Initial TBI Survey Results Minnesota Prison System

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Initial TBI Survey ResultsMinnesota Prison System
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• Overview of MN DOC
• Behavioral Health Svs
• Initial survey results
• 3 year plan
• Reactions/Responses

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Minnesota Corrections System
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MN DOC Mission and Vision

• Our Mission   To hold offenders accountable and
  offer opportunities for change while restoring
  justice for victims and contributing to a safer
  Minnesota  
• Our dedicated staff will accomplish this by 
• Fostering community partnerships
• Optimizing best practices.
• Creating a respectful diverse culture.
• Utilizing effective communication.
• Strategic and efficient use of resources 
• Our Vision FOCUS on reducing risk.

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Minnesota Department of Corrections Prison
Facilities

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Classification Levels
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MN DOC Population

• Total MN DOC population 9270
• 8674 Adult Males
• 596 Adult Females
• 109 serious and chronic male juvenile offenders
  (Average population CY2007 121)

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Community Philosophy
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Behavioral Health Services

• Includes
• Mental health
• Chemical dependency
• Sex offender
• Release planning
• Approximately 200 staff
• All State employees

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Focus of resources

• Provide mental health care for offenders with
  mental health concerns
• Focus on relevant functional impairment
• Level of Care
• Risk, Needs, Responsivity
• Reduction in recidivism rates
• CD
• SO

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Risk

• Identify the range of risks
• Decompensation
• Suicide
• Violent recidivism
• What are the risks to not providing treatment?

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Needs

• What is the range of intervention needs?
• Mental health
• Physical health
• Education
• Vocation
• Drug Alcohol
• Sexual offending
• TBI

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High Needs MH Resources

• Residential MH care
• Supportive Living Services
• MI pods
• Menu approach
• Segregation Contracts

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Responsivity

• Axis II vs. Responsivity
• Responsivity as resource restriction
• Paradox Offenders at highest risk with highest
  needs are often least responsive
• Responsivity as treatment target
• TBI

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Effective Strategies

• Teamwork
• Facility Department-wide
• Teamwork
• Within Unit
• Teamwork
• With offenders

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Accountability

• Offender accountability
• What are offenders doing for their own stability
  and risk reduction?
• Staff accountability
• Focus on routine contact
• Clear, meaningful, efficient, documentation
• Flexibility in clinical approaches
• Follow best practices

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Efficiency Strategies

• Be proactive
• Transitions group
• Treatment readiness
• Treatment modalities
• Group therapy
• Short-term therapy, long-term view
• Treatment failures highly inefficient
• Pre-treatment Take advantage of the long
  time-line

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Introduction

• Studies have found a strikingly high prevalence
  of Traumatic Brain Injury (TBI) in correctional
  samples.
• Brain injuries may result in cognitive problems
  (learning, memory, problem solving and planning).
  
• Cognitive problems may lead to behaviors that
  others see as due to antisocial personalities,
  criminal thinking or being intentionally
  disruptive.

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Part II Agenda

• Discuss the survey process with male offenders
  and, time permitting, new data obtained from the
  Female (Shakopee) and Juvenile Facilities (Red
  Wing)
• Talk about follow-up neuropsychological screening
  of 100 randomly chosen Offenders
• Provide a specific case to highlight TBI and its
  impact on an offenders incarceration

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Review of First Phase Findings

• 1,029 adult male consecutive admissions
• The TBI screening was done from September 2006 to
  January 2007 at admission as part of the routine
  battery of psychological, medical, chemical
  dependency and educational assessments
• Assessments occur in the first month of each
  offenders admission.

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Data Collection Contd

• To participate in the study, offenders had to
• Understand sufficient English to be interviewed
  (20 did not meet this criteria),
• Agree to the interview (two refused to
  participate) and,
• Be available for the interview (9 were in
  segregation at the time they were scheduled to be
  interviewed).

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Data Collection Contd

• 998 of the 1,029 adult male consecutive
  admissions were successfully interviewed
• MCF-SHK (100 interviewees) and MCF-Red Wing (52
  interviewed)

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Data Collection Procedures

• Interviewed individually
• Advised that the interview was a screening for
  head injuries they may have experienced.
• Male offenders consistently denied having a
  brain injury but were very open to describing
  their head injuries.

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TBIQ

• The Traumatic Brain Injury Questionnaire (TBIQ)
• Pamela Diamond, Ph.D., University of Texas School
  of Public Health
• This questionnaire was developed on and intended
  for offenders

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TBIQ

• Consists of 3 Sections
• Part 1 12 head-injury situations (car accident,
  assault, etc) are reviewed with the interviewees
• Part 2 Questions include age at the time of the
  injury, whether there was any loss of
  consciousness or post-traumatic amnesia and what
  care was received.

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TBIQ Contd

• Part 3 Assesses the frequency and severity of
  15 cognitive and physical symptoms commonly found
  with head injury (e.g., trouble concentrating or
  remembering, dizziness or headaches).

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Review of the Male Findings

• The severity of head injury was broken down into
  commonly used categories
• Mild, Moderate, Severe based upon reported Loss
  of Consciousness (LOC) and Posttraumatic Amnesia
  (PTA) time estimates.
• While the number of offenders reporting a TBI is
  strikingly high (82.1), this percentage is
  consistent with previous findings

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Male Findings Contd

• 86 for a New Zealand offender sample of 118
  offenders with 57 reporting multiple injuries
• 87 of a sample of 69 U.S. county jail inmates
• 88 of a sample of 225 offenders in the U.S.
  Bureau of Prisons .

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Demographics

• Table 1. Subject Characteristics
• (N 998)
• Mean
  Range_______
• Age 32.7 Years 16 73
  Years
• Education 11.8 7 16
• (Highest grade completed)

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Primary Current Offense

• n ()
• Person Offense (e.g., Assault) 202 (20.2)
• Property Offense (e.g., Theft, Fraud) 217
  (21.7)
• Sex Offense 148 (14.8)
• Drug Offense 305 (30.6)
• Other (e.g., DWI, Weapons) 129 (12.9)

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Interesting Findings

• Admission Process All new offenders are
  interviewed by a nurse within hours of admission
  and by a psychologist within days.
• During both of these interviews, the offenders
  are asked whether they have ever had a head
  injury.
• Out of the 998 offenders participating in this
  study,1 reported a head injury during the nurse
  assessment and 9 reported head injuries at the
  psychological interview.

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Classification

• One of the difficulties that we have encountered
  is determining what criteria to use to determine
  head injury severity
• Initial criteria had a large percentage of male
  subjects categorized as having Severe and
  Moderate head injuries
• Decision was made to look at other community
  standard criteria

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TBI Severity Criteria

• Severe
• gt24 hours LOC and/or gt7 Days PTA
• Moderate
• 60 minutes-24hrs LOC and/or 1-7 days PTA
• Mild
• 0-59 minutes and/or PTA 0-lt24hrs PTA

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Male Findings

• Severe 10.3
• Moderate 14
• Mild 58
• Severe and Moderate were nearly double using the
  other criteria

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• Table 11. Percentage of Offenders
• Reporting Current TBI Symptoms (N 990)
• No TBI
  1MI/MO Severe 1
• Symptom N 172
  311 170
• 1. Easily
• Distracted 81
  90 95
• 2. Trouble
• Concentrating 75
  84 92
• 3. Trouble
• Remembering 82 84 92
• 4. Headaches 79
  82 88
• 5. Dizziness___________51___________60____________
  ___70

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Most Striking Aspects

• The consistently high rates of offenders who
  report problems.
• That offenders who deny ever having a TBI report
  problems as often as offenders with severe TBIs.
• The wide range of reported problems.

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Common Causes of TBI

• General Population MVA (50)
• Young children and Older adults
• (Falls-25)
• Violence (20)

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Our Population

• Assaults
• MVA
• Sports
• Bicycle
• Falls

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Female Data

• 100 Female offenders were interviewed
• Median age range was 35.5 years
• (range 19-60)
• Education 11 years (range 7-12)

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• Current Offense
• Person Offense (Assault, Armed Robbery) 18 18
• Property Offense (Theft, Fraud) 25 25
• Sex Offense 1 1
• Drug Offense 49 49
• Other Offense 5 5
• Major Mental Illness 12 12
• Personality Disorder 13 13
• Chemical Dependency
• No Chemical Dependency (Alcohol and/or
  Drug) 16 16
• Alcohol Abuse 3 3
• Alcohol Dependent 25 25
• Drug Abuse 5 5
• Drug Dependent 59 59

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Findings

• 96 out of 100 female offenders met criteria for
  having sustained a head injury
• 29 Severe (male10.3)
• 45 Moderate (male14)
• 21 Mild (male58)

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Findings

• The high number of women meeting moderate-severe
  criteria
• Multiple head injuries
• Mechanism of head injury
• Assault (Domestic Violence)
• Other Assault (fights)
• Motor Vehicle Accident (MVA)
• Falls

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Female TBI Findings

• Offenders were asked if they were currently
  experiencing symptoms commonly associated with
  TBI
• Most common ongoing symptoms almost regardless of
  head injury severity
• Easily distracted
• Trouble Concentrating

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Symptoms Associated with Moderate/Severe TBI

• Forgetting Appointments
• Dizziness
• Headaches
• Difficulty Finding the right word

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Male Juvenile Findings

• Of the 50 male offenders (15-20 age range)
  interviewed 49 reported having experienced a head
  injury
• 10 met criteria for Severe head injury
• 23 met criteria for Moderate
• 16 met criteria for Mild

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What Does This Mean?

• A lot of current symptoms are being reported that
  can interfere with the offenders daily
  activities, which not only have ramifications for
  the offender but also the management of that
  offender
• Separating out what is a TBI-related symptom
  versus another condition is likely too problematic

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Study Issues

• Difficulty is with the individuals who classify
  as having mild TBI
• Most symptoms should attenuate/resolve within 3
  months, but for some the difficulties persist
• Base rates in the general population for these
  symptoms are high and often one cannot
  distinguish between Mild TBI and non-head injured
  folks.

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Follow-up

• It was decided that we would take 100 individuals
  from the initial male pool of 998 and conduct an
  intermediate neuropsychological screening
  evaluation
• The purpose is to take a look at critical aspects
  of cognition that if compromised may affect an
  offenders quality of incarceration and/or
  successful transition back to the community

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Neuropsychological Screening

• Given time and location issues a brief, but
  thorough assessment of important aspects of
  cognition was needed
• Chose the Repeatable Battery for the Assessment
  of Neuropsychological Status (RBANS).

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RBANS

• RBANS is a brief, individually administered test
  that helps you measure cognitive decline in
  adults who have neurologic injury or disease such
  as dementia, head injury or stroke.
• Administer the 12 subtests to obtain a quick
  sampling of five important cognitive areas
• Immediate memory
• Visuospatial/constructional
• Attention
• Language
• Delayed memory.

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RBANS

• Currently completed 60 RBANS
• Results of this assessment along with a test of
  effort and task of executive functioning, are
  reviewed by this presenter
• Decision is made as to whether the
  neuropsychological screening results require a
  more thorough neuropsychological evaluation
• Will also look at those who require follow up and
  their TBIQ results.

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Case Example

• 52-year old, Caucasian male who obtained his GED
• Diagnoses of record includes Dysthymic Disorder,
  Personality Disorder NOS, and Alcohol Dependence
• Multiple probation revocations, failed chemical
  dependency treatments

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Assessment Results

• Significant memory Attention issues
• Fell below the first percentile for Immediate and
  Delayed memory.
• Recognition Memory was severely impaired
• An attention/EF task that requires alternating
  between letters and numbers that should take no
  longer than a minute to complete (and thats
  generous) took him 3 minutes to make and he made
  4 sequencing errors

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Why is this Important?

• Additional information obtained after the
  assessment showed that he experienced a severe
  TBI at the age of 35 and was determined fully
  disabled
• A review of various records revealed limited
  documentation recognizing the cognitive
  impairment.
• An intake CD form noted it, but it appears no
  where else in terms of future management,
  treatment recommendations.

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Why is this Important?

• To what extent is this individuals behavior being
  attributed to other factors (i.e., Personality
  Disorder NOS)?
• To what extent was his CD treatment failure a
  result of his TBI?
• To what extent was his multiple probation
  failures a result of his TBI?

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Grant Expectations

• Educating staff
• Expanding our efforts to identify TBI
• Determining how best to meet the needs of
  offenders with TBI
• Currently, devising a pilot project to look at
  release planning with offenders with TBI