Due to the cognitive, behavioural, psychological and emotional manifestations of childhood acquired brain injury (ABI), it is possible that some young people affected by ABI have a higher likelihood of entering the criminal justice system 24% - 32% general public (McKinley et al, 2008; McGuire et al, 1998) and 65% - 72% young offenders institution (Williams et al, 2010; Davies et al, 2012); and once there, their neurological needs are frequently poor or indeed appropriately supported.
By providing better and appropriate support, earlier in life, there is potential to reduce the offender population it is our argument that this must start to take place within the education environment and with the full support of educators.
The Child Brain Injury Trust (CBIT), a lead provider of family support in the UK following childhood ABI understand not only the difficulties families face following injury, but also the complexities of associated brain injury on adolescent behaviour and how it can change over time.
Generally we have found that educators, health professionals and other associated practitioners such as social workers often do not have the time or necessary expertise to manage individuals with ABI and as such many of these professionals find themselves facing a different person than they knew before the brain injury who now may have issues with concentration, fatigue, social interaction, behaviour, memory for example and find themselves on a road that they were not expected to travel. In our experience this can also cause a significant and detrimental pressure on the young person with the ABI and their family.
According to the Independent Commission on Youth Crime & Antisocial Behaviour, (2010) the cost of youth Crime and antisocial behaviour in 2008/9 was in excess of £4Billion and is generally linked to a break down in communities, lack of family support and / or lack of resources. We suggest that it is equally important to acknowledge causal factors such as ABI in understanding criminal behaviour.
Children and young people with ABI are frequently misunderstood by authority figures, peers, families and friends. Their often disinhibited behaviour can mean that they are more likely to take risks, get in with the wrong crowd and have particular difficulties with social competence including problem solving, making sound judgement and understanding consequences. This coupled with other common issues associated with brain injury sets the scene for an uneasy future for these individuals.
This paper aims to inform the reader of the very practical approach the Child Brain Injury Trust is taking to reduce youth offending behaviour and to provide support to families affected by ABI.
Start reducing crime in early years
There is still a lack of knowledge about ABI within education in the UK even though there are many published articles and books including Sue Walker’s and Beth Wicks’ Educating Children with Acquired Brain Injury 2005 which describes the difficulties children may face following ABI. There is however no evidence to show that there are any formal training opportunities for teachers, Special Educational Needs Coordinator’s (SENCOs) and Educational Psychologists (EP) about understanding and managing children and young people with ABI.
Many professionals report they have worked with a child who has had learning or behavioural difficulties, but they just could not put their finger on exactly what the diagnosis could be. Many symptoms of an ABI are similar to those of children with Attention Deficit Hyperactivity Disorder (ADHD) or who are within the Autistic Spectrum, which can sometimes lead to misdiagnosis. This in turn brings about greater problems as the support that a child or young person with an ABI needs in school is very different to children with other special educational needs (SEN). This is mainly because issues and problems may arise over time as the brain develops. Maturation of the brain happens slowly over a period of 20+ years with the Frontal Lobes being the final part of the brain to mature. This means when the brain demands greater thinking and analysing skills during the latter stages of education, the young person and thus when called upon the higher executive function, thus this may require complex SEN support at a time when it is most crucial to the future of the young person.
In addition, due to lack of residential rehab and paediatric neurological support for children and young people, school/education becomes the primary place for rehabilitation. In addition the ABI may also be either un-diagnosed or family/school have been told the child has made a “full” recovery.
As a child develops and their brain starts to mature, damaged areas of the working brain start to become apparent:
- Usually behavioural, social and emotional issues being worst affected
- Schools often state they understand brain injury “behaviour” issues which often results in children with ABI being excluded
- Children who are excluded from school have a greater likelihood of committing criminal or antisocial behaviour
- Figure 1. Source Child Brain Injury Trust
It’s not just ABI
In our experience and in the context of crime and ABI there are many other factors that must also be taken into account in addition to the ABI; often Young Offenders have a complex and challenging set of environmental and mental health care needs and disadvantages that can account for some of their offending attitudes and behaviours:
- Circumstances – Family circumstances affect how a young person feels about themselves and how they perceive others. Such as a death of a parent; a divorce; financial issues, relocation etc.
- Adolescence - Issues of high risk taking behaviour, poor judgment, drugs and alcohol, peer influence etc.
- Family - The type of family unit that the young person lives within – single parent, absent parent, parent in prison etc.
- Support networks – how well supported and understood outside of the family unit is the young person; do they have people supporting them who have a knowledge and an understanding of ABI?
In addition, there is the question of whether the family has the capability, capacity or indeed the inclination to support the young person,
One must also acknowledge vulnerability due to typical manifestations of ABI including
- Issues of low self-esteem and gravitation towards unsuitable friendship groups
- Poor social awareness
- Possible over sexualized behaviours
- Lack of impulse control and consequential thinking
The social demography for risk of ABI is almost a mirror on the social demography for risk of offending (Yates, Williams et al. 2006). Many young offenders will have at least one or more of these risks – add in ABI and you have a volcanic eruption waiting to happen.
There are various international studies (see below) which focus on adult offenders, but very few on children:
A study on prevalence of Traumatic Brain Injury (TBI) in 69 randomly selected inmates, 60% of the sample reported TBI over their lifetime and 36% reported TBI in the prior year concluded that TBI during childhood or adolescence increased risk of developing mental disorder tow fold. It also found that TBI was significantly related to later mental disorder with coexisting criminality in the male cohort.
Lumsden et al 1998 Study of 100 consecutive admissions to Broadmoor high security hospital concluded that 31% had a history of [known] traumatic head injury with loss of consciousness.
Sarapata et al 1998 Study of nonviolent convicted offenders in US concluded that people with TBI were significantly at greater risk of committing crimes. It also found that 50% of nonviolent convicted offenders reported history of TBI, compared 15% in a control community sample and 83% of offenders who had reported a history of similar injury in the past also reported injury preceding first encounter with the law.
Langevin et al 2006 Canadian study of 476 sexual offenders concluded that almost half had sustained traumatic brain injuries.
Lastly, Results were concluded by Williams et al 2010 published Self-Reported Traumatic Brain Injury in Male Young Offenders: A risk factor for re-offending, poor mental health and violence?
TBI with a Loss of Consciousness (LOC) was reported by 46% of the sample. LOC consistent with Mild TBI was reported by 29.6% and 16.6% reported LOC consistent with Moderate-Severe TBI. Possible TBI was reported by a further 19.1%. Repeat injury was common – with 32% reporting more than one LOC. Frequency of self-reported TBI was associated with more convictions. Three or more self-reported TBIs were associated with greater violence in offences. Those with self-reported TBI were also at risk of greater mental health problems and of misuse of cannabis.
The study concluded that TBI may be associated with offending behaviour and worse mental health outcomes. Addressing TBI within adolescent offenders with neuro-rehabilitative input may be important for improving well-being and reducing re-offending.
There has yet to be any international studies comparing the numbers of young offenders in prison with TBI. The Child Brian Injury Trust in collaboration with the Criminal Justice Acquired Brain Injury Interest Group (CJABIIG) are looking to scope this as part of their future work.
Entering the Criminal Justice System
At each stage the criminal justice system is not prepared for assessing or managing offenders (youth or adult). The Youth justice Board (YJB), for England and Wales acknowledge that there is a lack of knowledge and awareness of ABI within criminal justice system:
According to the YJB assessment of any neurological conditions is not included in any formal or informal assessment of offenders entering the ‘justice system’
Presently within the justice system, interventions do not take account of any neurological difficulties which may have a direct impact on the outcome of the intervention. For example Young offenders often “breach” community orders which require them to attend certain places at certain times – with possible poor planning and organizational skills, this is hard for some offenders with ABI. The result – they forget to turn up, “breach” the order, and can then be given a custodial order.
Also “Cognitive Behavioural Therapy” is a commonly used therapeutic model in this client group. However this is not always a suitable approach for those with cognitive processing difficulties.
“Restorative justice” is commonly used with young offenders –may also cause a problem for some people with ABI as they can have little or no empathy, and often lack consequential thinking.
In addition custodial sentences are often “ideal environments” for people with ABI – they are told where to go, what to do, when to eat etc. This in turn may cause difficulties on release from custody. Lastly, probation services that are not aware of ABI and the huge potential difficulties that the person is likely to face thus resulting in a higher risk of re-offending.
As described in figure 1 and supported by the evidence, young offenders with undiagnosed ABI may have a higher risk of continued offending and entering adult offending system.
It is therefore in our opinion intervening with this vulnerable group at the earliest opportunity at point of education or earlier for young offenders, and early screening for adult offenders.
A Practical Solution
Since 2007 the Child Brain Injury Trust has designed and delivered knowledge based learning programmes to educators, social and health practitioners. During this time as research studies were becoming more reliable and through worried parents calling the Helpline the Trust scoped and researched a new specific learning programme aimed at increasing the knowledge and understanding on a practical level for practitioners working within the Justice system. A key part of this work was to establish an effective dialogue with the Youth Justice Board for England and Wales (YJB) and with local delivery partners. Following an extensive ‘pilot’ programme, endorsement was achieved in 2010 from the YJB. Again, there is very little understanding of how other countries are addressing the issues
The practical and participative one day workshop ‘Youth Justice or Rough Justice?’ enables practitioners to understand what an ABI is and why some young people may not have been diagnosed, despite manifesting classic difficulties; it also explores the similarities and distinct differences of ABI compared to other common mental health issues found among young offenders and those at risk of offending (eg ADHD/Dyslexia/Speech language and communication difficulties).
The workshop reviews research and case studies to ensure that not only an understanding is gained, but that the learning is based on ‘sound and relevant’ footings. Delegates experience a highly practical “Mind Boggle” session which provides great insight into the actual cognitive and practical difficulties that a young offender may experience.
The final part of the day reviews practical strategies and explores existing interventions to see which are most appropriate to meet a young person’s neurological needs and promote effective rehabilitation of offending behaviours. Further information can be found on the organisation’s website www.childbraininjurytrust.org.uk
A joined up Approach
In the UK there are a number of other organisations and individuals working towards the same aim. In 2010 this group was brought together by the authors in order to ensure that a joined up approach was taken in furthering the work of both academic and delivery partners. The group was formally launched at the House of Lords in 2011 by Lord Hastings.
The Criminal Justice Acquired Brain Injury Interest Group (CJABIIG) is working hard to achieve a number of key objectives which it is hoped will improve outcomes for people with ABI who find themselves in the justice system. Further information can be found at http://www.childbraininjurytrust.org.uk/about_partnerships_CJABIIG.html
Objectives of CJABIIG
The objective of the Criminal Justice System is to create a safer society (Green paper) by reducing custodial time/sentences and by reducing the number of children in the Youth Justice System.
CJABIIG believes that there is a need to review ways of diverting and maintaining resources into more appropriate offending rehabilitation systems for those with ABI.
Aims of CJABIIG
- To increase awareness of ABI amongst professionals working with offenders and those at risk of offending (via media campaigns, publicity, distribution of outcomes of the group .
- To identify how rehabilitation of offenders may take account of the specific needs associated with ABI (through training, awareness raising, partnership working, lobbying).
- To explore how re-offending rates may be reduced by improved service provision for offenders and those at risk of offending who are affected by ABI (through early screening, intervention, education).
The key to achieving these aims is to establish better awareness of ABI within education and child services, as an early intervention rather than reactive one, once offenders have entered the Criminal Justice System. In order for this to be achieved, a method of early assessment is essential. In addition further work needs to be done within the justice system and investment made to ensure that improved interventions and appropriate sentencing by magistrates and judges are implemented across the board.
Conclusion - What needs to be done?
In a new report published October 2012 for the Children’s Commissioner of England and Wales recommendations were made which include the following:
- Ensuring early identification
- Enabling early effective intervention
- Reforming the Youth Justice System
- Addressing gaps in research
In addition to these recommendations The Trust with its years of practical and extensive experience would go further and suggest that the following be considered as a way of changing outcome for young offenders with ABI:
- Inclusion of ABI awareness training across all disciplines who work with or support youth offenders and those at risk of offending.
- Further development and implementation of suitable ABI assessment in School
- Family support provision
The challenge for us is to ensure the recommendations are implemented and that a follow up mechanism is in place to record effectiveness both medium and long term:
- ABI awareness training will be offered to both statutory and for profit organisations at a reasonable cost. The child Brain Injury Trust is working hard to secure funding from Government sources in order to roll out a progressive programme. In light of the economy this could prove to be the biggest challenge
- Through the consortium and with appropriate educational psychologists and neuropyschologists we are looking to develop a greater awareness of ABI and the ‘hidden’ effects with educationalists. Again funding will be the key to the success of this programme.
- Family Support is an integral part of community support for children and young people with ABI. Families are the glue to ensuring that the child/young person achieves positive outcomes. The Child Brian Injury Trust provides a cost effective family support model across most of the UK. It is our intention to develop and grow this programme within 5 years in order to meet the need and demand. More information can be found at www.childbraininjurytrust.org.uk
Nobody Made the connection: The prevalence of neurodisability in young people who offend Nathan Hughes, Huw Williams, Prathiba Chitsabean, Rebecca Davies, Luke Mounce www.childrenscommissioner.gov.uk
McGuire, J. and Priestly, P. (1995), ‘Reviewing “What Works”: Past, Present and_Future’ in J. McGuire (ed) What Works: reducing Reoffending: Guidelines from Research and Practice, pp.3–34). Chichester: Wiley.
McGuire, L.M., Burright RG, Williams R, Donovick PJ. (1998) Prevalence of traumatic brain injury in psychiatric and non-psychiatric subjects. Brain Injury. 12(3): 207-214
Williams, W. H., Cordan, G., Mewse, A. J., Tonks, J. and Burgess, C. N. (2010). Self-reported traumatic brain injury in male young offenders: a risk factor for re-offending, poor mental health and violence? Neuropsychological Rehabilitation. 20(6): 801-812.
Davies, R.C., Williams, W.H., Hinder, D., Burgess, C.N.W, and Mounce, L.T.A (2012) 'Self-reported Traumatic Brain Injury and Post-Concussion Symptoms in incarcerated youth: A dose response relationship'. Journal of Head Trauma Rehabilitation. 7(3):E21-7
The Commission's report Time for a Fresh Start out wide-ranging proposals for reforming the response to youth crime and antisocial behaviour in England and Wales.
Wicks B and Walker S (2005) Educating Children with Acquired Brain Injury. Abingdon, UK: David Fulton Publishers
Yates, Williams 2006, Journal of Neurology Neurosurgery and Psychiatry : Attendance rates for moderate to severe head injury
Slaughter et al (2003 Study in Finland of 10,000 birth cohorts followed for four decades)
Lumsden et al 1998 Neuropsychiatric indices in a high security admission sample I: estimating the prevalence
Sarapata, Hermann, Johnson and Aycock et al 1998: Non-violent convicted felons
Langevin et al 2006 Canadian study of 476 sexual offender.