Initial TBI Survey Results Minnesota Prison System Adam L' Piccolino, Psy'D'

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Initial TBI Survey ResultsMinnesota Prison
SystemAdam L. Piccolino, Psy.D.
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• Overview of MN DOC
• Behavioral Health Svs
• Initial survey results
• 3 year plan
• Reactions/Responses

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Minnesota Department of Corrections Prison
Facilities

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Classification Levels
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MN DOC Population

• Total MN DOC population 9500
• 8896 Adult Males
• 604 Adult Females
• 150 serious and chronic male juvenile offenders

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Behavioral Health Services

• Includes
• Mental health
• Chemical dependency
• Sex offender
• Release planning
• Approximately 200 staff
• All State employees

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Focus of resources

• Provide mental health care for offenders with
  mental health concerns
• Focus on relevant functional impairment
• Level of Care
• Risk, Needs, Responsivity
• Reduction in recidivism rates
• CD
• SO

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Agenda

• Discuss the survey process with male offenders
  and, time permitting, data obtained from the
  Female (Shakopee) and Juvenile Facilities (Red
  Wing)
• Talk about follow-up neuropsychological
  screenings of 100 randomly chosen Offenders
• Provide a specific case to highlight TBI and its
  impact on an offenders incarceration

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Grant Objectives

• 3-year federal grant secured through the
  Department of Human Services
• The study was supported in part by project
  H25MC00264 from the Maternal and Child Health
  Bureau (Title V. Social Security Act), Health
  Resources and Services Administration, Dept of
  Health and Human Services.
• Grant Initiatives Prevalence rates, provide
  training and education, and discharge
  planning/community resources

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Review of First Phase Findings

• 1,029 adult male consecutive admissions
• The TBI screening was done from September 2006 to
  January 2007 at admission as part of the routine
  battery of psychological, medical, chemical
  dependency and educational assessments
• Assessments occur in the first month of each
  offenders admission.

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Data Collection Contd

• To participate in the study, offenders had to
• Understand sufficient English to be interviewed
  (20 did not meet this criteria),
• Agree to the interview (two refused to
  participate) and,
• Be available for the interview (9 were in
  segregation at the time they were scheduled to be
  interviewed).

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Data Collection Contd

• 998 of the 1,029 adult male consecutive
  admissions were successfully interviewed
• MCF-SHK (100 interviewees) and MCF-Red Wing (52
  interviewed)

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Data Collection Procedures

• Interviewed individually
• Advised that the interview was a screening for
  head injuries they may have experienced.
• Male offenders consistently denied having a
  brain injury but were very open to describing
  their head injuries.

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TBIQ

• The Traumatic Brain Injury Questionnaire (TBIQ)
• Pamela Diamond, Ph.D., University of Texas School
  of Public Health
• This questionnaire was developed on and intended
  for offenders

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TBIQ

• Consists of 3 Sections
• Part 1 12 head-injury situations (car accident,
  assault, etc) are reviewed with the interviewees
• Part 2 Questions include age at the time of the
  injury, whether there was any loss of
  consciousness or post-traumatic amnesia and what
  care was received.

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TBIQ Contd

• Part 3 Assesses the frequency and severity of
  15 cognitive and physical symptoms commonly found
  with head injury (e.g., trouble concentrating or
  remembering, dizziness or headaches).

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Review of the Male Findings

• The severity of head injury was broken down into
  commonly used categories
• Mild, Moderate, Severe based upon reported Loss
  of Consciousness (LOC) and Posttraumatic Amnesia
  (PTA) time estimates.
• While the number of offenders reporting a TBI is
  strikingly high (82.1), this percentage is
  consistent with previous findings

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Male Findings Contd

• 86 for a New Zealand offender sample of 118
  offenders with 57 reporting multiple injuries
• 87 of a sample of 69 U.S. county jail inmates
• 88 of a sample of 225 offenders in the U.S.
  Bureau of Prisons .

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Offenders at Intake (N998)
TBI Registry (N67,000)
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Demographics

• Table 1. Subject Characteristics
• (N 998)
• Mean
  Range_______
• Age 32.7 Years 16 73
  Years
• Education 11.8 7 16
• (Highest grade completed)

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Primary Current Offense

• n ()
• Drug Offense 305 (30.6)
• Property Offense (e.g., Theft, Fraud) 217
  (21.7)
• Person Offense (e.g., Assault) 202 (20.2)
• Sex Offense 148 (14.8)
• Other (e.g., DWI, Weapons) 129 (12.9)

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Interesting Findings

• Admission Process All new offenders are
  interviewed by a nurse within hours of admission
  and by a psychologist within days.
• During both of these interviews, the offenders
  are asked whether they have ever had a head
  injury.
• Out of the 998 offenders participating in this
  study,1 reported a head injury during the nurse
  assessment and 9 reported head injuries at the
  psychological interview.

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Classification

• One of the difficulties that we have encountered
  is determining what criteria to use to determine
  head injury severity
• Initial criteria had a large percentage of male
  subjects categorized as having Severe and
  Moderate head injuries
• Decision was made to look at other community
  standard criteria

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TBI Severity Criteria

• Severe
• gt24 hours LOC and/or gt24 hours PTA
• Moderate
• 60 minutes-24hrs LOC and/or 1-24 hours PTA
• Mild
• 0-59 minutes LOC and/or PTA lt 1hr PTA

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Male Findings

• Severe 13.9
• Moderate 12.4
• Mild 73.7
• Severe and Moderate were nearly double using the
  other criteria

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• Table 11. Percentage of Offenders
• Reporting Current TBI Symptoms (N 993)
• No TBI
  Severe Moderate Mild
• Symptom N 172
  114 102 170
• 1. Easily
• Distracted 81 96 94 91
• 2. Trouble
• Concentrating 75
  95 93 86
• 3. Trouble
• Remembering 82 96
  90 84
• 4. Headaches 79
  88 89 83
• 5. Dizziness___________51__________75________71___
  __ 62

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Male Inmate Mental Health Status
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Most Striking Aspects

• The consistently high rates of offenders who
  report problems.
• That offenders who deny ever having a TBI report
  problems as often as offenders with severe TBIs.
• The wide range of reported problems.

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Common Causes of TBIGeneral Population

• Falls (28)
• Motor vehicle-traffic crashes (20)
• Struck by/against (19) and
• Assaults (11)
• (Brain Injury Association of America)

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Our Male Population

• TBI Cause Percentage
• Assaults (fights) 35.5
• MVA 19.9
• Sports 10.5
• Bicycle 10.3
• Falls (gt10 feet) 6.6

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Reported Age at time of TBI

• Men experienced the most head injuries between
  the ages of 15-24, which is consistent with the
  literature.
• Age range 20-24 is the period of most
  vulnerability
• Suspect the number of folks over age 55 will
  increase as our population ages-only had four
  folks in the study in this age range

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Female Data

• 100 Female offenders were interviewed
• Median age range was 35.5 years
• (range 19-60)
• Education 11 years (range 7-12)

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• Current Offense
• Person Offense (Assault, Armed Robbery) 18 18
• Property Offense (Theft, Fraud) 25 25
• Sex Offense 1 1
• Drug Offense 49 49
• Other Offense 5 5
• Major Mental Illness 12 12
• Personality Disorder 13 13
• Chemical Dependency
• No Chemical Dependency (Alcohol and/or
  Drug) 16 16
• Alcohol Abuse 3 3
• Alcohol Dependent 25 25
• Drug Abuse 5 5
• Drug Dependent 59 59

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Findings

• 96 out of 100 female offenders met criteria for
  having sustained a head injury
• 33.7 Severe (male13.9)
• 44.2 Moderate (male12.4)
• 22.1 Mild (male73.7)

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Findings

• The high number of women meeting moderate-severe
  criteria
• Multiple head injuries
• Mechanism of head injury
• Assault (Domestic Violence)
• Other Assault (fights)
• Motor Vehicle Accident (MVA)
• Falls

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Female TBI Findings

• Offenders were asked if they were currently
  experiencing symptoms commonly associated with
  TBI
• Most common ongoing symptoms almost regardless of
  head injury severity
• Easily distracted
• Trouble Concentrating

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Causes of TBI

• TBI Cause Percentage
• Domestic Violence 54.7
• MVA 17.6
• Fights 8.2
• Shaken 4.1
• Falls (gt10 feet) 3.8

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Male Juvenile Findings

• Of the 50 male offenders (15-20 age range)
  interviewed 49 reported having experienced a head
  injury
• 10 met criteria for Severe head injury
• 23 met criteria for Moderate
• 16 met criteria for Mild

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• Of the 50 subjects, 267 incidents of head
• injury were reported.
• Assault 36
• Sports Events 19.5
• Assaulted (severe discipline) 16.1
• Car crash 6.4
• Falls 4.1

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• Injuries reported
• At least 1 49/50 98
• At least 2 48/50 96
• At least 3 47/50 94
• At least 4 45/50 90
• At least 5 40/50 80
• At least 6 38/50 76

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Implications

• Prisoners who report head injuries are more
  likely to have disciplinary problems during
  incarceration.
• Prisoners with head injuries may have problems
  such as seizures or mental health problems such
  as anxiety or suicidal thoughts and/or attempts.
• Studies of prisoners self-reported health
  indicate that persons with one or more head
  injuries have significantly higher levels of
  alcohol and/or drug use in the year preceding
  their current incarceration.

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• Children and teenagers who have been convicted of
  a crime are more likely to have sustained a pre-
  crime TBI and/or some other form of physical
  abuse.
• Among male prisoners, a history of TBI is
  strongly associated with perpetration of domestic
  violence and other kinds of violence during their
  lifetimes.
• Among female prisoners, those 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.

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What Does This Mean?

• A lot of current symptoms are being reported that
  can interfere with the offenders daily
  activities, which not only have ramifications for
  the offender but also the management of that
  offender
• Separating out what is a TBI-related symptom
  versus another condition is likely too problematic

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Correctional and Law Enforcement Officers

• Correctional personnel and law enforcement
  officers are at risk for head injury or fatal
  head trauma.
• Interactions with suspects prior to arrest and
  with inmates during their incarceration are
  considered high risk situations for injury or
  death due to head trauma.

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Study Issues

• Difficulty is with the individuals who classify
  as having mild TBI
• Most symptoms of mild TBI should
  attenuate/resolve within 3 months, but for some
  the difficulties persist
• Base rates in the general population for these
  symptoms are high and often one cannot
  distinguish between Mild TBI and non-head injured
  folks.

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Follow-up

• It was decided that we would take 100 individuals
  from the initial male pool of 998 and conduct an
  intermediate neuropsychological screening
  evaluation
• The purpose is to take a look at critical aspects
  of cognition that if compromised may affect an
  offenders quality of incarceration and/or
  successful transition back to the community

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Neuropsychological Screening

• Given time and location issues a brief, but
  thorough assessment of important aspects of
  cognition was needed
• Chose the Repeatable Battery for the Assessment
  of Neuropsychological Status (RBANS).

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RBANS

• RBANS is a brief, individually administered test
  that helps you measure cognitive decline in
  adults who have neurologic injury or disease such
  as dementia, head injury or stroke
• Administer the 12 subtests to obtain a quick
  sampling of five important cognitive areas
• Immediate memory
• Visuospatial/constructional
• Attention
• Language
• Delayed memory

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RBANS

• Currently completed 90 RBANS
• Results of this assessment along with a test of
  effort and task of executive functioning, are
  reviewed by this presenter
• Decision is made as to whether the
  neuropsychological screening results require a
  more thorough neuropsychological evaluation
• Will also look at those who require follow up and
  their TBIQ results.

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Case Example

• 52-year old, Caucasian male who obtained his GED
• Diagnoses of record includes Dysthymic Disorder,
  Personality Disorder NOS, and Alcohol Dependence
• Multiple probation revocations, failed chemical
  dependency treatments

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Assessment Results

• Significant memory Attention issues
• Fell below the first percentile for Immediate and
  Delayed memory.
• Recognition Memory was severely impaired
• An attention/EF task that requires alternating
  between letters and numbers that should take no
  longer than a minute to complete (and thats
  generous) took him 3 minutes to complete and he
  made 4 sequencing errors

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Why is this Important?

• Additional information obtained after the
  assessment showed that he experienced a severe
  TBI at the age of 35 and was determined fully
  disabled
• A review of various records revealed limited
  documentation recognizing the cognitive
  impairment.
• An intake CD form noted it, but it appears no
  where else in terms of future management,
  treatment recommendations.

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Why is this Important?

• To what extent is this individuals behavior being
  attributed to other factors (i.e., Personality
  Disorder NOS)?
• To what extent was his CD treatment failure a
  result of his TBI?
• To what extent was his multiple probation
  failures a result of his TBI?

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Year 3 Grant Objectives

• Further pursue screening and screening follow-up
• Recognize that screening is not a diagnosis
• What can be done from a systems perspective to
  better ensure that the offenders who screen
  positively for TBI, are experiencing long-term
  consequences that interfere with the quality of
  their life and may adversely impact their
  incarceration and/or transition back into the
  community at large.
• How can we make this a feasible, workable plan
  for the DOC and the community where resources
  will be pursued following an offenders release
  from prison?

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Year 3 Grant Objectives

• Build capacity Medical, Education, Behavioral
  Health
• Co-Occurring disorders SA, MI, SO TBI
• Do we add to current list of release planners
  (SPMI) or do we bring in a specialist?
• Training of additional doctoral-level clinical
  psychologists through the use of a monthly
  cognitive assessment consultation group

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Grant Acknowledgement

• The study was supported in part by project
  H25MC00264 from the Maternal and Child Health
  Bureau (Title V. Social Security Act), Health
  Resources and Services Administration, Dept of
  Health and Human Services.

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References

• Commission on Safety and Abuse in Americas
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  Confronting confinement online. 2006 cited
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  violent criminal behaviour rehabilitation of
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• McCrea, M. A., (2008). Mild traumatic brain
  injury and postconcussion syndrome. The new
  evidence base for diagnosis and treatment. Oxford
  University Press
• Schofield PW, Butler TG, Hollis SJ, Smith NE, Lee
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• Slaughter B, Fann JR, Ehde D (2003). Traumatic
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