Guidance

Traumatic brain injury in the prison population

A summary of evidence about traumatic brain injury (TBI) in the prison population, it’s effects and how to help people with TBI.

Traumatic Brain Injury (TBI) may be a key factor in crime and in psychological wellbeing. It is linked to violence and suicidal behaviour. It can be readily screened for, and in different ways, managed. But more work is needed to identify how this may be best done.

What is TBI and who is at risk?

Brain injury is a major cause of death and disability in children and working age adults1. Acquired Brain Injury (ABI) may occur for many reasons. It is usually a result of trauma, infection, or stroke.

TBI is the biggest cause of injury and often results from an external force to the head. It is one of the leading causes of death and disability in young people and adults worldwide.

The most common causes are falls, road traffic accidents, being struck by/against objects, and assaults. Most are mild, with minor symptoms which usually go away after a few weeks. More severe injuries can lead to cognitive and developmental difficulties. These include problems with attention and concentration, planning ahead, and memory. Often there are changes in personality, typically with impulsiveness, poorer temper control & social skills. Experiencing several, more minor, TBIs can have a similar impact as having one severe injury.

People most at risk of TBI tend to be:

  • from a low socio-economic status
  • children under 5 and young people between 13 and 22 years old
  • with low education
  • male, and
  • with a tendency for risky behaviour

TBI is higher in vulnerable groups like:

  • homeless people
  • substance abusers
  • prison populations, and
  • those with mental health problems, especially suicidal behaviour

How good is the evidence?

There is good quality international evidence on TBI in prison populations and in England and Wales, but these use different sampling methods and definitions. This makes it difficult to identify the severity of TBI and link it to frequency or severity of crime2. Although it seems that a TBI, in general, doubles the risk of more serious forms of crime. There is a clear need for future studies to use valid and reliable measures in screening of TBI.

How many people in prison have a brain injury?

TBI in prison populations is much higher than the general population. Around half or more people in prisons may have had a TBI compared to less than 1 in 10 of people in the general population. Possibly 2 in 10 people in prison have had a serious TBI. The rate is high in male and female prisoners3 . Many women suffered their injuries in intimate partner violence.

Does TBI make it more likely that someone will commit crime?

Yes. There is a relationship between TBI and criminal, violent behaviours, imprisonment and recidivism. There is some debate about how the relationship works although it seems that a TBI, in general, doubles the risk of more serious forms of crime. TBI raises the likelihood of committing crime for both men and women. People with more than one TBI have higher rates of criminality. Injury in childhood and young adulthood may be particularly associated with criminality.

Aggressive behaviour, temper outbursts and disinhibition increase with TBI. These problems relate to offending behaviour and inprisonment. Injuries tend to be within frontal areas of the brain that are important for control of emotions. Therefore, injury affects these skills. Injury to a developing brain may affect the future development of these skills. TBI in frontal areas of the brain links with violent and criminal behaviour, and an increased risk of impulsive aggression.

What does TBI mean for people in prison?

A moderate TBI can result in a range of cognitive and developmental impairments and difficulties, like difficulty in processing information , social impairments and aggression. TBI also often occurs alongside other problems, like drug-use, and mental health issues. People with TBI can find adjusting to prison life difficult. They are more likely to self-harm, are easily led into trouble by others, liable to aggressive outbursts and breaking rules. They may not understand “the rules” as they have poorer language and memory skills.

What can we do better to help people with TBI?

We need routine, effective and standardised screening and assessment for TBI. Initial screening tools should be brief for use in courts, prison and probation. Ideally screening should take place at the earliest contact.

TBI should be referred to in pre-sentence reports so it is considered in decision-making about individuals. Where TBI is indicated by an initial screening it should be referred for further assessment by Healthcare professionals.

Increased staff awareness and training of TBI will improve how we help and manage affected people through the system.

People with TBI often have problems with memory, planning and managing emotion. They can appear hard to manage in the criminal justice system, particularly in prison. Sanctions and punishments will not work. People with TBI need help and coaching to manage their feelings and experiences.

Being in prison presents specific challenges for people with TBI. But there is a need for better awareness and understanding of TBI across the criminal justice system. For example:

  • early identification prior to sentencing is crucial
  • understanding how a TBI may affect someone’s ability to comply with community supervision
  • evidence-based resources for frontline staff can help them effectively and fairly manage people with TBIs throughout the offender journey
  • more effective management of people with TBI across the system can improve continuity of care and the effectiveness of community supervision

Tips to help manage people with TBI:

  • provide extra support and help with court proceedings, prison rules, and completing forms
  • don’t expect people to understand complex instructions or remember an instruction next time - explain things in clear, simple language and be prepared to repeat what you say.
  • where possible give simple written guidance as well as verbal
  • focus on short-term goals and break down objectives into steps to achieve - people with TBI may not be able to think about multiple long-term goals
  • provide extra time for decision-making and for taking instructions on board
  • speak calmly - shouting instructions or orders to someone with a TBI may cause confusion or panic
  • talking about their TBI and its effects can help people understand their own behaviour - seek guidance on how to do this from professionals like G.P.’s, Clinical and/or Forensic Psychologists
  • memory aids like diaries, attention and thought records can help with memory problems - use pictograms and visual aids to help when verbal skills are affected
  • self-calming through mindfulness and relaxation, and increasing awareness and identifying triggers for anger
  • support for mental health, managing impulsivity, and aggression could help people manage some of the difficulties which arise from their TBI
  • being patient, flexible and supportive with individuals is important as are regular ‘brain breaks’ - many people with a TBI may struggle to concentrate after 20 to 30 minutes so use short 5 minute distraction activities in between
  • only coaching will help people manage themselves better, using punishment for aggressive outbursts, poor behaviour or misconduct will not help

Further reading

Tips & Tricks for Individuals with a Brain Injury resource provided by The Disabilities Trust to assist those working with adults who present with a brain injury

Young people with Traumatic Brain Injury in custody: An evaluation of a Linkworker Service Williams WH and Chitsabesan P. Barrow Cadbury Trust and The Disabilities Trust. (2016)

Traumatic brain injury: a potential cause of violent crime? Williams, W. H., Chitsabesan, P., Fazel, S., McMillan, T., Hughes, N., Parsonage, M., & Tonks, J. (2018). The Lancet Psychiatry, 5(10), 836-844.

Time for change. All-party parliamentary group on acquired brain injury report (2018)

Making the Link: Female Offending and Brain Injury The Disabilities Trust (2019)

References

  1. Repairing Shattered Lives (2012) A comprehensive review of brain injury and its implications for criminal justice published by the Barrow Cadbury Trust on behalf of the Transition to Adulthood Alliance.

  2. Traumatic brain injury and offending: an economic analysis Parsonage M. London: Centre for Mental Health; 2016.

  3. Traumatic brain injury and offending: an economic analysis Parsonage M. London: Centre for Mental Health; 2016.

This page summarises the available evidence base and is informed by independent academic peer review. It does not represent Ministry of Justice or Government policy.

Published 3 October 2019