Challenges and Promising Practices
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).
Crosscutting Issues: Substance Abuse and Mental Health
The literature reveals that persons with the co-occurrence of substance use disorders and mental illness may have a high rate of TBI, which can complicate treatment and can impact a person’s ability to manage ‘stability’ in community living (Corrigan and Deutschle, 2008). With regard to inmates the CDC study found:
- Prisoners who have had head injuries may also experience mental health problems such as severe depression and anxiety, substance use disorders, difficulty controlling anger, or suicidal thoughts and/or attempts.
- Studies of prisoners’ self-reported health indicate that those with one or more head injuries have significantly higher levels of alcohol and/or drug use during the year preceding their current incarceration.
Addressing the Problem: Promising Practices
Some states have begun to address the identification of individuals with TBI in juvenile justice, corrections, mental health and substance abuse systems. A few state legislatures have passed legislation directing the state agencies to study the needs of inmates including those with TBI. Another impetus has been the US Health Resources and Services Administration (HRSA) TBI Program which awards grants to states to expand service delivery. These efforts include education and training of sister state agencies; screening and identification, and initiated collaborative efforts to improve diagnosis, treatment and care of those with TBI and co-occurring conditions. Examples are listed below.
A) Education and Training
Maryland’s HRSA Federal TBI State TBI Implementation Partnership Grant funds training for Community Mental Health Centers and other systems on TBI issues, and funds were used to provide materials produced by the Ohio Valley Center for Brain Injury Prevention and Rehabilitation for practical guidance in assessment, planning, and accommodations for those with TBI and co-occurring conditions.
The Minnesota TBI program, in collaboration with the Department of Corrections, developed on-line training (three modules) for correction’s staff, including training on release planning and TBI resources.
B) Screening and Identification
States are using various screening tools, usually those developed by the National Institute on Disability and Rehabilitation Research (NIDRR) TBI Model Systems or Centers for Disease Control and Prevention (CDC), to screen for TBI. In each of those states, researcher consultation assists the efforts to implement the screening processes and to analyze results.
Alcohol and Substance Abuse
Kentucky added a TBI question to their annual alcohol and substance abuse screening to determine the number of individuals seeking substance abuse rehabilitation and treatment that also have a TBI. An analysis of the findings of Kentucky’s TBI screening question found that almost one-third (31.7%) of substance abuse treatment clients reported one or more TBI-related loss of consciousness (LOC). The clients reporting two or more TBI-LOCs were more likely than clients with none or one TBI-LOC to have serious mental health problems (i.e., depression, anxiety, hallucinations, and suicidal thoughts and attempts), trouble controlling violent behavior, trouble concentrating or remembering, and more months of use of most substances (Walker, et al., 2007).
Minnesota uses the Traumatic Brain Injury Questionnaire (TBIQ) to survey inmates in correctional facilities and youth in juvenile detention centers. In a screening of 998 male state inmates 82.8% reported having had one or more TBIs during their lifetime (Wald, et al., Slaughter et al., 2003). South Carolina is using the Ohio State University Traumatic Brain Injury – Identification Method (OSU TBI-ID), as modified by South Carolina, developed by John D. Corrigan PhD, ABPP, and Jennifer Bogner PhD, ABPP, to screen inmates.
Texas is using the Brain Injury Screening Questionnaire (BISQ), developed by the New York TBI Model System, to screen approximately 3,000 children and youth in juvenile detention and 203 youthS served through the Texas Juvenile Probation Commission for unrecognized TBI. The state is using its HRSA TBI Systems Change Implementation Partnership Grant to conduct the screening.
Since 1991, the Minnesota Wilder Research Foundation surveys persons without permanent shelter every three years. Questions to address brain injury were incorporated in 2003. In the most recent survey, in 2009, 35% of adults who were homeless at least a year reported symptoms of a TBI; 38% reported a cognitive disability; 59% have a serious mental illness; 49% reported a chronic health condition, and 27% reporting a drug or alcohol disorder. The reporting of mental health problems and cognitive disabilities and symptoms of TBI has been increasing over time (Wilder Research Foundation).
C) Collaboration Across Agencies
In Minnesota, the Governor’s plan to end long-term homelessness has been jointly led by three state agencies: the Minnesota Departments of Corrections, Human Services, and the Housing Finance Agency. The state legislature provided funding for pilots which were later funded as part of a collaborative related to the Long-Term Homelessness Supportive Services fund.
In addition, the Department of Corrections is developing a release planning program specific to the needs of offenders with TBI, including culturally appropriate services for Native Americans returning to their communities. The Minnesota Department of Corrections is a partner in Minnesota’s HRSA TBI State Implementation Partnership Grant administered by Human Services.
The South Carolina Department of Corrections is a key partner with the CDC funded research grant to the Medical University of South Carolina to study the prevalence of TBI and adverse health conditions among incarcerated adults. Additionally, the study is looking at the potential impact of TBI on community reintegration.
D) Expanding TBI Programs
Collaborating with shelters and other programs is another important strategy. The Massachusetts Brain Injury and Statewide Specialized Community Services, a component of the Massachusetts Rehabilitation Commission, has been a pioneer in focusing on homelessness for approximately fifteen years. Efforts include the availability of Stateside Head Injury Program (SHIP) staff who provide intensive outreach in shelters to identify individuals with brain injury, including veterans. The program staff also provides TBI training for personnel in various systems. SHIP provides intensive case management through trained brain injury specialists who link individuals to services.
Another example of expanding TBI program services is the New York’s Neurobehavioral Resource Project, which was developed to assist persons with TBI with significant community reintegration challenges served by the state’s TBI Medicaid Waiver. The individuals served have chronic behavioral difficulties along with a co-occurring diagnosis of substance abuse and/or mental health disorder. The highly skilled staff provide on the scene, tailored positive behavioral supports consultative and training services which have been proven to be cost-effective (Ylvisaker, et al. 2007).
E) Using Federal Resources
Several federal agencies administer grant programs associated with homelessness which states and other organizations may apply to address the daunting problem of persons who are homeless; often with multiple and confounding health issues. These agencies include the US Housing and Urban Development (HUD), SAMHSA, HRSA, and the Department of Veterans Affairs.
The Project for Assistance in Transition from Homelessness (PATH) is administered by the Center for Mental Health Services within SAMHSA and is a formula grant to states and territories providing funding for persons with serious mental illness, including those with co-occurring substance use disorders who are experiencing homelessness or at risk of the same.
Another approach is to coordinate multiple grants. Minnesota’s current HRSA TBI Implementation Partnership Grant is focusing on two Department of Corrections (DOC) facilities and their substance use treatment programs that were voluntary implementation sites for a Co-occurring Disorders State Incentive Grant (COSIG) from SAMHSA to implement Integrated Dual Disorder Treatment (for persons with mental illness and substance use disorders).
The collaboration supported by these two projects provided an impetus to develop a TBI screening protocol system to track offenders identified with TBI who require complementary services to support an effective chemical dependency treatment experience. This will also lead to the development of community resources to prepare for discharge from prison with linkage to appropriate supports. As the result of a previous Minnesota Department of Education Physical and Neurological Disabilities Assistance (PANDA) grant, funded by US Office of Special Education, the TBI project is able to collaborate with the PANDA Coordinator, who is an Adult Basic Education Teacher and is also a Certified Brain Injury Specialist, to train DOC educators and offender mentor tutors.
State government works in partnerships with other agencies to administer and pay for services and supports to meet the needs of their citizens with TBI who often have complex needs. States rely on the researchers, the advocacy community, practicing clinicians and providers, as well as individuals and family members to inform and assist in promoting the development of effective programs and options in filling gaps in the continuum of services and supports needed by persons with brain injury. States use a variety of approaches to build a safety net, often times incrementally, with a patchwork of seed monies through grant projects, state funding or trust funds, and strategies to serve persons with brain injury in various disability programs. Since many individuals with TBI, including those with dual diagnosis, are also served by juvenile and correctional systems, states are beginning to reach out to those agencies to better address their needs.
- National Center for Mental Health and Juvenile Justice. Mental Health Screening Within Juvenile Justice: The Next Frontier. Retrieved from: http://www.ncmhjj.com/pdfs/MH_Screening.pdf.
- Stateline.org. Funded by the Pew Center on the States. Retrieved from: http://www.stateline.org/live/details/story?contentId=407573
- New York Model TBI System. TBI Research Review – Policy & Practices: Unidentified Brain Injury. New York, NY: NYTBIMS. 2006. Retrieved from: https://tbitac.norc.org/download/screeninginstruments.pdf.
- Perron B and Howard M. Prevalence and correlates of traumatic brain injury among delinquent youths. Criminal Behaviour and Mental Health. 2008; 218: 243-55.
- Solliday-McRoy C., Campbell TC, Melchert TP, Young TJ, Cisler R.A. Neuropsychological functioning of homeless men. Journal of Nervous and Mental Disease. 2004; 192(7), 471-478.
- Shiroma EJ, Ferguson PL, Pickelsimer EE. Prevalence of traumatic brain injury in an offender population: a meta-analysis. Journal of Correctional Health Care. 2010; 16(2) 147-159.
- Highley JL and Proffitt, BJ. Traumatic Brain Injury Among Homeless Persons: Etiology, Prevalence and Severity. Nashville: Health Care for the Homeless Clinicians’ Network, National Health Care for the Homeless Council, Inc., June 2008.
- Centers for Disease Control and Prevention. Traumatic Brain Injury in Prisons and Jails: An Unrecognized Problem. Retrieved from:http://www.cdc.gov/traumaticbraininjury/pdf/Prisoner_TBI_Prof-a.pdf.
- Corrigan JD, Deutschle JJ Jr. The presence and impact of traumatic brain injury among clients in treatment for co-occurring mental illness and substance abuse. Brain Injury. March 2008; 22(3): 223-231)
- Wilder Research, Wilder Foundation. (2010). Homelessness in Minnesota: Key Findings from the 2009 Statewide Survey. Saint Paul, MN; 2010. Retrieved from: www.wilderresearch.org.
- Ylvisaker M, Feeney T, Capo M. Long-term community supports for individuals with co-occurring disabilities after traumatic brain injury: cost -- effectiveness and project -- based intervention. Brain Impairment. 2007; (8)3 276-292.
- Walker R, Cole JE, Logan TK, Corrigan JD. Screening substance abuse treatment clients for traumatic brain injury: prevalence and characteristics. Journal of Head Trauma Rehabilitation. 2007; 22(6) 360-367.
- Wald, MM, Helgeson SR, Langlois JA. Traumatic brain injury among prisoners. Brain Injury Professional. 2008; 5(1) 22 – 25.
ABOUT THE AUTHOR
Sharyl R. Helgeson, RN, PHN, Mental Health Program Consultant, has held a variety of public policy positions for over twenty years in the MN Department of Human Services (DHS). She has served as Project Director for Minnesota’s five HRSA Federal TBI State Grants; the current and most recent being conducted in partnership through Minnesota Department of Corrections. She has experience in brain injury and co-occurring conditions in mental health, post-acute rehabilitation, and nursing facility settings. She’s active in the National Association of State Head Injury Administrators and serves on its Board.
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.