Traumatic Brain Injury in Prisons and Jails

An Unrecognized Problem

Many people in prisons and jails are living with traumatic brain injury (TBI)-related problems that complicate their management and treatment while they are incarcerated. Because most prisoners will be released, these problems will also pose challenges when they return to the community. The Centers for Disease Control and Prevention (CDC) recognizes TBI in prisons and jails as an important public health problem.

What is known about TBI and related problems in prisons and jails?

General:

• More than two million people currently reside in U.S. prisons and jails.¹
• According to jail and prison studies, 25-87% of inmates report having experienced a head injury or TBI ^2-4 as compared to 8.5% in a general population reporting a history of TBI.⁵
• Prisoners who have had head injuries may also experience mental health problems such as severe depression and anxiety,³ substance use disorders,^6-8 difficulty controlling anger,⁶ or suicidal thoughts and/or attempts.^6,9

Women:

• Although women are outnumbered by men in U.S. prisons and jails, their numbers more than doubled from 1990 to 2000.^1,10 As of June 2005, more than 200,000 women were incarcerated.¹ Women now represent 7% of the total U.S. prison population and 12% of the total U.S. jail population.¹⁰
• Women inmates who are convicted of a violent crime are more likely to have sustained a pre-crime TBI and/or some other form of physical abuse.¹¹
• Women with substance use disorders have an increased risk for TBI compared with other women in the general U.S. population.¹²
• Preliminary results from one study suggest that TBI among women in prison is very common.¹³

Substance abuse, violence, and homelessness:

• 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.⁶
• The U.S. Department of Justice has reported that 52% of female offenders and 41% of male offenders are under the influence of drugs, alcohol, or both at the time of their arrest,¹⁴ and that 64% of male arrestees tested positive for at least one of five illicit drugs [cocaine, opioids, marijuana, methamphetamines, or PCP].¹⁵
• Among male prisoners, a history of TBI is strongly associated with perpetration of domestic and other kinds of violence.¹⁶
• Children and teenagers who have been convicted of a crime are more likely to have had a pre-crime TBI ^17,18 and/or some other kind of physical abuse.^17,19,20
• Homelessness has been found to be related to both head injury²¹ and prior imprisonment.²²

How do TBI-related problems affect prisoners with TBI and others during incarceration?

A TBI may cause many different problems:

• Attention deficits may make it difficult for the prisoner with TBI to focus on a required task or respond to directions given by a correctional officer. Either situation may be misinterpreted, thus leading to an impression of deliberate defiance on the part of the prisoner.^2,23
• Memory deficits can make it difficult to understand or remember rules or directions, which can lead to disciplinary actions by jail or prison staff.²⁴
• Irritability or anger might be difficult to control and can lead to an incident with another prisoner or correctional officer and to further injury for the person and others.^23,25
• Slowed verbal and physical responses may be interpreted by correctional officers as uncooperative behavior.²³
• Uninhibited or impulsive behavior, including problems controlling anger6 and unacceptable sexual behavior, may provoke other prisoners or result in disciplinary action by jail or prison staff.^23,26

What is needed to address the problem of TBI in jails and prisons?

Abuse in America’s Prisons recommends increased health screenings, evaluations, and treatment for inmates.²⁷

In addition, TBI experts and some prison officials have suggested:

• Routine screening of jail and prison inmates to identify a history of TBI.^28,29
• Screening inmates with TBI for possible alcohol and/or substance abuse and appropriate treatment for these co-occurring conditions.^15,30,31
• Additional evaluations to identify specific TBI-related problems and determine how they should be managed.²⁸ Special attention should be given to impulsive behavior, including violence,^2,26 sexual behavior²³ and suicide risk if the inmate is depressed.³²

What is needed to address TBI-related problems after release from jail and prisons?

Lack of treatment and rehabilitation for persons with mental health and substance abuse problems while incarcerated increases the probability that they will again abuse alcohol and/or drugs when released.^15,31 Persistent substance problems can lead to homelessness,³³ return to illegal drug activities,^34,35 re-arrest,³⁶ and increased risk of death³⁷ after release. As a result, criminal justice professionals and TBI experts have suggested the following:

• Community re-entry staff should be trained to identify a history of TBI and have access to appropriate consultation with other professionals with expertise in TBI.^17,29,30
• Transition services for released persons returning to communities should accommodate the problems resulting from a TBI.^17,28,29
• Released persons with mental health and/or substance abuse problems should receive case management services and assistance with placement into community treatment programs.^27,30,37

CDC supports new research to develop better methods for identifying inmates with a history of TBI and related problems and for determining how many of them are living with such injury.

References

1. Department of Justice (US), Office of Justice Programs, Bureau of Justice Statistics. Prison and jail inmates at midyear 2005 [online] 2006 [cited 2006 May 22]. Available from URL: www.ojp.usdoj.gov/bjs/pub/pdf/pjim05.pdf.
2. Schofield PW, Butler TG, Hollis SJ, Smith NE, Lee SJ, Kelso WM. Traumatic brain injury among Australian prisoners: rates, recurrence and sequelae. Brain Injury 2006;20(5):499-506.
3. Slaughter B, Fann JR, Ehde D. Traumatic brain injury in a county jail population: prevalence, neuropsychological functioning and psychiatric disorders. Brain Injury 2003;17(9):731-41.
4. Morrell RF, Merbitz CT, Jain S, Jain, S. Traumatic brain injury in prisoners. Journal of Offender Rehabilitation 1998;27(3-4):1-8.
5. Silver JM, Kramer R, Greenwald S, Weissman M. The association between head injuries and psychiatric disorders: findings from the New Haven NIMH Epidemiologic Catchment Area Study. Brain Injury 2001;15:935-45.
6. Walker R, Hiller M, Staton M, Leukefeld CG. Head injury among drug abusers: an indicator of co-occurring problems. Journal of Psychoactive Drugs 2003;35(3):343-53.
7. Barnfield TV, Leathem JM. Neuropsychological outcomes of traumatic brain injury and substance abuse in a New Zealand prison population. Brain Injury 1998;12(11):951-62.
8. Barnfield TV, Leathem JM. Incidence and outcomes of traumatic brain injury and substance abuse in a New Zealand prison population. Brain Injury 1998;12(6):455-66.
9. Blaauw E, Arensman E, Kraaij V, Winkel FW, Bout R. Traumatic life events and suicide risk among jail inmates: the influence of types of events, time period and significant others. Journal of Traumatic Stress 2002;15(1):9-16.
10. Womens’ Prisons Association. Hard hit: the growth in the imprisonment of women, 1977-2004. Greene J, Pranis K, editors; New York; Women’s Prison Association, [online]. 2006 [cited 2006 Aug 3]. Available from URL: www.wpaonline.org/institute/hardhit/part1.htm#np.
11. Brewer Smyth K, Burgess AW, Shults J. Physical and sexual abuse, salivary cortical, and neurologic correlates of violent criminal behavior in female prison inmates. Biological Psychiatry 2004;55(1):21-31.
12. Felde AB, Westermeyer J, Thuras P. Co-morbid traumatic brain injury and substance use disorder: childhood predictors and adult correlates. Brain Injury 2006;20(1):41-9.
13. Diamond P, Magaletta P. TBI in the Federal prison: assessing history of traumatic brain injury in a prison population. A lecture given at the National Center for Injury Prevention and Control. Centers for Disease Control and Prevention; February 17, 2006; Atlanta, GA.
14. Department of Justice (US), Office of Justice Programs, Bureau of Justice Statistics. Substance abuse and treatment, state and federal prisoners, 1997 [online]. 2001 [cited 2006 Nov 8]. Available from URL: www.ojp.usdoj.gov/bjs/pub/pdf/satsfp97.pdf.
15. Department of Health and Human Services (US), Substance Abuse and Mental Health Services Administration. Put prevention into practice. Rockville (MD): Department of Health and Human Services; 1998. Treatment Improvement Protocol (TIP) Series 44, DHHS Publication No. (SMA) 98-3249. [cited 2006 Aug 3]. Available from URL: www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.chapter.80044.
16. Cohen RA, Rosenbaum A, Kane RL, Warnken WJ, Benjamin S. Neuropsychological correlates of domestic violence. Violence and Victims 1999;14(4):397-411.
17. Leon-Carrion J, Ramos FJ. Blows to the head during development can predispose to violent criminal behaviour: rehabilitation of consequences of head injury is a measure for crime prevention. Brain Injury 2003;17(3):207-16.
18. Timonen M, Miettunen J, Hakko H, Zitting H, Veijola J, von Wendt LRP. The association of preceding traumatic brain injury with mental disorders, alcoholism and criminality: the Northern Finland 1966 Birth Cohort Study. Psychiatry Research 2002;113(3):217-26.
19. Department of Justice (US), Office of Justice Programs, Bureau of Justice Statistics. Women offenders [online]. 2000 [cited 2006 May 15]. Available from URL: www.ojp.usdoj.gov/bjs/abstract/wo.htm.
20. Yeager CA, Lewis DO. Mental illness, neuropsychologic deficits, child abuse, and violence. Child & Adolescent Psychiatric Clinics of North America 2000;9(4):793-813.
21. Bremner AJ, Duke PJ, Nelson HE, Pantelis C, Barnes TR. Cognitive function and duration of rooflessness in entrants to a hostel for homeless men. British Journal of Psychiatry 1996;169(4):434-439.