subscription to BIP as a benefit of NABIS membership. Click here to learn more about membership in NABIS.

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