1. Brain Injury in Minnesota Correctional Facilities: Changing the System
Dr. Charlotte Johnson Psychologist, MN Department of Corrections
Mary Enge Regional Resource Specialist, MN DHS, Disability Services Division

2. Types of Brain Injury
Traumatic Brain Injury (TBI) is an injury to the brain caused by an external force after birth
Acquired Brain Injury (ABI) is an injury to the brain which is not hereditary or congenital, occurs after birth, & includes all types of TBI

3. Centers for Disease Control (CDC) Traumatic Brain Injury (TBI) Statistics
TBI is a contributing factor to a third of all injury-related deaths in the United States
About 75% of all TBIs each year are concussions or other form of mild TBI
TBI is a contributing factor to a third (30.5%) of all injury-related deaths in the United States

4. Centers for Disease Control TBI Statistics
Each year there are a reported 1.7 million TBIs in the United States
An estimated 5.3 million Americans - 2% of the U.S. population - live with a long-term or lifelong need for help due to TBI
an estimated 5.3 million Americans —2 percent of the U.S. population — live with a long-term or lifelong need for help with everyday activities due to TBI

5. Demographics of MN
US Census population for the state of MN estimated in 2010 as 5,303,925
85.3% White
5.2% Black
4% Asian
1.1% American Indian/Alaska Native

6. TBI in State of Minnesota
2011 Dept. of Health TBI Registry Data
5,713 Hospital Admissions
10,429 ER/ED Visits
853 Deaths
2011 Population of Minnesota: 5,303,925

7. Chronic TBI in Minnesota
Estimate: 90,000 to 100,000 Minnesotans live with a disability that is caused or made worse by a traumatic brain injury

8. Traumatic Brain Injury Grant 2006-2009 Goals
Measure prevalence rates of TBI in state correctional facilities
Provide training & education to Department of Corrections employees & partners
Identify / develop release planning & community resources for offenders & ex-offenders

9. Minnesota Department of Corrections Prison Facilities

10. Minnesota State Prisons

11. What Did We Learn? 2006-2009: TBI Prevalence
998 adult male offenders were successfully interviewed to determine TBI History (MCF-St. Cloud)
100 adult women offenders were successfully interviewed (MCF-Shakopee)
52 adolescent male offenders were successfully interviewed (MCF-Red Wing)
998 successful interviews were obtained from 1,029 adult male consecutive admissions
TBI screening was done from September 2006 to January 2007 at admission as part of the routine battery of psychological, medical, chemical dependency & educational assessments
Assessments occurred in the first month of each offender’s admission.

12. What Did We Learn? 2006-2009: TBI Prevalence
82%+ of offenders successfully interviewed had a history of TBI

13. 2006-2009 Major Grant Products Prevalence Data
Extensive TBI Training for Department of Corrections Staff
Development of Three on-line Training modules for Department of Corrections staff & partners

14. Prevalence Data: What Did We Learn?
Major Grant Products
Prevalence Data: What Did We Learn?

15. TBI Severity Criteria Severe: >24 hours Length of Coma (LOC) &/or
>24 hours Post Traumatic Amnesia (PTA)
Moderate:
60 minutes to 24 hours LOC &/or
1-24 hours PTA
Mild:
0-59 minutes LOC &/or PTA <1hour PTA

16. Another Measure of Severity
Type
Glascow Coma Scale
Loss of consciousness
Post traumatic Amnesia
Mild
13 to15
30 minutes or less
(or none)
Less than 1 hour
Moderate
9 to 12
30 minutes to 24 hours
1 to 24 hours
Severe
Less than 8
More than 24 hours

17. Male Findings Severe: 13.9% Moderate: 12.4% Mild: 73.7% No TBI: 172
Severe & Moderate counts were nearly double using less conservative criteria

18. Juvenile Males 49 out of 50 reported history of TBI
Most were moderate & severe
Most were due to domestic assault

19. Female Findings
96 out of 100 female offenders met criteria for having sustained a head injury
22.1% Mild (male=73.7%)
44.2% Moderate (male=12.4%)
33.7% Severe (male=13.9%)

20. TBI in Minnesota Prison Population

21. MN DOC Offender Statistics as of 01-01-2012
Incarcerated:
9,302 adults
43 juveniles
Average age: 36

22. MN DOC Offender Statistics as of 01-01-2012
Approximately:
53% White
35.5% Black
9% American Indian
7.3% Hispanic
2.4% Asian

23. What Did We Learn? Needed:
Refined process to identify offenders with TBI & related functional impairment
Plan to assist in prison & with discharge back to the community
Ongoing training & staff dedicated to TBI in critical programs

24. TBI in Minnesota Correctional Facilities: Changing the System (2010-2014)
MN Departments of Human Services & Corrections 2nd partnership grant is building on the work of our earlier grant
Current grant life:
$250, award per year

25. Current Grant Project
Literature suggests that cognitive problems associated with a past TBI may affect potential to succeed in rehabilitation
(Valliant, et al, 2003; Corrigan, 1995, as cited in Wald, Helgeson, & Langlois, 2008, para. 8), including SA treatment (SAMHSA, 1998a, as cited in Wald, Helgeson, & Langlois, 2008)

26. Current Grant Project: Successful Return to Community
Long term goal: systemic change within the DOC to offer an improved response for offenders with TBI
Coordination of services to better transition to the community

27. Current Grant Project: Successful Return to Community
Development & implementation of DOC system to identify & track offenders with TBI requiring supportive services
Follow identified offenders as they complete chemical dependency treatment

28. Current Grant Project: Successful Return to Community
Release planning to coordinate appropriate TBI services in the community after leaving prison
Comprehensive psychological / cognitive assessment process to identify offenders with special needs

29. Changing the System: Current Grant Accomplishments
Developed / Refined MN DOC TBI Screening Tool
Grant funded DOC Neuropsychologist & TBI Release Planner
Developed CD Treatment protocols for offenders with TBI / cognitive deficits

30. Changing the System: Current Grant Accomplishments
Continue DOC staff/ Community Training
Established DHS TBI Advisory Committee grant subcommittee
Developed Native American Resource Guide
Held American Indian Listening Session

31. Changing the System: Identified Populations
Primary population served: “Offenders in the state prison system, including those who test positive for TBI & have functional needs”
Secondary population served: “incarcerated American Indians”

32. American Indians
U.S. Study found TBI-related hospital discharge rates were highest for American Indians / Alaskan Natives per 100, (Langlois, Kegler, & Butler, 2003, as cited in McCrea, 2008)
Risk factors include SES & substance abuse
American Indians are identified as a group of interest for the current grant

33. 2005-2009 MDH TBI Registry: Rate of Nonfatal Hospitalizations
White: 87.7
Black: 100.2
Am. Indian/Alaska Native:
Asian/Pac. Island: 48
Hispanic: 1.1

34. American Indian Listening Session: Suggestions On Policy
TBI education for Chemical & Mental Health workers
Ensure TBI is taken into account during sentencing, mental health assessment, & child protection case investigations
Department of Human Services (DHS) employs American Indian liaison staff
DHS has an American Indian Advisory Council on Chemical Dependency & an American Indian Mental Health Advisory Council that assist the MH Division

35. American Indian Listening Session: Suggestions On Policy
Inform Law Enforcement/Community Services of offender return to community
Formalize inmate access to spiritual & cultural practices – increase access to spiritual leaders.
Department of Human Services (DHS) employs American Indian liaison staff
DHS has an American Indian Advisory Council on Chemical Dependency & an American Indian Mental Health Advisory Council that assist the MH Division

36. Changing the System: Grant Plans
Share updated on-line DOC training
Work with MNHELP.INFO to enrich site content for ex-offenders & people with BI
Follow-up on selected American Indian Listening Session recommendations

37. What You Need To Know About TBI Symptoms

38. TBI Symptoms Tremors Weakness/fatigue Sensation deficits
Vision problems

39. TBI Symptoms Language problems Poor judgment of space
Confusing right/left

40. TBI Symptoms Problems reading or writing or adding
Problems following conversations
Getting stuck on topics
Not following instructions

41. TBI Symptoms Tremors Weakness/fatigue Sensation deficits
Vision problems

42. TBI Symptoms Cognitive: Learning new information Easily Distracted
Losing train of thought
Forgetting things that have been completed

43. TBI Symptoms Ignoring one side of body
Irritability, anger, mood swings
Change in appetite / hygiene / social skills

44. TBI Irritability & Anger
35% to 96% show agitated behavior during acute recovery (Silver, Yudofsky, & Anderson, 2011)
Of 60 offenders in jail those who sustained TBI in last year showed worse anger/aggression (Slaughter, 2003)
Risk factors: irritability, impulsivity, & past aggression

45. What You Need To Know About TBI Diagnostic Considerations & Memory Strategies

46. Diagnostic Considerations
Post-traumatic Stress Disorder
Frequent incidence in soldiers—blast injury
Amnesia for certain parts of the trauma
Difficulty concentrating

47. Diagnostic Considerations
Somatic complaints
Perceptual symptoms
Severity does not influence
Over 40% comorbid PTSD/TBI failed effort tests (consideration of meaning of effort)

48. Diagnostic Considerations
Obsessive-compulsive behaviors
Comorbid with attention deficits
Perseveration & hyper vigilance

49. Diagnostic Considerations
Schizophrenia-like psychosis
● Paranoid delusions
● Auditory hallucinations
● Catatonic features, formal thought disorder & negative symptoms uncommon (Johnson & Lovell, 2011)

50. Memory Strategies
Take notes—Keep notepad, post-it, or cell phone handy to immediately record
Things to do
What was completed in a day
Important phone numbers & addresses
Ideas & feelings
What to do in an emergency

51. Memory Strategies
Use electronic devices to program reminders in advance of appointments, assignments, projects, etc.
Focus on one task at a time
Take breaks

52. Memory Strategies Take breaks Be organized—structure & routine
Repetition
When reading: preview, question, read, state, & test

53. Memory Strategies Visual imagery Elaborative encoding
Grouping or chunking
Decrease distractions when working

54. How Does This Effect You?
Likely to appear attentive … but misses information
Hard to sit still
Fidgety & moving around

55. How Does This Effect You?
Appears to forget 5 seconds (or less) after being told information
Appears defiant
Irritable & easily angered

56. Methods for Assistance
Divide instruction into small concrete components of expectations
Model cues & gestures to comprehend expectations
Written instructions alone are not sufficient

57. Methods for Assistance
When learning something new:
Master each small task of multi-part process
Provide opportunity to practice & Provide feedback to correct problems

58. References
Gordon, W.A., Haddad, L., Brown, M., Hibbardt, M.R., & Sliwinski, M. (2000). The Sensitivity & Specificity of Self-Reported Symptoms in Individuals with Traumatic Brain Injury. Brain Injury, 14,
McCrea, M. A., (2008). Mild traumatic brain injury & post concussion syndrome. American Academy of Clinical Neuropsychology.
Minnesota Department of Health. (2011). Minnesota Injury Data Access System (MIDAS).

59. Brain Injury in Minnesota Correctional Facilities: Changing the System