1

repairing
shaTTered lives:
Brain injury and its implications
for criminal justice
Professor Huw Williams
Centre for Clinical Neuropsychology Research, University of Exeter

Acknowledgements
The author would like to recognise the
contribution of:
Dr Prathiba Chitsabesan
Consultant Child Psychiatrist - Offender
Health Research Team (OHRN) Research Team
Child and Family Service (Stepping Hill Hospital),
Pennine Care NHS Foundation Trust, Manchester
Development of the Comprehensive Health
Assessment Tool

Dr James Tonks
Clinical Psychologist & Honorary Research
Fellow (CCNR University of Exeter)
Early injury and how schools may respond to
children with brain injury

Dr Seena Fazel

This report has been commissioned by the Barrow Cadbury
Trust, as part of its work to support the Transition to
Adulthood (T2A) Alliance
Who is this report for?
The audience for this report is broad, but will be of particular interest to commissioners and
practitioners working in the fields of criminal justice, health and social care. It is also of great
relevance to policy-makers with an interest in crime prevention and health improvement.
What is the Transition to Adulthood Alliance?
The Transition to Adulthood (T2A) Alliance is a coalition of 12 of the leading organisations in the
criminal justice, youth and health sectors. Convened by the Barrow Cadbury Trust in 2008, the
Alliance has conducted research and demonstrated practice to support the development of a
more effective approach for young people in the transition to adulthood throughout the criminal
justice process. A 2012 report, Pathways from Crime, set out ten steps to delivering a T2A
approach (www.t2a.org.uk/pathway). Three T2A pilot projects, running since 2009, have
demonstrated that the holistic integrated approaches that support desistance from crime, and
improve employability, health and family relationships.

Clinical Senior Lecturer in Forensic Psychiatry

University of Oxford
Honorary Consultant Forensic Psychiatrist

Oxfordshire and Buckinghamshire Partnership
Mental Health NHS Trust
Risk analyses

The Transition to Adulthood Alliance’s work on maturity and criminal justice
In 2011, T2A began a specific work stream to look at the concept of maturity in a criminal
justice context. At a meeting hosted by Lord Keith Bradley, experts from neurology, psychology
and criminology all confirmed that research supports the T2A position that developmental
maturity should be taken into account throughout the criminal justice process. Indeed, maturity
can be a better indication of adulthood than reaching a particular chronological age.

Mr Howard Jasper
Strategy Advisor, Health Lead

Youth Justice Board

Dr Nathan Hughes
Lecturer in Social Policy and Social Work

University of Birmingham
Maturity factors in crime

Dr Simone Fox
Senior Lecturer, Department of Psychology, Clinical,

A subsequent poll for T2A by Com Res found public and political support for this position, with
7 in 10 members of the public agreeing that the maturity of a young adult should be taken into
account in sentencing. 8 out of 10 MPs thought the same. A literature review by Birmingham
University for T2A in 2011 found that the adult brain is not fully mature until at least the mid20s, and that temperance and impulse control are among the last areas of the brain to develop
fully. Later in 2011, the Sentencing Council for England and Wales included, for the first time,
‘lack of maturity’ as a mitigating factor in sentencing guidelines for adults. The Crown
Prosecution Service is currently consulting on including ‘lack of maturity’ as a factor reducing
culpability in its new Code of Conduct.

Health and Social Psychology

Royal Holloway, University of London
Consideration of interventions for young offenders
and issues of gender

Given the prominence of research findings from neurology in T2A’s work on maturity to date,
this report sets out more clearly the key issues related to brain functioning and development,
with a focus on the impact of brain injury and its association with offending.

Dr Susan Young

About the author: Professor Huw Williams
Huw Williams is an Associate Professor of Clinical Neuropsychology and Co-Director of the
Centre for Clinical Neuropsychology Research (CCNR) www.psychology.ex.ac.uk/rescntr/ccnr.shtml
at the University of Exeter. He gained his PhD and his Doctorate in Clinical Psychology from the
University of Wales, Bangor. He trained in Neuropsychology at Walton Centre for Neurology and
Neurosurgery in Liverpool and then worked at a number of Clinical Neuropsychological services
in London. He was on the founding staff team of the Oliver Zangwill Centre (OZC) for
Neuropsychological Rehabilitation in Ely and was a Visiting Scientist at the Cognition and Brain
Sciences Unit in Cambridge. He has also been a visiting scholar at key Australian centres of
excellence in brain injury: The Rehabilitation Studies Unit, University of Sydney and the MonashEpworth Rehabilitation Centre, Melbourne.

Clinical Senior Lecturer in Forensic Clinical Psychology
in the Department of Forensic and
Neurodevelopmental Sciences

Institute of Psychiatry, King’s College London
Integrating care and justice Pathways

Dr Karen McAuliffe
Senior Lecturer in Law

University of Exeter
National and International legal Frameworks

Dr Adrian Harris
Consultant in Emergency Medicine

Royal Devon and Exeter Hospital, Exeter

Dr Adam Reuben
Consultant in Emergency Medicine

Royal Devon and Exeter Hospital, Exeter

Ms Rebecca Davies
Research Assistant

University of Exeter
Literature Searches

Mr Max Rutherford
Criminal Justice Programme Manager

Barrow Cadbury Trust
Editorial Guidance

He has been a frequent key note speaker nationally and internationally. He has published widely
in Neuropsychology, from assessment and management of the effects of Mild through to severe
TBI - in children, adults and in particular populations such as athletes and offenders. He has
honorary positions with the OZC and the Royal Devon and Exeter Hospital‘s Emergency
Department. He is past Chair of the Division of Neuropsychology of the British Psychological
Society. He has worked with a range of charity sector organisations, such as Headway UK and
the Encephalitis Society. He recently worked with the Child Brain Injury Trust to establish the
Criminal Justice and Acquired Brain Injury Group (CJABIG) as an umbrella organisation for a
range of law and brain injury charities for working on brain injury issues within the justice
system. His has had funding for research in the area of crime and brain injury from the Economic
Social Research Council (ESRC), UK Brain Injury Forum (UKABIF), the Big Lottery Fund, Barrow
Cadbury Trust and the Office of the Children’s Commissioner.
w.h.williams@exeter.ac.uk
(44)1392 264661

Deborah Fortescue
Head of Foundation

The Disabilities Trust
Service development

Repairing Shattered Lives © Barrow Cadbury Trust

Contents

01

Contents
Foreword
Introduction
Executive Summary

Part One: Brain systems and development
Brain systems and functions

02
03
04
07

Brain development in childhood and adolescence
Brain injury

Part Two: Brain injury and criminal justice
Research linking brain injury and offending

15

Prevalence, and associated features, of traumatic
brain injury in offender groups
Young offenders
Complexity of need
Implications of International and European law for children and young
people with brain injury in the criminal justice process

Part three: Key action points
Criminal justice screening and assessment

24

Criminal justice responses
Training for criminal justice professionals
Managing young people with brain injuries in custody
and probation settings
Commissioning appropriate and effective services
Early responses to children and young people with brain injury
Research
Immediate opportunities

Final Thoughts
References
Glossary of terms

29
30
33
Repairing Shattered Lives © Barrow Cadbury Trust

02

Foreword

Foreword

The concept of managing youth to adult transitions in
the criminal justice process has been around for many
decades. I remember it was part of the discussions in the
early days of the Youth Justice Board. Many of us were
concerned that there was too great a divide between
youth justice and adult justice, resulting in many young
people, who were being steered away from crime by the
youth justice system, suddenly having the help pulled
from under them and ending up deep in the adult system
post 18.
At that time there was insufficient academic, practitioner
or political backing for substantial change. Trying to
discuss the concept of transition and the need to treat
young adults differently to older adults, whether with the
media, policy makers or even friends was usually met
with similar responses based on a belief that young
people: ‘know what they are doing’; ‘should think of the
consequences’; ‘have to be taught a lesson’; ‘there are no
excuses for their behaviour’. Reasoning on my part about
the developmental process of maturity, impulsive and risk
taking behaviour and brains that were still forming were
met with raised eyebrows.
For the last few years this has begun to change, with
increasing interest in concepts of maturity and brain
development. What excellent timing then for this report
by the University of Exeter’s Centre for Clinical
Neuropsychology Research. Its findings, into the effects
of brain injury, and the recommendations add
significantly to the knowledge and practice research that
the Transition to Adulthood (T2A) Alliance has been
amassing since 2008. This growing body of knowledge
supports the T2A’s view that young adults, at every stage
in the criminal justice system, need a distinct, focused
and flexible approach if we are going to reduce
reoffending and improve social outcomes for the young
adults themselves, their families and our communities.
We need to get the message of this report out far
and wide.

Repairing Shattered Lives © Barrow Cadbury Trust

In 2011, research by the University of Birmingham
highlighted that there were lessons from neurology that
supported T2A’s work. It showed that the human brain is
not fully developed or ‘adult’ until the early or even mid20s. Aspects such as impulse control and forward
planning are the last elements in the brain to develop
fully, and these directly correspond to the behaviours we
often see (or remember having) in young people in the
transition to adulthood.
In this report the University of Exeter goes further and
details the impact that a brain injury can have on a young
person’s behaviour and life, and highlights the
relationship between receiving an acquired brain injury
and involvement in the criminal justice system. It draws
together the important research from the UK and abroad
to show that there is a high prevalence of acquired brain
injuries among those in the criminal justice system, many
of whom have received little or no treatment, and whose
injury has not been taken into account at any stage of
the process.
The transition to adulthood is difficult enough for all of
us even when we have family and friends to rely on. The
process gets longer and longer as we take on those
markers of adulthood, such as employment or starting a
family of our own, later and later. Our developing brains
can lead to behaviours ‘not expected of adults’. For those
who lack the family support and rely on services that are
not geared to their particular needs the result can be
poor indeed. Add to this the effects of acquired brain
injury that this report sets out for us and it becomes
clearer and even more important that agencies and
practitioners, who will come across such young people
within the criminal justice system, know and understand
what can and should be done.
The report makes clear recommendations for service
commissioners and providers in the health and criminal
justice sectors as to how they should work together to
respond appropriately, ensuring that acquired brain
injuries are picked up early, treated effectively, and taken
into account throughout the criminal justice process. It
outlines some simple steps that can be taken by
practitioners, which, if implemented, would have a major
impact on the lives of people with acquired brain injury,
and to our efforts to reduce offending amongst
young adults.

Joyce Moseley OBE,
Chair of the Transition to Adulthood Alliance

Introduction

03

Introduction
Brain Injury is a major cause of death and disability in children and working age
adults [1]. Acquired Brain Injury (ABI) may occur for many reasons, but most
commonly it is a result of trauma, infection, or stroke. Traumatic Brain Injury (TBI)
is the biggest cause of injury. TBI may affect around 8.5% of the population during
their lifetime. Prevalence of ABI among certain populations is much higher – such as
those involved in contact sports, victims of domestic violence, and adolescent males
who drink.
In recent years, repeated calls have been made for better means of meeting the
mental and physical health needs of prison populations [2-4], not only to improve
individual wellbeing, but also as a way to divert those with underlying health
problems into appropriate services at multiple stages in the criminal justice process,
to reduce reoffending among this ‘revolving doors’ population, and importantly to
reduce costs.
Yet it is rare that brain injury is considered by criminal justice professionals when
assessing the rehabilitative needs of an offender. Recent studies from the UK have
shown that prevalence of TBI among prisoners is as high as 60%, and brain injury
has been shown to be a condition that may increase the risk of offending. It is also a
strong ‘marker’ for other key factors that indicate risk for offending.

Brain injury
has been
shown to be a
condition that
may increase
the risk of
offending”.

Brain injury is largely neglected in recent policy documents (see for example [4, 5]).
This report provides an overview of developments in understanding of TBI in relation
to crime, with a particular focus on its impact on developmental maturity. The links
between TBI and crime may be complex, but three key themes have emerged in
recent research:

1
2
3

There is growing evidence of links between incurring a TBI and subsequent
offending. This indicates a need to reduce injuries and to manage
consequences of injury to enable rehabilitation to be at its most effective;
There is compelling evidence of a very high prevalence rate of TBI in
offenders in custody relative to the general population. Moreover, such
injury may be linked to earlier and more frequent custodial sentences, and
to more violent offending; and
TBI in childhood and young adulthood may be particularly associated with
offending behaviour. Earlier and more effective means to assess and
manage the consequences of TBI in the offender population, and those at
risk of offending, may lead to improved outcomes for affected individuals
and for society.

Such findings underlie calls for increased awareness of TBI throughout the
criminal justice process and, indeed, related areas of health, social, and
educational provision.

This report is in three parts:
Part one outlines a brief overview of the brain – its structures and functions,
and how it develops – how the brain may be injured, who is at risk of injury,
and the consequences of injury.
Part two explores the links between TBI and offending behaviour.
Part three provides a summary of key action points to enable more effective
management of brain injury in children and young people, people at risk of
offending, and those already in the criminal justice process.
A full glossary of terms (where written in bold)
is provided at the end of the report.
Repairing Shattered Lives © Barrow Cadbury Trust

04

Executive Summary

Executive SuMMary
This report explains the connection between acquired brain injury (ABI) and increased contact between
children, young people and young adults with criminal justice processes, with a particular focus on the
impact of ABI upon developmental maturity. This report combines a review of current studies on the
subject with recommendations for commissioners and practitioners.

RESOURCE

• University of Birmingham literature
review on maturity and criminal
justice 2011
http://www.t2a.org.uk/wpcontent/uploads/2011/09/BirminghamUniversity-Maturity-final-literaturereview-report.pdf

What is Traumatic
brain injury?
Traumatic Brain Injury (TBI) is the
leading form of Acquired Brain
Injury (ABI) and is considered a silent
epidemic. The condition most
frequently occurs in young people,
resulting predominantly from falls,
sporting injuries, fights and road
accidents, and is the major cause of
death and disability amongst this
group. Both sexes are equally
affected when very young, however
males are much more at risk than
females in teenage years and
adulthood.
The consequences of brain injury
include loss of memory, loss of
concentration, decreased awareness
of one’s own or others emotional
state, poor impulse control, and,
particularly, poor social judgment.
Unsurprisingly behavioural problems
such as conduct disorder, attention
problems, increased aggression, and
impulse control problems are
prevalent in people with ABIs.
The brain during childhood,
adolescence and young adulthood is
rapidly growing and its connections
are shaped and strengthened by
experience. It is these developing
connections and pathways which
enable it to pass information and
drive the processes necessary to
respond to and sustain life. An injury
to the brain before these areas have
fully developed may cause them to
never entirely evolve or ‘misfire’.
Recent research has shown that skills
that are developing at the time of
injury may be the most vulnerable to
being disrupted, while already
established skills may be more
robust.

Repairing Shattered Lives © Barrow Cadbury Trust

For example, a literature review by
Birmingham University on maturity
and criminal justice in 2011 found
that temperance and impulse
control, located in the frontal lobes
at the front of the brain, are among
the last areas of the brain to develop
fully, often as late in life as the midtwenties.
An injury to this part of the brain
during its development can result in
long-term problems with impulse
control and decision-making, both of
which are factors associated with
anti-social and violent behaviour.
Consequently, while those without a
TBI are likely to grow out of
immature and antisocial behaviour
by their mid-twenties, those with TBI
are likely to continue to grapple with
these issues throughout young
adulthood and beyond.
The most damaging brain injuries are
those that are classified as moderate
(more than 30 minutes unconscious)
and severe (more than 6 hours). It is
worth noting, however, that even a
mild TBI can result in changes in
brain function and can have lasting
effects.
While the brain is resilient, it is not
always able to repair the damage
done. When a TBI occurs during
childhood or adolescence, the brain
will attempt to compensate for the
damage or disruption caused to it
structures and find a way of
rerouting functions. However this
compensation is not the same as the
brain being able to regenerate in the
same way as skin or muscle. There
may be some ‘neuro-plasticity’,
particularly in younger brains, but
even though some functions may be
‘re-routed’, problems can still
emerge.

Executive Summary

Why brain injury is relevant to
criminal justice?
In a review of the research, in this report, it is shown that the level of brain
injuries amongst offenders in custody is much higher than in the general
population. A recent study in England found that 60 per cent of young
people in custody reported experiencing a traumatic brain injury, a finding
consistent with others from around the world.
Despite their prevalence, it is rare for criminal justice professionals to consider
whether an offender may have a brain injury, or for neuro-rehabiliation
services to be offered. Consequently it is common for related health and
mental health needs of children, young people and young adults go unmet,
while appropriate care and treatment that could divert away from the criminal
justice process or help to manage the factors that contribute to criminal
behaviour is not provided.
Such findings indicate the need for increased awareness of ABI throughout
the criminal justice process and beyond, in related areas of health, social care,
and educational. The recommendations of this report have been written with
commissioners and practitioners in mind, identifying steps that can be taken
to assess, manage and divert people with brain injuries earlier before they
enter into the criminal justice process, support desistance for those within
prison, and to improve the effectiveness of rehabilitation services.
While the links between brain injury and criminal justice are evident, it should
be noted that the research found that there is a two-way link between brain
injury and criminal justice, in that risk-taking individuals may be at particular
risk of impulsive criminal behaviours, and similarly, at greater risk of engaging
in thrill-seeking behaviours where injury is more likely. Furthermore, being
involved in crime may put individuals into situations where injury is more
probable. Finally, in younger people and children, there is a link between
deprivation and brain injury, while in women there is a clear link between
victimisation from domestic violence and brain injury.

05

Conclusion
There is already a substantial body of
evidence that defines why younger
offenders up to their mid-twenties require
a distinct and more effective approach
throughout the criminal justice process.
The transition to adulthood is a critical
time, where the right intervention can lead
to a life free of crime, and the wrong one
to a criminal career. However, the need for
a distinct approach is even more acute for
offenders with a brain injury, where the
severity of the injury and the
developmental stage at which the injury
occurred will dictate the extent to which
skills and brain functions may have been
lost. Importantly, the effects of injury in a
young person may not be fully realised,
given that functions that may be
developing may be compromised. This
underlines the importance of assessment
and management of brain injury in young
people.
This research shows that people with brain
injury are substantially overrepresented in
prison, and that brain injury is associated
with earlier, repeated, and greater total
time spent in custody. Given that brain
injury is largely neglected within the
criminal justice process, both as a health
issue and as a factor in offending, it is
clear that addressing the rehabilitative
needs resulting from brain injury would
deliver significant benefits in terms of
reducing offending, improving lives and
saving money to public services.

Repairing Shattered Lives © Barrow Cadbury Trust

06

Executive Summary

Key findings:

1

2

3
4
5

There is compelling evidence of a very high
prevalence rate of TBI in offenders in custody relative
to the general population.

Studies of TBIs amongst offenders in custody show a high
prevalence. A study of young people in a Young Offender
Institution in England found that 60% reported some kind
of ‘head injury’, with 46% of the sample reporting loss of
consciousness. These findings are consistent with other
studies undertaken in Europe and the United States.
There is growing evidence of the links between an
TBI and subsequent offending

Studies have shown that the rate of TBI is much higher in
offenders compared to society as a whole. As well as much
higher prevalence rates of TBI among prisoners, a recent
Swedish study found that 8.8% of people with an TBI later
committed a violent crime, compared with 3% of the
general population. Young offenders with a history of TBI
were 2.37 times more likely to commit a serious violent
crime. This further increased if the young person had lost
consciousness. Research has also shown that there are
certain factors that make brain injury and offending more
likely, such as social deprivation, risk-taking behaviour and
addictions.
Injury in childhood and young adulthood may be
particularly associated with offending behaviour.

Offenders who acquired a head injury younger than age 12
were found to have committed crimes significantly earlier
than those who acquired a head injury later in their lives.
TBI in adult offenders seems to be associated with younger
age of first imprisonment.

Key action points:
Early intervention

1

2
3
4

TBI increases the risk of offending in women

Studies suggest that the prevalence of TBI may be even
higher in female prisoners than in males. An analysis of
women offenders found that 42% who had committed
violent offences had suffered an average of two TBIs.
Further analysis revealed that three factors were
significantly associated with current violent convictions: the
number of years since their last episode of
receiving domestic violence, the number of prior
suicide attempts, and traumatic brain injuries
with loss of consciousness.

Repairing Shattered Lives © Barrow Cadbury Trust

There should be improved management of brain
injuries in the immediate period following the incident

There should be improved monitoring of the
symptoms of brain injuries amongst children and
young people in their developing and adolescent
years

Training for education staff should be routine,
particularly head-teachers, to raise general awareness
of brain injury

Criminal justice responses

1
2

TBI, mental health and drug problems

People with an TBI are at risk of greater mental health
problems and adults who were younger when the acquired
their head injury had higher rates of depression or mood
disorder and /or childhood developmental disorders
including Attention Deficit Hyperactivity Disorder (ADHD) or
disruptive behaviour difficulties. Research in Finland found
that a brain injury acquired during childhood or adolescence
was associated with a fourfold increased risk of developing
later mental health problems in adult male offenders.

Brain injury is a chronic health condition with
associated on-going symptoms, and this should be
recognised throughout service delivery

3

As part of comprehensive health assessments, there
should be standardised screening of young people for
brain injury when they come into contact with
criminal justice process, particularly pre-sentence and
in custody

There should be increased awareness for criminal
justice professionals about the prevalence of brain
injury among offender populations, and an
understanding of the need for assessment and
management within the justice system, in both
community (e.g. Youth Offending and Probation
Teams) and custodial settings

There should be reference to brain injury history in
pre-sentence reports, which should be considered as a
factor in decision-making in the same way that
maturity and mental health are already considered.

Part
one
Brain systems

and development

Repairing Shattered Lives © Barrow Cadbury Trust

08

Part One:
Brain systems and development

Brain systems and development
Frontal lobe
Parietal lobe

Occupital lobe

Temporal lobe

Brain systems and
functions
The brain can be viewed as being
constructed in layers. The inner layer
of the brain, and most basic in terms
of function, is the brain stem. This
is responsible for the tasks necessary
to sustain life, including breathing,
heartbeat, and blood pressure.
Above this is the limbic system that
deals with ‘primitive motivation
drives’ (such as sleep, pleasure, fightor-flight, and ‘habits’).
Finally, the more sophisticated forms
of complex decision making are dealt
with in the peripheral layer, the
cerebral cortex. These different layers
are split into two, linked, hemispheres
each containing four lobes.
For the most part, particular
functions can be linked to each
hemisphere and lobe, although many
of these, especially complex
functions, involve whole networks
across the brain.
The occipital lobes (back of head)
are dedicated to processing visual
information. The parietal lobes
(upper posterior area) relate visual
and spatial information (in three
Repairing Shattered Lives © Barrow Cadbury Trust

dimensions), whilst the temporal
lobes (behind the ears) are, for the
most part, a memory store. The left
lobe for language-based material,
and right lobe for visual (such as
places and faces). The frontal lobes
(above and behind the eyes), by far
the largest, are associated with most
high-level conscious and nonconscious processing. Typically
thought of as the areas where the
‘executive’ system lies, their
functions include setting up searches
of memory, holding information ‘in
mind’, and decision-making.
These ‘neurocognitive abilities’,
particularly when coupled with
emotion processing systems, are
critical in social behaviour.
The ‘frontal’ (executive) systems
along with parts of the limbic
system (amygdala, hippocampus
and insula) are involved in
responses to situations which require
such important capabilities as
impulse control, empathic
responding and consideration of
consequences of action [6-8]. For
example, when seeing a facial
expression that is sad, to be moved
to feel and show sympathy; or, when
seeing anger, to take appropriate
evasive action. Critically, then, the
brain is a processor of varied, diverse
and intermingling data streams.

Early development and
pruning
The brain is made up of 100 billion
brain cells (neurons), largely present
at birth. These communicate with
each other by releasing electrical and
chemical messages via dendrites
and axons. See Figure 1.
Dendrites are branchlike structures
of the neurons that typically act to
receive electrochemical stimulation
from other neurons. Axons are
projections from a neuron that send
impulses away. The electrical
impulses are insulated by a myelin
sheath that surrounds the axon. In
between neurons are synapses that
allow communication across the gap
between neurons. These involve the
release of ‘neurotransmitters’ such
as serotonin, dopamine,
and melatonin [9].

Figure 1: The synapses-connection point between
neurons

Part One:
Brain systems and development

Brain development
in childhOOd and
adolescence
Connections between neurons get
shaped and strengthened by
experience. The brain evolves rapidly
over early childhood and continues
to evolve over the first two decades
of life. In the first three years
neurons migrate, differentiate, and
build up synaptic strength.
After age three, the brain is
constantly sculpted (a critical process
known as cortical pruning) and the
strength of the connections in a
child’s brain improved (becoming
increasingly myelinated) [10]. The
different brain systems thus become
more fully evolved towards being
‘adult-like’.

09

Developmental peaks
Across childhood and adolescence
there are peaks in brain development
– at age 3, 8, 11 through to 15 and
even later at 19 [12]. Such ‘peaks’
are – like iceberg tips - only a small
indication of the complexity of the
underlying changes happening in
brain systems and their related
cognitive and emotional functions.
The frontal system begins to assume
control over socio-emotional and
purposeful behaviour from 3-4 years.
A four year old child may understand
how more ‘smiley faces’ on a chart
could be linked to a trip to a play
park and an ice cream and decide (or
not) that the trade-off is worth
sharing a toy for.
This capacity to link behaviour and
consequence accelerates rapidly in
development from around 7 to 11,
with language skills allowing logical
deduction and more abstract
thought [12]. See Figure 2. The
consequences of such cognitive
changes, in terms of control of
behavior, can be seen in the ability to
resist distraction being relatively
matured by 6 years or so and
impulse control becoming
established by age ten, and these
abilities continue to evolve over early
adolescence, with planning and dual
attention improving with age [13].

Each one of our
perceptual,
cognitive,
and emotional
capabilities is
built upon the
scaffolding
provided by early
life experiences”
(Fox [11] p. 28)

5y
rs

AG
E

20
yrs

Gray Matter
Volume
Figure 2: Dynamic mapping of human cortical development
during childhood through early adulthood

© Gogtay, N., Giedd, J.N., Lusk, L., Hayashi, K.M., Greenstein, D.,Vaituzis, A.C., Nugent III, T.F., Herman, D.H., Clasen, L.S.,
Toga, A.W., Rapoport, J.L., Thompson, P.M., 2004. Dynamic mapping of human cortical development during childhood through
early adulthood. Proceedings of the National Academy of Sciences of the United States of America 101 (21), 8174–8179.

Repairing Shattered Lives © Barrow Cadbury Trust

10

Part One:
Brain systems and development

..biologically
speaking it’s
like starting
the engines
without a
skilled driver
behind the
wheel” [15]
Impulsivity for short-term
reward in adolescence
Importantly, over late childhood and
adolescence, there seems to be a
lack of synchrony in the development
of two of the critical brain systems
that enable fully adaptive behavior.
The ‘rational’ cognitive system,
which allows for understanding a
problem and arriving at a solution,
appears to be well formed at age
16.[14] This seems in step with the
maturation of frontal cortex, and
on testing a child may give
appropriate, adult-like, answers.
However, the system for effective use
of information in context – balancing
long term consequences with
immediate social and emotional
concerns – does not develop in
synchrony with such rationality [14],
and so there is a ‘gap’ between the
‘systems’.
Studies show that adolescents and
young adults become poorer at
responding on problem solving tasks
when the complexity of emotion is
added [14]. Such tasks would likely
involve the interaction of functions

Repairing Shattered Lives © Barrow Cadbury Trust

across a range of brain areas
(including limbic, thalamoamygdala pathway and both left
and right frontal systems) [8].
Furthermore, this ‘gap’ between
reason and emotion is exacerbated
by an underlying susceptibility for
responding to immediate rewards
that emerges early in adolescence.
In the ‘teenage brain’ there is a surge
of an infusion of reward-oriented
neuro-transmitters (dopaminergic
activity) and an associated increase
in reward-seeking behavior.
It appears, therefore, that the brain
system related to rewards (the
meso-limbic area) is developing
rapidly relative to the other systems.
Especially, it seems, compared to the
frontal system that is supposed to
regulate it, and the social and
emotional systems that will, in time,
moderate it.
Changes in brain systems
configuration – as connectivity
improves with increased
myelination and ongoing cortical
pruning - has been shown in longterm neuro-imaging research.
This work shows that the areas

responsible for high level thinking
such as control of impulses and
making judgments about the longer
term (the dorso-lateral- prefrontal
cortex) only reach adult levels of
‘cortical thickness’ in the late
teenage years [16].
The teenage brain, therefore, has an
adult-like ability to reason, but with a
heightened need for basic reward,
and a lowered capacity to buffer
immediate influences and potential
short-term rewards for greater,
longer-term gains – especially in
contexts involving peers. This sets
the scene for risky decision-making.
As one commentator described,
biologically speaking it’s like ‘starting
the engines without a skilled driver
behind the wheel’.[15]

Part One:
Brain systems and development

Brain injury
Around 8.5% of the general
population at one point in their lives
suffer an acquired brain injury (ABI),
the most damaging of which is
Traumatic Brain Injury (TBI). The
condition most frequently occurs in
young people, resulting
predominantly from falls, sporting
injuries, fights and road accidents,
and is a major cause of death and
disability amongst this group. Both
sexes are equally affected when very
young, but males are much more at
risk than females in teenage years
and adulthood.
The consequences of brain injury
include loss of memory, loss of
concentration, decreased awareness
of one’s own or others emotional
state, poor impulse control, and,
particularly, poor social judgment.
Unsurprisingly behavioural problems
such as conduct disorder, attention
problems, increased aggression, and
impulse control problems are
prevalent in people with ABIs [17].
Consequently, while those without a
TBI are likely to grow out of
immature and antisocial behaviour
by their mid-twenties, those with TBI
are likely to continue to grapple with
these issues throughout young
adulthood and beyond. Such issues
are critical to consider when
assessing and managing the long
term effects of brain injury from
childhood.

Blow to head
against an object
(eg. windscreen,
pavement or fist.)

Coup Injury

‘Open’ and ‘Closed’
Traumatic Brain Injury
There are two main types of TBI;
‘open’ and ‘closed’. Open injury is
where the skull is penetrated and the
brain is exposed such as from a
bullet or knife wound, and typically
leads to focal damage (injury to a
specific area of the brain).
More common are closed TBIs, such
as from assaults or road traffic
accidents [18]. In these injuries there
is an insult to the brain from an
external mechanical force but the
brain is not penetrated or exposed.
They may involve a blow to the
head, or a car coming to a sudden
halt in a crash. These injuries lead to
lacerations and bruising of the brain
structures, especially around areas
where there are bony protrusions on
the inner surface of the skull,
typically in the base of the skull [19,
20]. See Figure 3 below.
Internal bleeding may occur as blood
vessels are injured, which leads to
further injury from compression and
loss of oxygen to brain areas [21].
Various studies have shown that the
frontal and temporal areas are the
most common sites of injury [22].
Furthermore, injuries from such TBI’s
tend to lead to diffuse (widespread)
injury across the brain with damage
or disruption to the white matter
tracts that communicate across the
brain [17, 23].

Contra-coup
Injury

11

RESOURCE

Brain development through
childhood and adolescence:
• for stages of brain growth see
http://www.internationalbrain.org/?q=no
de/112
• for neuroimaging findings see
http://www.loni.ucla.edu/~thompson/DEV
EL/dynamic.html

RESOURCES

Traumatic Brain Injury (TBI):
• Centre for Disease Control and
Prevention for an overview to TBI and
helpful factsheets, advice and areas of
research
http://www.cdc.gov/TraumaticBrainInjury/i
ndex.html
• Centre for Disease Control and
Prevention for an overview to TBI in
prisoners
http://www.cdc.gov/traumaticbraininjury/p
df/Prisoner_TBI_Prof-a.pdf
• National Institute for Health and
Clinical Excellence (NICE) guidelines for
what should be done when someone
has, or is suspected to have, suffered a
head Injury
http://guidance.nice.org.uk/CG56
• Headway, the brain injury charity
http://www.headway.org.uk/home.aspx

Figure 3: Brain injury may
occur for example, when
the brain hits the inside of
the skull (coup injury) and
is then jarred backwards
(contra-coup). The diffuse
white matter tracts
(bundles of axons) may
also be sheared by
rotational forces.

Repairing Shattered Lives © Barrow Cadbury Trust

12

Part One:
Brain systems and development

Prevalence
TBI is the most prevalent form of brain injury [24]. In a general (‘community’)
population, the number of people that are estimated to have suffered a TBI of
some form (from mild to severe) is approximately 8.5% [30]. In males, a range
of 5 – 24% of prevalence for TBI of all severities has been given across studies [31].
The yearly incidence of TBI ranges from 180–250 per 100,000 people in the
US [25] to 91 – 419 per 100,000 people (variation is across health authorities)
in England [26] A study conducted by Exeter University showed that the
incidence was 430 per 100,000, with 40 per 100,000 categorized as
moderate to severe injuries (see Table 2 for definitions of severity and
Figure 4 for age trends of attendence to an emergency department) [27].
In general terms, then, this suggests that around 80-90% of all TBIs are mild
[28]. The global effect of TBIs as a disease, with various degrees of severity,
and therefore burden, is thought to be greatly underestimated and to be likely
to increase substantially in the future [29].

Rate per 100,000 popn

Figure 4: Rates of moderate to severe head injury per 100,000 of the population,
by 5 year range, gender and area of residence, UK.
200

Urban Male

180

Urban Female

160

Mixed Rural Male

140

Mixed Rural Female

120
100
80
60
40
20

+
85

9

4
-8
80

4
-7

-7

70

75

4

9

-6

-6
65

60

4

9
-5
55

9

-5

-4

50

45

9

40
-4
4

4
-3

-3
35

30

4

9
-2
25

9
-1

-2

15

20

9

4
-1
10

5-

04

0

Age Group

© original figures: An epidemiological study of head injuries in a UK population attending an emergency
department. P J Yates, W H Williams, A Harris, A Round, R Jenkins. J Neurol Neurosurg Psychiatry 2006;
77:699–701. doi: 10.1136/jnnp.2005.081901

Causes and risk factors
The main causes of TBI include road accidents, falls, sporting injury, and
assaults. Age is a major risk factor for injury, with the very young being most
at risk, particularly from falls. Adolescents and younger adults are then the
most at risk group, from road accidents, assaults etc. In the very young both
genders are at equal risk, but in teenage years and throughout most of adult
life, males are much more at risk than females [27]. Other factors that can
substantially increase risk include:
• Being from a deprived socio-economic group;
• Geographical location, with urban dwelling youth being more at
risk [27]; and
• Use of alcohol and or other drugs, particularly in adolescence and
young adulthood [32].

Severity of injury
The severity of a TBI can be classified from ‘mild’ through to ‘severe’,
although any TBI may be sufficient for actual changes in brain integrity and
function. In essence, the level of severity indicates the level of impact that an
injury will have on an individual’s functioning. A very mild injury – typically
referred to as a ‘concussion’ (where there may be some disorientation or
Repairing Shattered Lives © Barrow Cadbury Trust

Part One:
Brain systems and development

confusion at the time but no loss of consciousness or other symptoms) would
rarely lead to any permanent brain changes. However, with greater signs of
‘dosage’ (such as being knocked out for longer period and/or a ‘deeper’ level
of unconsciousness), actual changes in the brain may be expected.
TBIs are often classified according to initial level of loss of consciousness using
the Glasgow Coma Scale (GCS; [33]; see table 1). A GCS score of 13 or
above denotes mild ‘Head Injury’; a score of 9 – 12 is moderate; 8 or below is
severe. The duration of Post-Traumatic Amnesia (PTA), the period of time after
an injury that a person is alert but unable to take on new information, is also
used to grade severity [22]. Severity can also be assessed by length of loss of
consciousness following injury. (See table 2).
In determining whether there are actual changes in the brain after an injury,
and/or risk of on-going or emerging problems, neuro-imaging is undertaken.
In the acute period, ‘Computed Tomography’ (CT) is routinely used to
identify such problems as collections of blood (hematomas) and swelling of
the brain that can lead to raised pressure inside the skull (intracranial
pressure). Such investigations are important for immediate management of
injury and can guide prediction of outcomes [35-37]. ‘Magnetic Resonance
Imaging’ (MRI) is also becoming routinely used and gives a more accurate –
fine grain – analysis of injury. In particular, MRI can show whether there are
changes in the diffuse white matter tracts - which can be common after a
TBI [38].

13

Table 1. Glasgow coma scale
Feature

Sale

Eye opening

Spontaneous

4

To speech

3

To pain

2

None

1

Orientated

5

Confused
conversation

4

Words
(inappropriate)

3

Sounds
(incomprehensible)

2

None

1

Obeys commands

6

Localises to pain

5

Withdraws from pain

4

Abnormal flexion

3

Extension

2

None

1

Verbal response

Best motor
response

Score

Minimum score

3

Maximum score

15

Injury at younger age
Outcomes after brain injury in children and young people are hard to quantify
or predict because their brains are undergoing phases of dynamic change.
Recent work has shown that skills that are developing at the time of injury
may be the most vulnerable to being disrupted compared to established skills
[39]. Also, injury at various times points in early childhood may lead to very
different profiles difficulties (neuro-cognitive dysfunction) such as planning
and problem solving, in later childhood [17].
Furthermore, in children the effects of impairments are particularly
detrimental, as the cognitive abilities that children rely on to learn new
information may be compromised. For example, an attention problem after
injury in adulthood remains an attention problem, but children who develop
attention problems are at risk of additional learning difficulties, such as in
language ability.
To some degree, the brain’s ability to adapt to injury (neuro-plasticity)
confers some protection of functions [40]. For example, if a child suffers a
stroke during the period prior to language development (typically in the left
temporal lobe), language functions might develop in the right hemisphere.
However, this area is not pre-disposed to take on (‘home’) language
functions, and so full recovery is improbable.
To make matters more complicated, this may also mean there is less capacity
for this ‘host’ site to develop its own functions. For example, the right
hemisphere is associated with the ‘prosodic’ qualities of speech – e.g. rhythm,
intonation, and emotional tone. These skills may then be compromised, or
crowded out [8]. Unfortunately, injury in developing brains is particularly
complicated. Brain cells and systems do not regenerate in the same way as
skin or muscle and, even if there may be some ‘plasticity’, and some functions
may be ‘re-routed’, problems can still emerge.
It is important, therefore, to be mindful of a need for monitoring for problems
that might be expressed over time, particularly of abilities that a child or
young adult may have been developing at the time of injury.

Table 2. Classification System

There are various classification systems for use
of loss of consciousness as a measure of
severity. In general:
Up to
10 minutes

Considered a mild TBI

Between 10-30
minutes

Considered mild but
caution is needed as
patients may typically be
admitted to hospital for
observation in case of
complications [20]

Between
30 minutes
and 6 hours

Considered to be a
moderate injury

Over
6 hoursShattered Lives
Considered
severe
Repairing
© Barrow
Cadbury Trust
[34]

14

Part One:
Brain systems and development

RESOURCES

• For general information see Child
brain injury trust homepage
http://www.childbraininjurytrust.org.uk
/index.html
• For brain injury at developmental
stages see:
http://www.internationalbrain.org/?
q=node/112

Consequences of TBI
The consequences of injury (‘pathology’) can result in impairments in
processing within the brain that relate to functioning in daily life. After
moderate to severe TBI there are often ‘neuro-cognitive deficits’ such as:
• poor memory (particularly after a delay of a few minutes or more);
• reduced concentration capacity;
• reduced ability to attend to different streams of information; and
• disorders of the executive system (‘dys-executive syndrome’ – typically poor
initiation and planning, lack of self-monitoring and poor judgement [8]).
A resultant de-coupling of ‘cognition and emotion’ after injury can be
expressed as:
• decreased awareness of one’s own or others emotional state;
• poor impulse control; and particularly
• poor social judgments.
Not surprisingly, then, behavioural problems are common, such as conduct
disorder, attention problems, increased aggression, and impulse control
problems.
Unfortunately, mental health problems, especially anxiety and depression are
very common after TBI. Loss of social roles is an endemic issue, with survivors
often unable to return to work, having problems in forming and maintaining
relationships, and subsequent family and social disruption [41, 42]. The net
effect of such stresses and strains is that severe mental health disorders are
common, with a high risk of suicide [43].
Milder forms of injury can lead to symptoms that are usually short-lived (days
or weeks) for most survivors, but some will experience Post Concussion
Symptoms (PCS), which can persist for over 3 months, with symptoms such as
headaches, poor concentration and irritability [44]. This may be due to
neurological changes reflecting a more complicated injury and/or
psychological response to trauma [28, 45, 46]. There does, however, seem to
be a risk of younger age being associated with less optimal outcomes. In
school age children, recent research has indicated that 13.7% have PCS
symptoms at three months, dropping to 2.3% by one year post-injury [47].
There is accumulating evidence that repeat concussive injury has a detrimental
effect on cognitive and behavioural functions (such as the ability to pay
attention, or inhibit behaviour). That is, some form of greater ‘dosage’ of
injury may occur, particularly in younger people [48]. Furthermore, long term
follow up studies have shown that mild injuries, where there was some
indication of greater Post-Traumatic Amnesia, are linked to forms of subtle
neurocognitive inefficiencies in children and adolescents, relative to adults,
over 20 years post injury [49]. Such research underlines the need for
monitoring of potential problems post brain injury in immature brains.
RESOURCES
--• Executive functions and decision
making after TBI
http://www.ozc.nhs.uk/default.asp?id=105

Repairing Shattered Lives © Barrow Cadbury Trust

Part
two
Brain Injury and
criminal justice

Repairing Shattered Lives © Barrow Cadbury Trust

16

Part Two:
Brain Injury and criminal justice

Brain Injury and
criminal justice
This chapter comprises a literature review of national and international
research on both the links between brain injury and offending, and the
prevalence of brain injury among people in custody.
The ‘cognitive’, ‘behavioural’ and ‘neuropsychiatric’ consequences of TBI
described in theprevious chapter might be expressed in terms of inappropriate
(‘dys-regulated’) behaviour.
Brain injury may lead to particular social problems, such as being less able to
de-escalate threats, and acting without considering consequences of action
[50]. Moreover, it is likely that problems with attention, memory, and
executive functions (neuropsychological sequelae) would limit capacity to
fully engage in forensic rehabilitation to enable behaviour change, such as the
ability to pay attention, remember, and follow through on advice about new
ways to manage a problem situation

Research linking brain injury
and offending
There are a range of studies that have indicated possible links between TBI
and offending. Longitudinal studies (where people are ‘tracked’ over many
years) have shown that there is a link between TBI and later offending.
Studies of groups of young offenders also seem to indicate a specific
contribution that TBI can make to increasing the risk of offending over a
lifetime, as well as increasing the severity of the crime.
RESOURCES
• Podcast on brain injury & crime
http://www.bbc.co.uk/programmes/b00vrvx3
• BBC News article on brain injury and
offending behaviour
http://www.bbc.co.uk/news/health-11718241
• Child brain injury trust on brain injury in
young offenders
http://www.childbraininjurytrust.org.uk/servi
ces_training_youthoffending.html
• Brain injury information for professionals
in the CJS
http://psychology.exeter.ac.uk/research/centr
es/ccnr/professionals/braininjury/

Repairing Shattered Lives © Barrow Cadbury Trust

Importantly, however, there is a co-morbidity for such outcomes. Risk taking
individuals, who may have a high need for novelty seeking and a low level of
harm avoidance, may be at particular risk of impulsive actions (including
criminal behaviour), and are therefore at greater risk of engaging in thrill
seeking behaviours where injury is more likely. Furthermore, being involved in
crime may put individuals into situations where injury is more probable.
Brain injury dysfunction in frontal areas has been linked to violent and
criminal behaviour and, in particular, increased risk of impulsive aggression
[51, 52]. Interestingly, persistent offenders are often described as impulsive
and lacking affective empathy [53, 54].
For example, a study of cognitive differences between adolescent boys who
would go on to be long-term (‘life course persistent’) offenders compared
with those who stopped after adolescence (‘adolescent limited’) found that
both groups had neurocognitive deficits. However, adolescent-limited
offenders had significantly fewer ‘knock out’ head injuries than those who
were life-course persistent [55]. As the study noted, ‘This [absence of TBI with
loss of consciousness] may explain why...they avoid a negative antisocial
outcome in later life’ (p.46). These findings come not just from the UK, but
from across the world.

Part Two:
Brain Injury and criminal justice

USA
A study with veterans from the
Vietnam war indicated that injury to
frontal systems could put survivors at
risk of crime [56]. Patients with
injuries to the area involved in
decision making (frontal
ventromedial system) [57] were
consistently reported to show greater
aggression and violence compared to
non-injured controls and to patients
with lesions in other brain areas. In
another study, Blake, Pincus and
Buckner [52] assessed thirty-one
individuals awaiting trial or
sentencing for murder, and found
evidence of frontal dysfunction in 20
of them (64.5%).

Finland
In a population based cohort study in
Finland involving more than 12,000
subjects, TBI during childhood or
adolescence was found to be
associated with a fourfold increased
risk of developing later mental
disorder with coexisting offending in
adult males [58]. The type of injuries
sustained were generally in keeping
with other reported trends (see [27]),
with the substantial majority (93.8%)
in the form of concussion. Those
who had a TBI earlier than age 12
were found to have committed
crimes significantly earlier than those
who had a head injury later, which
may suggest a degree of causality
between TBI and crime.

Sweden
More compelling evidence for the
risk of violent crime after a TBI
comes from a recent study from
Sweden [59]. Researchers had
previously shown that TBI was a
moderate risk factor for violence
[60]. In this total population study,
the hospital records of Sweden from
1973 to 2009 were examined for
associations of TBI with subsequent
records for violent crime (convictions
for homicide, assault, robbery, arson,
sexual offenses, and illegal threats or
intimidation).

Of TBI cases (a total of 22,914),
8.8% committed violent crime,
compared with 3% in the population
controls. This corresponded to a
substantially increased risk of violent
crime in the TBI population.
Importantly, the researchers then
examined the risk of violent crime in
siblings (who would be likely to have
shared similar social and economic
backgrounds), and found that risk
was still greater among TBI cases
when compared with their
unaffected siblings. People with TBI
therefore committed more violent
crimes compared to other people,
including their own siblings.

17

problems increased the risk of having
a violent offending profile. They
noted that violent offending was
‘associated with non-treated brain
injury’.
These findings therefore indicate a
risk of offending, particularly violent
crime, post TBI. Importantly, these
links appear for TBI in general,
including mild TBI, and to particular
types of injury, especially involving
frontal areas, and across gender.
However, it is important to note the
potential role of other key factors
that may increase the risk of
offending and TBI.

Australia
Links between TBI, and severity of
TBI, and crime have also been
reported for youth offenders. In a
study of 242 young offenders in
Australia, the contribution of the
severity of injury, and of harmful
alcohol use, were assessed in relation
to violent offending [61]. Violent
offences were rated as ‘low’ (common
assault), ‘moderate’ (robbery with
weapon), or ’serious’ (homicide).
They found 85 participants had a
history of TBI, and that the young
offenders with a history of TBI were
2.37 times more likely to have
committed a serious violent crime.
When the young offender had lost
consciousness (indicating greater
severity of injury) this ratio was
increased to 2.82. A hazardous
alcohol drinking history also
increased risk of severe violent
offending. The risk of serious crime
was most elevated when offenders
had a history of TBI combined with
hazardous alcohol abuse.

Spain
Leon-Carrion and Ramos [79]
undertook a study of the links
between head injuries (in childhood
and adolescence) in adult prisoners,
violent and non-violent. There was a
trend for both groups to have had
behavioural and academic problems
at school. Head injury in addition to
prior learning disability/school

Focus on women offenders
TBI has been shown to play a
significant role in increasing the risk of
offending in women. In a study of 113
female prisoners in the USA, BrewerSmyth et al. [62] found that 42% had
TBI histories, and those who had
committed violent offences had
suffered an average of two TBIs.
Further analysis revealed that the
number of years since their last
episode of domestic abuse, the number
of prior suicide attempts, and traumatic
brain injuries with loss of
consciousness, were significantly
associated with current violent
convictions.

Repairing Shattered Lives © Barrow Cadbury Trust

18

Part Two:
Brain Injury and criminal justice

Prevalence, and aSSociated
features, of traumatic brain injury
in oFFender groups
The studies above show that TBI is indicated to be a factor which may be
linked to offending. What follows are the key studies across various
jurisdictions that show that the rate of TBI is much higher in offenders
compared to society as a whole. While less than 10% of the general
population has experienced a head injury, studies from across the
world have typically shown that this is between 50-80% in offender
populations. Moreover, there is evidence of TBI being linked to being in
custody at an earlier age, incarceration for longer sentences, greater
reoffending, and committing more violent crimes.
Studies of TBI prevalence in offender groups either rely on medical records
available for analysis or self-report. Prevalence estimates of self-reported brain
injury within a forensic (secure) context vary considerably, with 25% to 87%
of inmates reportedly experiencing a ‘head injury’ [63-65]. Medical records
may, potentially, provide under-estimates of injury as such issues are not being
routinely examined for. Self-reports may be over-estimated due to response
biases. However, it is worth noting that recent work on the veracity of selfreports of offenders indicate that such reports are largely valid [66].
A recent analysis that compared frequencies of lifetime prevalence of TBI in
incarcerated groups (across all ages and both genders) with the general
population showed that the rate of TBI in the incarcerated group was
significantly higher [67]. The un-weighted average for TBI was 51.1%.
Importantly, the systematic review revealed only one ‘female-only’ study and
eleven that were ‘male-only’. The remaining 9 studies in the review reported
data from both genders, although the percentage of women, relative to men,
in samples was very much lower.

United Kingdom

New Zealand

In a UK study of 200 adult prisoners
(all male), 60% claimed to have
suffered a TBI of some form [70].
Moderate to severe TBI was reported
by 16.6%. Those with a selfreported history of TBI were, on
average, five years younger at the
age of first prison sentence than
those who did not report such a
history (age 16 compared to 21).
Those reporting TBI also reported
higher rates of entry into
custody.[70]

Barnfield and Leathem [69], in New
Zealand, had 118 respondents
(gender not reported, but implied as
all male) to a questionnaire survey of
prisoners of which 86.4% reported
some form of ‘head injury’ with
56.7% reporting more than one
blow to the head. There were
concomitant reports of difficulties
with memory and socialization. TBI
was also associated with higher
levels of drug misuse.

Repairing Shattered Lives © Barrow Cadbury Trust

Part Two:
Brain Injury and criminal justice

19

USA
Slaughter, Fann, and Ehde [64]
investigated the presence of TBI (as
defined by whether they had ever
had an ‘injury to the head which
knocked [them] out or at least left
[them] dazed, confused or
disoriented’) in inmates in a county
jail in the USA (91% male and 9%
female). They found 87% had
suffered a brain injury during their
lifetime, with 36% experiencing
injury in the previous year. Those
with a TBI in the previous year had
worse anger and greater psychiatric
disturbance than those who had not.
A recent US based study of the
lifetime prevalence of traumatic brain
injury showed that TBI is highly
prevalent in both male and female
prisoners. The state-wide study
grouped prisoners into categories
that reflected whether they would be
scheduled for release imminently or
not. It was found that 65% of male
prisoners (releases and non-releases),
and 72% and 73% of female
‘releases’ and ‘non-releases’ reported
at least one TBI that had resulted in
an ‘alteration of consciousness’ [68].
Forty-two per cent of male releases
and 50% of non-releases, and 50%
of female releases and 33% of nonreleases, reported at least one TBI
with a loss of consciousness.
When asked whether they
experienced on-going symptoms of
TBI 35% of male releases and 42%
of non-releases, and 55% of female
releases and 58% of non-releases,
reported that they did. These
symptoms included headaches,
problems with memory and/or
concentration. Moreover, they found
a dose response relationship where
longer loss of consciousness was
associated with more symptoms.
These findings suggest that the
prevalence of TBI may be even higher
in female prisoners than in males,
and that TBI may lead to on-going
symptoms in both groups.

While less than
10% of the
general
population has
experienced a
head injury,
studies from
across the world
have typically
shown that this
is between 50-80%
in offender
populations.”
Repairing Shattered Lives © Barrow Cadbury Trust

20

Part Two:
Brain Injury and criminal justice

Young OFFenders
Children and
young people are
at particular risk
of TBI, and TBI in
adults who offend
seems to be
associated with
younger age of
first imprisonment”.

As noted above, children and young
people are at particular risk of TBI,
and TBI in adults who offend seems
to be associated with younger age of
first imprisonment. There have been
a number of studies recently that
have shown how TBI is a particular
concern within youth who offend,
with a high prevalence rate of
typically at least 50%, and up to 90%.
Williams [34] interviewed 197 young
male offenders in a prison about
head injuries, their crime history,
mental health problems and drug
usage. Of those contacted, 94%
took part. They were, on average, 16
years of age. Around 60% reported
some kind of ‘head injury’, but,
importantly, the study found a TBI
with a loss of consciousness in 46%
of the sample. The main cause of
injury in the young offenders was
violence. Repeat injury was common
with a third reporting being
‘knocked out’ more than once.
Self-reporting three or more TBIs was
associated with greater violence in
offences. Those reporting TBI were
also at risk of greater mental health
problems and misuse of cannabis.
In a related study Davies et al. [71]
showed that, in a group of 61
participants, over 70% had TBI
histories, and, importantly, that there
was a relationship between TBI and
current concussion symptoms –
those with more serious mild injuries
reported a greater degree of ongoing problems. Drug and alcohol
use did not confound these findings.
This indicates that those with TBI are
likely, depending on the severity of
injury, to have brain injury related
problems that may interfere with
their ability to engage in forensic
rehabilitation.

Repairing Shattered Lives © Barrow Cadbury Trust

Perron and Howard [72] examined
the period prevalence and correlates
of TBI in 720 residents of offender
rehabilitation facilities (average age
of 15.5 years and 87% male). TBI
was defined as having sustained a
head injury causing unconsciousness
for more than 20 minutes. 18.3%
reported such an injury. Male gender,
psychiatric diagnosis, and earlier
onset of criminal behaviour and
substance use were associated with
brain injury.
A limitation of these studies is a lack
of control groups. There has,
however, been some work in the
area of youth who offend where
control groups have been used. A
study comparing non-offending and
offending youths showed that, in the
group of offenders, there was a
higher level of injury (50% versus
40%), and that the non-offender
group were typically injured in
sporting events whilst the offenders
had a range of equally occurring
causal events including fights, road
traffic incidents, falls and sports [73].
Farrer [74] recently conducted a metaanalysis of traumatic brain injury in
juvenile offenders. The majority of
the studies related to males only.
They identified four studies without
control groups and 5 with.
They reported that the rate of TBI
(which appears to include at least a
knock out history) across 9 studies
was approximately 30%. This is
consistently high relative to the
general population. In the five
studies that used a control group,
they calculated that juvenile
delinquents were significantly more
likely to have a TBI compared to
controls.

Part Two:
Brain Injury and criminal justice

Complexity of nEEd
From the studies reported thus far, a
trend emerges is that TBI is one of
many factors that has been found to
be much more prevalent among
offenders than the general
population. It is important, therefore,
to explore how TBI may be linked to
other problems.

Mental health problems,
drug and alcohol misuse
and learning difficulties
Mental health issues are very
common in offender groups [3, 4].
For example, a systematic review of
62 surveys by Fazel and Danesh [75]
identified that prisoners were seven
times more likely to have psychosis
and major depression than the
general population, and ten times
more likely to have anti-social
personality disorder. Importantly,
they note that the burden of
treatable serious mental health
disorder is substantial.
Grann and Fazel [76] found that
16% of all violent crimes committed
in Sweden from 1988-2000 were
committed by people who had
previous diagnoses of alcohol misuse
and that 11% of all violent crimes
were committed by patients
diagnosed as having misused drugs.
Mental health and drug misuse
issues may well be independent of
TBI but may also be a result of TBI
(see [42] re: mental health post-TBI).
Even if such issues are separate from
TBI in terms of causation, it is very
likely that they are particularly
relevant in the context of TBI. Drug
and alcohol abuse and levels of
mental health problems (depression,
anxiety and suicidality) have been
shown to be elevated in prisoners
who have a TBI history, and a person’s
capacity in coping with such mental
health issues would be compromised
in the context of a TBI [77].

Despite the links found in research,
mental health practices often neglect
to assess patients for TBI. De Souza
[78] examined the existence of TBI in
a forensic psychiatric population in
Brazil. The authors were interested in
whether the TBI occurred prior to
incarceration and whether such
injury was recorded by service
providers. Of 3,233 offenders there
were 133 cases of TBI reported (39
‘mild’ and 94 ‘moderate or severe’).
In the majority (111 cases) there was
no account taken of the injury by
service providers.
In Canada, Colantonio et al. [53]
investigated whether adults with a
documented history of TBI differed
from non-TBI in a forensic population
with respect to demographic
background and psychiatric
diagnoses. A review of all
consecutive admissions to the
forensic psychiatry programme
revealed that history of TBI was
ascertained in 23% of 394 eligible
patient records. Those with a TBI
history were less likely to be
diagnosed with schizophrenia but
more likely to have an
alcohol/substance abuse disorder.
They recommend routine screening
for a history of TBI in forensic
settings.
Forrest, Tambor, Riley, et al. [84]
report that in the USA, 5.5% of all
youths aged 10 or older are referred
to juvenile court. They showed that
those in custody had much worse
health status in terms of perceived
well-being, self-esteem and other
issues such as family involvement,
than those not in custody.

ADHD and PTSD
Fazel, Langstron, Grann & Fazel [80]
investigated psychopathology in
adolescent offenders (15 - 17 years)
and young adults (18 -21 years) as
reported in a national database in
Sweden. Data on 3,058 offenders
was analysed. Those who were
younger had higher rates of

21

depression or mood disorder and/or
childhood developmental disorders
including Attention Deficit
Hyperactivity Disorder (ADHD) or
disruptive behaviour difficulties.
Lower rates of psychosis, bipolar
disorder, and substance misuse were
found in comparison with older
groups.
It is particularly interesting to note
that ADHD appears to be a factor in
the profile of younger offenders. A
recent study by Max, Lansing, Koele,
Castillo, Bokura, Schachar et al. [81]
showed that ADHD is a commonly
occurring syndrome after TBI during
childhood or adolescence. It is also a
risk factor for TBI [82], therefore
likely to contribute to problematic
behaviour. A recent consensus review
from the UK Adult ADHD Network
provided a helpful overview to how
such neurodevelopmental disorders
can be managed within the criminal
justice process [83].
In a recent study of the mental
health needs of 301 young offenders
in the UK (aged 13 to 18),
Chitsabesan, Kroll, Bailey, et al. [85]
reported that one in five had
significant depressive symptoms, one
in ten had anxiety or Post Traumatic
Stress Disorder (PTSD) symptoms
and one in ten reported self-harm in
the past month. One in ten had
alcohol problems and one in five had
drug problems. Aggressive
behaviour towards people and
property was reported in one in four
and one in five respectively.
Evidently, then, the needs of younger
offenders are different, and require
specific management, compared to
older groups. Importantly, in the
context of TBI, the effects of injury
may not be fully realised, given that
functions that may be developing
may be compromised. This
underlines the importance of
assessment and management of TBI
in such groups.

Repairing Shattered Lives © Barrow Cadbury Trust

22

Part Two:
Brain Injury and criminal justice

International and European law for children
and young people with brain injury in the
criminal justice proceSS
Contributed by Dr Karen McAuliffe
Senior Lecturer in Law, University of Exeter
This report has a number of implications for policy and
practice, and there are also implications for legislation. In
addition to central legislation that applies the UK (or
England and Wales in a criminal justice context), there is
a multilevel system of rights and obligations applicable to
people throughout the criminal justice process with
which the UK is obligated to comply. The system exists
on three levels: international, Council of Europe, and
European Union. The UK is bound by international law
under a number of conventions and rules, including the
1985 Beijing Rules, the 1989 UN Convention on the
Rights of the Child and the 1990 Riyadh Guidelines and
Havana Rules.

Implications of international and EU law on
UK legislation
While the UK may be under obligations in international
law, the reality is that such rights and assurances are not
always fully or even adequately protected at national
level – a fact acknowledged by international
organisations. The interaction of international and
national law can be complicated and all too often the
recommendations and proposals made by international
organisations have no real teeth. Indeed, compliance
with international law itself is often difficult to achieve in
practice, particularly when rights are formulated and
discussed in rather general terms.
However, such compliance can be more easily assured in
the context of European Union law. European Union law
differs from broader international law in a number of
ways. Most importantly, unlike traditional international
law which binds states in the international arena,
European Union law actually becomes part of the law of
its member states, binding not only states, but giving
rights to individuals that can be relied on within the
national legal system.

RESOURCE
‘Towards an EU strategy on the rights of the child’, published by
the European Forum on the Rights of the Child. This is a
permanent group for the promotion of children’s rights in the
EU’s internal and external action, which focuses on child-friendly
justice and effective participation of children in the criminal
justice system
http://ec.europa.eu/justice/fundamental-rights/rightschild/index_en.htm)

Repairing Shattered Lives © Barrow Cadbury Trust

Part Two:
Brain Injury and criminal justice

‘Child-friendly justice’ and ‘Effective
participation’
Many international law obligations have been framed in
terms of rights for children and young people. Since the
mid 2000s, however, there has been a shift in focus from
a more general rights discourse to one that is more
focused on ‘effective participation’, which has particular
implications for the criminal justice process.
The arguments put forward in the case study above were
key in the development of the law in this area and, as a
result, the European Court of Human Rights set out that
a condition for a fair trial the ‘effective participation’,
meaning that the defendant must have a broad
understanding of the nature of the proceedings and will
be assisted if necessary. This requirement has since been
promulgated by the Council of Europe in the 2010
Guidelines on Child-Friendly Justice.
Most importantly, as part of the European Union’s
‘Procedural Rights Roadmap’, the Council of Ministers
has recently put forward a legislative proposal on special
safeguards in criminal procedures for suspected or
accused persons who are vulnerable. There is little
question whether children suffering from TBI will from
part of that group. There is clearly a role for neuroscience
when it comes to determining the level of understanding
of a child and young person with TBI – a level of
understanding that, under international law, has to be
assured right through the legal process, from contact
with police or social services, through to dealings with
solicitors and barristers and understanding of the court
process and language used throughout the legal
procedure.

23

International disparity in the protection
of vulnerable people in the criminal justice
process
The Council of Ministers has noted that at present there
appears to be a disparity in protection across EU member
states with regards to protection for children and other
vulnerable suspects and accused persons in criminal
proceedings. This lack of common standards has been
recognised by the Council as an obstacle to mutual trust
between judicial authorities in member states and to
mutual recognition of judicial decisions in criminal
matters. While member states do have minimum
standards for children, in line with the UN Convention on
the Rights of Child (which has been signed by all EU
Member States), these are not always enshrined in
legislation and practice.
Furthermore, there appears to be very little legislation in
member states protecting young and vulnerable adults,
who represent a considerable proportion of defendants in
the criminal justice system. The Council therefore has
asked the European Commission to propose further EU
action on this specific issue and member states
themselves have called upon the Commission to put
forward a legislative proposal in this area. That potential
proposal is currently under consideration and at the very
early stages of drafting at the Commission. It is therefore
important that recommendations to improve protection
of rights for people with brain injury are put forward to
policy-makers at EU level so that they may be
incorporated into the eventual EU legislation, which in
turn will form part of UK law.

CASE STUDY: EFFECTIVE PARTICIPATION IN
COURT PROCEEDINGS
In the 2004 case of SC v UK, the European Court of Human Rights
held that there had been a violation by the UK of Article 6 of the
European Convention on Human Rights (ECHR). A child, aged 11,
was charged with attempted robbery and stood trial in the Crown
Court where he was convicted and sentenced to two and a half
years’ detention. All appeals in the case were refused. The lawyer
for the child in question then took the case before the European
Court of Human Rights complaining that he had been denied a fair
trial because of his low age and limited IQ and submitted that he
was unable to participate effectively in his trial.

RESOURCE
• Council of Europe 2010 ‘Child friendly justice guidelines
http://www.coe.int/t/dghl/standardsetting/childjustice/default_en.asp)

Repairing Shattered Lives © Barrow Cadbury Trust

24

Part Three:
Key action points

Part thrEE
Key action points

Repairing Shattered Lives © Barrow Cadbury Trust

Part Three:
Key action points

25

Key action points
justice scrEEning
1 Criminal
and aSSeSSment
TBI should be viewed as a chronic health condition with
associated, on-going, symptoms. These range from the
somatic (e.g. headaches) through to the emotional (e.g.
anxiety and anger), behavioural (e.g. impulse control and
aggression), and cognitive (distracted and forgetting
easily). Each area of symptoms is, to some degree, related
to changes in the brain. Furthermore, the evidence
indicates that TBI is associated with earlier, repeated,
more serious and longer-term offending.
Given that TBI has been largely neglected within a
criminal justice context – either as a health issue and as a
factor in offending – it would be reasonable to assume
that, by attending to TBI, there would be benefits in
terms of reducing the burden and distress of injury, but
also the likelihood of offending. It is, moreover,
important to note that offenders are poor at accessing,
and often have limited access to, primary care health
services or attending specialist appointments.
Subsequently, admission to secure care, either in prison
or mental health settings, may provide an opportunity to
deliver routine health screening as well as engaging
young people in specialist services interventions.
More widely, there is a lack of services to ensure that
those who are injured are enabled to develop appropriate
skills to participate fully in society. Neuro-rehabilitation is
potentially very effective in enabling survivors to act
appropriately according to social roles, but is not readily
accessible in the UK.
This section details some key action points to enable
more effective management of brain injury in
children and young people, people at risk of
offending, and those already in the criminal justice
process.

As part of comprehensive health assessments, there
should be standardised screening of young people
for brain injury when they come into contact with
criminal justice process, particularly pre-sentence
and in custody.
TOP TIPS FOR INITIAL SCREENING
•

Initial screening tools need to be brief so as to be
appropriate for use in custody suites, courts, prison and
probation services

•

Screening assessments should be at the earliest contact
with the criminal justice process

•

Screening could be undertaken by a range of criminal
justice professionals, such as police officers, court staff,
probation officers and prison reception teams.

•

Screening assessments should identify relevant TBI history
(e.g. severity of injury and presence of neuro-behavioural
problems) and it would be important to follow this up with
advice regarding management and/or referral for further
assessment by relevant practitioners.

TOP TIPS FOR DETAILED SCREENING
•

Detailed assessments would need to take account of:
History of TBIs (frequency and severity); other forms of
Acquired Brain Injury; corroborative information; premorbid functions (possible intellectual disabilities and or
learning difficulties); and for identifying neuropsychological
dys-function (for example, for dys-executive syndrome,
planning problems, and deficits in social emotional
processing)

•

Such assessments would require oversight from suitably
qualified professionals (with relevant medical and/or
psychological training)

RESOURCE
•

For an example of screening for TBI in prisoners and further
assessment see:

http://www.brainline.org/content/2008/11/traumatic-braininjury-among-prisoners.html

Repairing Shattered Lives © Barrow Cadbury Trust

26

Part Three:
Key action points

Forensic services

2

Criminal justice responses

Probation pre-sentence reports
Assessments for TBI could be used to aid
recommendations and decision-making regarding
possible offender management so as to take account of
brain injury. This could serve to identify particular needs
that could be addressed within probation or prison
settings. It may be necessary to explore what additional
advice and input may be needed for most effective
management of the individual’s needs.
Court process and sentencing
At court, a person with TBI will may have problems with
memory, planning, and managing emotion, and would
have particular difficulty in following proceedings and
providing appropriate evidence. It would be vital that
when a relevant TBI is identified measures to enable
access to justice and ‘effective participation’ (see above).
It may be necessary that intermediaries are identified and
provided to support the defendant throughout the
process.
RESOURCES FOR COURT PROFESSIONALS:
•

Prison Reform Trust report ‘Fair Access to Justice: support
for vulnerable defendants in the criminal courts’
http://www.prisonreformtrust.org.uk/Portals/0/Documents/FairAc
cesstoJustice.pdf
• CPS ‘Special Measures’ for vulnerable witnesses
http://www.cps.gov.uk/legal/s_to_u/special_measures/

Forensic rehabilitation needs to be enhanced according to
the evidence base in neuro-rehabilitation for interventions
that can be provided to manage the health, cognitive and
behavioural issues stemming from TBI. There should be
access to clinical supervision and multi-disciplinary
approaches with referral to a Clinical Neuropsychologist,
or a clinical/forensic psychologists with access to
supervision from a Clinical Neuropsychologist.

RESOURCES
•

For experts in Psychology, as listed by the British
Psychological Society, see:

http://www.bps.org.uk/psychology-public/find-psychologist/findpsychologist
•

For the Division of Neuropsychology of the British
Psychological Society, which provides oversight for the
profession and training in the UK, see:
http://www.bps.org.uk/networks-and-communities/membernetworks/division-neuropsychology

3

Training for criminal justice
professionals

Training for front line staff (such as for Youth Offending
Teams, prison and probation staff) is necessary for
improved identification and management of TBI, and
should include:
• understanding what a TBI is

•

Operational Guidance for CPS Staff and Managers:
Implementing and complying with the Witness Charter
http://www.cps.gov.uk/legal/v_to_z/witness_charter_cps_guidance/
•

Prison Reform Trust report ‘Vulnerable Defendants in the
Criminal Courts: a review of provision for adults and
children’
http://www.prisonreformtrust.org.uk/Portals/0/Documents/vulne
rable%20defendants%20in%20the%20criminal%20courts.pdf

Custody and probation settings
Within custodial and/or probation systems it would be
important for front line staff to have sufficient knowledge
of TBI and its consequences so that they may take
account of any TBI based issues in their day-to-day
management of offenders. Specialist training, advice and
support would need to be provided where there is clear
evidence of significant TBI related behavioural and/or
psychiatric needs. This would necessitate referral
arrangements to clinical supervision and specialist multidisciplinary assessments.

• how prisoners with TBI may be affected
• what they may do for day-to-day management of
such problems (e.g. how to manage memory,
communication and attention problems by
modifying how staff ask an offender with TBI to
follow instructions or manage impulsivity.)
• how the TBI may impact on engagement in
offender treatment programmes (particularly
group programmes)
• where to access advice and support if problems
are more extensive
• who to refer to the individual on to if necessary
Training of solicitors to take account of TBI is
recommended, as is training of magistrates and
judges, so that they are aware of the potential for TBI
issues in offending, ‘effective participation’ in the
criminal justice process and rehabilitation
RESOURCE:
•

Repairing Shattered Lives © Barrow Cadbury Trust

For a summary of helpful advice for front-line criminal
justice professionals see:

http://www.brainline.org/content/2010/03/traumatic-braininjury-a-guide-for-criminal-justice-professionals_pageall.html

Part Three:
Key action points

4

Managing young people with
brain injuries in custody and
probation seTTings

There should be good awareness and training of staff in
TBI (screening) in assessment and management within
the justice system, within both community (e.g. Youth
Offending Teams) and custody, and for those working
with ‘at risk’ client groups e.g. specialist educational
placements, looked after children and alcohol and drug
services, and those who deliver evidence-based family
interventions aimed at reducing offending (such as
through the Troubled Families agenda).
There should be access to clinical supervision and multidisciplinary approaches relevant to this group that would,
for example, include Child and Adolescent Mental Health
Services (CAMHS) to manage mental health co-morbidity
and educational psychology for general learning profile.
Some young people may need to access specialist
neuropsychology assessments, either by referral to a
Clinical Neuropsychologist or educational, clinical and
forensic psychologists with access to supervision from a
Clinical Neuropsychologist.

aPPropriate
5 CoMMiSSioning
and eFFective services
It is vital that commissioners of social and health care
services for offenders ensure that there are packages of
care being developed and delivered that addresses the
range of issues related to TBI.
To ensure this, outcomes should be assessed with
reference to quality standards for social and health care.
Data on neuro-disability - including TBI - should be
collected and reviewed to identify the level of severity
and consequential needs that may arise
(see forthcoming report from the Office of the Children’s
Commissioner).

27

responses to children
6 Early
and young people with brain
injury

Services must work together more effectively to deliver
proactive measures to reduce risk of crime following a
brain injury. There should be early identification of TBI in
children and young people as it may lead to problems in
school and to socialisation which commonly leads to
exclusion and social isolation.
Thorough screening and assessment of TBI in children
and adolescents attending Emergency Department
should be standard practice. This should be both
focussed on immediate medical care, but also on
identifying factors that may indicate complicated recovery
which may interfere with schooling. This could be linked
to a system for alerting GPs and school nurses for postinjury monitoring when indicated.
There is a need for those with oversight to children’s
health (e.g. GPs and school nurses) to monitor whether
an injury may be linked to emerging problems in
behaviour and educational engagement over time. This is
critical for when the child may be facing both a transition
from structured schooling (primary) to less structured
environments (secondary). This is especially important as
there may be an issue relating to deficits becoming more
apparent over time.
There should be training for education staff, critically
head-teachers to raise general awareness of the issues,
and those coordinating and providing support such as
Special Educational Needs Coordinators (SENCOs) and
teaching assistants. In general, Teachers should be made
aware, e.g. through school staff in-service training, for
these issues. This will help address behavioural problems
and enable teachers top better understand learning
needs of any affected children. There should be
identification of areas where support for parents or
relevant guardians would be appropriate, particularly
where the TBI is more consequential.

Services should be commissioned based on a ‘pathway’
approach to effective practice (as described in the Bradley
report on mental health and criminal justice [4] and the
Transition to Adulthood’s 2012 report ‘Pathways from Crime’.
RESOURCE
•

Pathways from Crime: Ten steps to a more effective
approach for young adults in the criminal justice process’

http://www.t2a.org.uk/pathway

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28

Part Three:
Key action points

7 Research
While the research in this area is growing at a fast pace,
further studies to explore the links between brain injuries
and offending behaviour are needed so that assessment
and management practice can be improved. For example,
a better understanding of the role of frontal systems –
especially in developing brains – might offer insights into
treatment of impulse control which could be linked to
social violence.
More research is needed on women who offend, as they
may present with different risk factors for injury (for
example as a result of higher levels of being victims of
domestic violence). It is vital that research that addresses
the causes and consequences of TBI in women who
offend is conducted so that a better understanding of
women offenders’ health and social care needs are
developed. For example, factors for offending differs
between the genders, with socio-economic and childraising factors playing a more important role for girls and
parental characteristics (such as education and mental
health) being more of a risk for boys.[86]
Research is needed to develop and test screening
measures for identifying TBI throughout the criminal
justice process. Health and criminal justice economic
modelling is needed to establish the degree of saving
from earlier, more systematic, assessment and
management of TBI in offenders.

8 IMMediate oPPortunities
Some of these recommendations are already being
developed and may enable implementation in the short
term. Two immediate opportunities that may have a
lasting impact are described below.
Screening for TBI: The Comprehensive Health
Assessment Tool
Currently, in England, new screening processes are being
developed for assessing neuro-disability and informing
practice. The Youth Justice Board and Department of
Health have commissioned the development of a
Comprehensive Health Assessment Tool (CHAT). This
contains a first night reception screen - to assess for
immediate risks in physical health, mental health,
substance misuse and safety risks (part 1)- and
subsequent measures of physical health, substance
misuse and mental health (parts 2, 3 and 4) [87].

Repairing Shattered Lives © Barrow Cadbury Trust

In view of the prevalence of neuro-disability identified in
young offenders, a new section of the CHAT (part 5) has
been developed. This addresses neuro-developmental
disorders such as learning disability, autistic spectrum
disorders and speech, language and communication
needs, and also includes assessment for brain injury with
a section on TBI. This section is being validated on a
sample of young offenders in secure custody, with the
aim that all parts of the CHAT will then be used routinely
across the secure estates by April 2013. A community
version of the CHAT has also been developed and
currently in the process of being piloted within
community youth offending services.
The successful implementation of any screening tool
requires it to be embedded within local pathways for
further specialist assessment for young people who
screen positive. It should also be supported by
appropriate staff training and supervision of youth justice
staff on how to both identify young people with
neurodisabilities and health needs and how best to
support them through a robust care plan Importantly, the
CHAT could allow for more accurate data on the
prevalence of TBI in turn leading to better informed
commissioning decisions and resultant care pathways.
This may also be a model for how services for adults may
be developed in future. Within this context it is worth
noting that the Disabilities Trust Foundation has a pilot
programme underway at an adult prison with a specialist
brain injury linkworker providing assessments and
developing care pathways for offenders with a brain
injury. The outcomes are being monitored and this
model may be transferable to a youth justice setting. See
www.thedtgroup.org/foundation for further details.
The Criminal Justice and Acquired Brain Injury
Interest Group
Given the importance of addressing the needs of those
with brain injury in the Criminal Justice and Acquired
Brain Injury Interest Group (CJABIIG) was formed in 2011.
CJABIIG works to raise awareness and means for
addressing brain injury throughout the criminal justice
process. In particular to identify how rehabilitation of
offenders may take account of the specific needs
associated with brain injury (through training, awareness
raising, partnership working and parliamentary briefing).
This group currently provides a forum for a range of
stakeholders – from private, public and charity sectors to review progress in this area. In July 2012, Lord David
Ramsbotham, former Chief Inspector of Prisons, became
the group’s chair see
http://www.childbraininjurytrust.org.uk/information
_criminaljustice.html. The group’s secretariat is provided
by the Child Brain Injury Trust, which is supported to
undertake this work by the Barrow Cadbury Trust.

Part Three:
Final Thoughts

29

Final thoughts
Over the last two decades, there have been calls for developments to improve
access to mental health services for young and adult offenders with mental
health problems in the UK. Many of the issues identified are amenable to
psychological and psychiatric intervention [80], and significant progress has
been made following the Bradley Review of 2009 [4].
There have also been a number of important advances in the past few years
in our understanding of brain systems, their development, and what may
happen after injury. Critically, that certain neurological systems are important
for decision making that takes account of long term consequences of
behaviour, particularly under pressure. Such systems would therefore seem
crucial in areas important for functioning relevant to crime – such as impulse
control and consequential thinking.
Indeed, they are heavily implicated in the fast and accurate processing of
social demands – dealing with others. As children develop, their brains
become evolved to manage more complexity, and skills, such as these, come
‘on line’. Children and young people therefore have a degree of
neurologically-based immaturity relative to adults. Unfortunately, this is a
time-period also where risk of TBI is very high – the impact of which limits
maturity still further.
Not surprising, then, TBI in early life seems to be a major issue within offender
groups. It is associated with earlier onset, more serious, and more frequent
offending. Of course, it is important to note that it is not possible to know for
certain how brain injury increases likelihood of offending, and there may be
underlying risk factors for TBI and offending behaviour, including deprivation,
lack of life opportunities, low concern for self-care, and even being a person
who ‘takes risks’.
The research, however, seems to show that TBI is a very strong ‘marker’ for
these other factors. It is fair to say that the cognitive and behavioural
problems noted here are commonly observed within the young and adult
offender cohorts. Early recognition and intervention when there is a TBI in
childhood and adolescence, as well as in adults, could help to reduce crime.
There may well be critical ‘windows’ of opportunity that may be targeted for
diverting those with brain injuries at risk of greater offending into nonoffending lives, but those at most risk of injury are often those that are
furthest from appropriate support. The delivery of services to these groups will
therefore require close cooperation between criminal justice, health, social,
and educational systems and, in working together, shattered lives can be
repaired.

TBI in early life
seems to be a
major issue
within offender
groups. It is
associated with
earlier onset,
more serious, and
more frequent
offending”.
Repairing Shattered Lives © Barrow Cadbury Trust

30

Part Three:
References

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Repairing Shattered Lives © Barrow Cadbury Trust

Part Three:
References

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31

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in the custodial youth justice system. Youth Justice Board.

67. Farrer, T.J. and D.W. Hedges, Prevalence of traumatic brain injury
in incarcerated groups compared to the general population: a
Repairing Shattered Lives © Barrow Cadbury Trust

32

Part Three:
Glossary

GloSSary
Acquired brain injury
An acquired brain injury (ABI) is brain
damage caused by events after birth
Amygdala
An almond-shaped structure made of a
groups of neurons located deep within
the medial temporal lobes.
Axons
Projections from a neuron/nerve cell to
carry messages.
Brain stem
Part of the brain that connects the motor
and sensory systems from the main part
of the brain to the rest of the body –
crucial for respiration and cardiac
functions.
Cerebral cortex
Outermost layer of the brain, about 2-4
mm thick, which plays a key role in
cognitive functions.
Computed Tomography
A medical imaging procedure that uses
X-rays to produce cross sectional images
(or 'slices') of specific areas of the body.
Cortical pruning
Synapses in the cerebral cortex are
progressively reduced throughout
childhood and adolescence. The
elimination of synapses in prefrontal
cortex continues for a particularly long
period of time, extending into late
adolescence. It may be viewed as a way
the brain “sculpts” itself into being.
Cortical structures
Brain systems – typically in layers.
Dendrites
Projections of a neuron that conduct the
electrochemical stimulation from other
neurons.
Diffuse
Refers to a “wide area” – such as diffuse
white matter injury.
Dopamine
One of the key neurotransmitters chemical released by nerve cells to send
signals to other nerve cells - in reward
systems.
Dorso-lateral- prefrontal cortex
The anterior part of the frontal lobes of
the brain, lying in front of the motor and
premotor areas which has been implicated
in planning and social behavior.
Focal
Describing injury as being to one specific
area of the brain.

Repairing Shattered Lives © Barrow Cadbury Trust

Frontal cortex
The front part of the brain.
Frontal lobe
The front of each cerebral hemisphere
which is positioned in front of the parietal
lobe and superior and anterior to the
temporal lobes.
Frontal ventromedial system
A section towards the central (medial)
central (ventral) areas of the frontal lobes –
typically involved in decision making
involving emotion.
Haematoma
Commonly called a bruise, a localized
collection of blood outside the blood vessels
usually in liquid form within the tissue.
Hippocampus
This is a brain area located in the medial
temporal lobe and plays an important role
in the consolidation of information from
short-term memory to long-term memory
and in spatial navigation.
Insula
A deeply set section of the brain between
the temporal lobe and the frontal lobe, and
plays role in diverse functions from emotion
to homeostasis.
Intracranial pressure
Pressure inside the skull and thus in the
brain tissue and cerebrospinal fluid
Limbic system
A set of brain structures, which may be
cortical (e.g. orbito-frontal cortex) and subcortical (e.g. hypothalamus and amygdala),
for serving functions to do with “feeling
and reacting” rather than “thinking”.
Therefore particularly important in level of
arousal and motivation, and also particular
types of memory.
Magnetic Resonance Imaging
MRI is a technology that uses a magnetic
field to construct an image of the scanned
area of the brain. The MRI scanner’s
magnetic field interacts with atomic nuclei
in the brain and this information is then
recorded to construct an image.
Melatonin
A neurotransmitter that regulates circadian
rhythms and the sleep-wake cycle.
Meso-limbic
Then mesolimbic system is a pathway that
seems to involve linking up brain systems
involved in reward
Myelin sheath
This is a layer of cells, usually around the
axon of a neuron, which are essential for
the proper signaling along the tissue. It acts
as an “insulator” of the signal.

Myelination
The process by which axons become
sheathed in myelin - and so speed of
processing improves.
Neuro-cognitive dysfunction
When the cognitive system – which is
housed in the brain – starts to become
inefficient or impaired. Such as poorer
memory, trouble concentrating etc.
Neurons
Cells that processes and transmits
information by electrical and chemical
signals. They are the core components of
the nervous system – that is, the brain and
the spinal cord.
Neuro-plasticity
Changes in neural pathways and synapses
due to changes, for example, in behavior
and environment. Neuroplasticity occurs on
many levels, from cellular changes (learning)
through to cortical remapping in response
to injury – where a host site takes on a role
of an injured area.
Neuropsychological sequelae
The cognitive and affective changes that
may occur subsequent to a brain injury,
such as problems in decision making,
attention, memory, and emotion processing
(e.g. of facial expressions).
Neuro-transmitters
Chemicals used by nerve cells to
communicate – they are released and
absorbed at the junctions (synapse)
between cells – one to cell therefore
“triggers” activity in the other cell. There
are a number of such neurotransmitters,
such as dopamine, serotonin etc.
Thalamo-amygdala pathway
An important area in the brain for the
relaying of strong emotions, such as fear,
and for memory, therefore very important
for learning and survival.
Traumatic Brain Injury
A TBI occurs when an external force
(coming to a “fast-stop” in a car accident or
being kicked in the head in an assault)
traumatically injures the brain. TBI can be
classified on the basis of severity,
mechanism (closed or penetrating ) etc.

other t2a publications
Available at www.t2a.org.uk/publications
PATHWAYS FROM CRIME
Ten steps to a more effective approach for young adults in the
criminal justice process
This report identifies ten points in the criminal justice process where a
more rigorous and effective approach for young adults and young people
in the transition to adulthood (16-24) can be delivered (see the full
recommendations below). The audience for this report is broad, but it
should be of particular interest to commissioners, practitioners and policy
makers who work to support the criminal justice process. It is hoped that
professionals at all levels and across multiple sectors will act on this body
of evidence to adapt and adopt the T2A pathway to ensure that all areas
deliver an effective approach for young adults throughout the criminal
justice process.

WHY PRIORITISE YOUNG ADULTS
Key Messages for Police and Crime Commissioners

Young adults (18-24) are only 10% of the population but account for a
third of all crime, and are also the most likely group to be a victim of
crime. This group will be a vital consideration for Police and Crime
Commissioners (PCCs) as they set their local policing priorities and
commission services to reduce crime and reoffending. This briefing has
been prepared for PCC candidates to explore how they can commission
services differently for young adults, and embed a more effective approach
to young adult offenders in their local area. It brings together the most
recent research and practice to demonstrate what works and how
reoffending rates can be reduced while achieving cost benefit.

GOING FOR GOLD
Developing effective services for young adults throughout the criminal
justice process

This guide sets out how to develop services for young adults throughout
the criminal justice process. It is based on a set of guiding principles and
rules of engagement which can be applied flexibly within different local
contexts. Demographics, offender profiles, types of crime, resources and
available services will vary from place to place. But while the detail of how
the service is delivered can change, the approach remains consistent:
evidence-based, holistic, supportive and voluntary.

Report published by the Barrow Cadbury Trust on behalf of the Transition to Adulthood Alliance © 2012
© Photographs: Peter Smith, Andrew Aitchison & Catch 22.
All other photos are posed by models
Design and print: Creative Media Colour Ltd

is convened and funded by:

Download all of the T2A Alliance’s
publications at www.t2a.org.uk
Follow us @T2AAlliance

The Barrow Cadbury Trust is an independent, charitable
foundation, committed to supporting vulnerable and
marginalised people in society.
The Trust provides grants to grassroots voluntary and
community groups working in deprived communities in the UK,
with a focus on the West Midlands. It also works with
researchers, think tanks and government, often in partnership
with other grant-makers, seeking to overcome the structural
barriers to a more just and equal society.
www.barrowcadbury.org.uk
Registered Charity Number: 1115476