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Brain Injury in Minnesota Correctional Facilities:Changing the System

Dr. Charlotte Johnson Psychologist, MN Department of Corrections

Mary Enge Regional Resource Specialist, MN DHS, Disability

Services Division

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Types of Brain Injury

Traumatic Brain Injury (TBI) is an injury to the brain caused by an external force after birth

Acquired Brain Injury (ABI) is an injury to the brain which is not hereditary or congenital, occurs after birth, & includes all types of TBI

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Centers for Disease Control (CDC) Traumatic Brain Injury (TBI)

Statistics

TBI is a contributing factor to a third of all injury-related deaths in the United States

About 75% of all TBIs each year are concussions or other form of mild TBI

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Centers for Disease Control TBI Statistics

Each year there are a reported 1.7 million TBIs in the United States

An estimated 5.3 million Americans - 2% of the U.S. population - live with a long-term or lifelong need for help due to TBI

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Demographics of MN

US Census population for the state of MN estimated in 2010 as 5,303,925

85.3% White

5.2% Black

4% Asian

1.1% American Indian/Alaska Native

White89%

Black6%

Asian4%

Am. Indian/

Alaskan Na-tive 1%

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TBI in State of Minnesota

2011 Dept. of Health TBI Registry Data

5,713 Hospital Admissions 10,429 ER/ED Visits 853 Deaths

2011 Population of Minnesota: 5,303,925

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Chronic TBI in Minnesota

Estimate:

90,000 to 100,000 Minnesotans live with

a disability that is caused or made

worse by a traumatic brain injury

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Traumatic Brain InjuryGrant 2006-2009 Goals

Measure prevalence rates of TBI in state correctional facilities

Provide training & education to Department of Corrections employees & partners

Identify / develop release planning & community resources for offenders & ex-offenders

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Minnesota Department of Corrections Prison Facilities

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Minnesota State Prisons

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What Did We Learn?2006-2009: TBI Prevalence

998 adult male offenders were successfully interviewed to determine TBI History (MCF-St. Cloud)

100 adult women offenders were successfully interviewed (MCF-Shakopee)

52 adolescent male offenders were successfully interviewed (MCF-Red Wing)

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What Did We Learn?2006-2009: TBI Prevalence

82%+ of offenders successfully

interviewed had a history of TBI

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2006-2009 Major Grant Products

Prevalence Data

Extensive TBI Training for Department of Corrections Staff

Development of Three on-line Training modules for Department of Corrections staff & partners

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2006-2009 Major Grant Products

Prevalence Data:

What Did We Learn?

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TBI Severity Criteria Severe:

>24 hours Length of Coma (LOC) &/or

>24 hours Post Traumatic Amnesia (PTA) Moderate:

60 minutes to 24 hours LOC &/or

1-24 hours PTA Mild:

0-59 minutes LOC &/or PTA <1hour PTA

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Another Measure of SeverityType Glascow

Coma ScaleLoss of consciousness

Post traumatic Amnesia

Mild 13 to15 30 minutes or less(or none)

Less than 1 hour

Moderate 9 to 12 30 minutes to 24 hours

1 to 24 hours

Severe Less than 8 More than 24 hours

More than 24 hours

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Male Findings

■ Severe: 13.9%■ Moderate: 12.4%■ Mild: 73.7%■ No TBI: 172

Severe & Moderate counts were nearly double using less conservative criteria

mild moderate severe0

10

20

30

40

50

60

70

80

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Juvenile Males

49 out of 50 reported history of TBI

Most were moderate & severe

Most were due to domestic assault

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Female Findings

■ 96 out of 100 female offenders met criteria for having sustained a head injury

■ 22.1% Mild (male=73.7%)■ 44.2% Moderate (male=12.4%)■ 33.7% Severe (male=13.9%)

mild moderate severe0

20

40

60

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TBI in Minnesota Prison Population

No TBI

Mild

Mod

erat

e

Sever

e0

20

40

60

80

100

Self-Report TBI Hx

All Offenders (N=998)

Registry Only (n=52)

Self-report TBI Hx

Per

cen

t

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MN DOC Offender Statistics as of 01-01-2012

Incarcerated: • 9,302 adults • 43 juveniles

Average age: 36

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MN DOC Offender Statistics as of 01-01-2012

Approximately:■ 53% White ■ 35.5% Black■ 9% American

Indian ■ 7.3% Hispanic ■ 2.4% Asian

Whit

e

Black

Amer

ican

India

n

Hispan

ic

Asian

0%

10%

20%

30%

40%

50%

60%

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What Did We Learn? Needed:

Refined process to identify offenders with TBI & related functional impairment

Plan to assist in prison & with discharge back to the community

Ongoing training & staff dedicated to TBI in critical programs

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TBI in Minnesota Correctional Facilities: Changing the System

(2010-2014)

MN Departments of Human Services & Corrections 2nd partnership grant is building on the work of our earlier grant

Current grant life: 2010-2014

$250,000.00 award per year

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Current Grant Project

Literature suggests that cognitive problems

associated with a past TBI may affect

potential to succeed in rehabilitation

(Valliant, et al, 2003; Corrigan, 1995, as cited in Wald, Helgeson, & Langlois, 2008, para. 8), including SA

treatment (SAMHSA, 1998a, as cited in Wald, Helgeson, & Langlois, 2008)

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Current Grant Project: Successful Return to Community

Long term goal: systemic change within the DOC to offer an improved response for offenders with TBI

Coordination of services to better transition to the community

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Current Grant Project: Successful Return to Community

Development & implementation of DOC system to identify & track offenders with TBI requiring supportive services

Follow identified offenders as they complete chemical dependency treatment

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Current Grant Project: Successful Return to Community

Release planning to coordinate appropriate TBI services in the community after leaving prison

Comprehensive psychological / cognitive assessment process to identify offenders with special needs

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Changing the System: Current Grant Accomplishments

Developed / Refined MN DOC TBI Screening Tool

Grant funded DOC Neuropsychologist & TBI Release Planner

Developed CD Treatment protocols for offenders with TBI / cognitive deficits

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Changing the System: Current Grant Accomplishments

Continue DOC staff/ Community Training Established DHS TBI Advisory Committee

grant subcommittee

Developed Native American Resource Guide

Held American Indian Listening Session

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Changing the System: Identified Populations

Primary population served: “Offenders in the state prison system, including those who test positive for TBI & have functional needs”

Secondary population served: “incarcerated American Indians”

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American Indians

U.S. Study found TBI-related hospital discharge rates were highest for American Indians / Alaskan Natives - 75.3 per 100,000 (Langlois, Kegler, & Butler, 2003, as cited in McCrea, 2008)

Risk factors include SES & substance abuse

American Indians are identified as a group of interest for the current grant

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2005-2009 MDH TBI Registry:

Rate of Nonfatal Hospitalizations

White: 87.7

Black: 100.2

Am. Indian/Alaska Native: 162.7

Asian/Pac. Island: 48

Hispanic: 1.1

WhiteBlackAm. Indian-Alaska Nat.Asian-Pac. Isl.Hispanic

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American Indian Listening Session: Suggestions On Policy

• TBI education for Chemical & Mental Health workers

• Ensure TBI is taken into account during sentencing, mental health assessment, & child protection case investigations

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American Indian Listening Session:Suggestions On Policy

• Inform Law Enforcement/Community Services of offender return to community

• Formalize inmate access to spiritual & cultural practices – increase access to spiritual leaders.

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Changing the System: Grant Plans

Share updated on-line DOC training

Work with MNHELP.INFO to enrich site content for ex-offenders & people with BI

Follow-up on selected American Indian Listening Session recommendations

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What You Need To Know About TBI Symptoms

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TBI Symptoms

Tremors

Weakness/fatigue

Sensation deficits

Vision problems

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TBI Symptoms

Language problems

Poor judgment of space

Confusing right/left

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TBI Symptoms

Problems reading or writing or adding

Problems following conversations

Getting stuck on topics

Not following instructions

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TBI Symptoms

Tremors

Weakness/fatigue

Sensation deficits

Vision problems

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TBI Symptoms

Cognitive:• Learning new information

• Easily Distracted

• Losing train of thought

• Forgetting things that have been completed

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TBI Symptoms

Ignoring one side of body

Irritability, anger, mood swings

Change in appetite / hygiene / social

skills

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TBI Irritability & Anger

35% to 96% show agitated behavior during acute recovery (Silver, Yudofsky, & Anderson, 2011)

Of 60 offenders in jail those who sustained TBI in last year showed worse anger/aggression (Slaughter, 2003)

Risk factors: irritability, impulsivity, & past aggression

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What You Need To Know

About TBI Diagnostic

Considerations & Memory

Strategies

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Diagnostic Considerations

Post-traumatic Stress Disorder

Frequent incidence in soldiers—blast injury

Amnesia for certain parts of the trauma

Difficulty concentrating

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Diagnostic Considerations

Somatic complaints

Perceptual symptoms

Severity does not influence

Over 40% comorbid PTSD/TBI failed effort tests (consideration of meaning of effort)

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Diagnostic Considerations

Obsessive-compulsive behaviors

Comorbid with attention deficits

Perseveration & hyper vigilance

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Diagnostic Considerations

Schizophrenia-like psychosis

● Paranoid delusions

● Auditory hallucinations ● Catatonic features, formal thought disorder & negative symptoms uncommon (Johnson & Lovell, 2011)

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Memory Strategies

Take notes—Keep notepad, post-it, or cell phone handy to immediately record

• Things to do• What was completed in a day• Important phone numbers & addresses• Ideas & feelings• What to do in an emergency

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Memory Strategies

Use electronic devices to program reminders in advance of appointments, assignments, projects, etc.

Focus on one task at a time

Take breaks

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Memory Strategies

Take breaks

Be organized—structure & routine

Repetition

When reading: preview, question, read, state, & test

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Memory Strategies

Visual imagery

Elaborative encoding

Grouping or chunking

Decrease distractions when working

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How Does This Effect You?

Likely to appear attentive … but misses information

Hard to sit still

Fidgety & moving around

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How Does This Effect You?

Appears to forget 5 seconds (or less) after being told information

Appears defiant

Irritable & easily angered

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Methods for Assistance

Divide instruction into small concrete components of expectations

Model cues & gestures to comprehend expectations

Written instructions alone are not sufficient

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Methods for Assistance

When learning something new:

• Master each small task of multi-part process

• Provide opportunity to practice & Provide feedback to correct problems

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References

Gordon, W.A., Haddad, L., Brown, M., Hibbardt, M.R., & Sliwinski, M. (2000). The Sensitivity & Specificity of Self-Reported Symptoms in Individuals with Traumatic Brain Injury. Brain Injury, 14, 21-23.

McCrea, M. A., (2008). Mild traumatic brain injury & post concussion syndrome. American Academy of Clinical Neuropsychology.

Minnesota Department of Health. (2011). Minnesota Injury Data Access System (MIDAS).

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Brain Injury in Minnesota

Correctional Facilities:

Changing the System