TRAUMATIC BRAIN INJURY (TBI) is a significant public health concern. It is estimated that each year in the United States, more than 1.4 million individuals sustain a TBI with 1.1 million visits to an emergency department, more than 235,000 hospitalizations, and 50,000 deaths (Langlois, Rutland-Brown, & Wald, 2006). The estimated nationwide incidence of TBI in 2007 was 101 cases per 100,000 individuals with ages of peak incidence among young adults and individuals older than 80 years. Reported rates of TBI incidence for males are approximately twice that of females (Hirtz et al., 2007).
As of June 2007, more than 1,595,000 individuals were incarcerated in state (87.5%) or federal (12.5%) prisons in the United States. In the calendar year 2006, 713,473 inmates were released and returned to the community (Bureau of Justice Statistics, 2008). The increase in prison admissions is outpacing the number of releases. The overall increase in prison admission from 2000 to 2006 was 3.1% nationally, including both federal and state facilities, while the increase in releases was 2.8% (Bureau of Justice Statistics, 2008).
TBI can result in sustained physical, cognitive, behavioral, and emotional outcomes. It is estimated that 5.3 million individuals in the United States (2% of the population) live with a persisting disabling condition attributable to TBI (Langlois et al., 2006). Researchers report that more than 43% of 288,009 hospitalized individuals who survived a TBI in 2003 had developed long-term disability (Selassie et al., 2008). In 2000, the total estimated lifetime economic loss attributable to TBI exceeded $50 billion (Finkelstein, Corso, & Miller, 2006). TBI can further predispose an individual to other co-occurring conditions such as substance abuse, epilepsy, and depression (Ferguson et al., 2010; Horner et al., 2005). Following a TBI, individuals are 7.5 times more likely to die within the first year after hospital discharge compared to those without TBI (Selassie, McCarthy, Ferguson, Tian, & Langlois, 2005).
TBI-associated co-occurring conditions such as chemical dependency, aggression, and learning and problem-solving difficulties can affect prison management as well as community reentry. In addition, a few studies have reported in-prison behavior and its relation to brain injury, with results suggesting that inmates with TBI have a higher rate of disciplinary incidents and are slower to adapt to prison life and learn prison rules (Merbitz, Jain, Good, & Jain, 1995; Morrell, Merbitz, & Jain, 1998).
According to various TBI studies in offender populations, 25% to 87% of offenders reported having sustained a head injury or TBI (Barnfield & Leathem, 1998; Blake, Pincus, & Buckner, 1995; Brain Injury Association of Wyoming, 2008; Brewer-Smyth, Burgess, & Shults, 2004; Corrigan & Bogner, 2008; DelBello et al., 1999; Diamond, Harzke, Magaletta, Cummins, & Frankowski, 2007; Freedman & Hemenway, 2000; Hawley & Maden, 2003; Langevin, 2006; Lewis, Pincus, Feldman, Jackson, & Bard, 1986; Martell, 1992; Minnesota Department of Corrections, 2008; Morrell et al., 1998; Sarapata, Herrmann, Johnson, & Aycock, 1998; Schofield et al., 2006a, 2006b; Slaughter, Fann, & Ehde, 2003; Templer et al., 1992; Turkstra, Jones, & Toler, 2003; Walker, Hiller, Staton, & Leukefeld, 2003; Walker, Staton, & Leukefeld, 2001). In juvenile offenders, lifetime prevalence of head injury ranges from 4% to 74% with the observation that younger offenders have less time to sustain a head injury. On average, the rates seem elevated compared to nonoffenders (Carswell, Maughan, Davis, Davenport, & Goddard, 2004; Lewis, Pincus, Lovely, Spitzer, & Moy, 1987; Miura, Fujiki, Shibata, & Ishikawa, 2005; Perron & Howard, 2008). These estimates demonstrate that TBI appears to be more frequent in offender populations such as prisons than in the general population, where an 8.5% prevalence is estimated (Silver, Kramer, Greenwald, & Weissman, 2001).
Definitions of TBI and methods of screening for TBI vary in the literature. Screening methods include in-depth personal interviews, medical record reviews, and short surveys or questionnaires. With each of these methods come a host of definitions to identify head injury and TBI. The Centers for Disease Control and Prevention's (CDC) clinical case definition of TBI is “an occurrence of injury to the head (arising from blunt of penetrating trauma or from acceleration–deceleration forces) that is associated with symptoms or signs attributable to the injury: decreased level of consciousness, amnesia, other neurological or neuropsychological abnormalities, skull fracture, diagnosed intracranial lesions–or death” (2006). Other definitions include moderate or severe head injury, any head injury, and injury with a loss of consciousness (LOC) for any or a specific duration of time.
Due to differing definitions of head injury, source populations of the studies, differing proportions of males and females in the samples, screening methods, and some studies including both adults and juveniles, it is difficult to synthesize the literature and arrive at an overall estimate of TBI prevalence in offender populations. This analysis aims to systematically analyze the reported prevalence rates of TBI in offender populations in terms of gender proportion, case definition of TBI, method of determining TBI, and the referenced source population.
Literature selection and inclusion criteria
Epidemiologic studies were identified that (a) were written in English, (b) included adult (age 18 and older) offender populations, (c) reported lifetime prevalence of TBI, (d) defined TBI, and (e) described the method of determining TBI. Pubmed, Medline, EmBase, and PsycInfo (1983 to 2009) were searched using the MeSH headings for all forms of TBI and the following free-text search words: TBI, traumatic brain injury, offender, prison(er), jail, brain injury, incarcerated/incarceration, inmate, and head injury. Additional studies and data were found using references from the retrieved articles, other relevant review articles, abstracts, and unpublished reports and communication with authors.
Data abstraction and statistical analyses
Two independent reviewers (EJS and PLF) abstracted data from primary studies using predetermined criteria. These were setting, brief inclusion/exclusion criteria, proportion of each gender where available, determination of presence of TBI method, TBI case definition, sample size, and lifetime prevalence of TBI. Disagreements in abstraction results were resolved by the reviewers discussing why there was a difference and then drawing consensus. Lifetime prevalence of TBI and sample standard error (SE) were calculated for each study. SE was calculated based on the binomial distribution using the following equation, where p equals the prevalence as a decimal:
SEs for studies with 100% or 0% observed prevalence (empty cells) were calculated by adding a correction factor of 0.1 to each cell as described by Goodman (1970). This allowed for a nonzero SE to be used. Both fixed-effects and random-effects models were examined to combine prevalence estimates for TBI weighted by inverse variance. Heterogeneity among studies was investigated using Cochran's Q test with a significance level of an α of .1. If the study appeared to have significant heterogeneity, a random-effects model was preferred. The effects on the outcome measure of differing case definitions of TBI, gender proportion of the sample, whether the study used a general offender population or a specific type of offender, and the method of determining TBI were examined. Sensitivity analyses and trim and fill plots were performed for each analysis. The studies were not weighted by quality. MIX software, version 1.7, was used for all analyses (Bax, Yu, Ikeda, Tsuruta, & Moons, 2006, 2008).
Twenty studies met the inclusion criteria and provided a combined total of 4,865 offenders (Table 1). Individual TBI prevalence estimates ranged from 10% to 100% (Table 1). The Cochran's Q was < 0.01, confirming heterogeneity between studies, and hence, a random-effects model was applied. The overall estimated prevalence of TBI in offender populations was 60.25% (95% confidence interval [CI]: 48.08 to 72.41; Figure 1). The sensitivity and trim and fill analyses (see Figure 2) show that removal of one study does not alter the estimated prevalence or the 95% CI measurably.
Subgroup analyses were performed and prevalence estimates are numerically and graphically displayed in Table 2 and Figure 3. Sensitivity analyses and trim and fill analyses demonstrated heterogeneity in all subgroup analyses but largely did not change the prevalence estimates. Publication bias did not appear meaningful, given the nature of prevalence reporting.
TBI with LOC
Seventeen studies were examined that used a definition and severity of TBI as a head injury with change in awareness or LOC of any amount of time, totaling a sample of 4,191 offenders (Table 2). A study by Barnfield and Leathem (1998) was included in the analysis but excluded offenders with a “light injury.” Individuals in the study by Turkstra et al. (2003) were included if the individual sustained at least one injury described as “concussion+” or “moderate/severe.” The sample from Freedman and Hemenway (2000) described as “multiple injuries with LOC” was also included. In the study by Diamond et al. (2007), “suspected/minimal” head injuries were excluded. In the study by the Minnesota Department of Corrections (2008), excluded injuries were defined as “no or minimal LOC.” The overall estimated prevalence of TBI with LOC was 50.19% (95% CI: 39.77 to 60.61).
TBI in a general offender population
Ten studies were included in an analysis to investigate TBI prevalence in a general offender population (Barnfield & Leathem, 1998; Brain Injury Association of Wyoming, 2008; Brewer-Smyth et al., 2004; Corrigan & Bogner, 2008; Diamond et al., 2007; Minnesota Department of Corrections, 2008; Morrell et al., 1998; Schofield et al., 2006b; Slaughter et al., 2003; Templer et al., 1992). This included studies without restrictions on the study sample based on a particular crime conviction, security level, substance abuse status, and those who were still incarcerated. These 10 studies consisted of 3,442 offenders. The estimated prevalence of TBI in an incarcerated population-based sample was 67.7% (95% CI: 49.59 to 85.82) and 57.46% (95% CI: 41.89 to 73.03) with a LOC definition of TBI.
TBI identified by extensive in-depth interview
Nine studies determined TBI through an extensive in-depth interview. For these studies, clinicians, psychiatrists, psychologists, or other highly trained personnel used extensive questioning and probing of medical history, personal experiences, and in some cases corroborated the results through other means (Blake et al., 1995; Brewer-Smyth et al., 2004; Corrigan & Bogner, 2008; DelBello et al., 1999; Diamond et al., 2007; Freedman & Hemenway, 2000; Lewis et al., 1986; Minnesota Department of Corrections, 2008; Schofield et al., 2006b). The estimated prevalence of structured in-depth interviews to estimate TBI was 66.9% (95% CI: 54.62 to 79.19). Eight studies had an extensive in-depth interview and used LOC as the definition for TBI (Brewer-Smyth et al., 2004; Corrigan & Bogner, 2008; DelBello et al., 1999; Diamond et al., 2007; Freedman & Hemenway, 2000;
Lewis et al., 1986; Minnesota Department of Corrections, 2008; Schofield et al., 2006b). These studies had a composite sample of 1,794 offenders. The estimated prevalence of TBI with LOC determined by a structured in-depth interview was 52.31% (95% CI: 44.28 to 60.34).
TBI and gender
To control for potential gender differences, 15 studies with all-male samples and studies that reported a separate prevalence for the male proportion were pooled to create a total sample size of 3,245 male offenders (Barnfield & Leathem, 1998; Blake et al., 1995; Brain Injury Association of Wyoming, 2008; Corrigan & Bogner, 2008; DelBello et al., 1999; Diamond et al., 2007; Freedman & Hemenway, 2000; Langevin, 2006; Lewis et al., 1986; Martell, 1992; Minnesota Department of Corrections, 2008; Schofield et al., 2006b; Templer et al., 1992; Turkstra et al., 2003; Walker et al., 2003). The estimated prevalence of TBI in male offenders was 64.41% (95% CI: 53.3 to 75.53). Four studies with a combined total of 387 females were pooled to examine a female-only sample (Brain Injury Association of Wyoming, 2008; Brewer-Smyth et al., 2004; Corrigan & Bogner, 2008; Diamond et al., 2007). The estimated prevalence of TBI in a female offender population was 69.98% (95% CI: 50.18 to 89.79). Twelve studies using LOC to define TBI severity in male-only samples resulted in a pooled sample size of 2,610 males (Barnfield & Leathem, 1998; Brain Injury Association of Wyoming, 2008; Corrigan & Bogner, 2008; DelBello et al., 1999; Diamond et al., 2007; Freedman & Hemenway, 2000; Langevin, 2006; Martell, 1992; Minnesota Department of Corrections, 2008; Schofield et al., 2006b; Templer et al., 1992; Turkstra et al., 2003). The estimated prevalence of TBI with LOC in male offenders was 52.27% (95% CI: 43.72 to 60.81).
Seven studies (pooled N = 1,986) were identified and included for analysis with a male general offender sample and a definition of TBI that included LOC for any amount of time (Barnfield & Leathem, 1998; Brain Injury Association of Wyoming, 2008; Corrigan & Bogner, 2008; Diamond et al., 2007; Minnesota Department of Corrections, 2008; Schofield et al., 2006b; Templer et al., 1992). The overall estimated prevalence of TBI with LOC in a male nonspecific offender type population was 59.31% (95% CI: 47.38 to 71.23; Figure 4). Four studies comprising 387 females in a nonspecific offender sample with a severity of TBI of at least LOC were examined (Brain Injury Association of Wyoming, 2008; Brewer-Smyth et al., 2004; Corrigan & Bogner, 2008; Diamond et al., 2007). The estimated prevalence of TBI with LOC in a female nonspecific offender sample was 55.28% (95% CI: 41.26 to 69.29).
This study has combined epidemiological studies in a meta-analysis to estimate the prevalence of TBI in offender populations. Several subgroup analyses examined the effects of the source population, TBI severity and definition, gender, and method of determining TBI (Figure 3).
Without adjusting for differing definitions of TBI, methods of determination, proportion of males in the sample, or the similarities of the sample populations, the overall estimated prevalence of TBI in the overall offender population was 60.25% (95% CI: 48.08 to 72.41), which is narrower than the commonly reported range of 25% to 87%.
Males are reported to have a higher prevalence of TBI, which implies that attempts to analyze samples of differing proportions of males and females may not be appropriate (Hirtz et al., 2007). The male-only subgroup analysis estimated a 64.41% (95% CI: 53.3 to 75.53) TBI prevalence. The female-only subgroup had a higher prevalence of 69.98% (95% CI: 50.18 to 89.79). However, the female estimate had approximately twice the SE as the male. When comparing the male to female estimate, where both samples were of nonspecific offender types with a minimum injury severity of a LOC, the male estimate was higher than the female with comparable SEs (59.31% vs. 55.28%); this supports that males may have a higher prevalence of TBI in offender populations, but the difference is not statistically significant (Brewer-Smyth et al., 2004).
Comparing studies where the offender samples are drawn based on different offender types may not be appropriate because some offender types may have a higher or lower prevalence of TBI. In an attempt to examine a more representative sample of a general incarcerated population, the nonspecific offender type subgroup analysis estimated prevalence of TBI was 67.7% (95% CI: 49.59 to 85.82). Interestingly, this prevalence estimate had one of the larger CIs. This may be in part due to the various definitions of TBI, as well as the sampling methods in the general offender samples (i.e., randomized vs. convenience samples). Sampling in this manner tends to oversample those with higher entrance rates, generally those with less violent or severe crimes. These groups may be inherently different in terms of TBI prevalence. In addition, it is unknown whether international incarcerated populations are comparable to U.S. incarceration populations, although all countries in these studies were English-speaking and, thus, may have similarly derived legal systems. In this regard, this subgroup does allow for an estimate where the inclusion criteria are not limited by a characteristic of the incarcerated offender such as a chemical dependency or conviction for a specific crime.
The estimated prevalence of TBI with an associated LOC of any amount of time was 50.19% (95% CI: 39.77 to 60.61). As would be expected, this estimate is more conservative than the broader definition of any possible head injury. Further stratification by level of injury severity was not possible due to the heterogeneity with which various studies defined severity of TBI.
An extensive in-depth interview by trained psychological professionals is considered the gold standard of examining lifetime history of TBI, because in-depth interviews may help probe an individual's memory and uncover additional injuries (Corrigan & Bogner, 2007). Although susceptible to recall bias, this method should produce a more complete and accurate history than simple medical record abstraction or self-administered questionnaire. The subgroup analysis of those studies with in-depth interviews had a higher prevalence than the overall estimate that included all studies (66.9% vs. 60.25%). The higher prevalence may further be due in part, however, to a higher percentage of the not in-depth interviews recording only those injuries with LOC.
The subgroup analysis of TBI with LOC in a male nonspecific offender type population narrows the estimated prevalence 95% CI to 59.31% ± 12%. It should be noted, however, that this subgroup analysis was comprised of only seven studies and 1,986 offenders. The trim and fill plot in addition to the sensitivity analysis showed that the estimate was resilient and altered little when each study was removed and replaced.
Several limitations of this study have been mentioned, such as varying definitions of TBI, differing methods of TBI determination, and disparate sample populations and sampling methods. Inherent in all TBI studies is the difficulty in determining TBI, especially in less severe cases and in retrospective studies (Corrigan & Bogner, 2007). Publication bias should be minimal given that these are prevalence studies; thus, there are no “negative” results. Yet non-English studies would be missed. In addition, unidentifiable biases remain, such as the possibility of inmates with TBI being more or less likely to participate in studies or inmates being more or less likely to report TBI incidents accurately. Meta-analyses of observational studies are particularly susceptible to such biases, and restraint must be used when wanting to summarize to a single number.
In conclusion, this study systematically reviewed the literature of adult offender populations and analyzed their findings in terms of TBI prevalence. To our knowledge, this is the first study to apply the principles of meta-analysis to TBI in offender populations. The overall estimated prevalence of TBI in offender populations was 60.25% and narrowed the previous range from 25% to 87% to a 95% CI of 48% to 72% for all samples. The subgroup analyses, in an attempt to control for various factors, adjust this estimate based on TBI severity, gender, method of data collection, and offender type. Future investigations with more standardized measures of obtaining TBI history as well as documenting TBI severity could decrease the heterogeneity observed across all studies and allow for a more precise estimate of TBI prevalence.
A better estimate of the true prevalence of TBI in offending populations would inform public policies nationally that could improve the social functioning of incarcerated persons with TBI, inform correctional policies that lead to better resource allocation for screening and treatment, and improve the management of offenders. Development of partnerships with community health providers would further assure continuity of care and case management for offenders with TBI returning to the community and could lead to increased benefit to society.
The research team thanks Dr. Jennifer Bogner, Dr. John Corrigan, Dr. David Hoel, and Ms. Pamela Diamond for their contributions to this study.
Declaration of conflicting interests
The authors declared no conflicts of interest with respect to the authorship and/or publication of this article. For information about JCHC's disclosure policy, please see the Self-Study Exam.
The authors received no financial support for the research and/or authorship of this article.
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traumatic brain injury; inmates; prevalence; head injury; correctional health care