Brain Injury and Offending: The Development and Field Testing of a Linkworker Intervention

Abstract

Evidence suggests that traumatic brain injury (TBI) is more prevalent amongst offender populations than in the general population, and that it can lead to aggressive behaviour while in custody and impair engagement with offender rehabilitation programmes. The aim of this study was to develop, implement, and evaluate a brain injury Linkworker approach designed to support prisoners who report a significant TBI or multiple mild TBIs. Three clinical case examples are reported to illustrate the conceptual foundations of the approach and to demonstrate the feasibility of the service. Early results showed that engagement with a Linkworker led to effective identification of key areas of intervention and resulted in better integration for prisoners while in custody and in enhancement of the outcomes of offender rehabilitation. These initial findings provide justification for wider implementation and systematic evaluation of the efficacy of this model of service.

Keywords

traumatic brain injury acquired brain injury prisoners rehabilitation

Introduction

There is increasing evidence of a high prevalence of traumatic brain injury (TBI) amongst those convicted of criminal activity. Two recent meta-analyses estimate it to be around 51% to 60%, compared with 2% to 38% in the general population (Farrer & Hedges, 2011; Shiroma, Ferguson, & Pickelsimer, 2010). It is likely that the wide range in prevalence estimates is due to the differing definitions of TBI used, the heterogeneity of the samples studied, small sample sizes, and varied exclusion criteria (Ferguson, Pickelsimer, Corrigan, Boger, & Wald, 2012). The reliability of offenders self-reporting TBI has also been raised as a potential source of error, although there is increasing evidence that self-report measures can provide a valid means of identifying those who have experienced TBI. Self-report measures have been shown to be consistent with information held in medical records (Schofield, Butler, Hollis, & D’Este, 2011), and with reports on extended clinical interviews and the patterns of performance on neuropsychological tests (Pitman, Haddlesey, Ramos, Oddy, & Fortescue, 2015).

The effects of brain injury include impulsivity (e.g., Tate, 1999) and poor emotional regulation (e.g., Bechara, 2004), which may increase the likelihood of criminal behaviour through an inability to delay gratification or to control aggressive behaviour. Explosive outbursts, aggressive reactions to minimal provocation, and reduced social cognition, resulting in an inability to avoid conflict, are common following a TBI (Baguley, Cooper, & Felmingham, 2006; Brooks & McKinlay, 1983; Parker, 1996). The cognitive deficits which are associated with TBI and other forms of acquired brain injury (ABI), such as memory deficits, expressive communication deficits, and executive deficits, affect educational and social functioning (Hessen, Nestvold, & Anderson, 2007; McKinlay, Dalrymple-Alford, Horwood, & Fergusson, 2002) and may also lead to an inability to cope with the demands of life within the boundaries of the law and make people more likely to resort to criminal behaviour (S. Fazel, Lichtenstein, Grann, & Långström, 2011; Williams et al., 2010).

The incidence of TBI peaks in late adolescence and early adulthood (16-25 years), with men up to 4 times more likely to suffer an injury than women (Bruns & Hauser, 2003). Young males are more likely to engage in activities that make them more vulnerable to injury, such as engaging in contact sports, being employed in occupations that carry some degree of industrial risk, or fighting (Turner & McClure, 2003; M. Wilson & Daly, 1985). The brain systems affected by TBI are inherently linked with the neural networks underlying social behaviour, which do not fully mature until early adulthood (Steinberg, 2008). Therefore, injury during this period could interrupt the ongoing development of these systems, which in turn would result in greater risk of poor decision making, impulsive aggression, and lack of control, deficits that have been linked to offending behaviour (Williams et al., 2010).

In addition to an increased prevalence of TBI amongst offenders, there are studies suggesting that TBI is associated with offending at a lower age, longer sentences of imprisonment, greater rates of reoffending, and increased rates of violent crime (Pitman et al., 2015; Williams et al., 2010). TBI amongst offenders is also associated with increased use of medical and psychological services and higher rates of rule infractions while in custody (Piccolino & Solberg, 2014). The association holds true for female offenders (Brewer-Smyth, Burgess, & Shults, 2004), although there is currently a predominance of studies of male offenders (O’Sullivan, Glorney, Sterr, Oddy, & Ramos, 2015). Studies revealing these findings include those obtaining data from medical records as well as those using self-report methodologies (Brewer-Smyth & Burgess, 2008; Colantonio et al., 2014; Ferguson et al., 2012; Kaba, Diamond, Haque, MacDonald, & Venters, 2014; Shiroma et al., 2010).

The evidence for a high prevalence of TBI amongst offenders leads to a variety of questions concerning implications for intervention. Interventions could be targeted at various stages in the pathway. They could target the reduction of the incidence of brain injury, the management of those who have had a brain injury, particularly those with other risk factors for offending, or they could address how offenders are rehabilitated. León-Carrión and Ramos (2003) suggested that those with a history of head injuries who had never been treated were particularly prone to violent behaviour, and therefore, they proposed that early treatment of the cognitive, behavioural, and emotional consequences of brain injury could be a crime prevention measure.

The present article describes the implementation of such an initiative: The brain injury Linkworker is a service approach designed to identify and support those prisoners who have a history of brain injury of significant severity. Three case studies are described to illustrate the feasibility and potential benefits of such an intervention.

Ethics

The Linkworker service was designed to respond to the specific needs of those within a criminal justice setting, screening positive for brain injury. The delivery of this service was integrated with a study on prevalence of TBI in offenders (Pitman et al., 2015). The study received ethics approval from the National Health Service (NHS) Research Ethics Committee. Permission was sought and granted from the governor of a United Kingdom adult male prison to conduct the research. The prison governor also reviewed the present article to ensure the anonymity of the individuals described.

The Development of the Linkworker Service

“Linkworkers” (psychology graduates, often gaining experience before pursuing professional training in clinical psychology or a related field) were appointed by the Disabilities Trust Foundation, a division of The Disabilities Trust, an organisation with 25 years’ experience of providing brain injury rehabilitation. They were given training to equip them with knowledge of ABI (including its causes, common symptoms, how such symptoms influence functional ability, and how this may affect an individual’s engagement in society) and basic techniques and strategies to address these problems. A manual was developed to provide a guide and reference resource for Linkworkers.¹ The Linkworkers also received statutory training (e.g., safeguarding, health, and safety).

The Role of the Linkworker

Linkworkers offer direct help to the prisoners referred to them by providing psychoeducation concerning brain injury and by helping the individuals to develop strategies to circumvent their brain injury–related deficits (Williams & Chitsabesan, 2016). This article describes the work of a Linkworker in an adult male prison.

Linkworkers work with prisoners who have screened positive for brain injury to develop a comprehensive assessment of their needs and to develop a support plan. They also help the prisoners to formulate their goals and to identify the steps required to meet them.

A key aspect of the Linkworker role, as the job title suggests, is to link with other staff and to be a resource for them, explaining the impact the brain injury may be having on the individual’s behaviour, how this may affect the interventions delivered by other teams, and the best ways of managing this and helping enhance the benefits by engaging with these teams. This liaison work occurs with external personnel as well as prison staff. The crucial test of efficacy of an intervention with prisoners is the extent to which it influences what happens once they are released. Trying to ensure a support system is in place for prisoners upon their release, including the provision of a discharge pack, is likely to be a critical part of this role.

Another part of the Linkworkers’ role is to liaise with agencies and families outside prison to provide strategies and guidance on how to support people with a brain injury when the individual is released, and to make the necessary referrals to neurology, physiotherapy, nurse specialists, mental health, housing, substance, social work, and other relevant stakeholders.

The Linkworkers also provide “through the gate” support for prisoners being released from prison into the local community. This involves the delivery of face-to-face or telephone support sessions that encourage the generalisation of strategies learned while in custody into the offenders’ home environment, and liaising with agencies in the community by making appropriate referrals and developing “portable profiles” that inform agencies of the individual’s history of brain injury and how this is likely to affect them (e.g., alerting Probation Officers to memory problems that could impact appointment attendance and, when appropriate, ensuring that support strategies are put in place).

Screening and Intervention

A summary of the intervention characteristics is provided in Table 1. New admissions to prison are screened for ABI using a standardised self-report measure, the Brain Injury Screening Index (BISI; Pitman et al., 2015). Those prisoners identified as having had a significant brain injury or multiple mild traumatic brain injuries are seen by the Linkworker. Injury severity is initially determined on the basis of the BISI results and the TBI Index, which is calculated by multiplying the number of injuries reported by the length of unconsciousness (LOC) of the most severe injury. Pitman and colleagues (2015) validated this index by demonstrating that higher levels of neuropsychological impairment were associated with higher scores on the Index. Typically, injuries are deemed as “significant” when they involve LOCs of 10 min or longer (Sherer, Struchen, Yablon, Wang, & Nick, 2008). The Linkworker then seeks confirmatory evidence for a history of brain injury in the individuals’ medical records (e.g., hospital discharge notes, Glasgow Coma Scale scores) and screens for problems likely to be associated with a brain injury. These include memory problems, problems with emotional regulation, impulsivity and disinhibition, and problems of social perception and social behaviour (Ponsford, Sloan, & Snow, 2013). Brief cognitive assessments may also be carried out if the individual has not recently been assessed, or when specific areas (e.g., executive function) have not been explored in routine assessments. Simple aids such as diaries and prompt cards using fixed routines to assist memory can be effective. Similarly for executive deficits, external structure or helping the individual to plan systematically can be effective.

Table 1.

Intervention Characteristics.

Phases	Activities
Phase 1: Identifying a history and consequences of brain injury	Administration of the Brain Injury Screening Index (BISI; Pitman, Haddlesey, Ramos, Oddy, & Fortescue, 2015) Clinical interview Administration of questionnaires and standardised assessments exploring a range of areas, including history of brain injury, cognitive function, mood, and mental health.
Phase 2: Intervention in custody (The exact nature of the intervention is person-centred and tailored to individual needs.)	Individual Setting of personal goals Developing adaptive ways to cope with difficulties (psychoeducation, development and practice of compensatory strategies, therapy sessions) Environmental Brain injury awareness training Written behaviour support guidelines Linking with specific services to provide support where needed
Phase 3: Follow-up after release	Establishing a relationship with relevant agencies (e.g., employment, housing) Assessment and intervention reports and letters to agencies, general practitioner, and next of kin, as required

Supervision

Linkworkers are managed on a day-to-day basis by a project leader with experience of working with brain injury and with a background in nursing. They also receive regular supervision from a clinical psychologist.

Initial Findings

There was a total of 510 referrals to the Linkworker service in less than 2 years at three prisons. Of these referrals, 134 had been supported by Linkworkers at the time of this report (see indications and contraindications for service delivery on Table 2, which follows the reporting checklist for rehabilitation interventions recommended in van Heugten, Gregório & Wade, 2012).

Table 2.

Description of the Adult Linkworker Service.

Item	Descriptor
Patient characteristics
Age	≥18 years old
Gender	Any
Type of injury	ABI
Time since injury	1-25 years
Indications for referral	History of brain injury and presence of cognitive, adjustment, functional, or behavioural problems
Contraindications	Unwillingness to engage
Intervention characteristics
Frequency^a	1 to 3 times per week
Duration	30 to 60 min per session
Intensity^a	8-12 weeks
Delivery	Individual and group sessions
Involvement of others	Prison staff, next of kin, external agencies (health, probation, housing, employment)
Direct or contextual	Direct and contextual interventions
Goals and outcomes
Specific goals	Improvements in adjustment, well-being, and functional abilities
General goals	Increased participation, reduction in reoffending
Expected effect size	Small to medium (but clinically significant)
Effects for subgroups	All individuals that meet the indication criteria are expected to benefit
Adverse effects	None expected

Note. ABI = acquired brain injury.

The number and duration of sessions are tailored to individual needs.

Many offenders (40%) reported no residual problems as a result of their injuries, consistent with the effects of mild TBI in other populations. Others reported persistent problems with memory, concentration, and speech, both at initial screening and on further investigation.

Each Linkworker supported an active caseload of 15 clients at any one time and received, on average, 22 referrals per month.

Case Examples of the Adult Linkworker Service

Basic demographics and injury characteristics are described on Table 3.

Table 3.

Service User Profiles.

	Case 1—VW	Case 2—RR	Case 3—MB
Age	22	47	40
Confirmed brain injury	Yes	Yes	Yes
Offence	Violent	Non-violent	Violent
Difficulties	MemoryCommunicationHemiparesis	Word findingConcentrationMemory	AngerRefusal to receive help or engage with servicesVulnerable in custody
Interventions	Strategies to better understand and remember informationPhysiotherapySocial workCommunity rehabilitation	Strategies to complete complex tasksStrategies to improve written communicationFatigue management	Brain injury awarenessSupport plans for prison staff
Referrals	Liaison with other agencies	NeurologyEmployer	—
Key outcomes
Independence	Able to live independently with very little support	Still in prison	Still in prison
Constructive activity	Attends gym	“Advisor” roleQualification gained	Challenging behaviour replaced by constructive behaviour
Reoffending/prison infractions	No further criminal activity (3 years)	No infractions	Clear reduction of prison infractions to zero
Use of cognitive strategies	Uses memory and strategies to address dysexecutive problems	Uses strategies	Impact of environmental structures clearly identified

Case 1—VW

VW left school with no qualifications but attended a college where he trained as a bricklayer. He lived independently in a rented flat and was unemployed. Prior to his head injury, he had a diagnosis of attention deficit hyperactivity disorder (ADHD) and was prescribed methylphenidate. He reported a forensic history prior to his injury, including incidents of criminal damage, such as kicking fences. In 2013, VW was remanded in custody in relation to a violent offence. On remand, he completed the BISI and was identified as having sustained a TBI 2 years prior as a result of an alleged assault. Examination of clinical records revealed that VW had been admitted to hospital in 2010 following an unprovoked assault and that he had received 4 months of in-patient rehabilitation before being discharged to his mother’s care. On assessment, he was found to have below average memory, often forgetting names or appointments. He frequently misunderstood information that was given to him. He had a left-sided weakness rendering him unable to dress independently or to carry a tray. His cell mate helped him with these activities.

The Linkworker worked with VW for 6 months, helping him to use strategies to enable him to interpret correctly information given to him (Ponsford et al., 2013). He was encouraged to ask others to explain what they meant when he did not understand and to keep a journal of conversations (for example, with his solicitor, family, nurses, and prison staff). The Linkworker advised family members and professionals to provide information in small chunks, to be concrete, to ask VW to write information down, to confirm his understanding, and to explain further if he had misinterpreted information. The Linkworker referred VW to the Prison Physiotherapy Team, but due to his specific needs, they were unable to help. The Linkworker then liaised with the Community physiotherapy Team to ensure VW received a new splint and three monthly botulinum toxin injections for his left arm.

Before VW’s sentencing hearing, the Linkworker contacted the Community Social Work Team and the Specialist Continuing Care Team to present VW’s needs and to request funding for intensive brain injury rehabilitation. The Linkworker arranged for VW to be assessed by the consultant neuropsychologist at the local neurobehavioural rehabilitation centre, and this assessment of VW’s needs and recommendations was presented to the Court.

VW was given an 18-month suspended sentence on condition that he received intensive rehabilitation at the local neurobehavioural brain injury rehabilitation centre. The Judge stated that he believed VW would not receive the support he required if he were returned to prison.

At the rehabilitation centre, VW made good progress and was able to move on to a step-down, transitional living facility affiliated to the rehabilitation centre. There, he was responsible for making all meals, completing domestic activities, maintaining his own safety within the independent environment, and structuring his daily schedule. He joined a local gym and enjoyed building up his fitness and strength. He started learning to drive an adapted car, and served on an interviewing committee to select candidates for Linkworker posts.

After 6 months of intensive support, VW was able to live independently in a flat with minimal initial support from a physiotherapist, social worker, the Disabilities Trust Community Services, probation officer, and family.

Currently, VW continues to live independently, without formal support, and is able to dress, cook, and clean for himself and takes responsibility for his own finances. He has learned to use strategies to overcome his memory difficulties, he has a girlfriend, gained his driving licence, and his confidence in social situations has much improved. He sees his probation officer monthly and has help from his mother to do his shopping but no longer receives any other support.

Case 2—RR

RR screened positive for TBI on the BISI, where he reported a number of head injuries that resulted in loss of consciousness. He also reported having word finding difficulties, problems with concentration, and poor memory.

The first of these incidents had occurred 25 years earlier, and the Linkworker was able to obtain details of dates and hospital attendance. However, information about neurological examination, treatment, and follow-up was not available.

His offences concerned stealing cars and were committed to fund his drug habit. No violence was involved in his offending, although he had been assaulted.

Assessment by the Linkworker revealed slurred speech and a tendency to avoid eye contact. RR failed the finger nose test and showed a tendency to trip over his feet. The prisoner was concerned, as he had a family history of progressive neurological conditions. Upon collation of this information, the Linkworker referred RR to his general practitioner (GP) who referred on to a neurologist.

It was discovered that, before he was sent to prison, he was easily distracted at work and would forget what he was doing. He also had a tendency to do things in the wrong order but was helped by workmates to cover up his mistakes. The Linkworker introduced routines for tasks or jobs he was doing in the prison, using step-by-step methods and to-do lists (B. Wilson, Gracey, Evans, & Bateman, 2009). RR had a large laminated sheet with each step to follow in his cell, and a smaller laminated version in his pocket. He said this method helped a great deal. When he stopped using this method for a while, he floundered again.

The letters he wrote to his wife and daughter made no sense, apparently due to attentional difficulties. The Linkworker helped him to write letters in a quiet place and one line at a time (see Ponsford et al., 2013). Following this, his daughter reported that his letters were much easier to follow.

At work in the prison, if he became distracted, he was encouraged to use a checklist. RR was encouraged to take 5 to 10 min in his cell to get ready before leaving. RR also suffered from fatigue, so he was advised to take regular breaks and to do this whether he was feeling tired or not.

There was evidence that RR was not applying the memory strategies he had been taught in all relevant circumstances, so he needed support to develop these for each new situation (B. Wilson et al., 2009).

He gained a job as an “advisor” with a prison-based charity. He did well and achieved a qualification at the end of this. His role involved talking to prisoners near to their release. He was commended for his excellent work, especially his paperwork, which was said to be detailed, and of a very high standard.

At one stage, RR was transferred to another prison. However, the Linkworker ensured that he was transferred back, so that he would not miss his neurology appointments and lose his job.

A further concern was about how he would cope upon release. Before prison, he had avoided criminal behaviour for 8 to 9 years when he was supported by a partner. Prior to that period, he had been in and out of prison. His partner supported him in various ways, helping him with his finances and enabling him to work. He held down a job for 5 years and was in regular employment for an even longer period. When he and his partner separated, he became homeless and lived in a hostel. There, he slipped back into his previous drug-abusing lifestyle. When finally arrested, he claimed he was relieved, as he felt this saved him from addiction. He was worried that this pattern would recur upon his release if he had no support. He had difficulty managing his finances, and as he was not computer literate, he could not apply for his benefits online. To manage some of these risks, the plans for his release included ensuring he continued to play a role for the charity outside prison, which provided structure and purpose to his daily routine (Evans, 2009).

Case 3—MB

MB was identified by the BISI but would probably have been recognised through standard procedures, given his presentation. He was involved in a road traffic accident 10 years earlier and was in a coma for 10 weeks as a result of the TBI he sustained. He had a retrograde amnesia for the previous 8 years of his life. He was unable to remember his wife, his marriage, his home, or his dog. Following the accident, he was discharged home and his wife has been his full time carer ever since. He refused all other help, as he had no awareness of his deficits.

MB made a good physical recovery. He received a substantial personal injury award, although this was probably less than it would have been as he refused to accept care due to his lack of awareness. Since his TBI, he has not been able to work.

MB’s offence involved a serious common assault on his wife. He had a premorbid history of aggression, and he also served a prison sentence for grievous bodily harm (GBH) prior to his brain injury.

Since his injury, a recurring pattern had emerged whereby he would argue with his wife, leading to escalating violence against her. However, she and others were reluctant to press charges because of his TBI. This led to major concerns regarding his wife’s safety. She continued to be devoted to him but severely at risk. On admission to prison following a serious assault on her, he was extremely agitated, showed no awareness or remorse for what he had done, and expressed anger towards his wife.

MB was also at risk of being abused by other prisoners as he would make inappropriate comments, would easily get into a fight, and would be unable to de-escalate such situations. Due to considerations for his own safety, he often only spent 40 min over the course of a week out of his cell.

To ensure his safety, he was therefore transferred to the health care wing. There, he settled quickly, taking his medication (which he had resisted in the main wing). He got on well with staff and other prisoners, and behaved in a very friendly manner. He showed that he was capable of learning alternative responses to manage situations. Under these conditions, he posed no risk in prison, but concerns regarding his release home remained.

The role of the Linkworker involved seeing MB on a daily basis, but often just for a brief follow-up. Sometimes the Linkworker helped MB place orders for items such as clothes, or cigarettes, as he showed poor initiation and could not do this unaided. The Linkworker also developed support plans with staff. Once the Linkworker had enabled staff to see MB’s behaviour in terms of his brain injury, they became increasingly supportive. They previously believed something was wrong but did not know what. The Linkworker’s intervention enabled staff to understand MB better and work with him more effectively.

Support plans included basic guidelines (MB responded well to clear boundaries) and helping MB to organise himself and the tasks he needed to undertake. MB had a history of missing out on appropriate interventions for a variety of reasons, including forgetfulness and refusal.

The Linkworker intervention led to positive outcomes for MB while in custody. The Linkworker also managed to secure a place at a neurobehavioural rehabilitation centre for MB, but by the time funding was agreed for this, he had been released from prison without a court order made for him to receive rehabilitation. No follow-up information was available.

Discussion

The new intervention described here was developed from the premise that the only viable way of providing sustainable, but specialised support for prisoners with brain injury would be a low-cost, low intensity service. The approach is therefore based upon recent graduates with induction training, a manual and clinical supervision to allow them to recognise and respond to the type of problems commonly associated with TBI. The specific interventions delivered by the Linkworker are based on a neurobehavioural and cognitive approach to TBI rehabilitation, and consist of simple strategies, usually addressing functional difficulties associated with problems of memory, executive function, or emotional regulation (Cicerone, Langenbahn, Braden, Malec, Kalmar, et al., 2011; McMillan & Wood, 2017; B. Wilson et al., 2009). The case examples illustrate how such interventions can make a significant difference to the ability of the person to cope within prison and after release.

The three case reports reflect the heterogeneity and complexity of individuals identified as having a history of brain injury. They also suggest that the individuals supported have significant difficulties that reduce their ability to benefit from standard offender rehabilitation approaches and increase the risk of reoffending. These difficulties may arise from severe brain injuries but also from the cumulative effect of multiple minor TBIs (McCrea, 2008).

A number of important considerations are raised by the cases. Case 1 illustrates the role of the Linkworker in identifying suitable services for offenders and enabling them to access such services. The second case provides an example of the impact of multiple minor TBIs and highlights the potential value of brain injury support in reducing criminality. The third case illustrates the way in which a brain injury may interact with a predisposition to violence and criminality. This case also illustrates the role of the brain injury Linkworker in working with and advising other prison staff to ensure a supportive and facilitative environment, conducive to offender rehabilitation. In this instance, the prisoner was released before satisfactory plans for his support could be made. However, the case demonstrates the impact of the Linkworker intervention within the prison environment.

The greatest difficulty lies in differentiating between problems arising from a TBI and those emanating from other causes. There is considerable overlap between those problems, which are characteristic of a moderate to severe brain injury and those prevalent within a population of offenders (Young et al., 2011). Furthermore, mental health problems and disorders, such as ADHD and foetal alcohol syndrome, are all overrepresented in this population (M. Fazel, Långström, Grann, & Fazel, 2008; Mouridsen, Rich, Isager, & Nedergaard, 2008). Excessive use of alcohol and substance abuse are also extremely common.

There are situations when it seems quite clear that brain injury is a significant factor in an individual’s pathway to offending. In such cases, identifying this factor and providing an intervention that addresses the problems that arise from it is likely to have a significant influence on the probability of further offending and on the ability of the individual to cope with life demands without resorting to criminal behaviour. The case examples demonstrate how TBI can be overlooked or ignored within the prison system, to the detriment of society, as opportunities to prevent further criminal behaviour may be missed.

Even in those where the link between criminal behaviour and TBI is less clear, the “light-touch” intervention described here may be relevant in reducing recidivism and enabling the individual to lead a satisfactory life. For example, the type of specific interventions developed for ABI to address impulsivity or aggressive behaviour may also be of assistance to those with ADHD as they present with overlapping problems (Young et al., 2011).

The Linkworker intervention was deliberately designed to be low cost, as it is clear that expensive interventions are unlikely to be sustainable. However, if a low cost intervention can be shown to be feasible by promoting engagement with relevant support services to enable return to employment, and to manage difficulties that are likely to serve as barriers to reintegration, then there is a greater possibility of such interventions being funded.

Not all who suffer a brain injury are at risk of resorting to crime, but the combination of a brain injury with other risk factors increases the probability that criminal behaviour will occur (Williams, 2012). Equally, it is not suggested that addressing brain injury–related problems is the single solution to improve offender rehabilitation outcomes, but identification of, and support for, those offenders with a brain injury is an important step towards achieving such goals.

Conclusion

In general, each of these case studies suggests that identifying and intervening with prisoners who have had brain injuries is feasible and can lead to positive results (Table 3). The present report provides early indications of the benefits of the Linkworker approach and justifies a controlled study of efficacy. A service and training package have been developed so that Linkworkers can be quickly and efficiently trained to play the role described here. Further research, using controlled comparative and uncontrolled longitudinal designs, gathering specific measures of outcome such as scores on the Offender Group Reconviction Scale (Howard, Francis, Soothill, & Humphreys, 2009), level of engagement with education, employment and training agencies, and scores in standardised measures of mood, substance use, and psychological well-being, will enable a more objective evaluation of the role of brain injury Linkworkers, and determine whether this role does lead to cost-effective outcomes. There is also the human cost to the individuals and their family, and to the victims of their criminal behaviour. The opportunity for interventions which reduce the incidence of offences should be evaluated in this light as well.

Footnotes

Acknowledgements

The authors acknowledge all those involved in the delivery of the Linkworker service, specifically Sean Walsh, Linkworker, Dr. Ivan Pitman and Dr. Rachael McNulty, clinical supervisors, and Elizabeth Wilce, project manager. They also thank staff in all the various teams working in the prison establishments who supported the service creation and continued delivery. The authors have not disclosed the name of the prison, and changed some of the individuals’ details (e.g., initials) to further ensure anonymity of the cases reported.

Declaration of Conflicting Interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: The author(s) are or were employed by The Disabilities Trust, the charitable organisation who developed and delivers the Linkworker service. This manuscript was written as part of a service evaluation initiative.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Notes

References

Baguley

I. J.

Cooper

Felmingham

(2006). Aggressive behavior following traumatic brain injury: how common is common? The Journal of Head Trauma Rehabilitation, 21, 45-56. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/16456391

Bechara

(2004). Disturbances of emotion regulation after focal brain lesions. International Review of Neurobiology, 62, 159-193. doi:10.1016/S0074-7742(04)62006-X

Brewer-Smyth

Burgess

A. W.

(2008). Childhood sexual abuse by a family member, salivary cortisol, and homicidal behavior of female prison inmates. Nursing Research, 57, 166-174. doi:10.1097/01.NNR.0000319501.97864.d5

Brewer-Smyth

Burgess

A. W.

Shults

(2004). Physical and sexual abuse, salivary cortisol, and neurologic correlates of violent criminal behavior in female prison inmates. Biological Psychiatry, 55, 21-31. doi:10.1016/S0006-3223(03)00705-4

Brooks

D. N.

McKinlay

(1983). Personality and behavioural change after severe blunt head injury—A relative’s view. Journal of Neurology, Neurosurgery & Psychiatry, 46, 336-344. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/6842246

Bruns

Hauser

W. A.

(2003). The epidemiology of traumatic brain injury: A review. Epilepsia, 44, 2-10. doi:10.1046/j.1528-1157.44.s10.3.x

Cicerone

K. D.

Langenbahn

D. M.

Braden

Malec

J. F.

Kalmar

Fraas

. . . Landenhahn

(2011). Evidence based cognitive rehabilitation: Updated review of the literature from 2003 through 2008. Archives of Physical Medicine, 92, 519-530. doi:10.1016/j.apmr.2010.11.015

Colantonio

Kim

Allen

Asbridge

Petgrave

Brochu

(2014). Traumatic brain injury and early life experiences among men and women in a prison population. Journal of Correctional Health Care, 20, 271-279. doi:10.1177/1078345814541529

Evans

(2009). Rehabilitation of executive functioning: An overview. In Oddy

Worthington

(Eds.), The rehabilitation of executive disorders: A guide to theory and practice (pp. 59-74). Oxford, UK: Oxford University Press.

10.

Farrer

T. J.

Hedges

D. W.

(2011). Prevalence of traumatic brain injury in incarcerated groups compared to the general population: A meta-analysis. Progress in Neuro-Psychopharmacology & Biological Psychiatry, 35, 390-394. doi:10.1016/j.pnpbp.2011.01.007

11.

Fazel

Långström

Grann

Fazel

(2008). Psychopathology in adolescent and young adult criminal offenders (15-21 years) in Sweden. Social Psychiatry and Psychiatric Epidemiology, 43, 319-324. doi:10.1007/s00127-007-0295-8

12.

Fazel

Lichtenstein

Grann

Långström

(2011). Risk of violent crime in individuals with epilepsy and traumatic brain injury: a 35-year Swedish population study. PLoS Medicine, 8, e1001150. doi:10.1371/journal.pmed.1001150

13.

Ferguson

P. L.

Pickelsimer

E. E.

Corrigan

J. D.

Boger

Wald

(2012). Prevalence of traumatic brain injury among prisoners in South Carolina. Head Trauma Rehabilitation, 27, E11-E20. doi:10.1097/HTR.0b013e31824e5f47

14.

Hessen

Nestvold

Anderson

(2007). Neuropsychological function 23 years after mild traumatic brain injury: A comparison of outcome after paediatric and adult head injuries. Brain Injury, 21, 963-979. Retrieved from http://www.informaworld.com/10.1080/02699050701528454

15.

Howard

Francis

Soothill

Humphreys

(2009). OGRS 3: The revised Offender Group Reconviction Scale. In Research summary 7/09. (pp. 1-6). London, England: Ministry of Justice.Retrieved from: https://core.ac.uk/download/pdf/1556521.pdf

16.

Kaba

Diamond

Haque

MacDonald

Venters

(2014). Traumatic brain injury among newly admitted adolescents in the New York City jail system. Journal of Adolescent Health, 54, 615-617. doi:10.1016/j.jadohealth.2013.12.013

17.

León-Carrión

Ramos

F. J. C.

(2003). Blows to the head during development can predispose to violent criminal behaviour: Rehabilitation of consequences of head injury is a measure for crime prevention. Brain Injury, 17, 207-216.

18.

McCrea

M. A.

(2008). Mild traumatic brain injury and postconcussion syndrome: The new evidence base for diagnosis and treatment. New York, NY: Oxford University Press.

19.

McKinlay

Dalrymple-Alford

J. C.

Horwood

L. J.

Fergusson

D. M.

(2002). Long term psychosocial outcomes after mild head injury in early childhood. Journal of Neurology, Neurosurgery & Psychiatry, 73, 281-288. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/12185159

20.

McMillan

Wood

R. L.

(2017). Neurobehavioural disability and social handicap following traumatic brain injury—Brain, behaviour and cognition (2nd ed.). Hove, UK: Psychology Press.

21.

Mouridsen

S. E.

Rich

Isager

Nedergaard

N. J.

(2008). Pervasive developmental disorders and criminal behaviour: A case control study. International Journal of Offender Therapy and Comparative Criminology, 52, 196-205. doi:10.1177/0306624X07302056

22.

O’Sullivan

Glorney

Sterr

Oddy

Ramos

S. D. S.

(2015). Traumatic brain injury and violent behavior in females: A systematic review. Aggression and Violent Behavior, 25, 54-64. doi:10.1016/j.avb.2015.07.006

23.

Parker

(1996). The spectrum of emotional distress and personality changes after minor head injury incurred in a motor vehicle accident. Brain Injury, 10, 287-302. doi:10.1080/026990596124467

24.

Piccolino

A. L.

Solberg

K. B.

(2014). The impact of traumatic brain injury on prison health services and offender management. Journal of Correctional Health Care, 20, 203-212. doi:10.1177/1078345814530871

25.

Pitman

Haddlesey

Ramos

S. D. S.

Oddy

Fortescue

(2015). The association between neuropsychological performance and self-reported traumatic brain injury in a sample of adult male prisoners in the UK. Neuropsychological Rehabilitation, 25, 763-779. doi:10.1080/09602011.2014.973887

26.

Ponsford

Sloan

Snow

(2013). Traumatic brain injury: Rehabilitation for everyday adaptive living (3rd ed.). Hove, UK: Psychology Press.

27.

Schofield

Butler

Hollis

D’Este

(2011). Are prisoners reliable survey respondents? A validation of self-reported traumatic brain injury (TBI) against hospital medical records. Brain Injury, 25, 74-82. doi:10.3109/02699052.2010.531690

28.

Sherer

Struchen

M. A.

Yablon

S. A.

Wang

Nick

T. G.

(2008). Comparison of indices of traumatic brain injury severity: Glasgow Coma Scale, length of coma and post-traumatic amnesia. Journal of Neurology, Neurosurgery & Psychiatry, 79, 678-685. doi:10.1136/jnnp.2006.111187

29.

Shiroma

E. J.

Ferguson

P. L.

Pickelsimer

E. E.

(2010). Prevalence of traumatic brain injury in an offender population: A meta-analysis. Journal of Correctional Health Care, 16, 147-159. doi:10.1177/1078345809356538

30.

Steinberg

(2008). A social neuroscience perspective on adolescent risk-taking. Developmental Review, 28, 78-106. doi:10.1016/j.dr.2007.08.002

31.

Tate

R. L.

(1999). Executive dysfunction and characterological changes after traumatic brain injury: Two sides of the same coin? Cortex, 35, 39-55.

32.

Turner

McClure

(2003). Age and gender differences in risk-taking behaviour as an explanation for high incidence of motor vehicle crashes as a driver in young males. Injury Control and Safety Promotion, 10, 123-130. doi:10.1076/icsp.10.3.123.14560

33.

van Heugten

Gregorio

G. W.

Wade

. (2012). Evidence-based cognitive rehabilitation after acquired brain injury: A systematic review of content of treatment. Neuropsychological Rehabilitation, 22(5), 653-673. Retrieved from https://doi.org/10.1080/09602011.2012.680891

34.

Williams

(2012). Repairing shattered lives: Brain injury and its implications for criminal justice. London, England: Barrow Cadbury Trust. Retrieved from https://www.t2a.org.uk/wp-content/uploads/2012/10/Repairing-Shattered-Lives_Report.pdf

35.

Williams

W. H.

Chitsabesan

(2016). Brain injury in custody: An evaluation of a Linkworker service (Report for Barrow Cadbury Trust and The Disabilities Trust). London, England: Barrow Cadbury Trust.

36.

Williams

W. H.

Mewse

A. J. J.

Tonks

Mills

Burgess

Cordan

(2010). Traumatic brain injury in a prison population: prevalence and risk for re-offending. Brain Injury, 24, 1184-1148. doi:10.3109/02699052.2010.495697

37.

Wilson

Gracey

Evans

Bateman

(2009). Neuropsychological rehabilitation: Theory, models, therapy and outcome. Cambridge, UK: Cambridge University Press.

38.

Wilson

Daly

(1985). Competitiveness, risk taking, and violence: The young male syndrome. Ethology and Sociobiology, 6, 59-73. doi:10.1016/0162-3095(85)90041-X

39.

Young

S. J.

Adamou

Bolea

Gudjonsson

Müller

Pitts

. . . Asherson

(2011). The identification and management of ADHD offenders within the criminal justice system: A consensus statement from the UK Adult ADHD Network and criminal justice agencies. BMC Psychiatry, 11, 32. doi:10.1186/1471-244X-11-32