As shown in Table 1, the reported lifetime prevalence rates of TBI among incarcerated youth range from 16.5% to 72.1%, with the exception of a study of 14 young people sentenced to death for crimes committed when aged younger than 18 years, all of whom reported having experienced some form of head injury in their childhood. There are many explanations for this variability. Table 1 illustrates the varying definitions of TBI applied in different studies, in the range from “any head injury,” including cuts, whiplash, and blows to the head not resulting in LOC, to trauma resulting in LOC for a minimum of 20 minutes. It is clear therefore that these studies are measuring very different concepts. Nonetheless, as will be examined in the discussion that follows, even where definitions appear similar, reported prevalence rates still vary.
The variability in definition is reflected in the various measures, tools, and methods used to assess prevalence rates, which include analyses of medical records, self-administered surveys, semistructured interviews, and the use of validated instruments or clinical tests. Methodologies also vary in whether the respondent is the young person or parent, and whether surveys are self-administered, or data are collected by a researcher or medical professional. It is apparent that there is the potential for these varied approaches to lead to different assessments of levels of prevalence.51
Comparisons are also made difficult by the variation in samples and populations on which individual studies are focused. This includes variation in the age range considered, which was typically dependent on the age of young people within a particular custodial setting. The latter relates to a further, more significant challenge in drawing together studies from various national contexts. The comparison of populations of incarcerated youth masks considerable differences in the use of custodial interventions for young people in particular nation states. As illustrated by the study reporting a prevalence rate of 100%, variations in the seriousness of offence committed may also influence findings.
Studies also vary in their intent. While some studies are designed to establish a prevalence level within a custodial population, in other studies the reported rate is a by-product of a broader focus on physical and/or mental health issues or criminal justice experiences. In such studies, data regarding TBI may result from 1 or 2 simple questions, with little depth of discussion. This variation in purpose is reflected in the sampling frames utilized within the studies, in the range from convenience or purposive samples, to those that deliberately include an entire custodial population.
Given this heterogeneity in definition, methodology, and population, it is not possible to calculate a robust and meaningful overall estimate of the prevalence of TBI among incarcerated youth. Instead, the following sections provide a discussion of the various definitions used, and the range of prevalence estimates reported accordingly.
Where provided, prevalence rates among control groups drawn from nonoffenders in the general youth population are provided in Table 1. To support such comparison, the discussion later also utilizes studies of the general youth population in which similar definitions of TBI are used. These studies were purposively selected following the initial review and analysis so as to provide comparable definitions. In most cases, however, there remain slight discrepancies in definition, method of data collection and/or population. To enable comparison, information on these studies is provided in Table 2.
Though the degree of difference varies, regardless of definition, the 4 studies inclusive of a control group within the general youth population consistently demonstrate a prevalence of TBI among young offenders in custodial institutions that is greater than that in the general population. Similarly, where comparisons are made to studies utilizing similar definitions in examining prevalence in the general population, the rate among incarcerated youth is typically higher. In part, this may be explained by the higher proportion of females in general population samples and the apparent lower prevalence of TBI among young females, as discussed further later. In the following discussion, these patterns are examined in relation to the common categories of definition of TBI.
Any head injury
In 4 studies, a broad definition of head injury is used, incorporating a range of injuries, such as cuts, and/or including blows to the head that do not result in LOC. Three such studies directly compare samples of incarcerated youth to a control group within school settings. Hux et al54 asked parents a series of 21 “Yes/No” questions examining awareness of head injuries experienced by their child before the age of 18. The study reports that 49.7% of the incarcerated sample had experienced a concussion or cut to the scalp or forehead requiring stitches, compared with 42.1% of the control group.
Levine et al57 compare 53 young people in custody to an “age-matched comparison group” of 51 nonoffenders from a community that is “demographically representative of the region under study.” Parental report suggests that 55% of the offender population had experienced a head injury significant enough to require medical attention, compared with 24% of the control group. A higher rate is reported by Davies et al.52 Following semistructured interviews of young people in 1 custodial institution in the United Kingdom, they conclude that 72.1% had experienced a head injury causing them to be “knocked out and/or dazed and confused for a time.”
The rates among incarcerated youth reported in these studies appear to be greater than those identified when comparable definitions are applied in studies of the general youth population. For example, comparable definitions utilized in studies of high school students in the United States suggest a prevalence rate for any head injury of between 31%65 and 35%.66 One study runs counter to this trend. When surveying young offenders in custody in New South Wales, Australia, Kenny and Lennings56 suggest that 35.1% had experienced any kind of head injury, a rate in keeping with that of general population studies.
A different measure is employed by Forrest et al53 who consider prevalence rates in the previous 12 months. In this study “head injury” is one of a number of “acute major disorders” measured within the Child Health and Illness Profile used to assess a wide range of health needs. Among incarcerated youth, 12.5% experienced a head injury in the last 12 months, a significantly higher rate than that of 5.8% within a control group of school children. The latter is comparable to a rate of 4.7% identified by Riley et al57 utilizing the same tool and measure on a population of adolescents, aged 11 to 17 years, in public schools in urban and rural Maryland.
TBI resulting in LOC
The disparity between prevalence rates within incarcerated and nonincarcerated populations appears increasingly pronounced as the severity of the reported TBI increases. This is apparent in the single study including a control group in which a range of severities of TBI are measured. In the study by Hux et al,54 the relative difference in prevalence rates between the 2 samples increases when respondents report concussion and LOC; 11.7% of the control group report some form of concussion, compared with 16.5% of the incarcerated young people, whereas 1.5% of the control group report “moderate” or “severe” concussion compared with 3.5% of the incarcerated young people. (A definition of the levels of severity is not provided, however.)
The increasing disparity in relation to more severe injuries is also evident when comparing reported rates in studies of incarcerated populations to studies of the general youth population. Three further studies in our review consider the prevalence of TBI with any LOC among incarcerated youth, with reported rates of 32%,60 41%,52 and 49.7%.55 This compares with rates of between 5% and 24% identified by a review of studies of self-report surveys of college students in the United States.67
The lower of these prevalence rates defines TBI as trauma resulting in LOC of “greater than 20 minutes.” This definition is directly comparable with that of Perron and Howard,61 who report that 18.3% of their sample of incarcerated youth experienced such an injury. While limited to 2 studies, this suggests a near 4 times increase of such head injuries among the incarcerated sample.
Elsewhere, “moderate” or “severe” TBI is defined as a LOC of more than 30 minutes, with an injury classified as “very severe” if the LOC is greater than 60 minutes. Two studies utilize this definition in examining prevalence in custodial populations; both involving self-report of experience of TBI by the young person, although 1 in the United Kingdom52 and 1 in Australia.60 The 2 studies report an identical prevalence rate of 8.2%.
Repeat incidence of TBI
Two studies report on multiple experiences of TBI. Davies et al52 report that 45.8% of their sample of incarcerated young people had experienced more than 1 head injury of any severity, including 22.9% reporting 4 or more such injuries, whereas Moore et al60 suggest that around 13% of their sample of incarcerated youth had experienced a LOC on 2 or more occasions. While these studies did not include a control group, a self-report questionnaire of high school students in the United States65 found that 12% had experienced multiple head injuries of any kind, and a birth cohort study in New Zealand63 with a sample size of 1265 reports that, by the age of 25 years, 9.2% had experienced more than 1 TBI for which a diagnosis of concussion was given.
Sociodemographic variation in prevalence
Four studies compare prevalence rates of TBI by gender among incarcerated youth with contradictory results. Two studies report a significantly higher rate of TBI among males than females. Perron and Howard61 report that 19.6% of males and 9.6% of females had experienced a TBI resulting in LOC for at least 20 minutes, whereas Kenny and Lennings56 suggest that 37.7% of males and only 5.3% of females have experienced one of a wide range of head injury types.
In contrast, 2 studies demonstrate very similar rates among males and females. A recent study that screened young offenders in custody in New York State for TBI resulting in LOC reported only 1 percentage point difference with a prevalence of 50% among male respondents and 49% among female respondents.55 While the reported rates are notably different, Moore et al60 also suggest equivalency in prevalence with 32.1% of males and 33.3% of females in their sample experienced TBI with LOC.
It is difficult to explain this variation between studies, even with reference to the varying definitions of TBI and diverse sampling frames. While there is variation in the degree of difference reported, studies of the general youth population consistently suggest a significantly higher prevalence of TBI among males.62,63,65
Two studies consider variation by ethnicity, though neither study reports any significant difference. In a study of 9 Australian detention centers,60 the rate of TBI is slightly higher among Aboriginal young people (33.8%) than non-Aboriginal young people (30.9%). Interviews with 72 young people in custody in Missouri,61 suggest that 17.8% of white young people experienced TBI with LOC for more than 20 minutes, compared with 16.9% of non-white young people.
There is insufficient evidence upon which to draw firm conclusions, however these findings would suggest that TBI might act as a risk factor for criminality independent of ethnicity. Furthermore, such research examining sociodemographic characteristics is needed. In particular, consideration must be given to factors known to increase risk of criminality and/or criminalization that might therefore act as confounding variables in seeking to understand the relationship between TBI and offending.
Several studies have identified patterns of comorbidity of TBI with other neurodevelopmental disorders or mental health problems. Such associations are of 2 distinct types. First, the preexistence of other disorders, such as attention-deficit hyperactivity disorder, may heighten the risk of brain injury due to the types of behavior or activity that might more readily be engaged in.68 Second, there is evidence to suggest that TBI might increase the risk of developing other disorders. For example, TBI can result in speech and language difficulties69 and can increase the risk of mental health problems, such as depression, anxiety, and suicidality.29,70 Young offenders reporting TBI have also been found to be at greater risk of mental health problems and misuse of cannabis.47
Despite the heightened risk of comorbidity, none of the studies reviewed examined the co-occurrence of TBI and other conditions among incarcerated youth. Further research is required to understand experiences of comorbidity within this vulnerable population. Evidence is presented elsewhere in this special issue. In their study of young male offenders in custody, Chitsabesan et al71 found that the prevalence of deliberate self-harm and suicide risk factors was significantly increased in those experiencing a TBI, although rates of depression and other neurodevelopmental disorders, including ADHD and speech and language disorders, were not increased in this subgroup. The authors consider possible mediating factors for the comorbidity of TBI with self-harming behavior, including the presence of shared risk factors such as a history of being in care.
This review has identified a significant prevalence of TBI among young people in custody in multiple national contexts. Between 49.7% and 71.2% of incarcerated young people are reported to have experienced some kind of head injury, with between 16.5% and 49% having experienced TBI with LOC. While diverse definitions of TBI lead to a wide disparity in reported rates, this suggests high levels of associated need among young people in custody.
There is also strong and consistent evidence of a prevalence of TBI among incarcerated youth that is substantially greater than that in the general population and among offenders in community service settings. Where control groups or comparable studies within the general population exist, the rates of all forms of TBI appear higher among incarcerated youths. This disparity is seemingly more pronounced as the severity of the injury increases.
The correlation between TBI and incarceration does not imply causation. Engaging in types of behavior related to antisocial behavior, aggression and criminality may result in a greater risk of TBI. Nonetheless, as outlined in the Introduction, the strong evidence base regarding the association between TBI and subsequent deficits in a wide range of known risk factors for criminality, including cognitive skills, impulse control, academic engagement, and susceptibility to negative peer group influence, provides a strong theoretical framework with which to understand and explain the relationship between TBI and serious and/or persistent offending, and therefore the disproportionate prevalence among incarcerated youth.
There are a number of limitations with regard to the effectiveness of this review in addressing its aims. As discussed previously, there are numerous challenges in seeking to combining and comparing disparate research studies with diverse definitions, samples and methodologies so as to form a coherent picture of the prevalence of TBI among young people in custodial institutions. In particular, variation in the definition of TBI utilized in research, and indeed practice, inhibits clear understanding of both the prevalence of TBI and its relationship to offending. Furthermore, the relatively small number of sources identified demonstrates that, while greater focus is rightly being placed on this as an issue, there remains a lack of robust data upon which to draw comprehensive conclusions regarding levels of need or associations between serious and persistent offending and degrees of severity of TBI.
The heterogeneity in definition of TBI and study design limits the meaningfulness of combining estimates of prevalence to establish a general estimate. The review identified 10 studies across 3 countries. There are, therefore, insufficient studies from each country to draw firm and meaningful comparative conclusions. Such comparison is further limited by variations in policy and practice in specific states within each country, as well as by the varied definitions and measures employed in each study. This precludes any meaningful reflections on the relative impact or effectiveness of specific state policy and practice systems. There are also some specific gaps in the available evidence. Despite the likely vulnerability within this population, there appear to be particular limitations in the available evidence regarding experiences of comorbidity of TBI and other developmental and mental health difficulties among young people in custody. Similarly, few studies consider the prevalence or impact of repeat experiences of childhood TBI within this population. There is also insufficient consideration to sociodemographic characteristics that are commonly identified within criminological research as impacting on experiences within the criminal justice system, including ethnicity and socioeconomic status. Given concern for experiences of criminalization and disablement among young people who experience childhood TBI, the potential for complex and multiplicative experiences of disadvantage must be considered.
Notwithstanding these limitations in the evidence base, the findings presented here have clear implications for youth justice systems. The high levels of need emphasize the requirement for effective screening and assessment of TBI among offending populations so as to support the development of practices and interventions better able to meet the needs of young people in custody, both individually and collectively. Effective assessment provides the means to understand an individual young person's history of TBI and address its potential impact on aspects of behavior and functioning. In turn, such screening and assessment can provide an understanding of the collective level of need so as to inform the commissioning and development of specialist services. In addition, the prevalence of TBI, and indeed other neurodevelopmental disorders, among young people who offend suggests the need for youth justice processes to be revised, given the significant proportions of young people on trial or in contact with the police who may struggle to engage effectively with key aspects of the legal system, including forensic interviewing and courtroom procedures.
An awareness of this disparity among populations in custody also suggests a necessary focus on preventative services and earlier intervention where young people are known to have been affected by TBI. This might include specialist, responsive interventions during community youth justice orders. It might also inform interventions prior to any significant engagement in criminal behavior, including: the sharing of information regarding TBI between health services and schools; routine follow-up support with children and their families at various time points following medical attention for TBI; the provision of information to parents regarding the potential short, medium and long-term impacts of TBI, and the availability of support services. While requiring resources, such approaches might offer cost savings if preventing persistent engagement with the criminal justice system and eventual incarceration for a proportion of young people experiencing childhood TBI.
The findings of this review also have implications regarding research in this field. Comparative research between countries using standardized definitions and measures of severity will support analysis regarding the influence of youth justice practices, including preventative measures, on the criminality and criminalization of young people experiencing childhood TBI. This can be further supported by qualitative examination of the experiences of the youth justice system and criminal justice processes of young people who have experienced TBI. Consideration to and evaluation of interventions and practices better able to meet the needs of young people who have experienced TBI in custodial and community settings can support the development of youth justice practices better able to address the needs of these vulnerable young people.
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Keywords:Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
antisocial behavior; crime; custody; incarceration; prevalence; traumatic brain injury; young offenders