Professor Gus A Baker PhD FBPS Walton Centre for Neurology and Neurosurgery

Transcription

1 Professor Gus A Baker PhD FBPS Walton Centre for Neurology and Neurosurgery

2 This presentation will consider a number of themes including The Neuropsychological assessment The incidence and prevalence of traumatic brain injury and its relationship to offending behaviour.

3 Neuropsychological Assessment Background Clinical markers for brain damage PTA GCS Imaging Recovery Assessment Interpretation of test results

4 80 billion neurons and connections A brain sculpted by a life time of experiences especially in the first few years of life and during adolescence Preconceptual, prenatal, early postnatal and adolescent events alter brain and function Early experience alters the growth and pruning of neurones Kolb et al 2012

5 Developmental Neurodevelopmental Disorders

6 Sensory and motor experience Language and cognitive experience Pre and post natal stress Psychoactive drugs Parent-child relationship Peer relationships Diet Gut bacteria Placental dysfunction Perinatal injury

7 Brain development is prolonged and complex Brain development is influenced by a wide range of early experiences including both pre and post-natal experiences Adolescence is critical for experience dependent changes, especially in the Pre-frontal cortex

8 Family violence spouse or child related Parental alcohol or drug addictions Sexual abuse Growing up in a household where someone is in jail Parental chronic depression or mental illness Loss of a parent Abnormal brain development, Social and cognitive problems High vulnerability to behavioural problems

9 Background History Childhood History Parents and siblings Education Vocational History Personality and Behaviour

10 Traumatic Brain Injury - A bolt or jolt to the head or a penetrating head injury that disrupts the function of the brain Not all blows or jolts to the head result in a TBI. The severity of such an injury may range from mild (a brief change in mental status or consciousness)to severe (an extended period of unconsciousness or amnesia) after the injury. Post-injury individuals may experience symptoms These symptoms can result in short- or long-term problems with functioning CDC 2005

11 Neuropsychological Assessment Background Clinical markers for brain damage PTA GCS Imaging Recovery Assessment Interpretation of test results

12 John Kirk, Ph.D. Thanks John Kirk, Ph.D. Mechanism of Injury Acceleration/Deceleration

13 TBI: Mechanism Moderate-Severe TBI (e.g. 30 mins + LoC) insult to the brain from an external mechanical force. E.g. blow to the head - fast-stop in a crash, assault, fall. frontal and temporal most common sites of injury Contusions, lacerations etc. diffuse injury (eg diffuse axonal shearing) across the brain In MILD TBI same mechanisms - but difference of degree of dosage (LOC or repeated injury) (Bigler, 2008) Meta-analyses indicate 12% (adults) may have had a TBI with a LOC (Farrer et al, 2013)

14 Mild head injury (75%): loss consciousness <15 minutes/no loss of consciousness Moderate head injury: loss of consciousness between 15 minutes and 6 hours/post traumatic amnesia up to 24 hours Severe head injury: loss of consciousness >48 hours/post traumatic amnesia>24 hours

15 Types of TBI-Mild Most common, 75%-85% of all brain injuries are mild Individuals experience a brief (<15 minutes) or NO loss of consciousness Normal neurological exam 90% of individuals recover within 6-8 weeks, often within hours or days

16 Frontal Lobe Initiation Problem solving Judgment Inhibition of behavior Planning/anticipation Self-monitoring Motor planning Personality/emotions Awareness of abilities/limitations Organization Attention/concentration Mental flexibility Speaking (expressive language) Temporal Lobe Memory Hearing Understanding language (receptive language) Organization and sequencing Frontal Lobe Temporal Lobe Parietal Lobe Occipital Lobe Cerebellum Brain Stem Parietal Lobe Sense of touch Differentiation: size, shape, color Spatial perception Visual perception Occipital Lobe Vision Cerebellum Balance Coordination Skilled motor activity Brain Stem Breathing Heart rate Arousal/consciousness Sleep/wake functions Attention/concentration

17 Neuropsychological Assessment Background Clinical markers for brain damage PTA GCS Imaging Recovery Assessment Interpretation of test results Formulation

18 Poor memory Lack of insight Poor planning and problem solving skills Inability to understand and communicate Poor concentration Poor perception, recognition and judgement Inappropriate behaviour Slowed responses Lack of initiative Loss of physical sensations Personality changes Loss of skills, management and day to day affairs

19 Common Behavioral Complaints continued Impaired Judgment Impatience Depression Hypersexuality Hyposexuality Dependency Silliness Aggressiveness Apathy Immaturity Disinhibition Loss of interest Anxiety

20 An attention deficit might look like trouble paying attention or it might look like (Capuco & Freeman-Woolpert) He keeps changing the subject She doesn t complete tasks He has a million things going on and none of them ever gets completed When she tries to do two things at once she gets confused and upset

21 Unawareness might look like Insensitivity, rudeness Overconfidence (Capuco & Freeman-Woolpert) Seems unconcerned about the extent of her problems Doesn t think she needs supports Covering up problems ( everything s fine ) Big difference in what he thinks and what everyone else thinks about his behavior Blaming others for problems, making excuses

22 Possible Changes-Personality and Behavioral Depression Social skills problems Mood swings Problems with emotional control Inappropriate behavior Inability to inhibit remarks Inability to recognize social cues

23 Personality and Behavioral Problems with initiation Reduced self-esteem Difficulty relating to others cont.. Difficulty maintaining relationships Difficulty forming new relationships Stress/anxiety/frustration and reduced frustration tolerance

24 The term executive function describes a set of cognitive abilities that control and regulate other abilities and behavior They are necessary for goal directed behaviour and include the following: The ability to initiate and stop actions To monitor and change behavior as needed, and to plan future behavior when faced with novel tasks and situations. To anticipate outcomes and adapt to changing situations

25 Most people experience impulses to do or say things that could get them in trouble, such as making a sexually explicit comment to a stranger, commenting negatively on someone's appearance, or insulting an authority figure like a boss or police officer; but most people have no trouble suppressing these urges. When executive functions are impaired, however, these urges may not be suppressed. Executive functions are thus an important component of the ability to fit in socially.

26 Symptoms of Frontal Lobe lesions Reduced inhibition and abnormal sexual behaviour Failure to identify facial expressions Reduced verbal fluency Reduced sexual behaviour [dorsolateral region] Increased perseveration Inability to form a strategy Impaired temporal memory Impaired working memory Increased risk taking Impaired self-regulation Loss of associative learning Loss of response inhibition Impaired divergent thinking Loss of behavioural spontaneity Reduction in general behaviour

27 Very susceptible to Frontal Lobesdamage Planning Judgment Verbal fluency Time span Conceptual shifts Insight and foresight Attention Motor regularity control Ordering and sequencing Emotional regulation Visual scanning and shifting Inhibition

28 A memory deficit might look like trouble remembering or it might look like (Capuco & Freeman-Woolpert) She frequently misses appointments-avoidance, irresponsibility He says he ll do something but doesn t get around to it She talks about the same thing or asks the same question over and over-annoying perservation He invents plausible sounding answers so you won t know he doesn t remember

29 Neuropsychological Assessment Background Clinical markers for brain damage PTA GCS Imaging Recovery Assessment Interpretation of test results

30 HADS TOPF WAIS IV D-KEFS Emotional Wellbeing Pre-morbid abilities Intellectual WAIS IV Higher Executive Functioning Assessment Memory Constructional & Perceptual Functioning Language Effort Green s VOSP GNT

31 Standardised Neuropsychological measures Response Inhibition - WCST Verbal Fluency - DKEFS Planning Tower of London task Non verbal processing Rey Figure Visuospatial - Trail making test Family assessment BADS Q, BRIEF

32 Wisconsin Card Sorting Test Measures: Categories, Perseverations, Loss of Set

33 Test A Test B Test A: Please state the color of the ink in the following words. Test B: Please state the color of the ink in the following figures.

34 Interpretation of test results Do they make sense Are they consistent with our understanding of brain and behaviour

35 Implications for justice system

36 Implications for Justice system Improve detection and management of TBI e.g. at court proceedings, sentencing and in forensic rehabilitation Vital that probation staff record and reflect issues in court reports That magistrates & judges can take account of TBI in sentences etc. At 1 st and/or soon after 1 st contact Importance of screening for TBI in offenders (use of CHAT. S 5) Prison staff liaise with health re: best management Consider risk factors for violence in TBI persons, especially modifiable ones (e.g. alcohol or illegal drugs) Use of Link-workers to enable re-settlement (eg The Disabilities Trust) See: Healthcare Standards for Children and Young People in Secure Settings (June 2013) Royal College of Paediatrics & Child Health

37 TBI: in children and young people Moderate to Severe TBI: (20% approx) Mild TBI: (80% approx) Cognition - attention, memory, executive Behaviour - dis-inhibition, anger, etc Mood - depression, anxiety (Anderson et al 2006; Max, 2001; Tonks et al, 2010; Gracey et al, in press) Repeated MTBI: complicated, or cumulative, injury may be linked to: problems in attention and inhibitory control (Williams, Potter & Ryland, 2010; Wall, Williams et al, 2006; Williams et al, 2012) Difficulties considering alternative behaviours & controlling impulses (Fishbein 2009 et al; Pontifex 2009) 94 children with TBI aged 9 at time of injury showed Organic Personality Change (OPC) 57% of severe & 5% mtbi labile and aggressive OPC subtypes most common x more. (Max et al, 2001) ****Therefore in ALL TBI expect at least 3 in 10 to have ONGOING NEURO- PROBLEMS*** NOTE: EFFECTS MAY BE DELAYED IN DEVELOPING BRAINS

38 Offenders and Thinking problems Offenders cope poorly with life because they exhibit various cognitive deficits (Ross and Fabiano, 1985, cited in Home Office, 2002). lack of impulse control poor problem solving rigid and inflexible thinking inability to see other people s views Offender Management Community Cohort Study (OMCCS): Assessment and sentence planning (Cattell et al, 2013) Longitudinal survey of 2,919 representative sample of offenders young adult violence, theft, burglary on community orders Over four-fifths of offenders in the cohort had problems with recognising the consequences of their actions

39 Rates of Mild-Severe TBI in Adult Prisoners Williams et al (2010). Brain injury Other 453 males held in HMP Exeter Participants: 196 aged between 18 and 54 years (43% response rate) Murder/manslaughter Robbery Sexual offences Drugs offences Fraud/deception Driving offences Missing Burglary Shoplifting/theft sentenced or remanded Violent offences

40 % of Adult Prison Population Reporting TBI Williams et al (2010) Brain Injury. We estimate that: 65% may have had TBI 10% Severe 5.6% Moderate 49.4% Mild 40 Count 20 0 Missing No Yes Number of severe tbi Number of moderate t Any tbi? Any TBI? No 39.6 % Yes 60.4% Average age of first imprisonment: 16 Years TBI 21 Years non-tbi Number of mild tbi

41 TBI in Young Offenders in UK Williams, Cordan et al (2010) Structured interviews, youth offenders (YOI) (n = 192; 16 yrs) 65% reported history of head injury -Main injury category = VIOLENCE (57.6) MTBI with LOC up to 10minutes & moderate-severe TBI = 46% of overall sample Repeat injury common Those with TBI = more convictions X3+ TBIs = more violence TBI = more Mental Health problems

42 qualitative study of violent offenders, with routine CT and MRI scanning, showed that violent offenders had significantly greater number of neurological abnormalities, particularly involving the frontal lobes, compared to non-violent and non-offending controls

43 The cost of re-offending - UK In UK - Crime is down BUT re-offending rates are high 1 year post release 45% * 2 years post release 75% * Reoffending costs the UK somewhere between nine and 13 billion pounds a year. The taxpayer has so far got a poor return for the money invested in rehabilitation, which is why we need a new way of approaching the problem (Secretary of State for Justice: Chris Grayling MP) * Ministry of Justice 8/12 Analytical Services Prisoners Criminal Backgrounds and Reoffending report

44 The Walton Centre For Neurology and Neurosurgery Thank you for your time and attention Gus A Baker 10/30/