Transforming Minnesota's Correctional System for Traumatic Brain Injury

1. Brain Injury in Minnesota Correctional Facilities:Changing the System Dr. Charlotte JohnsonPsychologist, MN Department of Corrections Mary Enge Regional Resource Specialist, MN DHS, Disability Services Division

2. Types of Brain Injury • Traumatic Brain Injury (TBI) is an injury to the brain caused by an external force after birth • Acquired Brain Injury (ABI) is an injury to the brain which is not hereditary or congenital, occurs after birth, & includes all types of TBI

3. Centers for Disease Control (CDC) Traumatic Brain Injury (TBI) Statistics • TBI is a contributing factor to a third of all injury-related deaths in the United States • About 75% of all TBIs each year are concussions or other form of mild TBI

4. Centers for Disease Control TBI Statistics • Each year there are a reported 1.7 million TBIs in the United States • An estimated 5.3 million Americans - 2% of the U.S. population - live with a long-term or lifelong need for help due to TBI

5. Demographics of MN • US Census population for the state of MN estimated in 2010 as 5,303,925 • 85.3% White • 5.2% Black • 4% Asian • 1.1% American Indian/Alaska Native

6. TBI in State of Minnesota 2011 Dept. of Health TBI Registry Data • 5,713 Hospital Admissions • 10,429 ER/ED Visits • 853 Deaths 2011 Population of Minnesota: 5,303,925

7. Chronic TBI in Minnesota Estimate: 90,000 to 100,000 Minnesotans live with a disability that is caused or made worse by a traumatic brain injury

8. Traumatic Brain InjuryGrant 2006-2009 Goals • Measure prevalence rates of TBI in state correctional facilities • Provide training & education to Department of Corrections employees & partners • Identify / develop release planning & community resources for offenders & ex-offenders

9. Minnesota Department of Corrections Prison Facilities

10. Minnesota State Prisons

11. What Did We Learn?2006-2009: TBI Prevalence • 998 adult male offenders were successfully interviewed to determine TBI History (MCF-St. Cloud) • 100 adult women offenders were successfully interviewed (MCF-Shakopee) • 52 adolescent male offenders were successfully interviewed (MCF-Red Wing)

12. What Did We Learn?2006-2009: TBI Prevalence 82%+ of offenders successfully interviewed had a history of TBI

13. 2006-2009 Major Grant Products • Prevalence Data • Extensive TBI Training for Department of Corrections Staff • Development of Three on-line Training modules for Department of Corrections staff & partners

14. 2006-2009 Major Grant Products Prevalence Data: What Did We Learn?

15. TBI Severity Criteria • Severe: >24 hours Length of Coma (LOC) &/or >24 hours Post Traumatic Amnesia (PTA) • Moderate: 60 minutes to 24 hours LOC &/or 1-24 hours PTA • Mild: 0-59 minutes LOC &/or PTA <1hour PTA

16. Another Measure of Severity

17. Male Findings • Severe: 13.9% • Moderate: 12.4% • Mild: 73.7% • No TBI: 172 Severe & Moderate counts were nearly double using less conservative criteria

18. Juvenile Males • 49 out of 50 reported history of TBI • Most were moderate & severe • Most were due to domestic assault

19. Female Findings • 96 out of 100 female offenders met criteria for having sustained a head injury • 22.1% Mild (male=73.7%) • 44.2% Moderate (male=12.4%) • 33.7% Severe (male=13.9%)

20. TBI in Minnesota Prison Population

21. MN DOC Offender Statistics as of 01-01-2012 • Incarcerated: • 9,302 adults • 43 juveniles • Average age: 36

22. MN DOC Offender Statistics as of 01-01-2012 Approximately: • 53% White • 35.5% Black • 9% American Indian • 7.3% Hispanic • 2.4% Asian

23. What Did We Learn? Needed: • Refined process to identify offenders with TBI & related functional impairment • Plan to assist in prison & with discharge back to the community • Ongoing training & staff dedicated to TBI in critical programs

24. TBI in Minnesota Correctional Facilities: Changing the System (2010-2014) • MN Departments of Human Services & Corrections 2nd partnership grant is building on the work of our earlier grant • Current grant life: 2010-2014 • $250,000.00 award per year

25. Current Grant Project Literature suggests that cognitive problems associated with a past TBI may affect potential to succeed in rehabilitation (Valliant, et al, 2003; Corrigan, 1995, as cited in Wald, Helgeson, & Langlois, 2008, para. 8), including SA treatment (SAMHSA, 1998a, as cited in Wald, Helgeson, & Langlois, 2008)

26. Current Grant Project: Successful Return to Community • Long term goal: systemic change within the DOC to offer an improved response for offenders with TBI • Coordination of services to better transition to the community

27. Current Grant Project: Successful Return to Community • Development & implementation of DOC system to identify & track offenders with TBI requiring supportive services • Follow identified offenders as they complete chemical dependency treatment

28. Current Grant Project: Successful Return to Community • Release planning to coordinate appropriate TBI services in the community after leaving prison • Comprehensive psychological / cognitive assessment process to identify offenders with special needs

29. Changing the System: Current Grant Accomplishments • Developed / Refined MN DOC TBI Screening Tool • Grant funded DOC Neuropsychologist & TBI Release Planner • Developed CD Treatment protocols for offenders with TBI / cognitive deficits

30. Changing the System: Current Grant Accomplishments • Continue DOC staff/ Community Training • Established DHS TBI Advisory Committee grant subcommittee • Developed Native American Resource Guide • Held American Indian Listening Session

31. Changing the System: Identified Populations • Primary population served: “Offenders in the state prison system, including those who test positive for TBI & have functional needs” • Secondary population served: “incarcerated American Indians”

32. American Indians • U.S. Study found TBI-related hospital discharge rates were highest for American Indians / Alaskan Natives - 75.3 per 100,000 (Langlois, Kegler, & Butler, 2003, as cited in McCrea, 2008) • Risk factors include SES & substance abuse • American Indians are identified as a group of interest for the current grant

33. 2005-2009 MDH TBI Registry:Rate of Nonfatal Hospitalizations • White: 87.7 • Black: 100.2 • Am. Indian/Alaska Native: 162.7 • Asian/Pac. Island: 48 • Hispanic: 1.1

34. American Indian Listening Session: Suggestions On Policy • TBI education for Chemical & Mental Health workers • Ensure TBI is taken into account during sentencing, mental health assessment, & child protection case investigations

35. American Indian Listening Session:Suggestions On Policy • Inform Law Enforcement/Community Services of offender return to community • Formalize inmate access to spiritual & cultural practices – increase access to spiritual leaders.

36. Changing the System: Grant Plans • Share updated on-line DOC training • Work with MNHELP.INFO to enrich site content for ex-offenders & people with BI • Follow-up on selected American Indian Listening Session recommendations

37. What You Need To Know About TBI Symptoms

38. TBI Symptoms • Tremors • Weakness/fatigue • Sensation deficits • Vision problems

39. TBI Symptoms • Language problems • Poor judgment of space • Confusing right/left

40. TBI Symptoms • Problems reading or writing or adding • Problems following conversations • Getting stuck on topics • Not following instructions

41. TBI Symptoms • Tremors • Weakness/fatigue • Sensation deficits • Vision problems

42. TBI Symptoms • Cognitive: • Learning new information • Easily Distracted • Losing train of thought • Forgetting things that have been completed

43. TBI Symptoms • Ignoring one side of body • Irritability, anger, mood swings • Change in appetite / hygiene / social skills

44. TBI Irritability & Anger • 35% to 96% show agitated behavior during acute recovery (Silver, Yudofsky, & Anderson, 2011) • Of 60 offenders in jail those who sustained TBI in last year showed worse anger/aggression (Slaughter, 2003) • Risk factors: irritability, impulsivity, & past aggression

45. What You Need To Know About TBI Diagnostic Considerations & Memory Strategies

46. Diagnostic Considerations • Post-traumatic Stress Disorder • Frequent incidence in soldiers—blast injury • Amnesia for certain parts of the trauma • Difficulty concentrating

47. Diagnostic Considerations • Somatic complaints • Perceptual symptoms • Severity does not influence • Over 40% comorbid PTSD/TBI failed effort tests (consideration of meaning of effort)

48. Diagnostic Considerations • Obsessive-compulsive behaviors • Comorbid with attention deficits • Perseveration & hyper vigilance

49. Diagnostic Considerations • Schizophrenia-like psychosis ● Paranoid delusions ● Auditory hallucinations ● Catatonic features, formal thought disorder & negative symptoms uncommon (Johnson & Lovell, 2011)

50. Memory Strategies • Take notes—Keep notepad, post-it, or cell phone handy to immediately record • Things to do • What was completed in a day • Important phone numbers & addresses • Ideas & feelings • What to do in an emergency