Dr James Tonks & Prof. Huw Williams. *School of Psychology University of Exeter & *NHS Devon. j.tonks@exeter.

1. Keeping Children in Society: Youth offending and aquired brain injury. Dr James Tonks & Prof. Huw Williams. *School of Psychology University of Exeter & *NHS Devon. j.tonks@exeter.ac.uk, w.h.williams@exeter.ac.uk UK Brain Injury Forum Centre for Clinical Neuropsychological Research (CCNR) NHS Building the bridge between academic and clinical neuropsychology

2. Brain development in children and adolescents: Insights from anatomical magnetic resonance imaging Rhoshel K. Lenroota and Jay N. Giedd (2006) • dorsolateral prefrontal cortex • late to reach adult levels of cortical thickness • circuitry sub-serving control of impulses, judgment, and decision-making. • implications of late maturation of this area have entered educational, social, political, and judicial discourse http://www.loni.ucla.edu/~thompson/DEVEL/dynamic.html Savage, 2009

3. Yates, Williams et al. 2006, JNNP: Attendance rates for moderate to severe head injury per 100 000 population for each 5 year age band by sex and area residence (GCS under 12). Nb. Rates of TBI (across all severities) in males across severities are given as between 5% to 24% 250-450 per 100,000 across all severities (US/UK) - 80% approx are MILD

4. Traumatic Brain Injury (TBI)(from: www.netmedicine.com/xray/ctscan/img_ct) • Traumatic brain injuries: Penetrating injury • Closed Injury

5. Brain Areas that typically Injured… • frontal-tempo-limbic systems are crucial for Monitoring arousal level & control of behaviour towards “goal states” • Moderate to Severe TBI • Neuropsychological deficits, behavioural problems and poor social outcomes (Stambrook, Moore , Peters ‌, Deviaene ‌, & Hawryluk, 1990). • poor planning and inflexibility (Milders, Fuchs & Crawford, 2003) “poor anger management (irritability and impulse control are common” (Hawley et al. 2003) • Nb. Limbic systems more vulnerable in children • Mild TBI • When “complicated”, or cumulative, there can be neuropsychological sequelae (15%?), esp. attention and executive systems (Williams, Potter & Ryland, 2010).

6. Childhood Brain Injury: long term effects Problems: Attention, working memory, executive control disinhibition etc. lack of “moral” reasoning. (Damasio 1996; Anderson, Bechara, Damasio, Tranel, & Damasio, 1999; Hanks, Temkin, Machamer & Dikmen 1999; Levin & Hanten, Powell, 2004). Often there is inappropriate social behaviour the most common and disruptive issue (Henry, Phillips, Crawford, Theodorou & Summers, 2006). may not be evident until adolescence (Lishman, 1998; Teichner & Golden, 2000) point at which ‘delayed costs’ of earlier ABI are expressed (see Anderson 2008 re: neuroplasticity & crowding effects) may occur in isolation from cognitive deficits (Anderson, Northam, Hendy & Wrennall, 2001 persisting personality and emotional deficits – due to de-coupling of cognition and emotion - has been described by Damasio (1994), as “acquired sociopathy”” – Max et al, 2001: prospective study of 94 children with TBI aged 9 at time of injury OPC in 57% of severe TBI sample (22/37) & 5% mTBI (3/57) labile and aggressive OPC subtypes most common - 3-4 x more

7. Problems MIGHT also occur post MTBI Wrightson, McGinn and Gronwall (1995) • pre-school children - MTBI tested after injury and then at 6 months and a year (V. orthopdeic control group). • no differences after injury on a range of cognitive tasks. • But, at 6 months and then at 1 year, the MTBI children less good on visual problem solving and association with further injury. Limond et al. 2009 follow up of moderate-severe and (mostly) complicated MTBI showed persisting disabilities at 1 year – >lack of pro-social behaviour and emotional symptoms

8. Hessen et al, 2007 (BI) – 23 year follow up study of MTBI – role of (longer) PTA as a predictor of outcomes – SUBTLE neuropsych impairments (memory)

9. Long-term behavioural outcomes of pre-school mild traumatic brain injuryA. McKinlay1,*, R. C. Grace1, L. J. Horwood2, D. M. Fergusson2, M. R. MacFarlane (2010) • longitudinal epidemiological study of a birth cohort of 1265 children born in Christchurch (New Zealand) urban region in mid-1977. • Groups: MTBI “hospitalised” “Not hospitalised” and “No-Injury” • data obtained yearly from age 7 to 13 • evidence of deficits after inpatient MTBI (n = 21) compared to ctrls • increasing deficits over years 7–13. • Mother/teacher ratings for: attention deficit/hyperactivity disorder and oppositional defiant/conduct disorder

10. 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 • (? Cognitive empathy(see Shamay-Tsoory, 2009 - VPC) ) • 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” • “I feel what you feel” (IFG) • Sophisticated levels achieved during early adolescence • Pre-requisite – processing of other’s basic emotion

11. Emotion reading skills are developed across the span of childhood into late adolesecence. From birth Intrinsic bipolar emotional related to arousal - distress and pleasure (Schaffer, 2003). 6? months - primary emotions - surprise, interest, anger, sadness and fear From 1 yr Girls ‘empathising’ , by 3 Theory of Mind - boys slightly later By 7-9 Complex theory of mind (e.g. Detecting faux pas) (see Baron-Cohen et al, 1999). Continues to develop in late adolescence (14-17 yrs (ToM) (Dumontheil et al in press) Development is non-linear - rapid development associated with growth of the prefrontal cortex, (see Tonks et al. 2009) We were both, in our own way, manipulators — good at grasping the feelings of others and instinctively playing on them. Tony Blair, as reported in the Guardian, 1/9/10

12. Average Borderline/impaired Theory of Mind (complex) & Critical age of injury • 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)

13. The National Picture • No common agreed pathways • Little parity or standardisation of service provision • Paucity of research studies • Absence of a needs-based approach • Marginalisation of mild brain injury and paediatric injuries • National Service Framework & Every child matters (2005)

14. Piaget’s Four Stages Of Cognitive Development. Epstein’s Growth Spurts In Brain Growth. Birth to 18-24 months. Sensorimotor Stage 30% increase in brain weight by 1 ½ years. Approx 2 to 6 years. Preoperational Stage. Approx 2 to 4 years, 5 to 10% Approx 7 to 11 years Concrete Operational Stage. Approx 6 to 8 years, 5 to 10% 12 years + Formal Operational Stage 12 to 14 years 5 to 10 % . Problems typically emerge at around 10 years of age. (Perna, 2002). • This age is a stage of transition, when children have to adapt to meet the demands of ever-more complex social situations as they become more adult-like in their social functioning. (Turkstra, 2000). • Brain growth spurts, characterised by significant alterations in neural functioning, coincide roughly with the Piagetian stages of development (Kolb & Whishaw, 2003).

15. At 10 years- Improvement in visual structural elements. Between ten and eleven the difference was highly significant (F(1,61) = 9.573 p<.003). No other significant differences were found.

16. Brain injury will affect lots of social abilities.

17. . What emotion is this? Is she happy, sad, angry, Frightened, or normal/ neutral?

18. How do ABI children compare to healthy children? F(1,85)=14.227 p<.000 ANCOVA (FAS): F(1,84)=10.992 p<.001

19. Reading emotion/mind in the eyes .

20. How do ABI children compare to healthy children on the eyes task? F(1,85)=15.113 p<.000 ANCOVA (FAS): F(1,84)=6.760 p<.011

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

22. Peer relationships after ABI?

23. Peer relationships – critical for healthy development! positive peer relationships are an essential component of well-being social isolation from peers poses a considerable threat to children’s mental health in both the short and long-term (Guralnick, 2006). absence of peer relationships undermines self-esteem and deprives children of important pleasurable experiences, contributing to depression Windle (1992)

24. Impairments will impact upon peer relationships after ABI. • Impairments in recognizing and responding to emotional expressions are correlated with emotional distress and peer-relationship difficulties. (Tonks, Williams, Frampton, Yates & Slater, 2007). • impairments in self-regulation associated with executive dys-function have a negative effect upon social competence.Ganesalingham et al. (2006) • poor social competence = peer-relationship difficulties (Caspi et al., 1995)

25. Peer relationship difficulties and emotional distress Tonks, Yates, Williams, Frampton, & Slater (2010). 137 Healthy Childen (controls), 27 children using the Child and Adolescent Mental Health Services (CAMHS), 40 children with ABI, (All children aged 8 to 17 years old). Strengths and Difficulties Questionnaire (SDQ) Parent version (Goodman, 1999) • control group compared to CAMHS was significant (p<. 001) • difference between the controls and the ABI children (p<. 001). • There was no significant difference in reported peer difficulties between CAMHS and ABI children (or for distress) Controls CAMHS Children ABI Children

26. Emotional Distress Mean SDQ parent scores for emotional distress for healthy age-matched controls, CAMHS children and children with ABI. • control group compared to CAMHS was significant (p<. 001) • controls and the ABI children (p<. 001). • There was no significant difference in reported emotionality between CAMHS and ABI children.

27. Impairment to social skills + Loss of peer relationships= Vulnerability. Vulnerability and Resilience James & Huw’s equation

28. Family disruption, Depression & Anxiety

30. Clinical implications/ conclusions • There is emerging evidence of link between ABI and Youth offending. • Even when children are known to have an ABI we’re really poor at serving their needs/ their injury history is quickly discounted. • Impairments to social skills are detrimental to peer relationships and increase vulnerability to a range of difficulties (familial, mental health, etc.). • We are currently testing clinical interventions- working with schools, peers and families of children with ABI.

31. Problems of Empathy & ToM – (de)socialising consequences...(2) • Offender groups • psychosocial risks for poor empathic responding • harsh or inconsistent parenting , abuse “empathy poor” environments (Patterson, 82,95) • angry, coercive responding role models for emotional regulation rather than pro-social empathic models (see Robinson 2007). • Young offenders have been found to have less empathic responses compared to no-offending groups (Robinson, 07). • persistent offenders are described as impulsive and lacking affective empathy (see Williams et al 2010) • Such anti-social behaviours = rejection by peers and gravitation towards those with similar behaviours... • additional neurological injury may contribute to poorer functioning (*??).

32. Childhood TBI & Risk of Crime... • 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) • 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

33. McKinlay A., et al.“Are children who experience Traumatic Brain Injury more likely to engage in criminal behaviour during their adult lives?” 33rd ASSBI(Abstract) Brain Impairment. 2010 • longitudinal epidemiological study of a birth cohort of 1265 children born in Christchurch (New Zealand) urban region in mid-1977. • Groups: MTBI “hospitalised” “Not hospitalised” and “No-Injury” • Outcomes - ages 21-25 - self-reported arrests, violent offences and property offences. • adjustment for gender, SES...(BUT ?? Family issues) • Adjusted rates - compared to non-injured individuals, both TBI groups were more likely to be arrested (relative risk (RR)=2.03 and RR=1.68), involved in property offences (RR=2.08 and RR=1.54) and violent offences (RR=1.35 and RR=2.29) (all p<0.01). • “clear evidence of ongoing problems for individuals who had experienced a TBI compared to their non injured counterparts”.

34. Prevalence studies of TBI in young offender groups • Huxx, Bong, Skinner, Belau, & Sanger (1998) • TBI in offending and non-offending youths (50% versus 40%) • greater biomechanical forces - such as fights and road accidents versus sports injury • higher levels of immediate symptoms, such as headaches, dizziness and losses of consciousness. • Perron and Howard (2008) • period prevalence and correlates of TBI – with a LOC of 20 minutes or more - in 720 youth offenders. • 18.3% reported such a head injury. • Male gender, co-morbid psychiatric diagnosis, earlier onset of criminal behaviour and substance use were associated with TBI.

35. Rates of Mild – Severe TBI in Prisoners Williams et al (2010) Brain Injury 453 males held in HMP Exeter Pps: 196 aged between 18 and 54 years (43% response rate) sentenced or remanded

36. Percentage of population reporting TBI & type & TIME of injury (Williams et al (2010)) • we estimate that • 65% may have had a TBI. • 10% Severe • 5.6 % Moderate • 49.4% Mild Average age at 1st imprisonment: 21 Years – Non-TBI 16 years - TBI “Any tbi?” No 39.6 % Yes 60.4%

37. Young Offenders & brain injury 192 young male offenders ranging from 11 to 19 years of age (M = 16.63, SD = 1.07 years) (response rate of 98%). The mean number of convictions 6.95 (SD 4.56). Offences of violence accounted: 27.1% shoplifting, theft, and robbery: 25.5% Burglary: 18.2% “joyriding”: 14.7% drug offences: 11.6% Fraud: 2.5% Offences: 0.4% Williams, Cordan et al (in press, Neuropsychological Rehabilitation):

38. Young offender population and TBI 65% reported a history of “head injury” main category of injury was violence (57.6%) With falls “on drugs” being second most common “criminal cause”. MTBI with a LOC of up to 10 minutes & Moderate - severe TBI made up 46% of the overall sample. Repeated MTBI were also very frequent nearly twice as many multiple MTBI compared to single MTBIs

39. Conviction profiles • Participants w/ TBIs • had an average of 2 more convictions (M = 7.23) compared to non-TBI (sig. after age effects etc.) • Those with x3+ TBI with greater violence

40. Young Offenders, TBI and Drugs Frequency of cannabis use – (once a month –to – everyday)

41. TBI in Prisoners: Childhood injury and rehabilitation • Leon-Carrion J, Ramos FJ. (2003) (BI) • Retrospective factor analytic study of links between head injuries (in childhood and adolescence) in adult violent and non-violent prisoners. • subjects in both groups had a history of academic difficulties. • Trend for both groups to have had behavioural and academic problems at school • Head injury in addition to prior learning disability/school problems increases chances of having a violent offending profile • Violent offending (noted) to be “associated with non-treated brain injury” • ? rehabilitation of head injury may be a measure of crime prevention

42. 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 • the link between crime and TBI may be an epiphenomenon– whereby TBI is “marker” for of various contextual factors associated with crime - indeed • 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” • Turkstra, 2004 (P 40).

43. Tom McMillan – Head Injury & Offending

44. What can be done: Younger groups children are most likely to be injured & least likely to get support EVEN if TBI is a marker, it may be an important one to pick up! Systematic neuro-rehabilitation MAY BE A MEASURE OF CRIME PREVENTION IN IN ITSELF… “sleeper effects” (“crowding” as part of neurplasticity)– esp. relevant to socio-emotional functions at transition to adolescence – important to monitor The delivery of services to such groups would therefore require close cooperation between health, social and educational systems. Particularly focus on parenting of at risk children - http://www.scmh.org.uk/pdfs/chance_of_a_lifetime.pdf http://www.incredibleyearswales.co.uk/ & see Gardner, Hutchings, Bywater & Whitaker, 2010 J. Clin Child & Adol Psych. – use of <: in multi agency work

45. Conclusions • Deputy Prime Minister Nick Clegg recently noted that the nation was "criminalising far too many young children". http://news.bbc.co.uk/1/hi/uk/8565619.stm • Public safety and long term economic advantage could be gained by better, earlier, targeted interventions to: • prevent injury • reduce impact of injury • enhance outcomes • May be complicated to deliver – BUT: “pessimist sees the difficulty in every opportunity; an optimist sees the opportunity in every difficulty” W. Churchill