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Young people with Traumatic Brain Injury in custody. Professor W Huw Williams, Professor in Clinical Neuropsychology Co Director Centre for Clinical Neuropsychology Research CCNR. School of Psychology College of Life and Environmental Sciences University of Exeter Exeter EX44QG UK. Email w h williams ex ac uk,Dr Prathiba Chitsabesan. Consultant Child and Adolescent Psychiatrist Pennine Care NHS Trust UK. Honorary Research Fellow Centre for Mental Health and Risk Manchester Academic Health Science Centre. University of Manchester Manchester M13 9PY UK,Email pchitsabesan nhs net. Acknowledgements, This work would not have been possible without the engagement of the service users who were the focus and. participants in this study We are grateful to them for sharing their data and life stories In addition the. linkworkers who were also a focus of this work were invaluable for their contributions and openness We would. also like to thank the governors of both establishments for providing access and support for the study the National. Offender Management Service NOMS Research Governance and Ethics section and the Offender Health Research. Network OHRN for advice and guidance, The Linkworker Service was developed and delivered by The Disabilities Trust Foundation.
Declarations, Professor Huw Williams collaborated with The Disabilities Trust to secure additional funding from the Barrow. Cadbury Trust for the linkworker project and the production of this report Professor Huw Williams and Dr Prathiba. Chitsabesan provided initial advice and guidance on data collection and service evaluation to The Disabilities Trust. for the Youth Linkworker service Professor Huw Williams also co ordinated and or authored some recent reports. cited in this report such as the British Psychological Society BPS response to the Justice Committee Inquiry into. Young Adult Offenders and the BPS position paper on Children and Young People in the criminal justice system. Deborah Fortescue of The Disabilities Trust provided feedback on the penultimate draft of this report. Young people with Traumatic Brain Injury in custody. Executive Summary, There is growing evidence that young people YP within the youth justice system have high levels of needs with. regard to health education and social and emotional well being Studies consistently indicate high levels of mental. health needs and neurodevelopmental disorders amongst young offenders including Traumatic Brain Injury TBI. These needs are often unmet due to a lack of appropriate screening and identification limited access to evidence. based interventions and poor continuity of care This is particularly apparent amongst YP in custody. The initial aims of this project were to establish whether it was possible to. 1 Identify young adults with a brain injury who enter custody. 2 Develop a care pathway and provide dedicated support to YP with a brain injury. 3 Raise awareness of brain injury within a Young Offender Institution. From these aims a Linkworker LW service for YP was developed by The Disabilities Trust Foundation This report. describes that service and documents a preliminary service evaluation. In summary it was possible to set the service up evolve it in a dynamic and changing environment so that it. appears to fit the needs of the young person across a wider spectrum of ages It also appears that it is with. appropriate staffing feasible to screen for TBI in the population and this may contribute to increased awareness. of such issues in a young person s care and management. In conducting this service evaluation it was not possible to collect data that would show whether there was a. change in the trajectory health well being and crime of YP through LW involvement However service level data. was available on a sample of YP and in this context it is possible to note the following. The LW service was designed delivered and deployed within what would be expected for a neurorehabilitation. and forensic rehabilitation and forensic rehabilitation service hybrid. Referrals were made to the service and it was supporting YP who had relevant TBI in terms of severity and. neuropsychological impairments, Such TBI would be expected to interfere with traditional forensic rehabilitation FR. The young person had significant criminal histories and mental health problems. Additional input in a range of areas could well have improved outcomes for the young person in terms of mental. health well being and criminogenic needs, Therefore the service would appear to be meeting the key aims defined at inception From the feedback it appears. that the service was acceptable to and valued by YP and staff It is important to emphasise that the YP had. complex conditions because TBI is a keystone condition within a constellation of challenges drug and alcohol. mood disorder lack of familial coherence care home etc lack of education and work skills and or experience. This evaluation highlights the need for appropriate key working for such a vulnerable group. We would therefore recommend further adoption of linkworker type services within custodial settings and the. need to be embed them within larger multi site studies Such services could provide a vital link across staff teams. working with individuals with TBI and effect change A linkworker may enable the identification of an underlying. TBI which allows for services to be deployed that are responsive to specific needs and learning styles in order to. successfully engage with the young person This is essential in order to develop support plans and to allow. resources to be used cost effectively rather than attempting to engage YP in generic interventions which may not. take into account their specific profile of needs, Young people with Traumatic Brain Injury in custody.
Introduction 6,Section 1 Background, Traumatic Brain Injury scale and scope of the problem 7. Is Traumatic Brain Injury a cause consequence or catalyst for risky behaviour 7. People in custody and the prevalence of Traumatic Brain Injury 8. Co morbidities and the complexities of Traumatic Brain Injury 8. Role of neurorehabiliation 9,Forensic rehabilitation 12. Section 2 The Linkworker Service,Service organisation 14. Assessment 14,Intervention 15,Section 3 Service Evaluation. Research questions 17,Study design 17,Data capture 17.
Section 4 Results,Service user descriptions 18,Goals and goal attainment 22. Summary and comments on service user and linkworker service provision 22. Case illustrations,Traumatic Brain Injury and anxiety 24. Multiple Traumatic Brain Injury and anger 25, Traumatic Brain Injury and Attention Deficit Hyperactivity Disorder 26. Traumatic Brain Injury and suicidality 27,Feedback from linkworkers 28. Feedback from service users and providers 29, Reports from Her Majesty s Inspectorate for Prisons 29.
Section 5 Key Findings and Recommendations 30,References 33. Young people with Traumatic Brain Injury in custody. Introduction, Neurological disability ND is a major source of human suffering and socio health burden Acquired Brain Injury. ABI is one main form of ND where the brain is affected by a virus stroke or trauma Traumatic brain injury TBI. is the main form of ABI and the leading cause of death and disability in children and young adults 1 TBI is widely. acknowledged as a major global health and social concern 2. This report looks at individuals with ND who are at risk of offending and entering the Criminal Justice System. CJS ND is a major issue in this population and TBI is particularly prevalent For the purposes of this report we. draw on the ND literature in particular with reference to ABI and TBI Where relevant we note the umbrella of. disorders referred to in specific studies and programmes ABI and TBI are not directly interchangeable and every. individual with a ND may have various degrees of impairment severity with limits set by society on their optimal. life experience Nevertheless there is a substantial heterogeneity of experience across and within ND and key. themes emerge that may apply to the care treatment and support of this population. The development organisation and evaluation of a service is discussed that addresses the needs of YP aged 15 21. years with ND particularly with TBI and who are in the CJS The term Young People who Offend YPO and or. Service User SU will be used as appropriate, The report draws conclusions from the study and makes recommendations that will optimise care support and. better outcomes for this vulnerable population, Young people with Traumatic Brain Injury in custody. Section 1 Background, There is significant evidence associating TBI with considered a moderate to severe TBI More often than.
criminal behaviour 3 including earlier onset of not this kind of injury leads to changes in brain function. offending repeat offending and greater violence in and behaviour e g the person is more irritable and. offences Children and YP who survive TBI are likely to impulsive A LOC of 10 30 minutes is classified as. develop behavioural problems that are linked to an complicated mild TBI and there may be changes in the. increased vulnerability to offend Children and YP who brain and some on going symptoms Injuries resulting in. are socially disadvantaged are at risk of TBI If they do a LOC of less than 10 minutes are less likely to lead to. also experience a TBI then they may have an increased persisting problems unless the individual suffers. risk of poor life outcomes which represents a double further injury. hazard for this population 4 TBI is a major chronic. During childhood adolescence and young adulthood, health condition in offender populations 50 have had. the brain is rapidly growing and its connections are. some aspect of TBI and it is more prevalent by a factor. shaped and strengthened by experience Sustaining an. of three in this group than in non offenders TBI is. injury to the brain before key areas have fully, linked to psychiatric disturbance and in particular a risk. developed or during development may result in,of self harm 5 and a factor in re offending 6. impaired development Recent research has shown that. Generally re offending rates are reported to be very the skills that are developing at the time of injury may. high in younger individuals for example 72 of YPO be the most vulnerable to disruption and established. break the law 7 within 12 months post release These skills may be more robust 10 For a comprehensive. offending patterns have a substantial cost implication8 overview of the mechanism of injury see link below. and currently there is limited support available for. www t2a org uk wp content uploads 2016 02, offenders with TBI both in the UK and internationally. Repairing Shattered Lives Report pdf, TRaumaTIC BRaIn InjuRY IS TRaumaTIC BRaIn InjuRY a CauSE.
SCaLE anD SCOPE OF THE PROBLEm COnSEquEnCE OR CaTaLYST FOR. TBI is the leading form of ABI and considered to be a RISKY BEHavIOuR. silent epidemic At some point approximately nine,The links between TBI and criminal behaviour are. percent of the population have suffered a TBI of some. complex YP who offend do so for many reasons, degree of severity of which 80 are classified as mild. including genetics social disadvantages abuse anti. It most frequently occurs in YP resulting, social personality and peer pressure It is difficult to. predominantly from falls sporting injuries fights and. identify a clear causal link between TBI and offending. road traffic accidents RTAs Both sexes are equally. but it does seem to play a role,affected when very young under five years of age. however males are much more at risk than females in Adolescence is marked by increased risk taking It is a. teenage years and adulthood 9 life stage during which risky behaviour may foster a. drift towards criminal activity that may persist,Depending on the severity TBI can lead to loss of.
throughout a lifetime 11 The adolescent brain is being. memory loss of concentration decreased awareness of. sculpted by experience and reward centres evolve to. one s own or others emotional state poor impulse, drive goal oriented behaviours 12 The systems required. control and particularly poor social judgment,to control these drivers are being formed and. Unsurprisingly behavioural problems such as conduct. consolidated in the brain s frontal cortex 9 but not at. disorder attention problems increased aggression and. the same pace During the mid to late teens the brain s. impulse control problems are prevalent in people with. crucial ability to be able to offset immediate gains 13 for. a history of ABIs, more optimal benefits at a later time by withholding or. Severity of TBI is classified in a number of ways As a delaying gratification is not well developed Within a. rule of thumb a loss of consciousness LOC following judicial context it is important to note that in the late. a blow to the head that lasts longer than 30 minutes is teenage years the last area of the brain to become. Young people with Traumatic Brain Injury in custody. adult like appears to be the frontal system an area in juvenile offenders five of which included control. responsible for making decisions about long term groups of non offending youths The prevalence rate. benefits and the risks of actions see links below was approximately 30 which was significantly higher. than in the control groups In a recent systematic,www pnas org content suppl 2004 05 13 04026801. review Hughes et al 7 looked at 10 studies some,01 DC1 02680Movie3 mpg.
overlapping with Farrer et al 11 four of which included. www ncbi nlm nih gov pubmed 15148381,control groups The prevalence rates of TBI among. www ncbi nlm nih gov pmc articles PMC3432415, incarcerated youths ranged from 16 5 to 72 1 Where. www ncbi nlm nih gov pmc articles PMC419576 figur, e fig3 there were control groups or directly comparable. studies within the general population there was, TBI is more common amongst YP who take risks consistent evidence of a higher prevalence of TBI. especially in adolescence but it may be coincidental among incarcerated youths and this disparity was more. i e those who offend may do so whether or not they pronounced as the injury severity increased Two recent. sustain a brain injury Therefore TBIs may be the result studies have shown that approximately 50 of young. of high novelty seeking and low harm avoidance in offenders have a history of loss of consciousness 9 25. people who are already susceptible to risky behaviours with repeated injury being very common9 17 also see. including antisocial behaviour However TBI may still Moffitt 1993 re risk factors for crime26 TBI in. represent a catalyst for further risky behaviour and less offenders albeit mostly in adult studies has been. harm avoidance associated with higher rates of infractions while in. Longitudinal studies indicate that YP with ND may have custody and higher levels of re offending and. an increased risk of developing antisocial behaviour engagement in violent crimes 6 9 11 15 27 28 6 11 9 15 27 28. and are more likely to develop early onset and life Managing TBI may be important for improving. persistent offending patterns 14 In a Finnish birth cohort engagement in forensic rehabilitation FR and reducing. study of approximately 12 000 subjects a TBI during recidivism Guidance on how best to support YP people. childhood or adolescence led to a four fold increased with TBI is currently being developed for the juvenile. risk of experiencing a mental disorder with co existing justice system 9 However there are few if any studies. offending in adult males 15 More recently Fazel et al 16 evaluating the effectiveness of interventions Hence. showed that in a study of Swedish people over a 35 year. the evidence base for guiding intervention design,period those with TBI compared to those who were.
development and delivery is inadequate Furthermore. non injured were much more likely to commit violent. and crucially the needs of these YP are complex with. crimes 8 8 versus 3 The risk was also greater, multiple needs requiring a multi agency co ordinated. amongst TBI individuals when compared to siblings, Furthermore a history of being knocked out amongst. YPO has been linked to persistent rather than,CO mORBIDITIES anD COmPLExITIES. adolescence limited offending 17,OF TRaumaTIC BRaIn InjuRY. PEOPLE In CuSTODY THE PREvaLEnCE TBI is one of many challenges for YPO They often have. OF TRaumaTIC BRaIn InjuRY other forms of ND and a very high prevalence of. mental health issues together with problematic drug. Globally studies notably in Australia 18 Brazil 19. and alcohol usage, Canada 20 France 21 New Zealand 22 the UK 23 and the.
USA24 have shown that the prevalence of TBI is three to The ND could be due to a compromised central or. eight times greater in people in custody compared to peripheral nervous system which could be genetic. non offenders 7 A criticism of many studies exploring occur pre birth the result of a birth trauma and or. the prevalence rates of TBI in juvenile justice injury or illness in childhood There may be a range of. populations is the lack of control groups Farrer et al 11 resulting disorders including learning disabilities. conducted a meta analysis of nine studies involving TBI e g dyslexia communication disorders Attention. Young people with Traumatic Brain Injury in custody. Deficit Hyperactivity Disorder ADHD autistic primarily irritability poor concentration and. spectrum disorders non TBI e g epilepsy or foetal impulsiveness and 50 were assessed as being at risk. alcohol syndrome disorders29 The rates of these of deliberate self harm or suicide Suicide risk factors. disorders are typically much higher in offender than in were more common when the symptoms of TBI were. non offender groups 29 A report from the Office for the greater ADHD communication problems alcohol and. Children s Commissioner OCC documents evidence drug misuse were all highly prevalent. across a range of international contexts and reveals a. It is particularly interesting to note that ADHD appears. consistently high incidence rate of neuro, to be a factor in the profile of younger offenders. developmental impairment among incarcerated, A recent study by Max et al40 showed that ADHD is a. youths Indeed there was a disproportionate,commonly occurring syndrome after TBI during. prevalence in the range of conditions amongst this. childhood or adolescence It is also a risk factor for. group see link below, TBI27 and therefore likely to contribute to problematic. www childrenscommissioner gov uk sites default files behaviour A recent consensus review from the UK. publications Nobody 20made 20the 20connecti Adult ADHD Network provided a helpful overview of. on pdf how such neurodevelopmental disorders can be. managed within the criminal justice process 41, Mental health issues are also very common in Generally in the complex mix of issues that present in.
offenders 30 31 32 Alcohol and drug misuse is often a YPO TBI and ND may not only increase the chance that. complicating factor in violent crime 33 Mental health someone develops such neurodevelopmental. and drug misuse issues may be present irrespective of disorders but they also make intervention more. a history of TBI but they may also be a result of TBI 34 35 complicated. All these problems may start at an early age 36 37 Fazel. et al38 looked at the psychopathology in adolescent Clearly the needs of younger offenders compared to. offenders aged 15 to 17 years and young adults aged older groups are different and require specific. 18 to 21 years Data on 3 058 offenders was analysed management In the context of TBI the effects of the. The younger offenders had high rates of depression brain injury may not be fully realised because the. or mood disorders and or childhood developmental functions that might be developing may also be. disorders including ADHD or disruptive behaviour compromised This underlines the importance of. difficulties assessment and management of TBI in such groups in. order to improve and maximise outcomes42 43, A recent UK study of the mental health needs of 301 see link below. young offenders aged 13 to 18 years reported that one. www bps org uk system files Public 20files cyp wit. in five had significant symptoms of depression one in. h neurodisabilities in the cjs pdf, ten had anxiety or symptoms of post traumatic stress. disorder PTSD and one in ten had self harmed in the. previous month 39 The same study showed that one in. ROLE OF nEuROREHaBILITaTIOn, ten had alcohol problems and one in five had drug Neurorehabilitation NR encompasses a wide range of. problems Furthermore aggressive behaviour towards approaches that aim to improve the quality of life for. people and property was reported in one in four and individuals with ABI The main role of NR is to enable a. one in five respectively A recent study of 197 juvenile person to have a positive role in society through family. offenders in a custodial secure facility in England found life employment or in other ways that are self. that YP who reported having experienced a TBI were sustaining rewarding and protective of future well. more likely to misuse cannabis and suffer from mental being 34 44 NR is a process by which an individual with. health difficulties 6 23 Crucially another recent study by ABI can identify key life goals they may achieve with. Chitsabesan et al5 found that of 93 incarcerated boys guided support circumvent the deficits they have. 44 had on going neuro psychological symptoms 18 acquired with strengths that they may still have and. had moderate to severe post concussion symptoms develop new strategies they find helpful in managing. Young people with Traumatic Brain Injury in custody. cognitive emotional and behavioural issues possible solutions based on their general predictions. one of which will work based on past experience They. There are various time points to implement NR, also need to self monitor or assess their performance. from the acute stage and pre discharge from hospital. during an activity and change behaviour by choosing a. through to outpatient and community support, different strategy i e use self control if the goal has.
Post acute NR for YPO would be relevant within,not been met through self assessment 48. inpatient and outpatient programmes and in, community outreach settings particularly given the It is beyond the scope of this report to address the. scope for addressing issues within an institutional evidence for NR in detail However this report. setting i e in prison through to resettlement and summarises the key findings from two recent sets of NR. community environments such as probation reviews The Scottish Intercollegiate Network SIGN 47. guidelines and those developed by an international. Evidence shows that it is possible to address and, group of researchers and clinicians known as INCOG 49. manage underlying cognitive impairments such as,attention memory and executive functions 44. There is also evidence of improved outcomes for, emotional distress behavioural problems and Memory deficits are the most common sequela of ABI.
socialisation including employment 45 resulting in significant functional problems SIGN noted. that there is evidence to support the use of, Cognitive Neurorehabilitation CNR is one of the main. compensatory approaches including memory strategy, traditional forms of NR and enables clients or patients. training and electronic aids such as NeuroPage and. and their families to live with manage bypass or, personal digital assistants 50 51 52 However there is. reduce or come to terms with cognitive deficits,insubstantial evidence that repetitive practice. precipitated by injury to the brain 46 There are two. improves memory impairment SIGN recommended, main approaches to CNR compensatory or restitution.
memory impairment rehabilitation and supported the. The compensatory approach aims to improve, integration of internal e g mnemonics and external. functioning in everyday life by providing an aid or. compensatory strategies when appropriate, strategy that compensates for the deficit such as a. instructional techniques are provided and the use of. memory aid e g diary or smart phone prompt or a, these strategies in a social role or everyday situations. mnemonic strategy e g using paced rehearsal to recall. SIGN also noted that the evidence for restorative,numbers The restitution approach aims to restore. measures is weak, normal functioning through repetitive practice e g.
computerised cognitive training packages The latter. Executive function and attention, may be delivered by therapy staff individually or in. group based programmes Addressing the cognitive Impairments in executive function and self awareness. problems is vital however given the high rate of mental the ability to understand one s own problems and the. health drug and alcohol misuse issues relationship impact these have on function are some of the most. breakdowns and anger problems in ABI survivors there characteristic neuropsychological sequela of ABI and. is also a need to address the emotional psychosocial can have a profound effect on resuming previous life. and behavioural problems 46 roles 53, Metacognitive awareness is a consistent theme in SIGN noted that there are very few systematic reviews. effective NR 47 A metacognitive strategy instruction is or Randomised Controlled Trials RCTs in the area. a term frequently used and is a direct instruction to However treatment approaches based on training. teach individuals to regulate their own behaviour by patients in metacognitive strategies are effective at. breaking complex tasks into steps while thinking improving performance in practical or functional. strategically To self regulate individuals need to settings These interventions do not necessarily restore. identify an appropriate goal and predict their normal executive ability but can improve functioning. performance in advance of the activity identify in everyday problem solving The INCOG group. Young people with Traumatic Brain Injury in custody. emphasised the solid evidence base for intervention interventions that are based on typical presenting. programmes that incorporate metacognitive strategy cases When developing CBT for mood disorders in. instructions for planning problem solving and other neuro typical people RCTs include individuals that. cognitive executive impairments They also noted that meet certain criteria for a disorder e g anxiety or. there is new evidence to support the use of strategies depression and do not have co morbidity conditions. to improve reasoning skills and substantial support for However individuals with ABI will have some degree of. the use of direct corrective feedback in improving self co morbidity conditions e g they will present with TBI. awareness Organic Personality Disorder anxiety and alcohol. abuse They are likely to have pre existing conditions. With regard to attention SIGN noted that there together with a level of de novo mood and alcohol. is evidence that impairment focused training disorders 54 including PTSD 9 and as well as presenting. e g computerised attention training may produce with cognitive affective changes such as executive. small beneficial effects in the post acute phase of brain function and memory problems These are just some of. injury but generalisation of these effects is weak the factors that may lead to a diversity of needs and. However larger effects are found when interventions outcomes Management interventions are not very. focus on training specific functional skills which make advanced but case illustrations and increasingly. demands on attention through repetitive practice controlled studies do indicate which interventions. or teaching strategies that compensate for attention can be effective. impairments in everyday tasks INCOG noted that, metacognitive training appears to improve attention Williams and Evans44 provided an overview on the use. outcomes whilst other approaches such as dual task of cognitive behavioural therapy CBT to enhance NR. training environmental modifications and cognitive and provided a range of case illustrations for anxiety. behavioural therapy may offer some benefits management depression and PTSD with complicating. However there is insufficient evidence to support factors such as alcohol issues These approaches may. mindfulness meditation and practice on be described as comprehensive or holistic as they aim. de contextualised computer based tasks to simultaneously address cognitive emotional and. behavioural difficulties in the context of returning the. Socio communication individual to participate in meaningful activities. ABI may result in a variety of communication Interventions that target mood and behaviour issues. impairments from dysarthria or poor clarity of speech may be considered as overlapping with traditional. to social communication disorders such as reduced use psychiatric and CBT based therapies Typically indeed. of facial expression poor eye contact poor listening crucially therapies are modified to take account of the. skills and a reduced ability to read emotional cognitive and self regulatory deficits common in ABI 44. expressions 48 Additionally YPO are more likely to have. communication disorders 29 Several studies reviewed Depression. by SIGN suggest language deficits and or functional. SIGN noted that there are few studies specifically. communication deficits can be remedied through, designed to evaluate psychotherapy for depression in. techniques such as pitch biofeedback and expression. ABI The studies suggest that depression was improved. modelling Conversation group therapy can also have. in the context of multimodal interventions and that the. beneficial effects Emotion reading e g of facial, best preliminary evidence was the use of cognitive.
expressions can often be affected by TBI but there is. limited evidence on the best treatment for emotional behavioural interventions Other approaches such as. perception deficits telephone counselling had different findings with. contrasting results in terms of improved outcomes,mood and behaviour. Due to the heterogeneity of issues that present in ABI. there have been significant problems developing SIGN reported a Cochrane review55 that identified. Young people with Traumatic Brain Injury in custody. some evidence supporting CBT for the treatment of than in the standard rehabilitation group 21 45. acute stress disorder following TBI and for CBT, combined with NR to alleviate anxiety symptoms nR and children young people. following mild to moderate TBI There is however,Although much of the work in NR has focused on. a lack of RCTs in the area,adults there has been some work systematically. examining the role of NR for children and YP 57 The. anger authors noted that there was limited evidence for. SIGN noted that a wide range of non pharmacological effective interventions regarding cognitive outcomes. interventions have been used for adults with i e attention memory and learning difficulties There. challenging behaviours following ABI These tend to be was however evidence that interventions can alleviate. based on the principles of Applied Behavioural Analysis internalising symptoms for psychosocial outcomes. such as contingency management operant learning One interesting study in relation to crime was. theory positive behaviour interventions focusing on conducted by Leon Carrion et al58 who investigated. proactive prevention of maladaptive behaviours whether adult prisoners with ABI in childhood had. environmental modifications and CBT received any form of NR Those who had an ABI and NR. Elements of different therapeutic models are often were more likely to be in prison for less violent. combined within a multimodal treatment programme offences58 than those who had an ABI but no NR. However there was inconsistent evidence for any, positive effects Although in one study56 of 76 FOREnSIC REHaBILITaTIOn.
individuals with ABI of mixed causes who had A number of approaches have been developed with. persistent aggressive behaviour and were unable to live YPO over the past decade that have led to. independently there were positive outcomes regarding improvements in wellbeing and crime reduction 59. improved living arrangements hours of care required However to date ND issues have received very little. and employment These effects were maintained at attention. nearly three years follow up,The Harris Review60 of the number of young adult. offender deaths in custody identified a range of factors. Holistic and vocational approaches,that converge to increase the risk of such events. SIGN noted that there was sufficient evidence to However in considering vulnerability the role of ND. recommend the use of comprehensive holistic was not highlighted A recent response to the Harris. neuropsychological rehabilitation during post acute Review by the Ministry of Justice noted a range of. NR to minimise the impact of moderate or severe TBI actions that need to be addressed61 including maturity. They also noted that there can be benefits in return to factors But again there was insufficient consideration. employment In one study The Intensive Cognitive of ND issues see link below. Rehabilitation Programme which consisted of 15 hours. www gov uk government uploads system uploads a, of individual and group therapies conducted three days. ttachment data file 486564 gov response harris, per week individuals used a variety of functional and. review pdf, social problem solving tasks to tackle their individual.
problems They also addressed interpersonal The Justice Committee Inquiry into Young Adult. communication issues through role play and Offenders is currently looking into the Harris Review. videotaped feedback as well as the application and findings A response submitted to the inquiry by the. monitoring of strategies within each participant s home British Psychological Society BPS identified areas in FR. and community with regular homework exercises that may reduce the likelihood of self harm and suicide. On completion significantly more individuals in the and also noted the role of ND in terms of vulnerability. neuropsychological rehabilitation programme group The BPS report42 noted that socio educational and. 47 were engaged in community based employment healthcare based needs which feed into criminogenic. Young people with Traumatic Brain Injury in custody. risk factors need to be targeted and can be through better planning A substantial majority of young adult. a range of interventions The Risk Needs and offenders will have speech and language problems so. Responsivity RNR approach is an example of an modifications would be required to enhance. intervention62 which takes account of the risk of communication and engagement. re offending criminogenic needs and the YPO s,3 Transfer of training Programmes are designed to. psychological preparedness to respond to,prepare YP for the challenges on the out The out. interventions CBT is consistently associated with, contains threats and problems which these individuals. improved institutional behaviour lower recidivism, lack the skills to manage especially after TBI It is vital. rates and a longer time to re arrest, that the recipients of interventions are either provided.
The BPS report also noted that these types of with skills that lead to transfer such as metacognitive. approaches are not necessarily routinely or widely training and or compensatory aids e g prompts to. available to YP in the CJS This raises the question of enable them to use new strategies in the external. what systematic and service level factors need to be environment. addressed so that appropriate interventions are, deployed and more importantly how such approaches 4 Support across and into services Considering. can be delivered in ways to benefit those with ND the range of services involved or sometimes lack of. and TBI services when people are in transition from youth to. adult multi systemic interventions MSI are needed, BPS response to the justice Committee Inquiry MSI can have positive outcomes whether directed at. first time entrants 63 or those at risk of violent. 1 Screen for nD and TBI Although screening may be, re offending 64 with a decrease in recidivism and other. conducted on admission into forensic services it is not. beneficial outcomes The multi systemic team MST,routinely used to identify ND issues There are. develops positive working relationships with YP and. screening tools that could be used and or developed. between services For example as part of the transition. further to identify vulnerability in the young adult. package it is helpful for the MST to have management. population For example the Comprehensive Health, board representation and well structured partnerships.
Assessment Tool CHAT was developed for young, offenders in custody and community settings and between referral services stakeholders and other. screens for both mental health and ND issues 28 agencies such as housing Skilled mentors and well. trained transition co ordinators can help facilitate this. 2 modify and enhance treatments Research suggests, that individuals with a history of TBI may find it more 5 Staff awareness and action Effective training is. difficult to engage with offence related rehabilitation required for staff and services to help address mental. due to information processing difficulties or health and ND needs that are present in the prison. disinhibited behaviour 6 Any interventions that are population Staff working in custodial secure facilities. used guided by the principles used for RNR and CBT need to be educated about the impact of TBI and the. would need to be tailored for individuals and take management strategies available to support people. account of age development factors and ND issues This can have positive outcomes for both staff and. Support would be required for individuals with TBI to offenders leading to a reduction in the number of. enable impulse control recall of coping strategies and negative interactions between the two 65. Young people with Traumatic Brain Injury in custody. Section 2 The Linkworker Service, In 2013 The Disabilities Trust introduced a brain injury Initially two Young Offender Institutes YOI were. Linkworker LW Service in two custodial secure selected for a LW service However one YOI was. facilities in England to provide specialist support to YP decommissioned during the study The LW service at. with a history of TBI The LW was incorporated into a this site was then modified to meet the needs of those. service pathway and based on an existing service for aged 18 to 21 years It was noted via a telephone call. adult offenders with TBI in an adult custodial secure with a representative from Prison Psychology Welfare. facility HMP Leeds66 see link below that initially there was some ambiguity regarding the. www thedtgroup org foundation brain injury and potential roles of LWs with YPO compared to the LW. offending prison linkworker service service in adults in the CJS The ambiguity affected. personnel whose roles potentially overlapped with the. The LW programme was developed in a dynamic and LW i e social workers and educational clinical and or. challenging service during a time of general cultural forensic psychologists In response to raising. shift in justice and society The number of YPO entering awareness a ND programme was initiated in one YOI. the Secure Estate has dropped significantly in recent. years from 2 059 in March 2010 to 966 in March 2015 67 SERvICE ORGanISaTIOn. see link below, The LWs and Clinical Psychologist were managed by a. www gov uk government statistics youth custody project manager The Clinical Psychologist provided. data two hours of supervision per week to the LW and in. This decrease is due to complex reasons68 summarised turn received clinical supervision from a Consultant. by Rob Allen previously director for International Clinical Neuropsychologist The LW also had access to a. Centre for Prison Studies King s College London and specialist brain injury trainer using a neurobehavioural. member of the Youth Justice Board as follows approach of rehabilitation The team provided. awareness training to staff at both YOIs and training to. The fall in the use of custody for children is accounted the LWs as part of their induction into the role. for both by a drop in overall numbers being sentenced. by the courts and by a drop in the proportion aSSESSmEnT. sentenced to custody There have been changes to the. way that children are dealt with by the police which YP under the age of 18 years on admission had an initial. may have reduced their prospects of re offending and assessment of their health needs This screening was. have certainly provided more opportunities for them conducted routinely within 10 days of the young. to grow out of crime The overall level of crime has person s admission into custody by a nurse There are. fallen during this period indicating that reductions in five parts to the CHAT an initial assessment of. the use of custody can be achieved without a negative immediate risk in relation to physical health mental. effect on community safety There have also been health substance misuse and safety as well as. changes in the way the courts have sentenced those subsequent comprehensive assessments of physical. aged under 18 years stimulated in part by changes in health substance misuse mental health and. the law and sentencing guidance and also in part by the neurodevelopment disorders and TBI28 The full CHAT. improved performance and focus of the Youth e g Neurodisability section was used in some settings. Offending Team YOT This in turn has been stimulated Young Offenders and Adult Male Category C but not. and sustained in a low profile but effective way by the in another Male Young Person Centre 15 17 For those. Youth Justice Board and by campaign groups including institutions where the CHAT was not available referrals. Out of Trouble If the changes have not been directly were made by a mental health nurse to the LW service. stimulated by political leadership nor have they been following positive screening using a screening tool the. impeded p25 68 see link below Brain Injury Screening Index BISI see link below. www prisonreformtrust org uk Portals 0 Documents www thedtgroup org foundation about the. lastresort pdf foundation brain injury screening index. Young people with Traumatic Brain Injury in custody. The BISI is an 11 item questionnaire to help identify learning memory executive functioning and speed of. people with a brain injury which gives an indication of information processing as well as standardised rating. the level of severity of the injury Referrals were also scales of behaviour As the assessment of cognition in. made by a wide range of professionals working with the such institutions is more focused on intellectual. young person in custody following consultation or by abilities the LW focused on areas more pertinent to. the YP themselves All referrals were subsequently brain injury such as executive functioning and memory. triaged allowing prioritisation based on the severity of Portable profiles of the YP s strengths and needs were. symptoms and the impact on the functioning of the YP developed to help summarise issues relevant to their. Those identified as having mild difficulties due to TBI care and rehabilitation for the YP and other staff. and possible other ND were signposted and given This extended assessment also included identification. educational material on useful services and support of the YP s development goals These goals were based. If the difficulties were rated as moderate to severe the on the YP s opinion of their needs and developed. YP was accepted for further assessment For further ensuring that they were relevant and achievable. information see link below, www thedtgroup org media 4082 160115 linkworker InTERvEnTIOn.
service report pdf One to one support A wide range of support could. be provided to the YP including education about their. Initial assessment brain injury and its effects cognitive strategies. All YP accepted into the service had an initial involving functional intervention aids. assessment or clinical interview which provided an e g a diary to aid memory attention and thought. opportunity for them to report any concerns or records Behavioural management plans and guidelines. difficulties In addition mental health and self esteem were developed with the YP s involvement which. measures were completed and information collected could involve drawing up contracts with the YP. regarding alcohol and drug use In addition support was provided in the form of. psychological approaches to emotional regulation, All parts of the CHAT assessment were reviewed as e g mindfulness exercises relaxation increased. well as information held by the juvenile justice system awareness and the identification of triggers for anger. and education services Liaison took place with family Support was also provided for education e g a review. members and the professionals involved in the care of of learning strategies with the YP through problem. the YP to determine any relevant developmental solving difficulties encountered in a classroom setting. history and possible co morbidity needs All the plans were reviewed in accordance with goal. At the initial assessment a priority was to assess the attainment and where appropriate this became part of. YPO s current level of functioning within the prison their custodial sentence plan In addition one to one. This information helped determine their ability to support was provided to help the young person engage. engage with daily living activities health needs self in prepare for and attend professional meetings and. management e g medication potential safety and risk court appearances e g YOT. issues This would highlight for example the need for. Staff liaison YP were provided with indirect support. physical assistance or adaptation and also the need to. through the LW working with education personnel, be placed in a safe environment such as the healthcare. mental health nurses their keyworker and the YOT,wing due to vulnerability. The LW provided advice on specific issues relating to. Some YP required further assessment to identify the impact of the TBI This included developing. strengths and deficits in cognitive functioning which behavioural intervention plans general advice about. may have impacted on their symptoms and motivation how to engage and support them and ensuring the YP s. to engage Neurocognitive tests were administered education was adapted to account for the difficulties. including standardised tests of visual and verbal associated with their brain injury e g regular breaks. Young people with Traumatic Brain Injury in custody. provision of written material and the re wording of additional support The LW also provided telephone. questions support to the YP and their family where appropriate. multi agency work The LW could participate in the, support planning process to gather relevant information. and provide feedback to the wider multidisciplinary. team The LW also provided information and support,referrals for further assessment or treatment.
e g neurology and physiotherapy Individualised, support plans were produced for those professionals. working with the YP to supplement their overall plan. Staff training The brain injury trainer delivered staff. training to raise awareness of brain injury and to. support service delivery The LW provided ongoing, support to staff throughout the duration of the project. Discharge planning and community interventions,When a YP was near the end of their sentence. interventions were adapted in preparation for their. release including the development of a support plan. for maintaining any improvements made During, discharge planning the YP was supported to problem. solve i e to look at reducing re offending set goals and. plans of how to achieve these on release the,development of contracts between the YP and their.
family and relapse prevention plans A discharge,summary was completed and shared with community. support e g the YOT and the General Practitioner GP. to ensure TBI health related needs were supported, continuously in the community YP identified as having. severe impairment following a TBI would be referred to. a specialist brain injury rehabilitation service on release. or if access to specialist brain injury services was. unavailable they were helped to identify an,appropriate treatment NR or support network. The LWs also worked closely with the voluntary, sector to support the YP on release in their education. e g attending college occupation e g attending, interviews and housing e g arranging accommodation.
The LW worked with the SU and their YOT as, appropriate for up to eight weeks following release. They worked on strategies and a plan to address and. support any underlying TBI related needs to help them. organise and attend relevant appointments in the, community re engage with education and training as. well as signposting the YP to community services for.

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