TBI and Correctional Facilities

Key points

  • Many people in correctional or detention facilities have a history of one or more TBIs.
  • TBI symptoms may contribute to situations that increase the chance for disciplinary action.
  • Routine screening for TBI can help improve identification and management of this injury in correctional or detention facilities.
  • Leadership, healthcare providers, and individuals in correctional and detention facilities, as well as state brain injury organizations, can all play an important role in improving management of TBI.

The problem

A traumatic brain injury, or TBI, is an injury that affects how the brain works. It may be caused by a:

  • Bump, blow, or jolt to the head, or
  • Penetrating injury (such as from a gunshot) to the head.1

Did you know?‎

A person may also sustain a brain injury from an overdose or by being choked or suffocated as these events can result in a loss of oxygen to the brain. Symptoms and outcomes of these types of brain injuries can be like those of a TBI.2

Research in the United States and from other countries suggests that almost half (46%) of adults and about 1 in 3 juveniles in correctional or detention facilities have a history of TBI.34 However, the exact numbers are unknown and some studies suggest that these estimates may be much higher.5

Information on the differences between males and females living with a TBI in correctional and detention facilities is limited, as there are few studies on women and girls.6 Still, studies show that intimate partner violence-related TBIs are common among females in correctional and detention facilities.78

Research shows a link between people in correctional or detention facilities with a history of TBI, or other head and brain injuries, and:

  • Mental health problems, such as severe depression and anxiety9101112
  • Substance use disorders910111213
  • Uninhibited or impulsive behavior, difficulty controlling anger9101214
  • Self-harm, suicidal thoughts, or attempts10121516 especially among juveniles17
  • Problems with thinking and behavior18

People in correctional or detention facilities living with a TBI may face challenges with getting access to TBI-specific care and may have more difficulty adhering to treatment programs, such as for substance use disorders.19 Challenges with accessing care and adverse health behaviors may continue after a person with a TBI is released and returns to the community.20

Symptoms

Symptoms of TBI, may include physical problems (like headaches and sensitivity to light and noise), as well as problems with:2

  • Thinking (memory and attention)
  • Sleep
  • Behavior
  • Communication
  • Emotions

TBI symptoms may affect a person's ability to do regular daily activities and may last for months, years, or even longer.2 It is common for people living with a TBI in correctional or detention facilities to have a history of multiple TBIs.12 These individuals are at an even higher risk of displaying psychological, physical, sleep, and cognitive symptoms.29212223

People living with a TBI in correctional and detention facilities have higher rates of recidivism (return to a correctional or detention facility after release) and greater need for crisis intervention services compared to those without a TBI.1924 In addition, TBI symptoms may contribute to situations that increase the chance for disciplinary action within the correctional or detention facility setting.252627 Some examples include:

Problems with attention or memory
  • A person living with a TBI may have trouble focusing, remembering information, or be unable to learn instructions or complete a required task. This may appear as uncooperative or defiant behavior.
Irritability, anger, or impulsive behavior
  • A person living with a TBI may have poor judgement, exhibit impulsive behavior, or have trouble controlling their emotions. This may result in acts of physical violence or aggression that puts themselves and others at risk for harm or injury.
Trouble learning, communicating, or processing information
  • A person living with a TBI may respond slowly to questions or become confused or distressed when presented with information or instructions. This may appear as being uncooperative or indifferent.
Problems with motor skills and speech
  • A person living with a TBI may have problems with balance or walking in a straight line. They may also have trouble with speaking, such as slurring words. Together, this may appear as if the person is intoxicated.
Difficultly regulating emotions
  • A person living with a TBI may have trouble regulating their emotions. This may include showing emotions that do not match the situation (such as being easily irritated or angry without a specific cause or laughing or smiling when being disciplined). This can lead to miscommunications and an escalation of a situation.
Sensitivity to light or noises
  • A person living with a TBI may cover their eyes or ears, look distracted, or become distressed, irritable, or angry when exposed to loud noises (such as in crowded areas) or bright lights. This may appear as uncooperative or defiant behavior.
Problems with organization or planning
  • A person living with a TBI may have problems with organizing tasks, keeping their cell or living area clean, or planning. They may also become confused when their schedule is changed. This may appear as they are refusing to follow instructions.

Identification and management

Identification and management of TBI in correctional and detention facilities is critical but presents unique challenges. Screening for TBI in a correctional or detention facility is an important step to improve identification and management of this injury. However, screening for TBI in correctional and detention facilities is currently limited.28

Routine TBI screening in a correctional or detention facility may help:

  • Identify individuals in need of treatment, services, and accommodations, including those available through The Americans with Disabilities Act (ADA).
  • Increase awareness among correctional staff of individuals who may have TBI-related symptoms. This may assist with safety and management strategies, as needed.

Leadership, healthcare providers, and individuals in correctional and detention facilities, as well as state brain injury organizations, can all play an important role in improving identification and management of TBI.

Leadership at correctional and detention facilities may consider:

Correctional healthcare professionals may consider:

  • Evaluating for symptoms and behaviors among persons who screen positive for a TBI during intake or following a suspected TBI that occurs in the facility.
  • Identifying and implementing symptom-specific accommodations available for a person living with a TBI within the justice system.
  • Assessing what treatments, supports, or rehabilitative services are available to help with symptom management. This may include symptoms related to mental and physical health,6 as well as problems with cognition and behavior.
  • Screening people living with a TBI for substance use and mental health problems and referring them to available programs as appropriate.

People in correctional and detention facilities and their families may consider:

  • Equipping themselves with information on TBI, including strategies on managing TBI symptoms.
  • Learning about available accommodations and rights for persons with disabilities. Connecting with the facility's ADA compliance manager to discuss possible accommodations may help.
  • Asking about opportunities to join support groups or programs for people living with a TBI and their families (when available).
  • Making plans to connect to TBI services and programs prior to release to help with transition back into the community.

State brain injury organizations may consider:*

  • Building collaborations with leadership at justice systems and organizations in their state to promote screening, education and training, and support for people living with a TBI.
  • Developing pathways, as well as resource and care facilitation, to improve referral of people with TBI to brain injury services prior to release.
  • Evaluating programs and services and sharing information on lessons learned with other programs.

*Strategies for state brain injury programs were adapted from the Criminal and Juvenile Justice Best Practice Guide for State Brain Injury Programs created by the National Association of State Head Injury Administrators.

Programs and services

Some states and organizations have programs and services to improve identification and management of persons living with a TBI in correctional and detention facilities and upon release. Some examples include:

Print
Content Source:
National Center for Injury Prevention and Control
  1. Centers for Disease Control and Prevention. Report to Congress on Traumatic Brain Injury in the United States: Epidemiology and Rehabilitation. National Center for Injury Prevention and Control; Division of Injury Prevention. Accessed February 15, 2024
  2. Goldman L, Siddiqui EM, Khan A, et al. Understanding acquired brain Injury: a review. Biomedicines. 2022;10(9):2167. doi:10.3390/biomedicines10092167
  3. Farrer TJ, Frost RB, Hedges DW. Prevalence of traumatic brain injury in juvenile offenders: a meta-analysis. Child Neuropsychol. 2013;19(3):225-34. doi:10.1080/09297049.2011.647901
  4. Hunter S, Kois LE, Peck AT, Elbogen EB, LaDuke C. The prevalence of traumatic brain injury (TBI) among people impacted by the criminal legal system: An updated meta-analysis and subgroup analyses. Law Hum Behav. 2023;47(5):539-565. doi:10.1037/lhb0000543
  5. Farrer TJ, Hedges DW. Prevalence of traumatic brain injury in incarcerated groups compared to the general population: A meta-analysis. Prog Neuropsychopharmacol Biol Psychiatry. 2011;35(2):390-394. doi:https://doi.org/10.1016/j.pnpbp.2011.01.007
  6. O'Rourke C, Linden MA, Lohan M, Bates-Gaston J. Traumatic brain injury and co-occurring problems in prison populations: A systematic review. Brain Inj. 2016;30(7):839-854. doi:10.3109/02699052.2016.1146967
  7. McMillan TM, Aslam H, Crowe E, Seddon E, Barry SJE. Associations between significant head injury and persisting disability and violent crime in women in prison in Scotland, UK: a cross-sectional study. Lancet Psychiatry. 2021;8(6):512-520. doi:10.1016/s2215-0366(21)00082-1
  8. Durand E, Watier L, Lécu A, et al. Prevalence of traumatic brain injury among female offenders in France. Results of the Fleury TBI study. Ann Phys Rehabil Med. 2015;58:e146. doi:https://doi.org/10.1016/j.rehab.2015.07.348
  9. Moore E, Indig D, Haysom L. Traumatic brain injury, mental health, substance use, and offending among incarcerated young people. J Head Trauma Rehabil. 2014;29(3):239-247. doi:10.1097/HTR.0b013e31828f9876
  10. Walker R, Hiller M, Staton M, Leukefeld CG. Head injury among drug abusers: an indicator of co-occurring problems. J Psychoact Drugs. 2003;35(3):343-353. doi:10.1080/02791072.2003.10400017
  11. Ray B, Sapp D, Kincaid A. Traumatic brain injury among Indiana state prisoners. J Forensic Sci. 2014;59(5):1248-1253. doi:10.1111/1556-4029.12466
  12. Challakere Ramaswamy VM, Butler T, Ton B, et al. Self-reported traumatic brain injury in a sample of impulsive violent offenders: neuropsychiatric correlates and possible "dose effects". Front Psychol. 2023;14:1243655. doi:10.3389/fpsyg.2023.1243655
  13. McKinlay A, Albicini M. Prevalence of traumatic brain injury and mental health problems among individuals within the criminal justice system. Concussion. 2016;1(4):Cnc25. doi:10.2217/cnc-2016-0011
  14. Silver JM YS, Anderson KE. Textbook of Traumatic Brain Injury. 2nd ed. Aggressive disorders. American Psychiatric Publishing, Inc; 2005.
  15. Slaughter B, Fann JR, Ehde D. Traumatic brain injury in a county jail population: prevalence, neuropsychological functioning and psychiatric disorders. Brain Inj. 2003;17(9):731-741. doi:10.1080/0269905031000088649
  16. Blaauw E, Arensman E, Kraaij V, Winkel FW, Bout R. Traumatic life events and suicide risk among jail inmates: the influence of types of events, time period and significant others. J Trauma Stress. 2002;15(1):9-16. doi:10.1023/A:1014323009493
  17. Williams WH, Chitsabesan P, Fazel S, et al. Traumatic brain injury: a potential cause of violent crime? The Lancet Psychiatry. 2018;5(10):836-844. doi:10.1016/S2215-0366(18)30062-2
  18. Pitman I, Haddlesey C, Ramos SD, Oddy M, Fortescue D. The association between neuropsychological performance and self-reported traumatic brain injury in a sample of adult male prisoners in the UK. Neuropsychol Rehabil. 2015;25(5):763-79. doi:10.1080/09602011.2014.973887
  19. Piccolino AL, Solberg KB. The impact of traumatic brain injury on prison health services and offender management. J Correct Health Care. 2014;20(3):203-212. doi:10.1177/1078345814530871
  20. Fahmy C, Testa A, Jackson DB. Traumatic brain injury and mental health outcomes among recently incarcerated men. J Trauma Stress. 2023;36(5):873-883. doi:10.1002/jts.22954
  21. Williams K, Zeoli T, Allen JH, et al. Risk of two sport-related concussions in the same year: is the second concussion worse? Clin J Sport Med. 2024;34(1):38-43. doi:10.1097/jsm.0000000000001156
  22. Oyegbile TO, Dougherty A, Tanveer S, Zecavati N, Delasobera BE. High sleep disturbance and longer concussion duration in repeat concussions. Behav Sleep Med. Mar-Apr 2020;18(2):241-248. doi:10.1080/15402002.2019.1578223
  23. Schatz P, Moser RS, Covassin T, Karpf R. Early indicators of enduring symptoms in high school athletes with multiple previous concussions. Neurosurgery. 2011;68(6):1562-1567. doi:10.1227/NEU.0b013e31820e382e
  24. Ray B, Richardson NJ. Traumatic brain injury and recidivism among returning inmates. Criminal justice and behavior. 2017;44(3):472-486. https://doi.org/10.1177/0093854816686631
  25. Merbitz C, Jain S, Good GL, Jain A. Reported head injury and disciplinary rule infractions in prison. Journal of Offender Rehabilitation. 1995;22(3-4):11-19. doi:10.1300/J076v22n03_02
  26. Shiroma EJ, Pickelsimer EE, Ferguson PL, et al. Association of medically attended traumatic brain injury and in-prison behavioral infractions: A statewide longitudinal study. J Correctl Health Care. 2010;16(4):273-286.
  27. Matheson FI, McIsaac KE, Fung K, et al. Association between traumatic brain injury and prison charges: a population-based cohort study. Brain Inj. May 11 2020;34(6):757-763. doi:10.1080/02699052.2020.1753114
  28. Chari KA, Simon AE, DeFrances CJ, Maruschak L. National survey of prison health care: selected findings. Natl Health Stat Report. 2016;(96):1-23.
  29. Allely CS. Prevalence and assessment of traumatic brain injury in prison inmates: A systematic PRISMA review. Brain Inj. 2016;30(10):1161-80. doi:10.1080/02699052.2016.1191674
  30. Gordon WA, Spielman LA, Hahn-Ketter AE, Sy KTL. The relationship between traumatic brain injury and criminality in juvenile offenders. J Head Trauma Rehabil. 2017;32(6):393-403. doi:10.1097/HTR.0000000000000274
  31. Chitsabesan P, Lennox C, Williams H, Tariq O, Shaw J. Traumatic brain injury in juvenile offenders: findings from the comprehensive health assessment tool study and the development of a specialist linkworker service. J Head Trauma Rehabil. Mar-Apr 2015;30(2):106-15.
  32. Chan V, Estrella MJ, Syed S, et al. Rehabilitation among individuals with traumatic brain injury who intersect with the criminal justice system: A scoping review. Front Neurol. 2022;13:1052294. doi:10.3389/fneur.2022.1052294