Huw Williams School of Psychology University of Exeter & * Emergency Department Royal Devon & Exeter Hospital NHS Centre for Clinical Neuropsychological Research (CCNR) Brain Injury & Crime: Social emotional processing deficits in childhood and risk of offending

Anti-social Personality and brain activation… Birbaumer and colleagues (2005) –fMRI & clips of emotive film of facial expression (eg fear). Birbaumer and colleagues (2005) –fMRI & clips of emotive film of facial expression (eg fear). “psychopathic criminals” lacked activation in limbic structures “psychopathic criminals” lacked activation in limbic structures less amygdala activity = the higher score for “psychopathy” less amygdala activity = the higher score for “psychopathy” ? a lack registering fear linked to lack of inhibition ? a lack registering fear linked to lack of inhibition seeing fear inhibits one from acting violently (see Mobbs et al, 2008). seeing fear inhibits one from acting violently (see Mobbs et al, 2008). PFC (Pre-Frontal Cortex) & Amygdala Raine et al. (1998) - using (PET) normal functioning in the Pre Frontal Cortex of “predatory” murderers BUT “impulsive” had reduced activation in the PFC & enhanced activity in limbic structures. reductions in pre-frontal cortex & angular gyrus & corpus callosum in violent murderers – ? poor inter-regulation of cognition and emotion (eg inhibitory systems of left hem not affecting right etc.) ? poor inter-regulation of cognition and emotion (eg inhibitory systems of left hem not affecting right etc.)

Cautions…against primacy of biology What might cause these differential patterns of activation is not known What might cause these differential patterns of activation is not known Anti-social Personality Disorder (APD) often occur in the context of a range of issues - history of childhood maltreatment or trauma may be common. Anti-social Personality Disorder (APD) often occur in the context of a range of issues - history of childhood maltreatment or trauma may be common. “There are no concrete biological markers – genetic or physiological – that can predict [ASP] behaviour” (Mobbs et al, 2008) “There are no concrete biological markers – genetic or physiological – that can predict [ASP] behaviour” (Mobbs et al, 2008)AND When there is a biological risk eg from When there is a biological risk eg from Birth complications Birth complications Minor physical anomalies* Minor physical anomalies* Environmental Poisoning (e.g. lead) Environmental Poisoning (e.g. lead) Mal-nutrition (leading to brain mal-development) Mal-nutrition (leading to brain mal-development) Such issue is not usually significant unless there is a “evocative environment” “presence of negative psychosocial factor” (Raine, 2002) (esp. maternal rejection*) Such issue is not usually significant unless there is a “evocative environment” “presence of negative psychosocial factor” (Raine, 2002) (esp. maternal rejection*)

 frontal-tempo-limbic systems are crucial for Monitoring arousal level & control of behaviour towards “goal states”  Injury often leads to:  impulsivity, poor planning, inadequate response inhibition and inflexibility (Milders, Fuchs & Crawford, 2003). &  “poor anger management (reactive), irritability and impulse control are common” (Hawley et al. 2003). personality and emotional deficits – due to de- coupling of cognition and emotion has been described by Damasio (1994), as “acquired sociopathy”” - personality and emotional deficits – due to de- coupling of cognition and emotion has been described by Damasio (1994), as “acquired sociopathy”” - Brain Areas that typically Injured…

Brain Injury: Scale of problem “TBI is an epidemic … yet it is silent … the public largely seem unaware of it… …” Thurman, 2002 Head Injury is the leading cause of death and disability in children & working age adults Head Injury is the leading cause of death and disability in children & working age adults (Leurssen et al, 1988; Graham, 2001; Maas et al, 2006) (Leurssen et al, 1988; Graham, 2001; Maas et al, 2006) Prevalence rate of 8% (Silver et al, 2001) to 30% (McKinley et al, 2008) in population studies Prevalence rate of 8% (Silver et al, 2001) to 30% (McKinley et al, 2008) in population studies

Yates, Williams et al. 2006, JNNP

Differences in socio-economic status (SES) between attendees with MHI and Orthopdedic (OI) comparison group. SES determined by the “Index of Multiple Deprivation” and put into quintiles. A greater proportion of those with MHI are in the 2 most deprived quintiles than in the comparison group with upper-limb orthopaedic injuries (OI). Chi-square = 36.4, p <

Poverty puts children at higher risk of accidents WHO REPORT Guardian – "Over the last 20 years, there have been very dramatic decreases in child injury deaths," said Prof. Elizabeth Towner…but "The figures mask a very deep social divide, a strong and persistent social divide," she said. "The poorer children have not shared equally in the progress of the last 20 years."

What are the rates for TBI in prison populations? mental health & drug/alcohol problems identified mental health & drug/alcohol problems identified “relative to general population, [prisoners]…experience poorer physical, mental, and social health…[more] mental illness and disability, drug, alcohol…suicide, self harm…lower life expectance [etc.]…” Orme et al. BMJ editorial, 2005, 330. p 918 “relative to general population, [prisoners]…experience poorer physical, mental, and social health…[more] mental illness and disability, drug, alcohol…suicide, self harm…lower life expectance [etc.]…” Orme et al. BMJ editorial, 2005, 330. p 918 and see Fazel & Danesh (2002a (Lancet)) and see Fazel & Danesh (2002a (Lancet))2002a Studies seldom examine the serious physical illnesses OR intellectual disability prevalent in prisons Studies seldom examine the serious physical illnesses OR intellectual disability prevalent in prisons “….delivery of services to prisoners with anxiety and affective disorders, drugs and alcohol problems, brain injury, learning disability, challenging behaviour and repetitive self-harm has changed little or worsened.” Dearbhla Duffy, et al. (2003) p. 242 (our emphasis) “….delivery of services to prisoners with anxiety and affective disorders, drugs and alcohol problems, brain injury, learning disability, challenging behaviour and repetitive self-harm has changed little or worsened.” Dearbhla Duffy, et al. (2003) p. 242 (our emphasis)

Report of the New South Wales Chief Health Officer - 45% male and 39% female reported at least one head injury…

TBI in Prison Populations Barnfield & Leathem (98) NZ study: Barnfield & Leathem (98) NZ study: 118 respondents to questionnaire survey 118 respondents to questionnaire survey 86.4% reported some form of head injury (56.7% MORE than 1). 86.4% reported some form of head injury (56.7% MORE than 1). Reported ++difficulties with memory and socialization Reported ++difficulties with memory and socialization

Rates of Mild – Severe TBI in Prisoners Mewse, Mills, Williams & Tonks et al (in prep) 453 males held in HMP Exeter Pps: 196 aged between 18 and 54 years (43% response rate) sentenced or remanded

Percentage of population reporting TBI & type of injury “Any tbi?” No39.6 % Yes60.4% we estimate that 65% may have had a TBI. 10% Severe 5.6 % Moderate 49.4% Mild Average age at 1st imprisonment: 21 – Non-TBI 16 - TBI

Mild TBI Number of mild tbis Number of mild tbis No % 0.00 = NO TBI and Mod-severe TBI)

TBI a risk for Crime? - Population based study Timonen et al (2002) Timonen et al (2002) population based cohort study in Finland involving more than 12,000 subjects population based cohort study in Finland involving more than 12,000 subjects TBI during childhood or adolescence associated with TBI during childhood or adolescence associated with fourfold increased risk of developing later mental disorder with coexisting offending in adult (aged 31) male cohort members (OR 4.1) fourfold increased risk of developing later mental disorder with coexisting offending in adult (aged 31) male cohort members (OR 4.1) TBI might have been a result of high novelty seeking and low harm avoidance in people susceptible (for issues of genetics, family background, social forces etc.) to risky behaviours – coincidental to crime….BUT TBI might have been a result of high novelty seeking and low harm avoidance in people susceptible (for issues of genetics, family background, social forces etc.) to risky behaviours – coincidental to crime….BUT TBI earlier than age 12 were found to have committed crimes significantly earlier than those who had a head injury later TBI earlier than age 12 were found to have committed crimes significantly earlier than those who had a head injury later Therefore - temporal congruency suggests a causal link Therefore - temporal congruency suggests a causal link

TBI in Prisoners: crime profiles and effects Leon-Carrion J, Ramos FJ. (2003) (BI) Leon-Carrion J, Ramos FJ. (2003) (BI) Retrospective factor analytic study of links between head injuries (in childhood and adolescence) in adult violent and non-violent prisoners. Retrospective factor analytic study of links between head injuries (in childhood and adolescence) in adult violent and non-violent prisoners. subjects in both groups had a history of academic difficulties. subjects in both groups had a history of academic difficulties. Trend for both groups to have had behavioural and academic problems at school Trend for both groups to have had behavioural and academic problems at school Head injury in addition to prior learning disability/school problems increases chances of having a violent offending profile Head injury in addition to prior learning disability/school problems increases chances of having a violent offending profile Violent offending (noted) to be “associated with non-treated brain injury” Violent offending (noted) to be “associated with non-treated brain injury” ? rehabilitation of head injury may be a measure of crime prevention ? rehabilitation of head injury may be a measure of crime prevention

TBI & Crime: Coincidence or causal? Turkstra et al. (2003) Turkstra et al. (2003) offenders with TBI against “true peers” without TBI offenders with TBI against “true peers” without TBI 20 individuals convicted of violent crime compared to 20 non convicted controls (matched for education, age and employment). 20 individuals convicted of violent crime compared to 20 non convicted controls (matched for education, age and employment). TBI NOT more common in the offender group BUT there was variance on severity of injury TBI NOT more common in the offender group BUT there was variance on severity of injury non-offending group– typically – Milder TBI from (eg sports). non-offending group– typically – Milder TBI from (eg sports). offending group injuries offending group injuries More assaults (with probable longer lasting changes in behaviour). More assaults (with probable longer lasting changes in behaviour). had more issue related to anger control. had more issue related to anger control. TBI is not necessary for crime, but that TBI may contribute to “expression of violence” - increase the risk “threshold” in vulnerable people. TBI is not necessary for crime, but that TBI may contribute to “expression of violence” - increase the risk “threshold” in vulnerable people.

TBI a contributory factor: Multiplicative Model Kenny et al (2007) Kenny et al (2007) juvenile detention in Sydney- 242 young offenders (76% response rate) juvenile detention in Sydney- 242 young offenders (76% response rate) Alcohol, substance abuse, TBI and cultural backgrounds Alcohol, substance abuse, TBI and cultural backgrounds offences rated as: offences rated as: low (common assault) low (common assault) moderate (robbery with weapon) moderate (robbery with weapon) serious (homicide). serious (homicide). 85 individuals had experienced a head injury 85 individuals had experienced a head injury Violent offending more common for those with KO history Violent offending more common for those with KO history

TBI a contributory factor: Multiplicative Model odds ratios: odds ratios: of 2.37 for having s serious violent crime if the young offender had had a head injury. of 2.37 for having s serious violent crime if the young offender had had a head injury if the YO had been unconscious if the YO had been unconscious. hazardous alcohol drinking history increased risk of severe violent offending. hazardous alcohol drinking history increased risk of severe violent offending. regression models produced “multiplicative model” of how TBI is related to crime. regression models produced “multiplicative model” of how TBI is related to crime.

Childhood Brain Injury & Social impairments Social behavioural problems: may not be evident until adolescence (Lishman, 1998; Teichner & Golden, 2000) may not be evident until adolescence (Lishman, 1998; Teichner & Golden, 2000) may occur in isolation from cognitive deficits (Anderson, Northam, Hendy & Wrennall, 2001) may occur in isolation from cognitive deficits (Anderson, Northam, Hendy & Wrennall, 2001) the most common and disruptive issue (Henry, Phillips, Crawford, Theodorou & Summers, 2006) the most common and disruptive issue (Henry, Phillips, Crawford, Theodorou & Summers, 2006) Anger episodes more “reactive” than “planned” in adolescence (Dooley et al. BI, 2008) Anger episodes more “reactive” than “planned” in adolescence (Dooley et al. BI, 2008) Symptoms persist long-term post-injury. (Anderson 2003) Symptoms persist long-term post-injury. (Anderson 2003) Injury leads to (potentially) an array of problems: Attention, working memory, disinhibition etc. See at Catroppa & Anderson, 2004Attention, working memory, disinhibition etc. See at Catroppa & Anderson, 2004 Dose responseDose response SelectiveSelective Some recoverySome recovery lack of “moral” reasoning.lack of “moral” reasoning. (Damasio 1996; Anderson, Bechara, Damasio, Tranel, & Damasio, 1999; Hanks, Temkin, Machamer & Dikmen 1999; Levin & Hanten, Powell, 2004). Often there is inappropriate social behaviour Often there is inappropriate social behaviour

The Role of Theory of Mind and Empathy  Theory of Mind (ToM): to attribute mental states to others, to know they have beliefs, desires and intentions that are different from one's own to attribute mental states to others, to know they have beliefs, desires and intentions that are different from one's own Early components achieved by 4yrs, later developments by 11yrs Early components achieved by 4yrs, later developments by 11yrs Empathy: Empathy: to recognise or understand another's state of mind or emotion & “co-experience” their outlook or emotions within oneself "putting oneself into another's shoes” to recognise or understand another's state of mind or emotion & “co-experience” their outlook or emotions within oneself "putting oneself into another's shoes” Sophisticated levels achieved during early adolescence Sophisticated levels achieved during early adolescence Both skills are fluid during childhood → likely to be vulnerable to the effects of an acquired brain injury (ABI)? Both skills are fluid during childhood → likely to be vulnerable to the effects of an acquired brain injury (ABI)?  ABI may impact on skills for emotional understanding of others (ToM and Empathy)  these deficits may be a key issue in social situations…  e.g. misperceive elements of a situation (not reading emotion of others & perceive threat when there was none), make poor social judgements (and behave inappropriately) and lack communication skills to negotiate out of conflict (Turkstra et al 2003)

Charles Robert Darwin ( ) The Expressions of Emotions in Man and Animals. London: John Murray, “Expression of emotion evolve from behaviours that indicate what an animal is likely to do next…If these expressions benefit the animal that displays them, they will evolve in ways that enhance their communicative function…” Understanding others through non-verbal cues

Amygdala. Emotion Recognition. Eye gaze detection/reading Hippocampus External context information Intrinsic emotional arousal/ control system. Face expression analysis Eye Configuration analysis Vocal Analysis Sensory/ spatial analysis system. Executive functioning Emotion regulation control Affect perception Executive system synthesis. Functional at birth. Enables association learning. Develops rapidly during the 18 months following birth, with an identifiable further significant stage of improvement at around 11 years old Develops throughout childhood and adolescence, assuming increasing executive control over emotions. Emotional response External stimuli Thalamo amygdala pathway. Tonks et al, 2007/2008: A HEURISTIC FOR SOCIO-EMOTIONAL PROCESSING (Le Doux, 1999; Rolls, 1999; Hornack, Rolls & Wade 1996; Jackson & Moffat, 1987; Baron-Cohen, 2000; Evans, 2003)

Age group Male or Female Total Mean Time Lapse Since Insult (yrs) Mean Injury Age (yrs) Nature/ Frequency of Insult. (M=Male, F=Female) malefemale Nine to ten M= 1 Severe TBI, 1 Stroke. F= 1 Severe TBI Ten to eleven M= 1 Heamorrage (AVM). F= 1 Meningitis F= 1 Meningitis Eleven to twelve M= 1 mild TBI, 2 Tumour. F= 1 moderate TBI F= 1 moderate TBI Twelve to thirteen M= 2 Severe TBI. Thirteen to fourteen M= 1 Severe TBI, 1 mod TBI. F= 1 Severe TBI. Fourteen to Fifteen M= 1 Severe TBI, 1 mod TBI. 1 mild TBI. 1 Stroke. Fifteen Plus* M= 1 Severe TBI. F= 1 Severe TBI Group Total TBI=14, Meningitis=1, Tumour=2, Heamorrage=1, Stroke=2. Table 5: Summary and injury profiles for the ABI participants in the study Tonks, Williams et al - Emotion processing post ABI

controls Tonks, Williams et al - Emotion processing post ABI controls 67 (age matched) children were recruited from primary and secondary schools. These were given the batteries of tests.

How do ABI children compare to non-injured children? F(1,85)= p<.000 ANCOVA (FAS): F(1,84)= p<.001

How do ABI children compare to non-injured children (“Mind in the Eyes”)?

Face-emotion processing problems in children with ABI (Tonks et al, 2007/2008/2009) Group trends: those with difficulties with angry faces experienced peer problemsthose with difficulties with angry faces experienced peer problems poor at identifying expressions reported less pro-social. poor at identifying expressions reported less pro-social. Specific deficitsSpecific deficits KL - not recognise sad facesKL - not recognise sad faces MN – not “getting” emotional tone. He could not understand sarcastic remarks MN – not “getting” emotional tone. He could not understand sarcastic remarks OP- reads all “eyes” as hostile. increasingly violentOP- reads all “eyes” as hostile. increasingly violent [also see: Milders, Fuchs and Crawford 2003 re: adults with TBI; Skye MacDonald & colleagues re: TASIT (awareness of social inference)] Skye MacDonald & colleagues re: TASIT (awareness of social inference)]

Static vs. Dynamic tasks. dynamic cues- movement and interaction- have been shown to be dissociated from static cues (Adolphs, Tranel & Damasio, 2003; McDonald & Saunders, 2005). dynamic cues- movement and interaction- have been shown to be dissociated from static cues (Adolphs, Tranel & Damasio, 2003; McDonald & Saunders, 2005). dynamic cues are infrequently used in research and clinical assessments (Atkinson & Adolph, 2005). dynamic cues are infrequently used in research and clinical assessments (Atkinson & Adolph, 2005). a gap between clinical assessments and reported social behavioural problems?

Communicating social emotions skills Tonks, Williams, Frampton, Yates, Slater (in prep) 20 ABI children aged 9 to 15 yrs (M 2.5, SD 2.1) were compared to closely age matched controls (M 11.6, SD 2.2). 20 ABI children aged 9 to 15 yrs (M 2.5, SD 2.1) were compared to closely age matched controls (M 11.6, SD 2.2). Parents of all participants completed the Parent SDQ as a measure of socio-emotional behaviour. Parents of all participants completed the Parent SDQ as a measure of socio-emotional behaviour. THEN, all participants watched the following Movie… THEN, all participants watched the following Movie…

so he is left out and is sad now “So they are having a game and he pushes that stick down and he is trapped. and sad. and they have gone off together. They made friends. so he is left out and is sad now” (C, aged 5) MOVIE CLIP: Inspired by Heider and Simmel

Comparisons: ABI vs. controls: Differences in Motion (“moved to”) and Emotion (“sad”) words used. ABI children and controls did not significantly differ in terms of % of Motion words used to describe the film. ABI children and controls did not significantly differ in terms of % of Motion words used to describe the film. Neither did they differ significantly in the % of Emotion words used. Neither did they differ significantly in the % of Emotion words used.

Comparisons: ABI vs. controls: Differences in Social communication words used. ABI children Controls ConditionMSDMSD Free description ** Guided Questions** Combined mean score* **p<.01, *p<.05 BUT - they did differ in terms of the number of social communication words used to describe the movie. Peer problems (on SDQ) correlated with lack of ‘Social communication’ words (r=-0.47, p=0.037)

Theory of Mind & Empathy in adolesence Sarah Wall, Huw Williams, & Ian Frampton ToM ToM A Test of Social Processing (Turkstra et al., 2001) A Test of Social Processing (Turkstra et al., 2001) Faux Pas test (Baron-Cohen et al., 1999) Faux Pas test (Baron-Cohen et al., 1999) Empathising Empathising Socio-Emotional Questionnaire for Children Socio-Emotional Questionnaire for Children “I (he/she) notice(s) when other people are happy” “I (he/she) notice(s) when other people are happy” “I (he/she) prefer(s) being alone than with others” “I (he/she) prefer(s) being alone than with others” + Strengths and Difficulties Q & DEX-C (Dysexecutive) + Strengths and Difficulties Q & DEX-C (Dysexecutive)

Empathy in non-injured children in early adolesence (100+ boys and girls) (Wall et al. in press) boys tended to show a decrease in positive social-emotional functioning, alongside self-reports of increased anti-social behaviour. Those with a history of MTBI rated particularly low

25 young adolescents (10 to 15yrs) with a history of ABI, 50 typically- developing (TD) matched controls 25 young adolescents (10 to 15yrs) with a history of ABI, 50 typically- developing (TD) matched controls Global impairments Global impairments Poorer empathic responding Poorer empathic responding Less accurate ToM Less accurate ToM Faux pas Faux pas SEQ-Kids SEQ-Kids Parental reports of poor emotion recognition and empathy Parental reports of poor emotion recognition and empathy Self-reports of poor emotion recognition and empathy Self-reports of poor emotion recognition and empathy + executive impairments (DEX-C + EF measures), increased daily difficulties and impact (SDQ) + executive impairments (DEX-C + EF measures), increased daily difficulties and impact (SDQ) Theory of Mind (complex) & Critical age of injury Wall, Williams, Frampton (in prep) Average Borderline/impaired

TBI and Crime – causal or co-incidental? The evidence The evidence is not clear cut there are many within the relationships between injury and later offending there are many confounding factors within the relationships between injury and later offending the link between crime and TBI may be an epiphenomenon whereby criminal behaviour “particularly violent crime, is likely to result from complex interaction of factors such as genetic pre-disposition, emotional stress, poverty, substance abuse and child abuse” the link between crime and TBI may be an epiphenomenon whereby criminal behaviour “particularly violent crime, is likely to result from complex interaction of factors such as genetic pre-disposition, emotional stress, poverty, substance abuse and child abuse” Turkstra, 2004 (P 40). Turkstra, 2004 (P 40). BUT: TBI may be an important factor in offending behaviour. BUT: TBI may be an important factor in offending behaviour. “poor prefrontal function [may be associated with] impulsive violence, [but] this brain dysfunction may be… a predisposition only” p.54 Raine, 2002 “poor prefrontal function [may be associated with] impulsive violence, [but] this brain dysfunction may be… a predisposition only” p.54 Raine, 2002 MOREOVER: catch 22… MOREOVER: catch 22… “The person at risk of violence needs to recognise his risk and take preventative steps…but [those with]…damage to…prefrontal cortex…may not be able to reflect on their behaviour and take responsibility…[as their] internal soul-searching [is] damaged…” Raine (2002) “The person at risk of violence needs to recognise his risk and take preventative steps…but [those with]…damage to…prefrontal cortex…may not be able to reflect on their behaviour and take responsibility…[as their] internal soul-searching [is] damaged…” Raine (2002)

So we need: So we need: better screening for head injury at pre-sentencing and on admission to prison/custodial services – better screening for head injury at pre-sentencing and on admission to prison/custodial services – for better understanding of risk, and for rehabilitative purposes for better understanding of risk, and for rehabilitative purposes Esp. those with executive (& socio-affective) difficulties who may have difficulty in changing behaviour patterns in response to contingencies. Esp. those with executive (& socio-affective) difficulties who may have difficulty in changing behaviour patterns in response to contingencies. Screening…for sentencing & rehabilitation*

…Developmental issues… Developmental factors may be particularly important: Developmental factors may be particularly important: There may be sleeper effects – esp. relevant to socio-emote functions at transition to adolescence There may be sleeper effects – esp. relevant to socio-emote functions at transition to adolescence public safety and long term economic advantage could be gained by better, earlier, targeted interventions to public safety and long term economic advantage could be gained by better, earlier, targeted interventions to prevent injury, prevent injury, reduce impact of injury reduce impact of injury Systematic neuro-rehabilitation - Systematic neuro-rehabilitation - Targetted at ?socio-emotional processing (esp. ToM/Empathy etc.): Targetted at ?socio-emotional processing (esp. ToM/Empathy etc.): eg “Mind Reading: An Interactive Guide to Emotions” (Baron- Cohen, 2004) eg “Mind Reading: An Interactive Guide to Emotions” (Baron- Cohen, 2004) Impulse control? (Stop, (breathe!!) Think, Do! (or DON’T Do)) Impulse control? (Stop, (breathe!!) Think, Do! (or DON’T Do))

"Brains become minds when they learn to dance with other brains” W.J. Freeman