Does Brain Injury Contribute to Risk for Criminal Behaviour? Lynn Stewart, Ph.D. Navigating the Trends of Brain Injury Conference
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Presentation Objectives Summarize the broad literature on the link of brain injury with antisocial and criminal behavior Focus on a series of studies conducted with Canadian federally sentenced offenders examining the prevalence of TBI, cognitive deficits, and their impact on correctional results. Goal: to disentangle the contribution of brain injury to the initiation and continuance of antisocial behaviour (recidivism) ADHD (and degree of symptomology) Cognitive deficits (IQ and screening) Traumatic Brain Injury and offending (x2) FASD 2
Association of Brain Injury and Antisocial Behaviour There is an evidence base showing the impact of brain injury and of cognitive deficits in general on antisocial and criminal behaviour. The research points to how these problems are implicated both in the initiation and the continuation of antisocial behaviour. Problems with the research: Agreed definitions what is brain injury? how do we define antisocial behavior? Recruited samples are we looking at those already in the CJS or those in the community? Adjudicated or assessed pre-trial? Direction of the effect does antisocial behavior put people at risk for brain injury, or does brain injury place people at risk for criminal behavior? Risk behavior, low harm avoidance à injury 3
Definitions Acquired Brain Injuries (ABI) include all traumatic brain injuries that occur after birth, in addition to non-traumatic brain injuries, such as strokes and meningitis. Traumatic Brain Injury (TBI) is a subset of Acquired Brain Injury (ABI). Cognitive deficits are specific cognitive impairments and are often symptoms of the above injuries to the brain or can be congenital (from or prior to birth). Some individuals with average or higher IQ can nevertheless have cognitive deficits. 4
Definitions: Recruitment Sample Caution with respect to the research on offenders with brain injury in the CJS. In federal corrections, in Canada at least, we are usually speaking about what would be considered mild to moderate brain injury and/or mild to moderate cognitive deficits. Those with serious injuries would normally be diverted from the CJS or their injuries would be associated with mobility impairment that reduces criminal risk. 5
Potential Outcomes Post ABI or TBI The majority, by far, of individuals who sustain brain injury are able to return to pre-injury levels of function. For others, however, one could see: Cognitive problems such as attention and memory. Bad temper, including threatened violence. A calm and controlled person prior to their injury may become quicktempered and lack inhibition. Increased risk for psychiatric disorders and substance misuse. Being a victim of abuse or other aversive experiences prior to the injury may further increase the inclination toward violence after brain impairment. 6
Evidence that Rates of Brain Injury are Elevated in Criminal Populations PREVALENCE 7
Traumatic Brain Injury Questionnaire (TBIQ) (Diamond et al., 2007) Asking general questions regarding a history of TBI produces rates, although elevated, that are not so high as when specific validated tools are used. Using the TBIQ, 82.8% of offenders in this US sample reported having had one or more head injuries during their lifetime. The majority were reportedly caused by assaults, followed by automobile crashes and sports. There are unique sources of TBI among prisoners. For example, some incarcerated gang members reported that they sustained their injury as a result of a gang initiation procedure called pumpkinhead in which new gang members are beaten until their heads swell like pumpkins. Women offenders In the same study, a high percentage of women offenders reported a history of TBI, especially multiple concussions, often totaling 10 or more, and these were usually associated with interpersonal relationship violence. 8
Large Scale Studies (Fazel et al., 2011) Risk of violent crime following injury among a large Swedish population cohort from 1973-2009. Looked at the outcome of individuals with epilepsy (N = 23,000) and brain injury (N = 23,000). Among those with brain injury, 8.5% committed a violent crime afterwards compared to 2.5% of population controls (Odds Ratio of 3.3). Unaffected siblings attenuated the result (OR = 2.0). Among those with epilepsy, 4.2% have a history of violent crime relative to population controls (OR = 1.5), but this difference disappears when researchers looked at unaffected siblings. Therefore, no evidence of the link to violent criminality for epilepsy, but substantial evidence for brain injury. 9
TBI or ABI Among Offenders Subgroups Some subpopulations of offenders have particularly high rates of deficits or impairments (Lewis et al., 1986; 1988). 15 death row inmates awaiting imminent execution in the US Researchers found brain impairments in 100% of the cases. 37 juveniles awaiting execution in the US Of a random selection of 14 cases, 100% were found to have had histories of head injury with associated signs of neurological dysfunction. There was also a history of physical and sexual abuse, family violence, and family psychiatric illness in both the adult and juvenile groups with brain injury. Among offenders with a substance misuse history, rates of deficits are higher. 10
Impact on the Correctional Experience of Offenders with TBI Correctional environment difficult to navigate for those with TBI. Memory and confusion, slow response appear as noncompliance. Potentially victimized by other inmates. Brain injury also increases the likelihood that people will have other mental health troubles, including substance misuse. 11
What Is Self Control and How Or Why Would These Deficits Explain Criminality? Self control theory is probably the dominate theory explaining antisocial behaviour (Gottfredson & Hirshi). Causal role of issues related to self control, impulsivity in criminality. 12
Theory: Head Injury and Deficits in Self Control Sustaining a head injury à damage to the frontal lobes à impaired executive function àlower overall levels of self control Individuals with a trait associated with poor self control are more likely to be involved in situations that increase the probability of sustaining a head injury (fights, accidents, serious substance misuse). Or (most likely) A feedback loop wherein low self-control à selection into negative life events, AND impaired coping strategies after sustaining such events. Also less likely to seek appropriate interventions afterward. Or 13
Examples of Poor Self Control/Poor Self Regulation: Cognitive problems such as: Reduced cognitive ability, attention, working memory, language fluidity, information processing speed. Behavioural problems such as: Hyperactivity Impulsivity Risk-taking (more accidents, financial problems, relationship problems, health problems associated with risky behavior) Poor planning and consequential thinking Failure to set goals and to work toward a future goal Substance use Failure of inhibition Discounting the value of future rewards in favour of an immediate reward 14
Neurological Underpinnings of the TBI and Offending Link Specific areas of the cortex regulate emotions in conjunction with a number of subcortical structures (amygdala, hippocampus and thalamus). Imaging studies point to areas that are compromised: Orbital frontal lesions à poor impulse control, difficulty recognizing facial and social cues and decision making 15
RESEARCH IN FEDERAL CORRECTIONS 16
The Federal Canadian Offender Population: Correctional Service of Canada National agency that oversees sentences 2 years and more; Both in-custody (63%) & conditional release across 5 regions. Population 23,060(2017-2018); 5% women 60% have a violent offence on their record 23% Indigenous (regional variation) 45% high risk; > 60% high need Most frequent needs (defined as moderate or high need): Personal/Emotional Orientation (77%; anger, impulsivity, mental health, etc.) Associates (74%) Attitudes (74%) Substance misuse (62%) 17
Federal Offenders in Canada: Study 1: Self Reported Head Injury Self report health issues among federal Canadian offenders (Stewart et al., 2016; N = 2,273). Men offenders = 34% Indigenous men in CSC = 43% Men offenders with histories of Intravenous Drug Use (IVDU) = 44.6% Women offenders (n = 271) = 23% Women with histories of IVDU = 43% By way of contrast, an estimated 12% of adults in the community have had a TBI based on a meta-analytic study of 15 research studies in developed countries involving 25,000 adults (Frost et al., 2013). 18
Study 2: TBI and Risk to Be a Federal Canadian Offender Epidemiological study completed in collaboration with St. Michael s Hospital (McIssac et al., 2016). Health (OHIP) records of individuals who had presented at a hospital or doctor s office with a head injury in Ontario (N = 1,479,406). Record of all federal offenders released from the Ontario region. Findings: One TBI event was associated with an increased risk of incarceration for serious and/or chronic offending among both men (HR = 2.77) and women (HR = 2.70). > 1 TBI event associated more strongly (HR = 4.5 for men). 19
Study # 3: ADHD A neurobiological disorder characterized by difficulties regulating attention, activity, and impulsivity. On a continuum from mild to severe. Impairment in self-control = a tendency not to consider consequences and discounting of inhibitions. Associated with a greater risk for a number of adverse outcomes for adults including: Substance misuse, Aggression, Development of antisocial and other personality disorders Impaired self control = singular explanation for chronic criminality. Gottfredson & Hirshi General Theory of Crime; Moffitt Life Course Persistent) 20
#3 ADHD: Prevalence Two studies in the Correctional Service of Canada determined rates of symptoms that would be associated with a diagnosis of ADHD (Adult ADHD Self-Report Scale (ASRS); Usher & Stewart, 2013; Stewart, Wilton, Kelly, & Nolan, 2015). Both found: 16.5% high level of symptoms = would meet the criteria for a diagnosis Another 25.2% moderate level In total, over 40% of federal offenders have significant symptoms associated with ADHD. Compares to estimates in the general population of 5% of adult men; 3% of adult women (Kessler et al., 2006) 21
Results: Profiles and ADHD Marital status Single, separated, or divorced None Low Moderate High % (n) % (n) % (n) % (n) 48.0 (48) 56.8 (108) 54.4 (68) 65.9 (54) Married or common law 49.0 (49) 40.5 (77) 43.2 (54) 29.3 (24) Current offence Homicide 5.0 (5) 10.0 (19) 8.0 (10) 2.4 (2) Sexual offence 6.0 (6) 10.0 (19) 3.2 (4) 6.1 (5) Robbery 15.0 (15) 18.4 (35) 21.6 (27) 32.9 (27) Assault 12.0 (12) 10.5 (20) 14.4 (18) 11.0 (9) Drug related 34.0 (34) 16.8 (32) 15.2 (19) 6.1 (5) Other non-violent offence 27.0 (27) 32.6 (62) 36.8 (46) 41.5 (34) 22
Results: Substance Use and ADHD ADS (alcohol) No ADHD (N = 100) High ADHD (N = 82) % (n) % (n) Substantial to Severe 2.0 (2) 7.3 (6) Moderate to Severe 6.0 (6) 13.4 (11) DAST (drugs) Substantial to Severe 22.0 (22) 50.0 (41) Moderate to Severe 40.0 (40) 73.2 (60) 23
ADHD and Institutional Infractions Moderate levels of ADHD = 1.8 times more likely to receive an institutional charge. High symptomology (clinical levels of ADHD) = 2.5 times more likely to receive an institutional charge. 24
ADHD and Returns to Custody Return within 3 months Return within 6 months Return within 1 year None n = 95 % Level of ADHD (ASRS Rating) Low n= 184 % Moderate n=120 % High n=76 % 3.2 2.2 8.3 7.9 19.4 15.7 28.4 35.6 30.1 31.0 44.2 47.0 25
Study 4: Intelligence and Self Control Can intelligence affect self control? In children there is evidence of higher self control among those with indication of higher intelligence. We explored whether this is true among federal offenders in Canada. 26
Study 4 Cognitive Deficits (Stewart, Wilton, Kelly, & Nolan, 2015) IQ (GAMA) is a routine intake assessment tool at CSC for all consenting offenders. 4,396 men and 292 women Findings: Men s average IQ was 98; women s was 93 2.8% of men had IQs < 70 (about the same as in the general population); 5% for women 22% of population above average or superior 27
Study 4: Profile Proportion of men and women offenders in each category of IQ GAMA Score Men Women Total % % % Above Average and Higher 22.81 15.75 22.38 Average 49.56 45.55 49.30 Low Average 17.53 20.55 17.73 Borderline 7.25 12.67 7.59 Low Extreme 2.84 5.48 3.01 28
Profile by IQ Group 30
IQ and Institutional Behaviour IQ Outcome > Average and Higher Average Low Average Borderline Low Extreme n = 1,003 n = 2,179 n = 771 n = 319 n = 125 % % % % % Charges 38.9 42.4 47.2 53.9 63.2 Serious 17.9 22.2 26.5 30.1 36.8 Minor 32.1 33.8 40.0 46.1 52.0 Incidents 51.7 55.3 60.3 65.5 68.8 Instigator 35.5 41.6 47.2 55.2 58.4 Victim 12.9 11.7 14.0 19.4 18.4 30
IQ and Outcome: Revocations Survival analysis for men (controlling for time at risk) As a continuous variable, IQ is related to revocation rates (Wald χ 2 (1, N = 1,783) = 10.76, p =.001, Hazard Ratio = 0.984). Pair-wise comparisons: Those with above average and superior IQs are less likely to have revocations than those with below average IQ. For women high IQ especially protective = those above average had 0 revocations in the time period examined 31
Models Predicting Revocations: Men N=1,778 Wald χ 2 (1) p Hazard Ratio Model 1 IQ score 5.83.016 0.99 Overall Criminal Risk 51.71 <.001 a Model 2 IQ score 6.50.011 0.99 Overall Criminogenic Need 41.39 <.001 b Model 3 IQ score 8.53.004 0.99 Substance Use Need Level 42.08 <.001 2.83 32
Conclusion: IQ IQ, even among offenders serving substantial sentences, predicts both institutional behaviour and outcomes on release, but other risk factors are much stronger. Higher IQ is protective. Among women offenders, no woman with an above average IQ returned to custody. IQ is a criminogenic factor, and, thus, is an individual difference that must be included in theories of crime causation. (Cullen, Gendreau, Jarjoura, & Wright, 1997) 33
Study 5: Assessment of FASD Method: FASD Brief Screen Checklist (BSC) was developed and a diagnostic protocol piloted. Over 18 months all newly sentenced offenders at a medium security institution in Manitoba, age 30 and under, were asked to participate in the research. Each offender underwent a full medical assessment for FASD. Results: N=91 offenders. Of these 10% were diagnosed with an FASD, while a diagnosis could not be confirmed or ruled out in 15% of offenders. 45% Neuropsychological deficits unrelated to prenatal alcohol exposure, and 30% were found to have no identifiable deficits. Severe deficits in attention, executive functioning and adaptive behaviour in particular. Much more likely to have had previous incarcerations as juvenile offenders, and previous incarcerations in adult provincial facilities. None of the offenders diagnosed in this study had been previously identified as having an FASD. 35
Issues with Assessing and Addressing FASD Although newer assessment tools in development assessment in adult difficult and expensive. Focus on FASD may mean less focus on other causes of brain impairment when the approaches to case management or treatment would be similar. 36
Conclusions (con t) Is having cognitive deficits associated with criminal and/or violent behavior among serious offenders? à yes. Offenders with cognitive deficits almost by definition have antisocial traits in combination with these deficits. We are not talking about a community sample but rather those who for the most part already have an established antisocial pattern. Traits associated with self-control problems: ADHD, APD, SUD appear to drive poorer results for offenders with cognitive deficits. 37
General Conclusions Neurological related problems are more elevated among CJ populations. For those in custody, some level of brain injury is evident in up to four in ten offenders. Impairment appears to be associated with earlier age of incarceration, increased risk of violence, and more convictions. Also related to poorer outcomes on release from prison. Brain functions in areas important for social functioning, such as impulse control and empathy, appear compromised after TBI. 38
General Conclusions (con t) Neuropsychological dysfunction is linked to higher rates of substance use, mental health problems, poor educational achievement, employment problems, violence, infractions in prison, and reconvictions. Premorbid aversive events such as histories of abuse, neglect, and trauma are more elevated in offender populations and in particular among those with brain injury versus those without. Some evidence that these conditions could amplify impact of TBI or that TBI could amplify the impact of aversive life events. 39
Policy and Treatment Implications Interventions: Primary and social policies. Addressing child abuse, neglect and other factors that set in place the conditions for greater risk for brain injury and greater impact of the injury. Post-injury. Prioritizing the monitoring and treatment of early head injuries may mitigate the impact of the injury and decrease the risk for future criminal behavior. Post-offence. Offenders with cognitive deficits, whether they are linked to acquired brain injury or are congenital brain injury, need interventions that directly target criminogenic factors related to impulse control and are adapted to their limitations. Case management should be aware of the level of deficits and take these into account when planning intervention and supervision Some interventions show promise 40
Policy and Treatment Implications Interventions or skills that are required: Skills that teach Planning Goal setting Consequential thinking Emotion regulation Anticipation and preparation for stressful or triggering events (relapse prevention). Risk and Case Management: Cognitive deficits issues with labeling, privacy In the absence of self-control factors may not be related to risk. Mitigation factor or risk factor? Difficult for decision makers in the CJ system to distinguish 41
Ethical and Legal Implications Privacy issues with using health care data; labelling issues such that the information may not be available to case management Offenders have so many disadvantages (e.g., brain injury, substance use, mental disorder, lives of poverty and early child abuse or neglect). At what level can we hold them responsible for their actions? 42
Contact Information For reports related to correctional research at CSC: http://www.csc-scc.gc.ca/research/index-eng.shtml To request associated reports: Contact research@csc-scc.gc.ca To contact Lynn Stewart Lynn.Stewart@csc-scc.gc.ca 43