How Understanding Causes and Consequences of Brain Injury may lessen Offending:

2. Brain injury is ….typcially associated with injuries to the approach/avoid systems!Brain injury is ….typcially associated with injuries to the approach/avoid systems!

3. Anti-social Personality and brain activation… Birbaumer and colleagues (2005) –fMRI & clips of emotive film of facial expression (eg fear). “psychopathic criminals” lacked activation in limbic structures less amygdala activity = the higher score for “psychopathy” ? a lack registering fear linked to lack of inhibition seeing fear inhibits one from acting violently (see Mobbs et al, 2008).

4. Cautions…against primacy of biology What might cause these differential patterns of activation is not known Anti-social Personality Disorder (APD) often occur in the context of a range of issues - history of childhood maltreatment or trauma may be common. “There are no concrete biological markers – genetic or physiological – that can predict [ASP] behaviour” (Mobbs et al, 2008) For example, when there is a biological risk eg from Birth complications Minor physical anomalies* Environmental Poisoning (e.g. lead) Mal-nutrition (leading to brain mal-development) is not usually significant unless there is a “evocative environment” “presence of negative psychosocial factor” (Raine, 2002) (esp. maternal rejection*) “We have to understand the brain as part of a socio-cultural environment….The brain is essentially a social organ that we can not understand isolated from its environment.” Wolf Singer (in Die Zeit, May 2008)

5. Brain Injury: Scale of problem “TBI is an epidemic … yet it is silent … the public largely seem unaware of it… …” Thurman, 2002 Head Injury is the leading cause of death and disability in children & working age adults (Leurssen et al, 1988; Graham, 2001; Maas et al, 2006) persistent and widening differences between socio-economic groups E.g. Pedestrian injuries risk highest in least advantaged groups (Hippisley-Cox, 02: Trent study, BMJ ) Prevalence rate of 8% (Silver et al, 2001) to 30% (McKinley et al, 2008) in population studies

6. Alan Tennant

8. Annual attendance rate per 100,000 population for moderate to severe head injuries in children aged under 15 by socio-economic Quartiles (Q4 = most deprived) and by type of residence.

9. Differences in socio-economic status (SES) between attendees with MHI and Orthopdedic (OI) comparison group.

11. Health conditions and TBI & prison populations mental health & drug/alcohol problems identified “relative to general population, [prisoners]…experience poorer physical, mental, and social health…[more] mental illness and disability, drug, alcohol…suicide, self harm…lower life expectance [etc.]…” Orme et al. BMJ editorial, 2005, 330. p 918 Eg. Fazel & Danesh (2002a (Lancet)) systematic review of 62 surveys from 12 countries ( 22 790 prisoners). 6-month prevalence of psychosis in 3.7% of men and 4% of women major depression in 10% of men and 12% of women. Studies seldom examine the serious physical illnesses OR intellectual disability prevalent in prisons “….delivery of services to prisoners with anxiety and affective disorders, drugs and alcohol problems, brain injury, learning disability, challenging behaviour and repetitive self-harm has changed little or worsened.” Dearbhla Duffy, et al. (2003) p. 242 (our emphasis)

12. Report of the New South Wales Chief Health Officer- 45% male and 39% female reported at least one head injury…www.health.nsw.gov.au/public-health/chorep/prs/prs_chronic_type.htm

13. TBI in Prison Populations Barnfield & Leathem (98) NZ study: 118 respondents to questionnaire survey 86.4% reported some form of head injury (56.7% MORE than 1). Reported ++difficulties with memory and socialization

14. Rates of Mild – Severe TBI in Prisoners Mewse, Mills, Williams & Tonks et al (in prep)

15. Percentage of population reporting TBI & type of injury

16. Mild TBI Number of mild tbis No % 0.00 = NO TBI and Mod-severe TBI) 1.00 19.5 2.00 16.9 3.00 6.7 4.00 2.1 5.00 3.1 6.00 .5 7.00 .5 8.00 .5

17. TBI a risk for Crime? - Population based study Timonen et al (2002) population based cohort study in Finland involving more than 12,000 subjects TBI during childhood or adolescence associated with fourfold increased risk of developing later mental disorder with coexisting offending in adult (aged 31) male cohort members (OR 4.1, 95% CI 1.2-13.6) TBI might have been a result of high novelty seeking and low harm avoidance in people susceptible (for issues of genetics, family background, social forces etc.) to risky behaviours – coincidental to crime….BUT TBI earlier than age 12 were found to have committed crimes significantly earlier than those who had a head injury later Therefore - temporal congruency suggests a causal link

18. TBI in Prisoners: crime profiles and effects Leon-Carrion J, Ramos FJ. (2003) (BI) Retrospective study of head injuries (in childhood and adolescence) in violent and non-violent prisoners. subjects in both groups had a history of academic difficulties. Violent offenders and non-violent had histories of head injury BUT the violent offenders tended NOT to have had rehabilitation post-injury rehabilitation of head injury is a measure for crime prevention

19. TBI & Crime: Coincidence or causal? Turkstra et al. (2003) offenders with TBI against “true peers” without TBI 20 individuals convicted of violent crime compared to 20 non convicted controls (matched for education, age and employment). TBI NOT more common in the offender group BUT there was variance on severity of injury non-offending group– typically – Milder TBI from (eg sports). offending group injuries More assaults (with probable longer lasting changes in behaviour). had more issue related to anger control. TBI is not necessary for crime, but that TBI may contribute to “expression of violence” - increase the risk “threshold” in vulnerable people.

20. TBI a contributory factor:Multiplicative Model Kenny et al (2007) juvenile detention in Sydney- 242 young offenders (76% response rate) Alcohol, substance abuse, TBI and cultural backgrounds offences rated as: low (common assault) moderate (robbery with weapon) serious (homicide). 85 individuals had experienced a head injury Violent offending more common for those with KO history

21. TBI a contributory factor:Multiplicative Model odds ratios: of 2.37 for having s serious violent crime if the young offender had had a head injury. 2.82 if the YO had been unconscious. hazardous alcohol drinking history increased risk of severe violent offending. regression models produced “multiplicative model” of how TBI is related to crime.

22. TBI & Crime: Crime type & risks of Re-offending Mewse, Mills, Williams & Tonks et al (in prep) Type of Offences

23. Repeat offending – Crime type & Injury

24. Injury, Repeat offending & Violence

25. Summary… TBI and Prison population There is a x2 (or 3) rate of TBI compared to general population Might be risk of more violent index event TBI may be associated with problems in rehabilitation (discharge plans etc.) Hawley et al. (03) (BI) repeat offending BUT has to be seen as a factor within many others, especially - alcohol/drug, mental health etc.

26. Developmental issues, TBI & Crime The rate of injury is highest in younger groups The young brain may be “plastic” BUT recent evidence suggests that some skills become crowded out Sleeper effect of injury Could childhood TBI be a particularly important factor to account for? Especially when we consider how such injury affects socialisation

27. Childhood Brain Injury & Social impairments Social behavioural problems are: may not be evident until adolescence (Lishman, 1998; Teichner & Golden, 2000) may occur in isolation from cognitive deficits (Anderson, Northam, Hendy & Wrennall, 2001) Often there is a discrepancy between psychometric assessment and psychosocial outcome. considered to be the most common and disruptive issue (Henry, Phillips, Crawford, Theodorou & Summers, 2006). Social impairments are often considered to be the most common and disruptive consequences of injury. Brain injury may lead to the development of various conduct disorders and socio-emotional behavioural problems are often present and continue to be reported at least three years post injury. Such effects may occur in isolation from other cognitive deficits and may not be evident until adolescence, often creating a discrepancy between psychological assessments and psychosocial outcome. Social impairments are often considered to be the most common and disruptive consequences of injury. Brain injury may lead to the development of various conduct disorders and socio-emotional behavioural problems are often present and continue to be reported at least three years post injury. Such effects may occur in isolation from other cognitive deficits and may not be evident until adolescence, often creating a discrepancy between psychological assessments and psychosocial outcome.

28. The Role of Theory of Mind and Empathy Theory of Mind (ToM): to attribute mental states to others, to know they have beliefs, desires and intentions that are different from one's own Early components achieved by 4yrs, later developments by 11yrs (basic level = understaned emotion, through to complex level of “intention” “motivation” Empathy: to recognise or understand another's state of mind or emotion & “co-experience” their outlook or emotions within oneself "putting oneself into another's shoes” Sophisticated levels achieved during early adolescence Both skills are fluid during childhood ? likely to be vulnerable to the effects of an acquired brain injury (ABI)?

29. Darwin was one of the first people to think about emotion scientifically. He proposed that emotional expression, like any other natural behaviour, could be explained through an evolutionary perspective. He suggested that emotional displays reflected behaviours that preceded certain behaviours. Eventually, the fact that certain behaviours were predictive of how an animal was going to react gave them a communicative function. This meant that execution of the precursor display alone might convey an adaptive advantage, and eventually the direct link to the associated behaviour was lost. Darwin also proposed the principle of antithesis, by which opposite signals indicated opposite messages…Darwin was one of the first people to think about emotion scientifically. He proposed that emotional expression, like any other natural behaviour, could be explained through an evolutionary perspective. He suggested that emotional displays reflected behaviours that preceded certain behaviours. Eventually, the fact that certain behaviours were predictive of how an animal was going to react gave them a communicative function. This meant that execution of the precursor display alone might convey an adaptive advantage, and eventually the direct link to the associated behaviour was lost. Darwin also proposed the principle of antithesis, by which opposite signals indicated opposite messages…

31. How do ABI children compare to non-injured children (“Mind in the Eyes”)?

32. Face-emotion processing problems in children with ABI (Tonks et al, 2007/2008)

33. Theory of Mind & Empathy in TBI (in prep) : Sarah Wall, Huw Williams, & Ian Frampton ToM and empathy are critical social-emotional skills for efficient, mature functioning, becoming increasingly important throughout late childhood and early adolescence. Over the first four years of life there is increasing understanding about the functions of the brain, and during the 3rd and 4th years there is increasing ability to understand the possibility that an individual can misconceive a situation. Later components of ToM are then achieved by age 11yrs, such as the ability to detect a faux pas. Established theories of EMPATHY development suggest that empathy skills are present in young children but become more sophisticated throughout childhood, with the emerging sense of person permanence and later understanding that people have stable identities and experiences that extend beyond the current situation. In Hoffman’s model, higher, mature levels of empathising are not achieved until late childhood or adolescence, although the less sophisticated levels remain accessible rather than progressed in a stage-like manner It has been argued that skills that are fluid are more vulnerable to the effects of an acquired brain injury than more consolidated, crystallised skills. Therefore, if both empathising and ToM are fluid skills during childhood, are they not likely to be vulnerable to the effects of childhood injury? Would it be possible to intervene if the problems were detected early enough to prevent the accumulation of deficits into adulthood? Adult ABI studies frequently report impaired social-emotional functioning. However, there is a paucity of research into the effects of a childhood brain injury on social-emotional functioning, particularly ToM and empathising, during the critical development years of young adolescence. ToM and empathy are critical social-emotional skills for efficient, mature functioning, becoming increasingly important throughout late childhood and early adolescence. Over the first four years of life there is increasing understanding about the functions of the brain, and during the 3rd and 4th years there is increasing ability to understand the possibility that an individual can misconceive a situation. Later components of ToM are then achieved by age 11yrs, such as the ability to detect a faux pas. Established theories of EMPATHY development suggest that empathy skills are present in young children but become more sophisticated throughout childhood, with the emerging sense of person permanence and later understanding that people have stable identities and experiences that extend beyond the current situation. In Hoffman’s model, higher, mature levels of empathising are not achieved until late childhood or adolescence, although the less sophisticated levels remain accessible rather than progressed in a stage-like manner It has been argued that skills that are fluid are more vulnerable to the effects of an acquired brain injury than more consolidated, crystallised skills. Therefore, if both empathising and ToM are fluid skills during childhood, are they not likely to be vulnerable to the effects of childhood injury? Would it be possible to intervene if the problems were detected early enough to prevent the accumulation of deficits into adulthood? Adult ABI studies frequently report impaired social-emotional functioning. However, there is a paucity of research into the effects of a childhood brain injury on social-emotional functioning, particularly ToM and empathising, during the critical development years of young adolescence.

35. 25 young adolescents (10 to 15yrs) with a history of ABI, 50 typically-developing (TD) matched controls Global impairments Poorer empathic responding Less accurate ToM Parental reports of poor emotion recognition and empathy Self-reports of poor emotion recognition and empathy + executive impairments (DEX-C + EF measures), increased daily difficulties and impact (SDQ) Theory of Mind (complex) & Critical age of injury Compared to their age- and gender- matched peers, the adolescents with a history of brain injury showed global impairments across the measures of intereste Hence, on the measures of interest here, the BI sample showed less ability to generate an appropriate empathic response to characters in auditory vignettes, and less accurate ToM responses to an AV conversation between two adolescents. The SEQ-C parental reports demonstrated poorer emotion recognition and empathy skills amongst the BI sample relative to the controls. Although the self-reports demonstrated a similar difference, it was less pronounced in the self- rather than the parent- reports thereby indicative of additional low levels of insight Further, there was evidence of increased executive dysfunction in daily life as reported by the parent as well as across the EF measures included in the battery. The BI sample were also shown to have increased daily difficulties on the SDQ, as well as higher impact on the family – Of note the impact was greater amongst the older sample. Compared to their age- and gender- matched peers, the adolescents with a history of brain injury showed global impairments across the measures of intereste Hence, on the measures of interest here, the BI sample showed less ability to generate an appropriate empathic response to characters in auditory vignettes, and less accurate ToM responses to an AV conversation between two adolescents. The SEQ-C parental reports demonstrated poorer emotion recognition and empathy skills amongst the BI sample relative to the controls. Although the self-reports demonstrated a similar difference, it was less pronounced in the self- rather than the parent- reports thereby indicative of additional low levels of insight Further, there was evidence of increased executive dysfunction in daily life as reported by the parent as well as across the EF measures included in the battery. The BI sample were also shown to have increased daily difficulties on the SDQ, as well as higher impact on the family – Of note the impact was greater amongst the older sample.

36. TBI and Crime – causal or co-incidental? The evidence is not clear cut there are many confounding factors within the relationships between injury and later offending, as Turkstra et al. (2003) notes the link between crime and TBI may be an epiphenomenon whereby criminal behaviour “particularly violent crime, is likely to result from complex interaction of factors such as genetic pre-disposition, emotional stress, poverty, substance abuse and child abuse” (P 40). TBI may be an important factor in offending behaviour. “poor prefrontal function [may be associated with] impulsive violence, [but] this brain dysfunction may be essentially a predisposition only, requiring environmental, psychological and social factors to enhance or diminish this tendency” p.54 Raine, 2002 Developmental factors may be particularly important: High rates of injury in childhood Injury increases risk of maladaptive coping, poor psycho-social functioing and impacts on educational opportunities etc.

37. What can be done: Prevention… Infants/toddlers – prevention of: “un-intentional” blows, falls? Targetted interventions? Adolescents and young adults Need to target alcohol a major contributor, esp. re assaults…. Safety in sports Especially in context of – Urban environment Lower SES Data systems need to be developed for monitoring trends, causes etc. guide preventative measures for appropriate resources & service provision

38. What can be done: Early intervention… Managing Early injury/experience: Providing better pre-post-birth health care esp. to poor mothers reduce complications improve maternal attachment/ parenting style/nutrition (mother/child)/ manage poor (and toxic) coping styles (alcohol/smoking) (Raine 2002) Rehabilitation after injury per se might be a factor in crime reduction (Leon-Carrion 2003). This would not be a straightforward as children who may be most at risk may be very hard “to reach” some at most risk could be stuck in a “catch 22” – lack of immediate support to access rehabilitative support to enable positive behaviour change The delivery of services to such groups would therefore require close cooperation between health, social and educational systems. Needs to account for sleeper effects – esp. relevant to socio-emote functions at transition to adolescence Targetted at ?socio-emotional processing (esp. ToM/Empathy etc.): eg “Mind Reading: An Interactive Guide to Emotions” (Baron-Cohen, 2004)

39. “The person at risk of violence needs to recognise his risk and take preventative steps to not hurt others …but responsibility and self-reflection are not disembodied…[but] rooted firmly in the brain…patients who have damage to…prefrontal cortex…may not be able to reflect on their behaviour and take responsibility for predispositions… internal soul-searching [is] damaged…” Raine (2002) So we need: better screening for head injury at pre-sentencing and on admission to prison services – for better understanding of risk, and for rehabilitative purposes Esp. those with executive (& socio-affective) difficulties who may have difficulty in changing behaviour patterns in response to contingencies. What can be done: Screening…for sentencing & rehabilitation*

40. What can be done: alternatives to prison… "Brains become minds when they learn to dance with other brains" W.J. Freeman “Normal” development- Brain finally finishes growing at 25 yrs maturation of PFC is correlated with counterfactual reasoning (“if- then” rules) and with the capacity for inhibiting inappropriate responses (Mobbs et al. 2008) The highest crime figures are for individuals between 16 and 24 (British rime Survey) – i.e. those with immature brains (Mobbs et al, 2008) Alternatives to prison (Postnotes – Parlimentary Office of Science and Technology, May 2008) “restorative justice seemed to work best in reducing re-conviction rates for more serious crimes involving personal victims such as violence….” But more so for adults that adolescents…with same level of re-conviction in adolescents Reduction in PTSD in victims Why? Does it involve a real shift in empathy? Awareness? Etc. linked to community orders that specifies treatments?

41. Conclusions lack of research on brain injury & crime – as a risk factor per se, or as it contributes to offenders not changing behaviour patterns More needs to be done to provide better guidelines for interventions… In context of other key issues, esp. drugs & alcohol Future work would need to be inter-disciplinary and inter-agency Public safety and long term economic advantage could be gained by better, earlier, targeted interventions to prevent injury, reduce impact of injury and enhance outcomes Systematic neuro-rehabilitation – not currently available in UK – is needed children are most likely to be injured & least likely to get support…