How to Identify TBI in Prisons and Build a System of Support
Randy Loss, M.A. CRC
PA Office of Vocational
Rehabilitation
Maine APSE June 12, 2014
All slides labeled Brain Injury Association of Pennsylvania
[graphics – see through human head with brain; man peering out and holding prison bars]
Slide 2
Objectives
Participants will learn about:
•The pervasiveness of Traumatic Brain Injury in the prison system
•How third party organizations can intervene early to assist those with TBI in preparing for reentry and obtaining employment, and
•Promising practices in establishing long-term support for those released from prison that have TBI.
Slide 3
How many people are locked up in the United States?
The United States locks up more people, per capita, than any other nation. But grappling with why requires us to first consider the many types of correctional facilities and the reasons that people are confined there.
[pie chart shows types of facilities and reasons for incarceration]
There are approximately 2.4 million people in 1,719 state prisons, 102 federal prisons, 2,259 juvenile correctional facilities, 3,283 local jails, and 79 Indian Country jails as well as in military prisons, immigration detention facilities, civil commitment centers, and prisons in the U.S. territories
Source and data notes: See
Slide 4
Brain Injury in Prisons and Jails
•Studies show 25-87% of inmates report having experienced a Brain Injury (CDC)
•Health Resources Services Administration (HRSA) reports that 60% of inmates have had a history of brain injury prior to incarceration
[photo – modern jail corridor, man in prison overalls walked on tether by official]
Slide 5
Prevalence and Causes of TBI Among Prisoners
•Study of male inmates in Minnesota
–83% reported having one ormore head injuries during their lifetimes
[pie chart – Figure 2 - Causes of Traumatic Brain Injury Among Male Prisoners, 37% assault, 11% sports, 11% falls, 10% bicycle, 25% auto, 6% other, Ages 18 years +, Minnesota 2006-2007, N=990]
Traumatic Brain Injury Among Prisoners Marlena M. Wald, MPH, MLS — Sharyl R. Helgeson, RN, BAN, PHN — Jean A. Langlois, ScD, MPH, Brain Injury Professional magazine
Some more recent findings shed new light on the epidemiology of TBI among prisoners. In a recent survey conducted among male state prisoners in Minnesota, a history of having head injury was assessed using the Traumatic Brain Injury Questionnaire (TBIQ) (Diamond et al., 2007). Of the 998 inmates assessed, 82.8% reported having had one or more head injuries during their lifetime, which is consistent with a previous study (Slaughter et al., 2003). The majority were reportedly caused by assaults, followed by automobile crashes and sports (Figure 2). Of note, some of the specific causes of assault-related TBI among prisoners are unique. For example, in the Minnesota project, some of the reported head injuries among incarcerated gang members were the result of a gang initiation procedure called "pumpkinhead" in which new gang members are beaten until their heads swell "like pumpkins." Also, anecdotal reports from corrections officials in South Carolina indicate that self-inflicted TBIs occur when inmates purposely knock their heads against the bars or the cell floor until they become unconscious. This usually happens when inmates are moved to isolated cells (Anbesaw Selassie, DrPH, Medical University of South Carolina, Personal Communication, November 2007).
Slide 6
Brain Injury and Violence
•Male Inmates
–A history of Brain Injury is strongly associated with perpetration of domestic violence and other kinds of violence during their lifetimes
•Female Inmates
–High percentage reported history of TBI
–Often multiple concussions – 10 or more
–Usually associated with interpersonal violence
•Children and Teenagers
–convicted of a crime more likely to have sustained a pre-crime brain Injury and/or some other form of physical abuse
CDC, National Center for Injury Prevention and Control
[photo – woman holding palm to camera with writing saying “Prevent domestic violence”]
Slide 7
Addressing TBI in Prisons and Jails
•A recent report from the Commission on Safety and Abuse in America’s Prisons recommended:
–increase health screenings and evaluations
–treatment for inmates
–development of partnerships with community health providers to assure continuity of care
–case management for released inmates
[photo – men in suits at hearing table with papers, mics]
Slide 8
Undiagnosed and Misdiagnosed
•Police misinterpret responses from individuals
•Courts Prison/Jail staff are uneducated on signs
•Expectations do not meet real abilities
•Length of prison time reaches maximums
•Interaction with authority figures in general
•Services offered do not address real issues
Slide 9
How Do You Work Together
[photo – six men in swim trunks in odd poses, four jumping into swimming pool]
Slide 10
NeuroResource Facilitation for Prison Inmates with Brain Injury to Improve Reentry
Edward Byrne Memorial Justice Assistance Grant (JAG)
Pennsylvania Commission on Crime and Delinquency (PCCD)
[seal of the Department of Justice]
Slide 11
You Can’t Do It All
[photo – bicyclist with amazingly large load of bundled Styrofoam cubes]
Slide 12
[logos – Brain Injury Association of Pennsylvania, Pennsylvania Commission on Crime and Delinquency, Pennsylvania Department of Labor and Industry Office of Vocational Rehabilitation, Commonwealth of Pennsylvania Department of Corrections, Pennsylvania Board of Probation and Parole]
Slide 13
Right Place, Right Time
[photo – man on ride-on mower suspended by crane above tall hedge]
Slide 14
NeuroResource Facilitation Goals
•Identify inmates who have brain injury
•Plan and develop services that will help returning citizens be successful upon release
•Coordinate with Reentry staff (DOC, Probation/Parole)
•Create linkages with community services prior to release
•Follow up post-release to ensure implementation of the plan.
Slide 15
Participation Criteria
An inmate must be:
•In specialized housing within the facility
•Willing to participate in programming
•Within 6-10 months to maximum sentence date
OR
•Within 6-10 months to minimum date with institutional support for parole
•Followed for up to a year post-release
Slide 16
How Did Vocational Rehabilitation Get Involved
•Offender Workforce Development Specialist
•Networking with other departments, agencies and community providers
•Looking at resources that exist and determine how to make linkages
•Member of PA Commission on Crime and Delinquency (PCCD)
Slide 17
It’s Not Easy
[cartoon – Two people facing away with signs taped to their backs, “Kick Me” and “Rehab Counsel”]
Slide 18
Riding a Dead Horse
Lakota tribal wisdom says that when you discover you are riding a dead horse, the best strategy is to dismount. However, in corrections, and in other affairs, we often try other strategies, including the following:
•Buy a stronger whip.
•Change riders
•Say things like “This is the way we always have ridden this horse.”
•Appoint a committee to study the horse.
•Arrange to visit other sites to see how they ride dead horses.
•Create a training session to increase our riding ability.
•Harness several dead horses together for increased speed.
•Declare that “No horse is too dead to beat.”
•Provide additional funding to increase the horse’s performance.
•Declare the horse is “better, faster, and cheaper” dead.
•Study alternative uses for dead horses.
•Promote the dead horse to a supervisory position.
Slide 19
PA Department of Corrections
•State Correctional Institution facility psychologists buy-in
•Determine best “fit” in existing programming for TBI assessment to occur
•SCI staff to understand purpose of program and be willing to link to outside services pre-release
•PA Board of Probation and Parole officer linked to project
Slide 20
PA Department of Corrections Transitional Housing Unit (THU)
•THU located at the DOC Graterford State Correctional Institution, PA
•Specifically created to assist reentry efforts
•Individuals who have a clean conduct record
•Individuals who have a home plan that is close to the prison
•Community resources are involved in information sessions and planning for the release of the returning citizen
Slide 21
PA Board of Probation and Parole
•Parole officer assigned to THU
•Creates linkage to outside Parole officer
•Assists in making connections to community resources
•Liaison between DOC and PBPP
Slide 22
PA Commission on Crime and Delinquency
•Working closely with the Governor's office, the Commission helps coordinate the work of state and local criminal justice agencies to increase communication, effectiveness and efficiency.
•PCCD provides training to deputy sheriffs and constables and technical assistance to communities and organizations to promote crime and delinquency prevention efforts. PCCD allocates federal and state funds to victims, victim service providers, criminal and juvenile justice and ancillary agencies, and helps communities to improve the administration of justice in a variety of ways.
Slide 23
Screening for Brain Injury History
TBI Questionnaire (TBIQ):
•Designed to screen TBI only
•More detailed than the HELPS
•A semi-structured interview instrument
•Administered by a trained staff person who is familiar with TBI and has training in basic interviewing techniques
•Used in the Minnesota project to screen state prisoners
Slide 24
TBI Questionnaire Sections
[photo – Boxing match, one man punching other in face]
Three (3) Sections
- Screening – Looking for
mechanically induced brain injury - Injury Detail – Looking for an ongoing pattern of injuries
- Symptom Checklist – Identify the most recent symptoms
Author Contact Information
Pamela Diamond, Ph.D.
Associate Professor of Behavioral Sciences and Biostatistics
University of Texas at Houston
Slide 25
Maine TBI Assessment
•State of Maine Aging & Disability Services
•Traumatic Brain Injury assessment:
–
•Handout
Slide 26
Additional Screening Items
•History of significant sicknesses affecting the brain
•Problems with anxiety, depression
•Changes in reading, writing
and calculation abilities
•Problems with relationships
•Problems with judgment,
temper or impulse control
•Educational history
•Employment history
[photo – Man biting thumbnail]
Slide 27
Clinical Probes
•Naming task
•Serial 3’s
•Short recall of passage
•Proverbs
•Problem solving task
•Release plan
[graphic – Brain labeled “Working Memory” with sectors: operates over a few seconds, temporary storage, manipulates information, focuses attention]
Slide 28
NeuroCognitive Testing
Testing battery:
•Repeatable Battery for the Assessment of Neurological Status (RBANS)
•brief neurocognitive battery
•detection and tracking of neurocognitive deficits
•includes measures of immediate and delayed memory for novel information,
•visuospatial
•constructional skills, attention, and language
•Trail Making Test A&B
•Category Test
•Brown-Peterson Consonant Trigrams
•Tower of London
Screening and testing can be administered in Spanish
[photos – Two men talking across a desk covered with papers]
Slide 29
Review of Findings
•Team meeting to review screening and testing results
•Look for strengths and weaknesses
•Determine potential outcomes
•Determine need for brain injury services and supports
•Meet with inmate to review findings
•Brain injury education and counseling with inmate
•Begin NeuroResource Facilitation
[photo – Two men casually seated conversing]
Slide 30
Results to Date
•72% screened positive for history of brain injury occurring prior to imprisonment
•Of those tested, 80% showed evidence of current cognitive impairment likely to affect successful reentry to the community
•First individual released from THU entered a previous job and had VR services once in the community
•Service wrap around better transitions individuals
Slide 31
NeuroResource Facilitation (Inside)
•Brain injury education and training of corrections staff and community resource organization staff members
•Cognitive support to assist inmate to maximally benefit from the content of workshops in THU
•Determine the inmate’s goals and needs regarding a productive daily activity pattern when released from prison.
•Coordinate reentry effortswith DOC and Parole Staff
[photo – Two men on edge of chairs facing each other, intent on talk]
Slide 32
NeuroResource Facilitation (Outside)
•Identification of programs in the community that the inmate would like to pursue upon reentry and determine steps to pursue them
- Reintegration Services (RISE) City of Philadelphia
•Identify community resources to support these goals and facilitate connections to them
- Reentry Organizations statewide
- Lancaster County Reentry Management Organization (RMO)
Slide 33
[screen shot – Webpage of RISE, The Mayor’s Office of Reintegration Services, picture of family with two kids]
Slide 34
Serious Challenges
•Sexual Offenders and Violent Offenders
•Community TBI Rehabilitation Providers
•Looking at developing a living situation where these individuals can reside together
Slide 35
Community Resources
•New Person Ministries-newsletter
•Desk References
- Legal Remedies-handout
- Legal Implications- handout
•Cumberland Legal Aid Clinic
•Pine Tree Legal-handout
Slide 36
[screen shot – Webpage of New Person Ministries, Community Renewal for Sex Offenders]
Slide 37
[screen shot – Webpage of University of Maine School of Law, Cumberland Legal Aid Clinic]
Slide 38
Vocational Rehabilitation-Street Level
•OVR counselors from two separate field offices assigned as liaisons to the project
•Identifying needs for the inmate prior to release
•Assist in application process
•Work with BIAPA staff to understand level of disability in preparation for release to community
Slide 39
Prepare/Apply for VR Services Pre-Release
- PA OVR application
- Acquire medical documentation
•diagnosis by appropriate professional
•impact on vocational functioning
- Obtain
•photo ID and/or birth certificate, or green card in order to show that the person is or will be legally available to work
•previous OVR records/services including dates and locations
•SSA Benefits Verification including income eligibility
- Determine
•availability for work - release status/plans
•where the inmate falls in the Order of Selection used by OVR
Slide 40
[cartoon – Man in prison garb in Resume Writing Service office, woman behind desk says, “R. Sims, A Man of Conviction sounds better than R. Sims, Prison Parolee.”]
Slide 41
Not Yet Ready for Employment
Consider Appropriateness and Assist with Applications for:
•Brain Injury Rehabilitation Services
•PA Head Injury Program
•CommCareWaiver
•OBRA Waiver
•Independence Waiver
•SSI/SSDI
•Veterans Benefits
•Other resources
[graphic – Soldier salutes American flag]
Slide 42
Post-Release Follow-up
The NeuroResource Facilitator two times per month for up to a year:
•Monitor reentry plan
•Review reentry plan elements to determine the status of each
•Provide supports as needed to implement/update elements of the plan
•Follow-up with OVR, Health Insurance Plan, or Medicaid Waivers to determine the outcome of inmates who were connected with those agencies
•Collect outcome data
Slide 43
Employment Resource: Lancaster County WIB
•OWDS and OES trained staff
•Prevocational and vocational training
•Assessment of job readiness
•Lancaster County RMO
•Consulting Neuroscience Project
Slide 44
Connection to Employers/Employment
•Good understanding of foundational issues of individual functioning
•Alternate employment
•Assistive Technology to provide support long term
•Customized Employment and Self Employment
•Forensic Certified Peer Specialist
Slide 45
Outcome Markers
•Community residence
•Employment
•Paying fines, costs and child supports
•Maintaining substance abuse treatment if identified in re-entry plan
•Participating in skills training and brain injury services identified in reentry plan
[graphics of residence, skills, AA – Unity/Service/Recovery, dollar sign highway, laborer]
Slide 46
Justice Grants in Maine
•Edward Byrne Memorial Justice Assistance Grant Program
•
•State of Maine Department of Public Safety
•
•For Further Project Information:
Slide 47
For Further Project Information:
Brain Injury Association of Pennsylvania
Slide 48
Thank You
Randy Loss M.A., CRC
717-787-5136