CHILDHOOD HEAD INJURY AS IT RELATES TO VIOLENT CRIMINAL
BEHAVIOR: KNOWLEDGE AND TREATMENT
A Project
Presented to the faculty of the Department of Criminal Justice
California State University, Sacramento
Submitted in partial satisfaction of
the requirements for the degree of
MASTER OF SCIENCE
in
Criminal Justice
by
Veronica Lynn Piazza
SUMMER
2013
CHILDHOOD HEAD INJURY AS IT RELATES TO VIOLENT CRIMINAL
BEHAVIOR: KNOWLEDGE AND TREATMENT
A Project
by
Veronica Lynn Piazza
Approved by:
__________________________________, Committee Chair
David H. Swim, D.P.A.
____________________________
Date
ii
Student: Veronica Lynn Piazza
I certify that this student has met the requirements for format contained in the University
format manual, and that this project is suitable for shelving in the Library and credit is to
be awarded for the project.
__________________________, Graduate Coordinator
Yvette Farmer, Ph.D.
Division of Criminal Justice
iii
___________________
Date
Abstract
of
CHILDHOOD HEAD INJURY AS IT RELATES TO VIOLENT CRIMINAL
BEHAVIOR: KNOWLEDGE AND TREATMENT
by
Veronica Lynn Piazza
Statement of Problem
Children suffer from head injury and traumatic brain injury due to the many sports
and activities in which they participate, which in many cases causes severe impairment or
death. The problem is that when juveniles are arrested, the criminal justice system is
unaware of whether the juveniles have suffered such injury or the significance of the
inquiry. Juveniles are being adjudicated for offenses they may not be able to prevent due
to changes in impulse control, such as vehicle theft or robbery, and they are being
referred to treatment programs that may not be able to address the juveniles’ actual
problems. These juveniles subsequently do not successfully complete said treatment and
are passed through the criminal justice system as persistent offenders.
The purpose of this project is to provide information about the symptoms and
consequences of head and brain injury, to review and examine current assessment tools
for questions about head injury, and to provide an assessment tool and protocol that can
be used by probation departments to gather the appropriate information regarding the
iv
juvenile, the alleged offense, and the possible dispositional alternatives. This information
will aid probation officers in developing the most accurate case plan for injured juveniles
and referring them to the appropriate evidenced-based treatment program.
Sources of Data
This project reviewed literature in the medical, psychological, and criminal justice
fields that analyzed and discussed head injury. This project also encompasses
information based on this researcher’s experience, expertise, and training as a Deputy
Probation Officer to further the understanding of the need to provide accurate and
thorough information in the criminal justice field. Information was also reviewed
regarding adult patients suffering from TBI, as research on TBI amongst youth is quite
limited. However, the information serves to show the detrimental effects of head and
brain injury on an individual, which would be worse for a juvenile, as their brains are still
growing and developing. This project provided information on three different assessment
tools, and examined them for any assessment of head injury. The assessment tool and
protocol developed in this project were based on the information reviewed in the
literature.
Conclusions Reached
Three of the current assessment tools used by probation departments around the
United States do not assess for head injury or traumatic brain injury. Therefore, a great
many juveniles are being adjudicated and held liable for actions they may not be able to
control, are being exposed to potential harm in general population housing units, are
v
being perceived as persistent, and are not receiving the proper rehabilitative services. If
probation departments were aware of the seriousness and impact of head or brain injury,
they might be able to make the proper dispositional recommendations in the juveniles’
cases, refer the juveniles and their families to the proper rehabilitative and treatment
agencies, and better serve the clientele they supervise. These tasks will be that much
easier with the implementation of the Assessment of Head Injury Tool (AHIT) and
protocol. This instrument will aid probation officers in more thoroughly assessing the
juveniles that enter their detention facilities, and help them determine who may be
suffering from a TBI, how to refer them for treatment, and how to report the information.
_______________________, Committee Chair
David H. Swim, D.P.A.
_______________________
Date
vi
DEDICATION
Dear sweet mother, Jac’lene Yvonne Rowe, you have always been my heart, my
soul, my teacher, my mentor, my inspiration, and my best friend! Without you, there
would be no me! When I placed my first college graduation cap on your head, it was to
symbolize your accomplishment in raising your daughter. As you sit in heaven looking
down on me wearing my second, please know that it symbolizes your success in
passing the torch that lights the womanhood and motherhood inside me aflame! You
continuously encouraged me to get my Masters, and now I have. I dedicate this project
to you, Momma! I never gave up because of you, and I never will. I thank God for you
and will miss you all the days of this life! By the Grace of God, you will live in my
heart and mind forever! Rest in Perfect Peace! Bunches Mom!
I would also like to dedicate this project to my two wonderful babies, Leilani
Jac’lene Piazza and Brian Piazza Jr., who spent many days in class with Mommy. You
two are the love of my life! You are the air that I breathe and the reason I live! This
achievement will symbolize the strength and dedication that lies deep inside you both.
Always know that Mommy did it, and you will too! Never give up on yourselves or
your dreams, and know that Mommy will always be here to support you both, as
Grammy was for me! Mommy loves you both!
Yours Always,
Veronica Lynn Piazza
vii
ACKNOWLEDGEMENTS
Education has always been a priority in my life, and as such, accomplishing my
educational goals was never a real struggle. However, during the course of the Graduate
Program, I lost my mother and maternal grandmother in one week. This was devastating,
and the loss of concentration was uncontrollable. I realized my mother’s spirit was still
encouraging me to continue my education through the encouragement and support of two
great women, Donna Vasiliou, the Administrative Support Coordinator II in the Division
of Criminal Justice, and Dr. Yvette Farmer, Associate Professor and Graduate Program
Coordinator in the Division of Criminal Justice. I could not have made it through this
program and the losses in my life without the Grace of God working through these two
wonderful women. From the bottom of my heart, I want to thank God and the both of
them for their continued support and guidance. I will always have a special place in my
heart for you both.
Also, I want to thank all of my family, especially my sister, Stephanie DennieSmith, and friends for their continued support, encouragement, and willingness to babysit
whenever I needed them. Pursuing higher education as a full-time working mother of
two is definitely not easy, so I greatly appreciate my family and friends stepping in to
help! Thank you so very much!
Love,
Veronica Lynn Piazza
viii
TABLE OF CONTENTS
Page
Dedication…………………………………………………………………………..vii
Acknowledgements……………………………………………………………….. viii
Chapter
1. INTRODUCTION……………………………………………………………......1
Statement of the Problem………….………………………………………….1
Purpose of the Project ………………………………………………………..5
Summary…………………..………………………………………………….6
2. REVIEW OF LITERATURE…………………………………………………... .7
Introduction………………………………………………………… …….....7
Neurological Consequences………………………………………………….7
Current Causes of Traumatic Brain Injury…………………….……………15
Treatment of Brain Injury ………………………………………………......22
Behavioral Changes……..……………………………………………….… 34
Conclusion: Knowledge, Assessment, and Treatment….…………………...38
Summary………………………………………….………………………....40
3. PROJECT OVERVIEW………………………………………………………...41
Introduction…………………………………………………………….…....41
Purpose and Intent………………………………………………………......42
ix
Risk Assessments……………………….....………………………………..43
Detention Risk Assessment Instrument….………………...……………….44
Analysis of DRAI…………………………………………………………...52
Youth Assessment and Screening Instrument……………………………....54
Analysis of YASI…………………………………………………………...58
Positive Achievement Change Tool………………………………………...59
Analysis of PACT…………………………………………………………...62
Summary…………………………………………………………………….64
4. ASSESSMENT TOOL AND PROTOCOL………………………………….....67
Researcher’s Proposal……………………………………………………….67
Assessment of Head Injury Tool…………………………………….……...69
Protocol…………………………………………………………….……......71
Implementation Concerns and Summary……………….……………..........74
5. CONCLUSION…………………………………………………………...…......77
Appendix A. Codification Key…………………...………………..…..........81
Appendix B. Assessment Analysis……………...…………………………..82
References…………………………………………………………………..83
x
1
Chapter 1
Introduction
Statement of the Problem
Injury to the head may damage the scalp, skull or brain, and the most important
consequence of head trauma is traumatic brain injury (TBI) (Miura, Fujiki, Shibata, &
Ishikawa, 2005, p. 662). Head injury may occur either as a closed head injury or as a
penetrating head injury, and both may cause damage that ranges from mild to profound
(Miller, 1999, p.158; Miura et al., 2005, p. 662). Closed head injuries are nonpenetrating injuries that usually result from incidents such as road traffic accidents,
assault, work, and sporting injuries and are a common form of brain damage in young
adults (Miller, 1999, p.158; Miura et al., 2005, p. 662). A penetrating head injury is a
brain injury that occurs when an object penetrates the skull or the skull is fractured, and
bone fragments, foreign material, or dirt can get into the brain, damage the brain tissue,
and cause infection (Miller, 1999, p.158; Miura et al., 2005, p. 662). Head injuries where
there is a loss of consciousness for a long period of time, minutes or hours, can have great
psychological consequences (Miller, 1999, p. 158). Damage to the frontal lobe portion of
the brain can be a major concern, as the frontal lobe is considered our emotional control
center and where our personality resides (Kolb & Milner, 1981, p. 507). There is no
other part of the brain where lesions, or injury, can cause such a wide variety of
symptoms (Kolb & Milner, 1981, p. 507). Cognitive functioning such as memory,
attention, and speed of information processing can occur with brain injury, along with
changes in personality (Miller, 1999, p. 157). Such changes in personality include the
2
lack of foresight, tact and concern, inability to plan ahead and judge the consequences of
an action, an easily attained feeling of well-being, disinhibition, irritability, and a
tendency to become verbally and physically aggressive (Miller, 1999, p. 158). It has
been suggested that irritability and aggression could be a possible link with violent
offending (Miller, 1999, p. 158). These changes in personality and behavior are what
cause the major difficulty in successfully rehabilitating individuals with head injuries
(Miller, 1999, p. 158).
Two more features are significant in individuals with head injury. The first is
significant head injuries are most commonly found in young adult males of lower
socioeconomic status (Miller, 1999, p. 159). Second, there is an association between
substance abuse and both head injury and offending (Miller, 1999, p. 159). Children are
usually at more of a risk for head injury, as they engage in more physical activities such
as sports and playing in general (Miller, 1999, p. 159). TBI is a leading cause of death
and disability in children under the age of 15 (Miller, 1999, p. 159). Children that sustain
a moderate or severe TBI in early childhood or infancy are more susceptible to having
significant and ongoing cognitive impairments (Sonnenberg, Dupuis, & Rumney 2010,
p. 1003). Evidence shows that elementary school children are at a higher risk of poorer
social problems following TBI than teenagers (Sonnenberg et al., 2010, p. 1003). The
brains of small children are at an earlier stage of development, as opposed to those of
teenagers (Sonnenberg et al., 2010, p. 1004). Children suffering from severe TBI have
more issues with social problem-solving and are said to be less socially competent and
lonelier than children with injuries not involving the brain, and these social problems
3
persist over time (Sonnenberg et al., 2010, p. 1004). However, social problems with
childhood TBI are not as understood as what is known for adult TBI (Sonnenberg et al.,
2010, p. 1004). Research is quite limited on the effects of TBI in general, especially as it
relates to criminal conduct, but it is extremely limited with respect to children
(Sonnenberg et al., 2010, p. 1006).
This limitation has led to professionals in the criminal justice system not knowing
about TBI, let alone knowing how to treat the population of juveniles suffering from head
injury. The Probation Department in Sacramento County, according to this researcher’s
employment with said agency, has in recent years, implemented many programs to assist
juveniles in institutions and the community with many different issues, and most of the
programs have mental health components. Since little research has been done on the
relationship between head injury and criminal behavior, professionals are not aware of
the consequences of TBI, and questions are not asked regarding the presence of head
injury, these programs do not focus on the specific and extraordinary needs of the
juveniles. Professionals simply determine these juveniles to be the most aggressive and
persistent. However, there may be factors that preclude these individuals from
participating in the everyday form of treatment. As it stands, people with traumatic brain
injuries face several challenges when trying to obtain treatment from substance abuse
providers (Sonnenberg et al., 2010, p. 1006). Cognitive impairments may affect their
learning style, which causes difficulty in participating in training and group interventions
(Sonnenberg et al., 2010, p 1006). Problems with memory are usually perceived to be
4
resistance to treatment, and damage to the frontal part of the brain affects thinking skills,
which leads to socially inappropriate behavior (Sonnenberg et al., 2010, p. 1006).
There is an association between those within society who most often suffer head
injury and those who most commonly participate in criminal activities, including those
linked to violence (Miller, 1999, p. 159). Three major pieces of evidence exist. First,
general neuropsychological studies of the consequences of head injury suggest changes
that might precipitate offending (Miller, 1999, p. 159). Second, there are a small number
of follow-up studies of the victims of head injury, which have recorded such things as
arrests and convictions (Miller, 1999, p. 159). Third, there are a series of investigations
of samples of violent offenders in prisons or special psychiatric facilities, which have
attempted to estimate the frequency of brain injury (Miller, 1999, p. 160). This project
will examine three assessment tools utilized by probation departments in the United
States and determine if the tools address TBI amongst youth entering detention facilities.
This project will also provide guidance in implementing possible treatment for TBI. Do
local probation departments assess their clients for brain injury at the intake level? This
question will be the basis of this project.
This project will contribute to the rehabilitative efforts of the Probation Department
in Sacramento County, as well as other criminal justice agencies. If these agencies
become aware of such head trauma and/or brain injury, proper diagnosis and treatment
can begin, as well as the proper classification and housing placement of juveniles in the
detention facilities. This project will also provide an assessment tool that can be used by
said probation departments as the basis for deciding which juveniles should be detained
5
in their detention facilities, where those detained juveniles should be housed, and the
selection of treatment options in their future case plans. Most therapies used today,
especially those based on evidence-based practices, are based on research that indicates
these therapies are effective. They may be that much more effective if all is known about
the behavior of the individual undergoing treatment. This project will provide evidence,
through previous research stated in the literature review, that juveniles who have suffered
head and brain injury, have also suffered a change in brain function, and in most cases, an
inability to control those brain functions. Hopefully, attention will be given to this issue
for the protection of injured juveniles, as well as the proper disposition of their cases and
placement into evidence-based treatment.
Purpose of the Project
The purpose of this project is to examine the significance of assessing youth
entering detention facilities for head injury, to inform probation officials about the issues
that surround head and brain injury, and to develop an assessment tool for said officials to
follow during their investigation. Probation officials should be notified of this
information, as they are usually the first criminal justice agency, after arrest, to fully
investigate cited or detained juveniles and their families. The assessment tool will
promote the thorough examination of the circumstances surrounding the alleged violation
of law and the overall behavior of the juvenile. Through this tool, the probation officer
will be able to determine if a juvenile would benefit most from a clinical interview and
diagnosis, possibly before continuing with the criminal process. The juvenile intake
probation officer will guide the juvenile through the questions of the assessment tool and
6
note the answers to the questions. If an interview with the parents of the juvenile is
possible, the juvenile intake probation officer will also guide the parents through the
questions of the assessment tool and note their answers. If an initial interview is not
possible with the parents, the assigned juvenile court probation officer will be responsible
for contacting the parents and guiding them through the questions of the assessment tool
and logging the answers. The focus for these officers will be to obtain as much
information about the juvenile as possible to provide the best and most appropriate
dispositional recommendation to the Court.
Summary
This chapter defined head injury and discussed some of the consequences of head
injury and damage to the brain. Traumatic brain injury, being the most serious
consequence of said injury was discussed, along with who is most at risk for injury.
Children are at most risk, as they participate in activities that can result in injury. The
purpose of this project is to examine the importance of head or brain injury assessment at
the juvenile intake level, to enlighten probation officials about this information, and to
provide guidelines to aiding those professionals in assessing for TBI. Chapter 2 will
provide information on what is known about TBI.
7
Chapter 2
Review of Literature
Introduction
There are many social factors that contribute to the commission of violent acts, but
there are other factors that may be beyond the control of the individual. Biological
factors are possibly the most controversial factors that contribute to the commission of
violent acts, and brain damage is one such factor that can occur due to head injury
(Farrington, 1982, p. 10). The effects of head injury can be serious and life changing, as
damage can occur to the brain, altering the thought process and behavior of the affected
individual, as indicated in the previous chapter (Farrington, 1982, p. 10). Research is
quite limited and no conclusions have yet been made linking violent behavior with head
injury. However, research has been conducted on the brain functioning of individuals
that were accused of violent acts and individuals that have suffered severe head trauma.
Neurological consequences of said injury, such as low impulse control and the inability to
control behavior in social situations will be discussed in the following review of the
literature. The behavioral changes of individuals that suffer from head injury will also be
reviewed, as well as possible treatment options.
Neurological Consequences
Since 1835, there have been case studies that have reported the onset of antisocial
personality traits after injury to the frontal lobe of the brain (Brower & Price, 2001, p.
720). These personality traits typically involve damage to the orbitofrontal cortex of the
brain, which causes a low level of impulse control, dangerously aggressive outbursts,
8
inappropriate verbal language, and decreased social sensitivity (Brower & Price, 2001, p.
720). The orbitofrontal syndrome is also called pseudopsychopathy, as it is similar to
psychopathy, which is a type of personality disorder that is related to violence and
criminal behavior (Brower & Price, 2001, p. 721). Another related syndrome is acquired
sociopathy, which describes adults suffering from ventromedial prefrontal brain injury
and who exhibit decreased functioning in judgment, decision-making in social
environments, and decision-making regarding the consequences of their actions (Brower
& Price, 2001, p. 721).
In studying veterans of war that suffered head trauma, Brower and Price (2001)
found a relationship amongst frontal lobe lesions on the brain and aggressive or antisocial
behavior, but actual violent crime was rare (p. 721). A consistent relationship was found
between orbitofrontal brain lesions and subsequent antisocial behavior (Blumer &
Benson, 1975, p. 160). Five patients out of a sample of 144 British World War II
veterans committed crimes, and all five had damage to the frontal lobe portion of their
brains (Brower & Price, 2001, p. 721). The Vietnam Head Injury Study found that
patients with brain lesions to their frontal lobes exhibited more aggressive and violent
behavior, as opposed to patients with non-frontal head injury and the control group that
had no head injury at all (Grafman, Schwab, & Warden, 1996, p. 1235). Out of the
patients participating in this study with frontal lobe injury, 14% engaged in fights or
damaged property, compared to 4% of the control group that had no head injury (Brower
& Price, 2001, p. 721). The Vietnam Head Injury Study, using a brain CAT scan, found
a compelling association between an elevated level of aggression and focal mediofrontal
9
and orbitofrontal injury (Brower & Price, 2001, p. 721). This study, along with other
neuropsychological studies, supports the relation between the malfunction of the
prefrontal executive portion of the brain and the high level of unsociable and aggressive
behavior (Brower & Price, 2001, p. 722).
The frontal lobe of the brain is involved in fine motor skills, problem solving,
spontaneity, memory, language, initiation, judgment, impulse control, and social and
sexual behavior; and it is extremely vulnerable to injury due to its location at the front of
the head (Levin et al., 1987, p. 707). MRI studies have shown that the frontal area is the
most common region of injury following mild to moderate traumatic brain injury (Levin
et al., 1987, p. 707). Low frontal lobe function has been used to explain the actions and
behaviors of accused and convicted violent offenders, and clinical observations of
prefrontal network functioning suggests that damage to the frontal lobe may contribute to
criminal behavior, especially violent criminal behavior (Brower & Price, 2001, p. 722).
As stated, loss of consciousness over a period of time after a head injury can have
major neurological consequences (Brooks, 1984; Richardson, 1990). Sonnenberg et al.
(2010) conducted a study of children that suffered a TBI under the age of six years old (p.
1004). The children that were younger at the time of injury suffered socially, and their
thinking abilities at the age of eight were significantly delayed compared to children that
suffered injury later in life (Sonnenberg et al., 2010, p. 1004). In essence, the minds of
children are always growing as they learn new things. Once the brain is injured, this
growth can significantly decrease. Sonnenberg et al. (2010) concluded that social
10
impairments continued over time in the injured children, as their social deficits persisted
(p. 1006).
Studying the most serious and violent offenders gives the most compelling
information regarding the correlation between head injury and offending, and Gibbens,
Pond, and Stafford-Clark (1959) were the first to suggest such a correlation (p. 108).
They performed a study of 72 extremely psychopathic offenders and 59 control offenders
over an eight-year period after they were released from custody (p.110). It was stated
that 29 members of the psychopathic group reportedly suffered a head injury at some
point in their lives, and had many more added convictions during the eight-year time
frame, which included violent offenses (Gibbens et al., 1959, p. 111). Three more studies
were conducted on murderers, maximum-security mentally ill offenders, and males
sentenced to death as juveniles, and a significant number of these offenders had
previously suffered head injuries of sufficient severity (Blake et al., 1995, p. 1645; Lewis,
Pincus, Feldman, Jackson, & Bard, 1986, p. 839; Martell, 1992, p. 880). Violent
offenders may exhibit neurological malfunction or a history of TBI early in life, and they
are also more likely to report such injury, especially in court proceedings to justify their
behavior. However, the mere fact that their symptoms are being left untreated explains
why they may have offended so violently or at all (Dinn, Gansler, Moczynski, &
Fulwiler, 2009, p. 117). These individuals may not realize or comprehend the fact that
they may have a serious brain dysfunction, and therefore do not seek treatment or
assistance in controlling their behavior (Matthes & Caples, 2013, p. 126). It should be
noted, however, research does not indicate that head injury will automatically result in
11
delinquent and/or violent behavior (Leon-Carrion & Ramos, 2002, p. 208). A large
proportion of individuals who do suffer head trauma do not become violent (LeonCarrion & Ramos, 2002, p. 208). Head injury may lead to violent behavior in those
individuals that are already at risk for such behavior due to their environment and family
history, and brain malfunction due to head injury decreases the ability to deal with
stressful situations, decision-making skills, and self-control (Leon-Carrion & Ramos,
2002, p. 209).
The knowledge regarding brain mechanisms that are associated with the
predisposition to violence is growing due to brain imaging research (Raine et al., 2001, p.
111). However, according to these authors, there are three significant issues regarding
the knowledge of these brain mechanisms. First, information regarding the brain
functioning of seriously violent adults that are not committed to an institution is unknown
(Raine et al., 2001, p.112). Second, there are no studies published to assist with the
understanding of why some people who have suffered severe physical abuse as young
children do not commit serious violent acts (Raine et al., 2001, p.112). Third, violent
offenders have not yet been studied using a process called functional magnetic resonance
imaging (fMRI) (Raine et al., 2001, p.112). Raine et al. (2001) focused their article on
the brain functioning of severely abused violent offenders, as physical child abuse and
violence are related (Tarter et al., 1984; Lewis et al., 1986, p. 839). Henry and Moffitt
(1997) and Raine (1993) found that, in two prior reviews using brain imaging, the
majority of studies exhibited either frontal or temporal lobe deficits in violent individuals.
In a few recent studies, researchers found reduced brain functioning (glucose
12
metabolism) in both medial temporal and prefrontal regions of the brain amongst
individuals that have committed violent acts (Volkow et al., 1995; Raine et al., 1997;
Raine et al., 2001, p. 112). However, these studies were conducted on individuals that
were committed to institutions such as psychiatric hospitals and prisons, and many of
these individuals suffered from schizophrenia (Raine et al., 2001, p. 112). It is difficult to
study or determine a possible link between individuals that have suffered severe abuse
and committed violent acts when the individuals also suffer from another mental illness.
Past research has also stated two different findings regarding violent and antisocial
individuals, which is that they have deficits in the right hemisphere of the brain or the left
hemisphere (Moffitt, 1990; Pine et al., 1997; Raine, 1993; Raine et al., 2001, p. 112;
Tarter et al., 1985; Volavka, 1995). The purpose of the Raine et al. (2001) study was to
explore why some severely abused children go on to commit violent acts and some do
not, and whether those that do not commit such offenses have better functioning in
another part of the brain or just have no biological predisposition to violence as that of
most abused violent offenders (p.113). In exploring this purpose, the authors also wanted
to address the limitations of previous studies that included individuals with schizophrenia
and the use of on-going activities that excessively favored the right hemisphere of the
brain (Buchsbaum et al., 1990; Raine et al., 1997; Raine et al., 2001, p.113).
Raine et al. (2001) recruited participants in their study about the decrease of right
hemisphere activation in severely abused and violent offenders and hired them from
temporary employment agencies in Los Angeles, California, as it was stated these
individuals commit many violent acts (p. 113). Individuals were excluded if they were
13
20 years old and younger or 46 and older, were not English-speakers, suffered from a
psychotic disease and epilepsy, had poor vision, feared small environments, or had metal
devices implanted in their bodies, and this left a sample of 23 individuals (Raine et al.,
2001, p.114). The history of serious violence, an act that caused bodily injury/trauma or
was life-threatening, and a history of severe physical childhood abuse (elementary school
age) was retrieved from self-report interviews (Raine et al., 2001, p.114). The 23
individuals were broken up into four groups by the degree of serious violent offending
and severe physical abuse. The groups consisted of a group with no abuse or violence, a
group exhibiting violence, a group that had been abused, and a group that had been
abused and exhibited violence (Raine et al., 2001, p.115). The participants were given a
memorization activity using sight and words, an activity to recall memory, a
questionnaire measuring cognitive functioning during an activity, and a questionnaire
measuring approaches to completing activities (Raine et al., 2001, p.115). A 1.5-T
Philips MRI system was used to obtain pictures of the participant’s brains as they
performed the tasks (Raine et al., 2001, p.115). The data were uploaded into SPSS and
analyzed (Raine et al., 2001, p. 118).
The major finding of the Raine et al. (2001) study was that seriously violent
individuals that suffered severe childhood abuse exhibited lower functioning in the right
hemisphere of their brains during the visual/verbal working memory task (p.124). These
authors also found that severely abused individuals, whether they were violent or not,
exhibited cortical activation to the working memory task, which was in the left
hemisphere of the brain (Raine et al., 2001, p. 124). Third, the authors found that the
14
severely abused individuals that did not become violent exhibited good right hemisphere
(temporal) functioning of their brains, but poor left hemisphere (temporal) functioning
(p.124). Low functioning in the right hemisphere of the brain may possibly lead people
to commit violent acts, as this area of the brain deals with emotion and can make these
individuals have no feeling when it comes to the distress felt by victims (Raine et al.,
2001, p. 124). In essence, these individuals will not feel compassion or be aroused by the
suffering of their victims or victims in general, which can lead to continued criminal
behavior. This idea of low arousal is believed to be the reason why these individuals
seek attention and more excitement (Raine et al., 2001, p. 124). In conclusion, one can
conceive that menacing criminal behavior is related to right hemisphere brain disturbance
at a young age, along with damage to the left hemisphere of the brain later on in life, and
these findings suggest that individuals that have been severely physically abused early on
in their lives may have left temporal brain dysfunction because of said abuse (Raine et
al., 2001, p.124). The major limitation of the Raine et al. study (2001) is the fact that the
researchers used self-reported information, which can be fabricated or altered by the
individual offering the information, while previous studies used information from official
records and studied individuals already committed to institutions for their violent acts
(p. 124).
According to Antonucci et al. (2006), the combination of multiple biological
factors is assumed to control aggressive behavior on a neurobiological basis (p. 214).
These factors are lesions on the brain, neurophysiological malfunction, and
neurochemical systems (Antonucci et al., 2006, p. 214). When a person loses control of
15
their ability to make sound decisions, along with the failure of meeting social, scholastic,
and employment expectations, the dorsolateral prefrontal cortex of the brain malfunctions
and creates a tendency for violence (Antonucci et al., 2006. p. 214, Brower & Price,
2001; Giancola, 1995). These dysfunctions can be impulsivity, difficulty in considering
alternatives, and the inability to produce courses of action (Antonucci et al., 2006, p.
214). Impulsivity is a critical aspect that controls the relationship between orbitofrontal
cortex malfunction and aggressive behavior (Brower & Price, 2001, p. 722). The frontal
lobe is involved in and necessary for the ability to reason in social situations (Antonucci
et al., 2006, p. 215). Volavka (1999) posed the view that violence can occur two ways,
one being through a genetic prefrontal problem surrounding impulsivity, and the second
being raised in an abnormal and deviant atmosphere, which can cause violence through a
lack of temporal lobe volume (p. 214).
Current Causes of Traumatic Brain Injury
The following sections will discuss ways that individuals in current times are
acquiring traumatic brain injuries. In recent years, attention has been focused on head
injuries acquired while playing football. Also, the current wars in Iraq and Afghanistan
have prompted research due to the number of head injuries reported. Studying head
injuries in professional football contributes to the understanding of what could happen
while children are participating in the sport at young ages. As stated above, children are
prone to acquiring a TBI, as they participate in more activities, such as sports. If adults
are suffering major brain damage from repeated concussions, then a child, with a growing
brain, would probably suffer a worse fate while participating in the sport of football.
16
These children could then have significant changes in their behavior, which could lead to
criminality. Studying the current military head injuries just allows for further
understanding of the basic issues and causes of TBI amongst young adults. Research on
childhood TBI is quite limited, but studying TBI in adults allows for the basic
understanding of the changes in the brain after injury.
Football Injury. Sports-related head injuries have recently received a great deal
of attention due to the number of suicides committed by retired and current football
players, as well as the lawsuits entered against the National Football League (N.F.L.) and
the National Collegiate Athletic Association (N.C.A.A.) (Nocera, 2012, p. A23). All
contact sports are of concern due to the risk of injury, but attention has been focused on
the game of football and the number of concussions football players suffer in the course
of their careers (Nocera, 2012, p. A23). Repeated concussions, or mild traumatic brain
injury (mTBI), are related to depression and cognitive dysfunction, which are symptoms
of a disease in the brain called Chronic Traumatic Encephalopathy (C.T.E.) (Nocera,
2012, p. A23). Research conducted by Kevin Guskiewicz, professor at the University of
North Carolina, about the damage that can occur to football players after multiple
concussions was used to encourage the N.F.L. to find a way to make “the kickoff” play in
the game safer (Nocera, 2012, p. A23). The “kickoff” is said to be the most dangerous
play in the game where the most serious injuries occur due to the momentum gained by
the defensive team running from downfield, and in response to these injuries, the N.F.L.
moved the kickoff line from the 30-yard line to the 35-yard line for the 2011 season
17
(Battista, 2012, p. SP1). This simple change dropped kickoff injuries by 40% in that
season compared to the previous seasons (Battista, 2012, p. SP1).
C.T.E. is a disease of the brain that accelerates in its deterioration and is found in
people with excessive brain injury, such as athletes (McKee et al., 2009, p. 720).
Concussions and severe blows to the head are examples of such excessive brain injury,
which is interesting when thinking about how many times football players hit each other
on the head or helmet in celebration of a successful play (McKee et al., 2009, p. 720). In
1928, Martland announced the concept of C.T.E. with the use of the description, “punchdrunk” relative to a person being repeatedly hit in the head (Martland, 1928, p. 1103;
McKee et al., 2009, p. 710). This term was originally introduced for professional boxers;
however, C.T.E. has recently been confirmed in athletes that have retired from their
sports, especially football players with a history of concussions (McKee et al., 2009, p.
720). This head trauma activates the deterioration of the tissue in the brain and causes
advanced growth of a protein in the brain called tau (McKee et al., 2009, p. 720). This
activation can occur years after the head trauma or years after the football player has
discontinued playing (McKee et al., 2009, p. 720). Once tau builds up in the brain, it
forms in clusters in places where it is not normally stored, which causes dysfunction in
the brain (Zeigler, 2012, p. 1).
At onset of C.T.E., the player can have symptoms such as attention deficits,
problems concentrating, memory loss, confusion, dizzy spells and headaches (McKee et
al., 2009, p. 710). As the disease progresses, the player can experience more symptoms,
such as impaired judgment, dementia, and the lack of intuitiveness (McKee et al., 2009,
18
p.710). Severe C.T.E. can cause the advanced decrease of movement of the muscles, an
unsteady walk, deafness, trembling, and loss of equilibrium (McKee et al., 2009, p. 711).
There are three stages of scientific degeneration, and the first deals with psychotic
symptoms and emotional disturbances (Mckee et al., 2009, p. 711). The second stage is
characterized by loss of memory, initial signs of Parkinson disease, imbalance in social
situations, and unpredictable behavior (McKee et al., 2009, p. 711). The third and final
stage is characterized by mental impairments that lead to dementia and possible actual
Parkinsonism, along with walking and verbal irregularities (McKee et al., 2009, p. 711).
The seriousness of C.T.E. is gauged by how long the football player performed the sport
and how many concussions, known or otherwise, he has suffered (McKee et al., 2009, p.
711). This disease continuously progresses even after more than ten years have passed
after the original injury occurred or after injurious activity is discontinued, and this fact is
one of the main aspects of C.T.E. (McKee et al., 2009, p. 719). It is unknown, however,
whether one concussion can jump start the onset of C.T.E. or if it takes recurring
concussions (McKee et al., 2009, p. 711).
In 2009, there were 51 cases of C.T.E. that were confirmed, and the majority of
those cases were athletes (39 boxers, 5 football players, 1 wrestler, and 1 soccer player)
(McKee et al., 2009, p. 711). All of the five football players abruptly died between the
ages of 36 and 50, which was earlier than the boxers with confirmed C.T.E. (McKee et
al., 2009, p. 711). Interestingly, all five football players were lineman, offensive and
defensive, and their symptoms ranged from depression and episodes of paranoia to
violent outbursts, which resulted in three suicides, one fatality after a high-speed chase
19
with police, and one gunshot wound to the chest (Omalu et al., 2005, p. 129; Omalu et al.,
2006, p. 1087). The latter was 45 years old when he died and had a long career playing
football, beginning in high school and ending with his retirement from the N.F.L.
(McKee et al., 2009, p. 712). He suffered 11 concussions throughout college and
professional football, but only one of the concussions was confirmed (McKee et al.,
2009, p. 712). This fact is interesting, but not uncommon. Players want to get back in
the game, and team staff members do not force the players to sit out in observation, so
symptoms after the concussion go unrealized and unreported (McKee et al., 2009, p.
713). Dr. Robert Cantu, co-director of the Boston University Center, stated in the New
York Times that previously in the N.F.L., team doctors missed the signs and warnings of
concussions, so players without a recognized history of concussion could have still
suffered such injury (Nocera, 2012, p. A23). Confirmed concussions are not the only
concern, it is all of the constant pounding and brain trauma that occurs in the game of
football that worry researchers and medical staff (Nocera, 2012, p. A23).
In the spring of 2012, a very famous N.F.L. linebacker that retired in 2006 and was
diagnosed with C.T.E., committed suicide by shooting himself in the chest (Pilon &
Belson, 2013, B13). This well-known player became the main player associated with
C.T.E., as he was diagnosed with the disease, and his death plagued the N.F.L., with
research studies surfacing that exhibit the potential lasting effects of blows to the head
received on the playing field (Pilon & Belson, 2013, B13). This player’s family allowed
his brain to be studied after his death, and small amounts of the tau protein were found in
many areas of his brain, which indicates that this player was suffering and may not have
20
really known why (Pilon & Belson, 2013, B13). Unfortunately, it can only be determined
that a person has C.T.E. by studying their brain after their death (Pilon & Belson, 2013,
B13). Among the 34 brains of formal football players in the N.F.L. that were examined,
33 were confirmed to have had C.T.E. (Pilon & Belson, 2013, B13).
In Nocera’s article in the New York Times, Should Kids Play Football? (2012), it
was stated that the brains of children are still growing and are more fragile (p. A23).
There is still a great deal of information about C.T.E. and the effects of the game of
football as it relates to said disease that is unknown, but this should be all the more reason
why parents should think about allowing their children to play (Nocera, 2012, A23).
Guskiewicz is one researcher that feels the proper techniques of blocking should be
taught to the children to keep them safer and protect their heads (Nocera, 2012, A23).
This way, as they progress to the high school levels and beyond of football, they will be
more educated about the game and a little more protected (Nocera, 2012, A23). It was
also stated that maybe children should play flag football until they reach the age of 14,
which would give their vulnerable brains more of a chance to develop (Nocera, 2012,
A23). Fortunately, it is known that repeated concussions can cause C.T.E., but at this
point, it is not known how much trauma can occur before the development of this disease
begins amongst football players (Nocera, 2012, A23). Therefore, the question of whether
children should play football cannot scientifically be answered at this point.
Military Injury. The continued issues in Iraq and Afghanistan over the past
several years have generated a new class of United States soldier that is suffering from
head trauma, resulting in brain injury (Carlson et al., 2011, p103). Falling and vehicle
21
accidents usually result in the majority of TBI cases, but since Operation Enduring
Freedom and Operation Iraqi freedom have been underway, blast injury has been another
cause of TBI (Carlson et al., 2011, p. 103). Blast injury is due to explosions and forces
that cause the head to hit something, or for an object to hit or penetrate the head
(DePalma et al., 2005, p.1335). Approximately 23 percent of the soldiers serving in the
above operations have suffered a TBI, and in most cases, the injury was mild (Carlson et
al., 2011, p. 103; Miller et al., 2013, p. 31). Six months is the usual amount of time the
majority of individuals suffering from a mild TBI take to recover; however, there are
many patients that continue to deal with physical and emotional symptoms, not to
mention issues regarding their conduct, after that initial six months (Carlson et al., 2011,
p. 104; McCrea, 2007; McCrea et al., 2009, p. 1369; Miller et al., 2013, p. 31; Ruff,
2005, p. 6).
The amount of pain and suffering a person endures from a mild TBI after six
months post-injury has not been thoroughly studied, but the severity of the injury is
believed to be the reason why symptoms last so long (Miller et al., 2013, p. 31). Most of
the information on this topic comes from studying sports injuries, and different findings
have been discovered. Some studies showed that symptoms did not increase with
football players sustaining two TBIs as opposed to one (Miller et al., 2013, p. 32).
However, another study discovered that football players that suffered multiple
concussions in one season, had an increased amount of symptoms, as opposed to players
that suffered just one concussion (Collins et al., 1999, p. 968; Miller et al., 2013, p. 32).
Miller et al. (2013) suggested football players may fear getting removed from the game
22
and are probably less likely to make their post-concussive symptoms known (p. 36). The
symptoms soldiers have after sustaining the TBI are related to other serious issues that
are common for soldiers such as PTSD (Miller et al., 2013, p. 36). War veterans from
Iraq and Afghanistan reported having constant post-injury symptoms, PTSD, and severe
pain occurring altogether Miller et al., 2013, p. 36).
To study this concept relative to soldiers, Miller et al., (2013) gave questionnaires
to 2,337 soldiers that were active in the United States Army from 1999 to 2000, and were
mostly paratroopers (p. 32). It was discovered that having a history of just one mild TBI
could determine if a soldier would have more symptoms after his injury (Miller et al.,
2013, p.36). Medical staff should make every effort to obtain the patient’s previous
medical history. Also, it was discovered that post-injury symptoms were worse for
soldiers that suffered more than one TBI (Miller et al., 2013, p. 37).
Treatment of Brain Injury
Treatment of brain injury begins and is centered on two separate time frames,
which are primary brain injury and secondary brain injury (Haddad & Arabi, 2012, p.
12). The primary brain injury deals with the trauma to the brain tissue and blood vessels
during the incident (Haddad & Arabi, 2012, p. 12). Secondary brain injury can occur
during the hours and days following initial injury and can occur as an intracranial,
extracranial, or systemic injury (Haddad & Arabi, 2012, p. 12). Hematomas, infection,
hypertension, calcium ion toxicity, and seizures are examples of intracranial and
extracranial injury, whereas hypotension, hypertension, hypoxemia, anemia,
hypoglycemia, fever, and hypothermia are examples of systemic brain injury (Haddad &
23
Arabi, 2012, p. 12). Interestingly, the initial (primary) injury or head trauma only causes
some of the damage to the brain, and this injury cannot be reversed, but secondary injury
can be avoided and possibly treated (Haddad & Arabi, 2012, p. 13). During the critical
time after the primary injury, stabilization and continuous monitoring is imperative to
avoid any further damage to brain tissue and functioning (Haddad & Arabi, 2012, p. 13).
Being that the extreme damage to the brain cannot be repaired, the primary goal of
treatment of brain injury is to attempt to restore as much brain functioning as possible
(Haddad & Arabi, 2012, p. 13).
Unfortunately, TBI causes about 52,000 deaths each year in the United States and
is one of the leading causes of death and impairment amongst youth (Harrison-Felix et
al., 2012, p. E69). Research on TBI among children is quite limited, as is information on
treatment of adolescents suffering from TBI. The following information on treatment is
used for youth and to understand exactly the best way to treat youth. To determine how
long a person suffering from a TBI will live or what type of treatment or care is needed,
the rates and causes of death need to be completely explored and figured out (HarrisonFelix et al., 2012, p. E69). According to a study in 2004 regarding rate of death and how
long a brain injured individual would live, it was found that the rate of death of TBI
patients was twice that of individuals dying from other causes (Harrison-Felix et al.,
2004, p. 50). Also, the life span of the injured person was reduced by seven years
(Harrison-Felix et al., 2004, p. 50). It appears that most of these deaths, resulting from
seizures, septicemia, pneumonia, and respiratory conditions, occur early on after the
injury, but the rate of death lessens over time (McMillan et al., 2011, p. 932). There is
24
also a strong relationship between increased disability and reliance on others for care and
death rates and how ill a TBI patient becomes (Baguley et al., 2012, p. 42). It appears
that people suffering from a TBI, especially one that is more severe, may feel more
depressed about how sick they are and how they have to rely on family and friends to just
complete simple everyday tasks, which in turn hinders their recovery.
Harrison-Felix et al. (2012) indicated that how the injury occurred, type of injury,
demographic information, drug abuse, medical status, whether insurance was an issue,
and recovery process were all causes of a shortened life span after TBI (p. E70). In their
2012 analysis, these authors found, out of 8,573 people treated for TBI, a 9.8% rate of
death, coupled with an average time of 3.5 years from the time their injury occurred to
their demise (p. E71). Interestingly, 23% of the deceased individuals lost their battle
during the rehabilitation phase of recovery, which is up to one year after they were
injured (Harrison-Felix et al., 2012, p. E71). The patients that died were said to have
been older and acquired TBI from falling down, which resulted in a longer time spent in
the hospital (Harrison-Felix et al., 2012, p. E71). It is much harder to recover when a
patient is older and other health concerns weigh in to the equation. This group of
patients, along with patients injured during a violent situation, had a much higher risk of
dying after injury than patients suffering a TBI from a vehicle accident (Harrison-Felix et
al., 2012, p. E73).
Interestingly, circulatory conditions, such as heart disease, were also a cause of a
great deal of deaths among TBI patients in recovery, as well as extrinsic or outside causes
of injury such as accidental poisonings and vehicular injuries (Harrison-Felix et al., 2012,
25
p. E75). Respiratory problems, such as pneumonia, were the next largest group of deaths
that occurred during recovery of TBI (Harrison-Felix et al., 2012, p. E75). Patients
suffering from TBI were 33 times more likely to pass away from seizure related deaths
than people with no injury, which is not surprising due to the cognitive injury (HarrisonFelix et al., 2012, p. E75). TBI patients were also 13 times more likely to expire from
fluid inhaled into the lungs, 10 times more likely from wound infection, poisoning, or
falling, six times more likely from pneumonia, four times more likely from outside forces
or homicide, three times from emotional, behavioral, or nervous disorders, two times
from suicide, and finally 1.3 times from blood circulation disorders (Harrison-Felix et al.,
2012, p. E75).
Many of these causes of death require continued investigation in order to be able to
treat TBI patients in the recovery stage. Seizure-related deaths after TBI have been a
persistent problem; however, there still appears to be a lack of knowledge about why
such severe seizures occur and how to prevent them post-injury (Harrison-Felix et al.,
2012, p. E77). It is also unknown how fluid is inhaled into the lungs, which causes
aspiration pneumonia (Harrison-Felix et al., 2012, p. E78). It was believed that there was
possibly a degenerative weakening in the nervous system that enabled the intake of fluid,
which also left these patients in a severe disabled state (Harrison-Felix et al., 2012, p.
E78). Most importantly, dangerous behavior, hostility, hindered comprehension, a
change in awareness and understanding, and drug abuse can cause some TBI patients to
commit murderous acts, which ultimately infringes on the lives of others (Harrison-Felix
et al., 2012, p. E78). The change in aggression and the inability to control one’s impulses
26
after TBI is of extreme concern, but needs more research (Harrison-Felix et al., 2012, p.
E78). It should be apparent that more development of treatment options needs to occur to
keep individuals from hurting others merely because they cannot control their emotions
and actions due to those emotions.
Currently, the main treatment for TBI symptoms is the use of medication such as
sedative-hypnotic chemicals, which help a person sleep and deal with tension and
anxiousness, and antidepressants (Zollman et. al., 2012, p. 135). However, these drugs
have side effects that can cause more symptoms with regard to the TBI such as memory
loss, drowsiness during the daytime, psychological problems, seizures, and sleeplessness
(Flanagan, 2007, p.68; Larson & Zollman, 2010, p. 62; Zollman et al., 2012, p. 136).
These medications can also negatively affect the patient’s ability to successfully
participate in a restoration program, as well as decrease the ability for molding and
recovery of the brain, which is a long-term effect (Zollman et al., 2012, p. 136).
Ultimately, medications can exacerbate the damage of TBI, and cause added symptoms
that confuse the diagnosis and treatment providers.
Zollman et al., (2012) studied acupuncture as a means to treat insomnia, which is
only one symptom of TBI, as it has been an effective treatment for patients suffering
from other illnesses such as stroke, and has little to no side effects or that can worsen the
TBI (p. 136). Insomnia is an enormous problem for those suffering from a TBI (30%80%), and can remain so from one day to many years post-injury (Zollman et al., 2012, p.
135). Insomnia is a difficulty in falling asleep and staying asleep for more than 30
minutes at a time at least three times throughout the week, which hinders the patient’s
27
effectiveness during the day (Zollman et al., 2012, p. 135). Insomnia can be an extreme
problem for youth with school and the many activities in which they participate. This
disruption in the patients’ sleeping ability is due to the damage to the brain occurring
during the initial injury, as well as the events that occurred post-injury (Thaxton & Patel,
2007, p.559). Acupuncture is a treatment that uses the method of piercing the patient’s
skin with hard, but thin, metal needles, and this process can be administered by human or
machine (Zollman et al., 2012, p. 136). Acupuncture can be seen as a form of sedation
and relaxation, as it activates the body’s nervous system so that hormones and chemicals
can be released in the brain, muscles, and spinal cord to regulate the body (Zollman et al.,
2012, p. 136).
In their study, Zollman et al. (2012) recruited 24 participants that suffered a TBI
five years or less prior to the study, and they all wrestled with insomnia (p. 136).
Participants were separated into a group that underwent acupuncture treatment and a
control group. Those in the treatment group were gradually released off of their
medication in the first week of treatment, but had no differences in the amount of time
they were able to sleep when compared to the control group (Zollman et al., 2012, p.140).
However, those in the treatment group experienced an improved feeling about the quality
of their sleep, which is in line with the belief that an altered perception of sleep and sleep
time is what maintains the sleeplessness (Zollman, et al., 2012, p. 140). If a treatment
can improve the patients’ feelings about their sleeping pattern and quality, then the
insomnia can cease, which is what occurred in the Zollman et al. (2012) study. This
improved feeling of sleep lasted for one month after the acupuncture treatment, and the
28
control group did not experience this change in perception with their medication
(Zollman et al., 2012, p. 141). The results of this study also showed improvement in
brain function with the acupuncture treatment; however, the reason was unknown since
the amount of sleep was unchanged and the same as the control group (Zollman et al.,
2012, p. 141). Therefore, it was believed that acupuncture had a positive effect on
insomnia and brain functioning in individuals suffering from a TBI (Zollman et al., 2012,
p. 141).
Another form of treatment used with people suffering from severe TBI is
deception. Severely injured individuals can suffer major changes in personality, mental
state, and conduct, which can cause aggressive fits of temper (Matthes & Caples, 2013, p.
126). These changes occur with juveniles as well and can be due to the mental
deterioration caused by the injury, as well as the fact that the injured person is unaware of
the deterioration and damage they have suffered (Matthes & Caples, 2013, p. 126). This
behavior can become a problem for treatment and rehabilitation providers, even with the
utilization of medication, because the injured person is not convinced there is a problem
that warrants therapy (Matthes & Caples, 2013, p. 126).
Matthes and Caples (2013) discussed an adult male in his late 30’s that suffered a
severe TBI due to falling from a moving vehicle approximately four years prior to the
study, and was in a coma for more than one month (p. 126). When he healed from his
physical injuries, he was sent home with serious mental and behavioral problems
(Matthes & Caples, 2013, p. 126). He was a high school graduate with no learning
problems, husband, and father, but was now on disability and needed care all day long for
29
his own well-being (Matthes & Caples, 2013, p. 126). He continued therapy on an
outpatient basis, but did not know basic things such as how many months were in a year
and his age (Matthes & Caples, 2013, p. 126). He also had verbal and visual impairments
and was eventually placed in an adult treatment facility for patients with TBI because his
wife feared for the safety of their children due to his aggressive fits of temper; however,
he was removed from this program for the same behavior and attacking a staff member
(Matthes & Caples, 2013, p. 126). This patient began having more problems and
deterioration in the brain, as well as changes in walking and standing, so he underwent
surgery and inpatient rehabilitative care to protect him from falling and suffering further
injury (Matthes & Caples, 2013, p. 127). His rehabilitation and therapy continued to
suffer due to his aggression and uncontrolled denial of disability, so his wife and
therapists agreed to make the patient believe he would now be working at the
rehabilitation center helping staff, but only if he completed his therapy every day, took
his medicine, and was not threatening or assaultive (Matthes & Caples, 2013, p. 128).
The patient previously indicated to therapists that he wanted to go home and take care of
his family and save money for his children, so therapists told him that if he did what he
was supposed to and remained professional on the “job”, he would receive his salary,
which was supplied by his wife (Matthes & Caples, 2013, p. 128). The patient agreed
and asked for the money to be placed in a bank account for him (Matthes & Caples, 2013,
p. 128).
This deception brought up many ethical issues about misleading patients with
cognitive deficits and not building trust between medical staff and the patient (Matthes &
30
Caples, 2013, p. 128). However, deception can be justified and acceptable when all other
therapies have been tried and have failed, especially when trying to get past their
understanding of nothing being wrong with them in order to medically treat them and
keep them safe (Matthes & Caples, 2013, p. 129). In this instance, consent was given by
his wife, and the patient’s cognitive injuries were so profound that he was not allowing
treatment and recovery to occur because of his inability to believe he had a disability
(Matthes & Caples, 2013, p. 129). His condition was worsening, so a creative approach
was the best option. Deception worked in regard to this patient, as his behavior improved
because he felt he was actually working instead of being a patient (Matthes & Caples,
2013, p. 129). The idea of his employment continued in the next rehabilitation facility,
and his condition continued to improve, while risk and harm to the patient and caregivers
was decreased (Matthes & Caples, 2013, p. 129).
Treatment of C.T.E. Causes. Unfortunately, this disease has not been studied in
great detail, as the brain tissue of affected individuals is only available to study after the
individual is deceased, as previously stated. There is still much to learn about C.T.E.,
and there are still many questions that need to be answered before the pathology of this
disease can be understood such as: How many concussions cause C.T.E.? How severe
do the concussions have to be? How many years after the concussion does C.T.E.
develop? (Zeigler, 2012, p. 2). The sole duty of the Center for the Study of Traumatic
Encephalopathy (CSTE) is to conduct the necessary research to determine and understand
the pathology of this disease, and once the disease is further understood, protocols to
prevent and treat C.T.E. can be established (Zeigler, 2012, p. 2). At this point, it is
31
known that head or brain trauma can cause C.T.E., so prevention efforts have begun by
giving proper diagnoses, paying closer attention to the athletes that have suffered
concussions, and following the recommendations set for when the athlete can return to
play (Zeigler, 2012, p. 3). Presently, it is recommended that an athlete that has sustained
a concussion be subjected to a progressive increase in activity following the injury, which
will begin with a minimum level of exercise and end with full activity (Zeigler, 2012, p.
3). The athlete cannot have any symptoms of the concussion while he or she is at rest to
be able to proceed through the post-injury exercise phase (Zeigler, 2012, p. 3). The
minimum amount of time for this exercise phase is five days, but can last as long as the
athlete needs to properly recover from the concussion (Zeigler, 2012, p. 3). These
guidelines do not allow for the affected athlete to continue playing the same day as his
injury, which has been the common practice in football for many years. The athletes
want to finish the game and strive to attain the victory by any means necessary, especially
professional athletes that have their careers to consider.
While ongoing research is conducted regarding C.T.E., several bills have been
passed to protect young athletes from head trauma and concussions. California, New
York, and Massachusetts are three states where such bills were presented (Zeigler, 2012,
p. 3). These bills do not allow the athlete to return to the game on the same day as his
concussion, but mandate that he receives medical clearance before returning to play. The
bills also provide information and training for team staff, parents, and athletes
regarding the negative consequences and outcomes of not properly dealing with the
concussion (Zeigler, 2012, p. 3; Abel, 2010).
32
Treatment of Military Causes. The issue of TBI amongst the soldiers in
Operation Enduring Freedom and Operation Iraqi Freedom has sparked a great deal of
interest in the recovery and rehabilitation of brain injured veterans. Health care providers
for the Department of Defense and the United States Veterans Health Administration
have focused the most attention on diagnosing mild TBI early so that appropriate care can
be administered at the initial stages of injury (Carlson et al., 2011, p. 104). One of the
issues with diagnosis and effective treatment of soldiers is the confusion of the symptoms
for mild TBI and Posttraumatic Stress Disorder (PTSD) (Bryant, 2001, p. 932; Carlson et
al., 2011, p. 104; Stein & McAllister, 2009, p. 768). PTSD is a disorder based on worry,
fear, and tension that forces an individual to relive, try to avoid, or become extremely
provoked due to experiencing a traumatic event (Carlson et al., 2011, p. 104). PTSD
amongst soldiers that fought in the war in Iraq was reported at a rate of 1.4% to 31%, but
for soldiers immersed in more war action, the rates were more constant at 10% to 17%
(Carlson et al., 2011, p. 104; Sundin et al., 2010, p. 368). Intense worrying,
sleeplessness, problems with cognitive and memorization skills, annoyance, rage, and
assaultive behavior are all possible outcomes of PTSD, as well as mild TBI, which
caused controversy with regard to the extent of their uniqueness (Carlson et al., 2011, p.
104). The individual would have to remember the triggering event in order to have
PTSD, but in extreme cases of TBI, the individuals could have no memory of said event
(Bryant, 2001, p. 935; Bryant & Hopwood, 2006, p. 19; Carlson et al., 2011, p. 104).
Evidence shows that individuals suffering from TBI can also exhibit symptoms of
PTSD from remembering their injuring traumatic event or as a consequence of another
33
event in their lives (Carlson et al., 2011, p. 104). Although there are numerous ways to
treat PTSD, such as with medicine and/or counseling, one of the best has been through
cognitive-behavioral therapy (CBT), which is also true for TBI (Carlson et al., 2011, p.
104; Foa et al., 2008, np). However, there are symptoms of TBI that can interfere with
the injured individual’s participation and the effectiveness of treatment through evidencebased practices, such as disadvantages in brain function, pain, and the inability to control
his impulses (Carlson et al., 2011, p. 104; Bryant & Hopwood, 2006, p. 19).
Carlson et al. (2011) reviewed a study involving 24 civilian males and females that
analyzed the success of CBT with patients suffering from traumatic stress and TBI (p.
110). The individuals participating in the study experienced severe motor vehicle crashes
or assaults and were separated into a supportive-therapy group or a CBT group (Carlson
et al., 2011, p. 110). The supportive-therapy consisted of skills to assist the individuals in
learning to effectively deal with their problems and to become familiar with the changes
in their brain functioning (Carlson et al., 2011, p. 110). The CBT consisted of brain
function awareness, as well as loosening and resting of the muscles, rearrangement of
emotions, the introduction of made up traumatic event scenarios, and the display of
provoked responses the injured patients have been avoiding since injury (Carlson et al.,
2011, p. 110). With the CBT group, as studied right after treatment, the prevalence of
PTSD was less after treatment than that of the supportive-therapy group, and these results
remained true six months after treatment (Carlson et al., 2011, p. 110). In essence, CBT
reduces and prevents PTSD symptoms in individuals that have suffered TBI, which is a
significant finding in the efforts to treat said injury (Carlson et al., 2011, p. 110). It
34
appears that teaching people about their injury, the changes the brain makes, exposing
them to trauma, and re- teaching them how to deal with that trauma, improves their
symptoms and recovery almost immediately (Carlson et al., 2011, p. 110).
PTSD is a significant issue with individuals that have experienced TBI, and
amongst United States soldiers that have experienced war, with rates of 10% to 40%
(Carlson et al., 2011, p. 111). The best way of screening for TBI is through clinical
interview; therefore, it is imperative that clinicians, especially when screening veterans,
pay close attention to the extreme chance that these soldiers may also suffer from PTSD
(Carlson et al., 2011, p. 111). Recently, there have been many veterans returning from
Operations Enduring Freedom and Iraqi Freedom with TBI and a high preponderance of
PTSD (Carlson et al., 2011, p. 111). With the current length and state of war amongst
United States soldiers, it is imperative that further studies occur regarding the relationship
between TBI and PTSD to further develop treatment and recovery of brain-injured
individuals (Carlson et al., 2011, p. 112). The development of social relationships and
the ability to obtain and keep employment by injured individuals hinges on the evaluation
of rehabilitative efforts in this area (Carlson et al., 2011, p. 112). It is very difficult to
treat an individual for TBI when they suffer from other symptoms and issues that are
unknown to clinicians (Carlson et al., 2011, p. 112).
Behavioral Changes
Four follow-up investigations were conducted on head injury victims that reported
information on offending. One of the investigations, by Brooks et al. (1986), compared
relatives’ reports at five years with similar information obtained at one year after head injury (p.
35
765). At both time frames, about two thirds of the relatives reported their family member
exhibited irritability and had a bad temper (Miller, 1999, p. 160). Threats of physical violence,
actual physical violence, and trouble with the law, on behalf of the injured family member,
increased after five years (Miller, 1999, p. 160). Kreutzer et al. (1991) surveyed 74 cases with a
past head injury that were examined again approximately six years after their injury (p. 178).
There was a significant decrease in arrests after injury; however, the people in this investigation
were extreme alcohol and drug abusers, which is a significant limitation of this study (Miller,
1999, p. 161). Alcohol and drug abuse has also been reported to have a connection with
offending, and since these cases decreased their use of said substances, their rate of arrests
declined (Miller, 1999, p. 161).
Hall et al. (1994) conducted an investigation using a six-month and two-year
follow-up period. Approximately 50% of the injured individuals were reported by their
caregivers to have irritability at both time frames, but their outbursts increased (Miller,
1999, p. 162). It appears that their aggressive behavior increased over time after head
injury (Miller, 1999, p. 162). Additionally, as stated in the investigation by Hall et al.
(1994), the level of arrests and incarceration increased in the injured individuals (p 880).
The final investigation was conducted by Kreutzer et al. (1991), and they were interested
in the relationship between substance abuse, crime, and aggression after injury (p. 180).
These authors’ sample consisted of 327 cases, with a follow-up period of approximately
two years (p.180). Kreutzer et al. (1991) found that there was also a decline in arrests
and convictions at the two-year mark, which was also believed to be due to a decline in
alcohol use (p.185). The findings of these investigations were mixed, but this was
36
believed to be due to the way the investigations were conducted (Kreutzer et al., 1991, p.
186).
Delinquent children engage in even more at-risk behavior, such as fighting and
gang activity, that can result in serious injury. Perron and Howard (2008) conducted a
study and interviewed 720 residents at 27 facilities within the Missouri Division of Youth
Services, and these residents were assessed for TBI where they were unconscious for
more than 20 minutes, screened for substance abuse and psychiatric symptoms, and
assessed for antisocial traits or behaviors (p.250). The results reported 18.3% of the
residents stated they previously suffered a TBI, and these residents were more likely to:
be boys, have received a mental diagnosis, report an earlier onset of criminal behavior or
substance abuse, previously commit crimes, exhibit suicidal behavior, not be able to
control their impulses, be unafraid, be victimized, and have a tendency to let others
control their actions (Perron & Howard, 2008, p. 250). These authors concluded that
youth that have suffered traumatic brain injuries were at a greater risk for depression,
anxiety, antisocial behavior, and substance abuse (p. 250). Aggression can lead to
altercations in life, which may result in physical acts that break the law (Dooley,
Anderson, Hemphill, & Ohan, 2008, p. 837). Physical aggression in childhood can
strongly predict adolescent violent delinquency, which may only be true for a small
number of children (Dooley et al., 2008, p. 837). The presence of aggression after injury
can hinder the injured individual and lead to adversity with friends, in education, and in
the workplace, especially for children with TBI (Dooley et al., 2008, p. 837).
37
Dinn, Gansler, Moczynski, and Fulwiler (2009) indicated that a large number of
closed head injury patients showed aggressive behavior during the initial post-injury
period, and frontal lobe injuries were related to aggression (p. 120). Violent TBI patients
had scarring in the front portion of their brains, and Dinn et al. (2009) found that this type
of damage made individuals receive higher scores on aggression tests than those
individuals with no scarring (p. 121). The Aspen Neurobehavioral Conference consensus
was that violence can result from brain problems, and research has discovered a high
incidence of head injury histories in the criminal population (Leon-Carrion & Ramos,
2002, p. 210). It has also been reported that due to injury to the frontal lobe, violent
behavior has resulted from the behavioral deficits, and people with frontal lesions showed
violent and aggressive behavior more frequently than people that suffered injuries to
other parts of their brain (Leon-Carrion & Ramos, 2002, p. 210). Frequent violent and
aggressive behavior was also noted in patients with mediofrontal brain injury (LeonCarrion & Ramos, 2002, p. 211).
According to Luiselli, Arons, Marchese, Potoczny-Gray, and Rossi (2000),
juveniles suffering from a TBI may also be prone to criminal behavior due to having
deteriorated control of their impulses, reasoning and examination skills, and
comprehension skills, which are all consequences of extreme brain trauma (p. 648).
These authors developed their claims from a survey that was given to juveniles critically
affected by TBI and participating in an educational program within the community that
focused on the restoration of brain function (p. 648). The differences in TBI amongst the
juvenile delinquent youth were contrasted with youth who were affected with TBI but did
38
not exhibit criminal behavior (Luiselli et al., 2000, p. 648). Over the course of three
years, 69 juveniles participated in the survey, and the majority lived in group homes in
the community, while the others resided at home with their families (Luiselli et al., 2000,
p. 648). The crimes the juveniles committed post-injury were alcohol and drug abuse,
arson, sexual offenses, cruelty to animals, theft, and vehicular homicide (Luiselli et al.,
2000, p. 649). About one third (9% female and 90% male) of the juveniles participating
in this survey committed one or more criminal acts (Luiselli et al., 2000, p. 651). In those
that did not commit criminal offenses, 25.5% were girls and 74.4% were boys (Luiselli et
al., 2000, p. 651). The post-injury criminal offenses occurred between the ages of 13 and
18, and there were no significant differences between the offending and non-offending
groups with regards to type of TBI sustained (Luiselli et al., 2000, p. 651). Luiselli et al.
(2000) found that criminal behavior is common amongst juveniles that have suffered a
TBI (p. 652). However, these findings definitely indicate that more research is needed on
why some juveniles with TBI commit crimes and others do not. One interesting outcome
of this survey was that the offending juveniles continued to offend even though they were
participating in the community-based program and receiving assistance, which indicated
that some may have needed a more secure environment where the impact of treatment
could have been more beneficial (Luiselli et al., 2000, p. 654).
Conclusion: Knowledge, Assessment, and Treatment
All of the information discussed in this review of literature can be used to
understand TBI amongst adults and juveniles. As previously stated, research on TBI
amongst juveniles is extremely limited, even though children are at great risk of head
39
injury due to the many activities in which they participate. C.T.E. is definitely a disease
that can affect juveniles that have played football or other contact sports since they were
a small children. Youth that are suffering from severe TBI can definitely suffer from
PTSD and the same symptoms as the adults discussed above. Therefore, the information
and treatments discussed above can aid medical professionals, as well as probation
officers assigned to detention centers, in helping youth understand and manage the
symptoms of their TBI. For those youth that are found to be suffering from TBI, but
cannot be released from custody pending court due to the severity of their crimes, such as
murder, acupuncture and deception could very well be used, with parent permission, to
treat and protect the youth, as well as gain their compliance.
There are an increasing amount of juvenile offenders entering the criminal justice
system with mental health concerns, possibly related to an unknown previous head
trauma. Unfortunately, there is a lack of knowledge about the effects of head injury,
brain damage, and specifically, damage to the frontal lobe, as it relates to criminal
behavior. Due to this fact, professionals in the system do not fully know how to treat this
population of juveniles suffering from head injury, and they eventually become persistent
adult offenders.
It is extremely difficult to combat crime, but it is impossible when all contributing
factors are unknown. As discussed in this chapter, TBI can cause so many cognitive
impairments that can lead to aggressive and/or violent behavior, and it is imperative that
the system helps these individuals discover the serious nature of their injury, understand
their injury, and begin the process of rehabilitation. These offenders may, and most
40
likely have, slipped through the cracks of the justice system as incorrigible or resistant to
change, but their behavior may not necessarily be intentional. Fortunately, our criminal
justice system is moving toward a more evidence based practice model, and there is a
growing desire to uncover any criminogenic needs that may contribute to negative
behavior.
Summary
In Chapter Two, this researcher discussed some of the neurological consequences
of TBI, the different areas of society where an individual can acquire a TBI (sports and
military), some of the ways to treat individuals with TBI, and the behavioral changes that
can occur after injury. The research in this chapter indicated there is a problem with TBI,
especially with youth, and there is evidence to warrant a closer look at why some
individuals behave criminally and violently. The research also indicated there are some
evidence-based ways to treat TBI.
The ART program is one such evidence-based
program that would succeed in being the catalyst in the effort to educate the world on the
significant effects of head injury and frontal lobe damage. Research shows that some of
the individuals that commit violent criminal offenses may also have frontal lobe damage.
Determining who may be suffering from frontal lobe damage and treating them prior to
the onset of suicidal, violent, and criminal behavior, is the focus of the treatment
discussed in this section.
41
Chapter 3
Project Overview
Introduction
This researcher is employed as a Deputy Probation Officer and has been for 17
years, while assigned to juvenile institutions, community-based programs, juvenile court,
juvenile and adult field units, as well as adult intake. In these assignments, this
researcher supervised juveniles housed in detention facilities, investigated and prepared
court reports, presented cases before the Judge in the courtroom, and supervised and
monitored juveniles and adults after adjudication and sentencing. These assignments
have afforded this researcher the opportunity to be trained to verbally and physically
supervise individuals involved in the criminal justice system, to investigate crimes and
violations of probation, and to write reports to the Court. The following information is
based on said experience and training.
The first criminal justice agency to receive juvenile offenders from law
enforcement officials and guide them through the delinquency process after arrest is the
Probation Department. The Probation Department assesses the juvenile for detention or
release, investigates the crime, investigates the juvenile’s conduct in the home,
community, and school, and prepares a report and dispositional recommendation to the
Court. The information that is gathered will be used and considered throughout the
delinquency process and beyond by other criminal justice agencies; therefore, it is
imperative that this information is as complete, thorough, and accurate as possible. The
disposition in the case and the juvenile offender’s life could be forever altered by the
42
decisions made during the delinquency process, so every effort should be made to
discover reasons why a juvenile has entered the criminal justice system and what
criminogenic needs should be addressed.
It is extremely difficult to determine if a juvenile needs to be in custody or just
needs therapy if specific information about their home life, social life, and health is
unknown due to having no knowledge of the importance of certain questions. Head
trauma and TBI have received a great deal of attention lately due to sports-related news
and research. However, these types of injuries have been occurring, especially with
youth in sports and motor vehicle accidents, for years, as stated in Chapter Two of this
project. Chapter Two discussed and showed that TBI can have a lasting effect on the
injured, as well as their family and friends. Cognitive functions that were once controlled
may no longer be, such as the ability to control one’s impulses and to appropriately
respond to social situations. Multiple TBI’s can also impact an individual and cause
severe damage. A juvenile that is being processed into a detention facility may have
suffered such injury and may not be able to successfully be housed on a general
population living unit. Also, a juvenile that may have a history of concussion, may not
be able to sustain another blow to the head. Understanding these issues could mean a
probation department escapes lawsuit and a juvenile escapes being labeled as a persistent
offender.
Purpose and Intent
The purpose of this research is to explore the consequences and treatment of TBI
and to evaluate whether three different assessment tools that are being utilized by local
43
probation departments within the United States assess for TBI. This researcher will also
develop an assessment tool and protocol that can be used by said departments in
determining who may be suffering from TBI, whether they need a clinical evaluation, and
what the treatment goals will be in their case plan. It is the intent of this researcher to
inform local probation departments about the issues, concerns, deficits, and treatment
needs surrounding TBI, so that they will understand the importance of knowing whether
the juveniles in their care and custody have suffered such injury. This researcher will be
reviewing and analyzing currently used assessment tools for any assessment questions
that relate to TBI.
Risk Assessments
Risk assessments were created to help guide practitioners, such as probation
officers, in making decisions regarding the custody, disposition, and treatment of the
juveniles that enter the criminal justice system based on the likelihood the juvenile will
not appear in court, will misbehave in custody, or will recidivate (Brumbaugh, HardisonWalters, & Winterfield, 2010, p. 6). These assessments vary across the United States and
are based on different principles, as they are created to fit the needs of each agency and
jurisdiction. This researcher will discuss and review three widely used risk assessments
to determine if they allow for the assessment of juveniles for head injury or TBI. These
three risk assessments are the Detention Risk Assessment Instrument, the Youth
Assessment and Screening Instrument, and the Positive Achievement Change Tool,
which are all used by probation departments throughout the United States. All of the
assessments chosen for review are used differently, and that is why they were selected.
44
The Detention Risk Assessment Instrument is solely based on determining the juveniles
risk to re-offend prior to appearing in court (Brumbaugh et. al., 2010, p. 3). The Youth
Assessment and Screening Instrument is risk-based, but mostly strength-based, as it
analyzes positive and negative behaviors and protective factors to decide which treatment
services would be most successful (Brumbaugh et. al., 2010, p. 8). The Positive
Achievement Change Tool is treatment-focused, and is used in determining case
disposition, which considers whether the juvenile would benefit from probation, what
form of probation, and what treatment options are appropriate
(Brumbaugh et. al., 2010, p. 3).
Detention Risk Assessment Instrument
In 1993, a juvenile detention reform began, and the Juvenile Detention Alternatives
Initiative (JDAI) was introduced by the Annie E. Casey Foundation, which allowed for
grants to be given to states and other agencies that chose to participate in the reform
(Steinhart, 2006, p. 5). The mission of the JDAI was to decrease the number of children
held in detention facilities that did not need a secured environment, limit the amount of
children detained and enhance the conditions of the facilities, inspire the growth of
options to secure detention, and dissuade the juveniles from not appearing in court and
committing new offenses (Steinhart, 2006, p. 5). The probation department in
Sacramento was one such agency awarded a grant under JDAI at the beginning of the
reform, and as a result, had to forego using certain security equipment inside the
detention facility, such as pepper spray. Risk screening, assessing whether secure
detention is necessary, at the detention intake level is the basic and most important way
45
of executing the JDAI mission (Steinhart, 2006, p. 5). Some jurisdictions in the United
States allow law enforcement officials to implement the risk screening in the field or call
in to the detention facility to complete the screening over the phone
(Steinhart, 2006, p. 5).
The detention risk assessment instrument (RAI) is the fundamental tool of risk
screening, and is a listing of written rules that govern how each juvenile entering the
detention facility will be rated (Steinhart, 2006, p. 5). The final risk score will be used
by the intake officer to determine if a juvenile should remain in secure detention, be
released home pending court, or be placed on a program of non-secure detention pending
court, such as home supervision or electronic monitoring (Steinhart, 2006, p. 5). All
RAIs are based on points under JDAI, but each jurisdiction within the United States
systematically develops their own RAI to best satisfy the needs of their agency (Steinhart,
2006, p. 5). The RAIs under JDAI have achieved their goals, in that decisions to detain
or release juveniles at the detention intake level have been standardized, overcrowding in
the detention facilities has been reduced, and agencies participating in JDAI have
lowered their culpability and expenses (Steinhart, 2006, p. 5).
Prior to the JDAI, the detention facility environments in many jurisdictions were
acceptable, and some were unfathomable, which resulted in the maltreatment and
impairment of many detained juveniles, not to mention the loss of these juveniles due to
the taking of their own lives (Steinhart, 2006, p. 7). Conditions in many facilities were a
definite issue at the beginning of the reform, but a more important issue, was the
overcrowding in most of the facilities run by government agencies (Steinhart, 2006, p. 7).
46
RAI’s were developed to control the amount of juveniles detained in these facilities using
rules that were more concentrated than the laws of detention set forth by state, city, and
county laws (Steinhart, 2006, p. 7). These more focused rules would guide the intake
staff in determining which youth did not pose a threat to themselves or the community
and which youth did pose such threats (Steinhart, 2006, p. 7). Liability issues arise when
low-risk youth are placed in secure-detention and are subjected to the abuses of more
criminally sophisticated youth. There were three basic fundamentals that guided the
formulation of the RAIs, and they were objectivity, uniformity, and concentration on risk
(Steinhart, 2006, p. 7). The decision to detain or release a juvenile should be based on
the alleged offense and the juvenile’s prior criminal history, not on the intake officer’s
opinion, and the screening questions should be uniform and consistent so that they are
used fairly for each juvenile being screened (Steinhart, 2006, p. 7). The screening
questions being used should only be based on the risk of the juvenile to re-offend or not
appear in court as ordered, and not on the subjectivity of the intake officer (Steinhart,
2006, p. 7). Officers can occasionally base their detention decisions on the attitude of the
juvenile or the way the juvenile dresses or carries himself, which is often times dictated
by the officers training and experience, but these reasons are not concrete, not based on
risk, and cannot be equally utilized. Many states, such as Florida, New Mexico, and
Virginia, began to see the accomplishments of the JDAI and changed their juvenile laws
to order the detention risk screening to be administered at the intake level (Steinhart,
2006, p. 8).
47
While the RAI under the JDAI measures the risk to the safety of the community
and the risk of the minor appearing in court for his detention hearing, it absolutely does
not measure the risk the juvenile poses to himself (Steinhart, 2006, p. 10). Historically,
the danger the juvenile posed to himself was often used as a reason to securely detain a
juvenile, but this reason was heavily used and abused (Steinhart, 2006, p. 10). The law
enforcement official or intake officer had the discretion of detaining the juvenile for
whatever reason and using the idea that he was a danger to himself, such as the juvenile
was out of control in the home, and the parent needed space, or the juvenile was
uncooperative with officials (Steinhart, 2006, p. 10). The officer could feel the juvenile
had a mental issue or was intoxicated due to his behavior, so the juvenile was detained
pending court. However, these personal and/or medical reasons cannot sufficiently be
measured in a detention risk screening instrument, and housing a beyond low-risk
juvenile in a secured facility to punish him can make the probation department liable for
any harm the juvenile suffers (Steinhart, 2006, p. 10).
RAIs are based on time, as they were developed to advise intake officers on the
decision to hold a juvenile in custody or not from the time of receiving the juvenile from
law enforcement until they appear in court for a detention hearing and subsequent
dispositional hearing (Steinhart, 2006, p. 10). After the case is adjudicated and a
disposition rendered, the RAI is no longer in effect, as the Court determines whether the
juvenile will remain in custody, be released, or participate in an alternative detention
program (Steinhart, 2006, p. 12). The RAI only covers this time period due to the fact
that this is when the greatest concern is placed on whether the juvenile will appear in
48
court to answer to the crimes alleged, and the intake officer is the person responsible for
ensuring he will appear based on his accepting custody of the juvenile from law
enforcement and his custody decision. Once the case is disposed of, the Court will take
on the responsibility of making a custody decision.
As previously stated, the jurisdictions that were awarded grants through the JDAI
use risk screening instruments that are point-based, and each question on the instrument
is attributed a certain number of points (Steinhart, 2006, p. 9). The total risk screening
score is placed onto a point scale that will reveal a decision on whether the juvenile
should be detained, released, or given an alternative to detention (Steinhart, 2006, p. 9).
If a juvenile has a score that is over a certain level, he is deemed high-risk and will be
eligible for secured detention (Steinhart, 2006, p. 9). Conversely, if a juvenile’s score is
lower than the designated level, he is determined to be low-risk and must be released;
however, the scores can be overridden by a supervisor (Steinhart, 2006, p. 9). There are
many jurisdictions that have a middle level of scores, and if a juvenile scores in that
range, he is released to a form of alternative detention that is not secure, such as
electronic monitoring (Steinhart, 2006, p. 9).
The point-based model was not always the only approach for a detention risk
screening instrument, as there were instruments that did not use points or calculate risk
scores (Steinhart, 2006, p. 9). Instruments that did not use points used matrix scales with
questions that only required yes or no answers, and if there were one or more yes
answers, the juvenile would be suitable for secure detention (Steinhart, 2006, p. 9).
Questions that could appear on these assessment tools were: Is the alleged offense a
49
felony? Is the juvenile currently on probation? Does the juvenile have a history of
abscond behavior from custody (Steinhart, 2006, p. 9)? However, within the JDAI, these
non-point instruments were discarded as validation studies stated that point-scale
detention screening instruments were more adjustable, precise, practical, and more in line
with the goals of the JDAI (Steinhart, 2006, p. 9). Essentially, the RAI is a tool that
brings reliability, organization, and consistency to the detention decision making process,
which does not totally discount the discretion of the intake officer to override the tool if
the alleged crime or behavior of the juvenile warrants such action (Steinhart, 2006, p. 9).
The Detention Risk Assessment Instrument (DRAI) is a fair and impartial riskbased tool that is based on the JDAI, and provides information to intake officers
regarding detention and release recommendations (Sacramento County Probation Manual
[SCPM], 2012). The DRAI is also a point-based tool, as designed by the JDAI. The
DRAI is used across the country by many different jurisdictions, though tailored for their
purposes, as previously stated. The following DRAI is what is used in many jurisdictions
in California, and it is completed on all juveniles pending charges and admitted to the
detention facility, with the exceptions noted in the DRAI instructions under “Automatic
Hold”, which are:
-
Present offense
Criminal history
Legal status – Probation or Parole
Warrant history
History of escape from secured custody
Most serious pending charge
Prior commitments
Aggravating factors
Mitigating factors
50
The juvenile will automatically be held in custody if he was arrested due to a
warrant for his arrest, as only “no bail” warrants are issued for juveniles. Juveniles are
not eligible for bail, unless being tried as adults. A person with a “no bail” warrant has to
remain in custody until he appears before the Judge. In this instance, a detention decision
is not necessary. The juvenile could also be held in custody automatically due to the
severity of the arresting offense, such as murder. The intake officer adds points to any of
the sections above where there is history (SCPM, 2012). Points will be added due to the
severity of the present offense, whether the juvenile has a prior criminal history, is on
active probation, has had previous warrants for his arrest, and/or has previously escaped
from custody (SCPM, 2012). Under mitigating factors, intake officers would ask about
good community ties, and the juvenile would have good community ties if they had three
or more of the following:
-Stable Living Address
-Educational Stability
-Supportive Family
-Active Connection to Adult(s)
-Participating in Treatment and/or Counseling
-Active in a Religious Organization
-Participation in Organized Sports within last 12 months
-Volunteers
-Active in Pro-social Clubs, Sports, Organizations, Community, or Cultural Groups
The intake officer will add points if the juvenile does not have a stable home
environment, not attending school regularly, no family ties, and does not participate in
any of the pro-social activities listed above (SCPM, 2012). The total number of points
will dictate to the officer whether the juvenile should be securely detained, released to his
parents, or placed on a program of alternative detention outside of the facility pending
51
court (SCPM, 2012). There is an override option that states the intake officer does not
have to accept custody of the juvenile after arrest until the juvenile is medically cleared,
which is for the safety and security of the juvenile (SCPM, 2012).
The DRAI further dictates that the intake officer would also advise the parent(s)
that the officer will interview the juvenile, after the Miranda admonishment (SCPM,
2012). The information gathered will be used in the intake report that is submitted to the
Court at the Detention Hearing (SCPM, 2012). This report encompasses family
background information and school history that is provided by the parent(s). The only
time a probation officer in Sacramento County, California, can speak to the juvenile prior
to an attorney being assigned is at the intake level. Therefore, obtaining a statement
and/or information from the juvenile at this time is paramount. The statement should
only be about the current situation, family life and behavior, and the alleged offense
(SCPM, 2012). The intake officer should ask the juvenile about his living situation,
which includes who resides in the home, sibling information if any, behavior of the
juvenile in the home, whether he follows the parents’ rules, and any history of running
away from home (SCPM, 2012). The intake officer should also ask the parent(s) about
the physical and mental health of the juvenile, which includes any drug and alcohol
abuse, gang membership or affiliation, whether they suffer from any medical or mental
health conditions, are taking any prescribed medication, participating in counseling, and
whether the juvenile has ever been the victim of any sexual, physical, or emotional abuse
(SCPM, 2012).
52
The intake officer should also ask about school progress, any school discipline,
whether the juvenile is or has been a special education student, and whether the juvenile
has an Individualized Education Plan (IEP) at the school (SCPM, 2012). The intake
officer should also ask if the juvenile participates in any extra-curricular activities such as
sports, and if there is anything the parent(s) want the Court to know (SCPM, 2012).
Finally, the intake report should also list available resources to assist the juvenile (SCPM,
2012).
Analysis of DRAI
The DRAI standardizes the process of detaining youth in juvenile detention
facilities and limits the amount of youth detained. In this researcher’s experience as a
Deputy Probation Officer, juvenile detention facilities have been overcrowded across the
country for many years, which often adds to chaos in the facilities. The DRAI was
designed to address standardization and overcrowding. The probation department in
which this researcher is employed is one agency that uses and has benefitted from the
DRAI. Youth are detained based on the points acquired during the DRAI and not any
other reason. The juvenile’s attitude and risk of harm to him- or herself are not used as
reasons to detain since they are not criteria used in the DRAI. Juveniles that score low on
the DRAI, are not detained, unless the score is overridden, and alternatives to detention
are used, such as electronic monitoring. Thus, overcrowding in the detention center has
been eliminated.
The DRAI collects information from the juvenile or parent that can be used by
other probation officers, law enforcement, and the court. The DRAI collects information
53
about the juvenile’s criminal history, family life, education, community ties, and
extracurricular activities, which gives the probation officer some insight to whether the
juvenile needs to be detained or released. This information is very important at the intake
level, as the officers need to know if the juvenile will ultimately appear in court for his or
her detention hearing and any subsequent hearings. However, this information can aid
staff inside the detention center in understanding the juvenile’s behavior and his or her
classification. This information can also be used by the juvenile court probation officer
in preparation of the court report to be submitted to the judge. It is vital to know whether
the juvenile has a stable home life, participates in activities outside of the home, and has
access to any community resources. If there are problems in the home, releasing the
juvenile to his or her parents while awaiting the detention hearing may not be in his or
her best interest. Also, if the juvenile is participating in activities in the community, s/he
may be that much more eager to appear for court, so as to not be detained and unable to
further participate.
Unfortunately, the DRAI cannot be used as the only form of assessment for a
probation department. The DRAI does not calculate risk to re-offend, assess for
criminogenic needs, and does not suggest treatment options, as do other assessment tools.
The DRAI was developed to only address the issue of detention after arrest and pending
court, which subsequently solves issues of overcrowding and unfair practices of detaining
youth based on subjective reasoning. Another tool would be needed to aid probation
officers and the court in determining what problems need to be addressed with the
54
juvenile and his or her family, upon adjudication, that might be contributing to the
juvenile’s criminal behavior.
One of the contributing factors could be head trauma; however, the DRAI does not
assess for head trauma or injury. There are many areas of the DRAI that can be expanded
to obtain possible information about a history of concussion, head injury, and/or TBI,
such as when asking about sports participation, medical and mental health, behavior in
the home, prescribed medication, and whether the juvenile participates in any treatment
or counseling. The questions about education could also be expanded to include
questions about head trauma, more specifically for those juveniles that have special
education needs and an active Individualized Education Plan (IEP). However, the DRAI
does not guide the intake officers or alert them to specifically ask about head injury,
concussion, or TBI.
Youth Assessment and Screening Instrument
The Youth Assessment and Screening Instrument (YASI), as developed and
marketed by Orbis Parthers Incorporated, is a program that not only determines risk, but
also determines what resources the high-risk juvenile may need and what protective
influences he has, so that a case plan may be developed (Orbis Partners Incorporated
(OPI), 2013, p. 1). This instrument can be used by any agency that must determine the
needs and risks of the juveniles in their care such as probation departments, schools, and
child protective services (OPI, 2013, p. 1). In essence, the YASI is a program that allows
probation officers to input information regarding juveniles and analyze the information to
formulate an appropriate treatment plan (OPI, 2013, p. 1). The partners at Orbis believe
55
that officers should not just simply assess the juveniles in their care, but use that
information to develop a case plan that is tailored for that specific juvenile, and this case
plan is the most important part of the assessment process (p. 1). The assessment reveals
certain characteristics and risks about the juvenile that can predict future criminality
(OPI, 2013, p. 1). These characteristics must be addressed to promote positive changes in
the juvenile and limit the risk of continued misbehavior or re-offending, and the case plan
displays what the characteristics are and how they should be addressed (OPI, 2013, p. 1).
This concentration on assessment, case plans, and discovering factors that aid the juvenile
were introduced by the Washington State Juvenile Assessment model, which was
developed in the latter part of the 1990s (OPI, 2013, p. 1). The YASI was based on the
improvements of the Washington model used in New York and Illinois, along with the
youth custody application used in California (OPI, 2013, p. 1).
The YASI connects the assessment with the case plan using accessible software
that can be purchased by agencies and tailored to fit the needs of that agency (OPI, 2013,
p. 2). The YASI has four basic elements, which are the initial assessment, finding the
motives of the juvenile, identifying formal and informal controls and applying treatment
and supervision goals, and following up with the progress of the case plan (OPI, 2013, p.
2). There are 10 basic domains in the YASI program that have become apparent from
current research on criminogenic needs, and they are:
-
Legal History
Family
Education
Community/Peers
Substance Abuse
56
-
Mental Health
Violence
Attitudes
Skills
Use of Free Time/Employment (OPI, 2013, p. 3)
The difference between the YASI domains and other assessments is the fact that YASI
uses the latest research to re-develop their domains and enhance the case plan
programming (OPI, 2013, p. 3). One of the most appealing features of the YASI is
offered to probation officers, and it is the idea of measuring and monitoring strengths in
the juvenile’s life such as family and community ties, educational goals and attachments,
and goals for the future (OPI, 2013, p. 3). The measuring and consideration of these
strengths is what sets the YASI apart from other assessments and solidifies the program
in the case planning process (OPI, 2013, p. 3).
The YASI consists of a pre-screening application, as well as a full assessment.
The pre-screening application is mainly used for classifying the juveniles and consists of
at least 30 questions that deal with facts in the juvenile’s life, such as criminal behavior
and family dynamics, as well as characteristics of the juvenile that can be changed (OPI,
2013, p. 5). The pre-screening application is used to assist probation officers with
detention decisions (OPI, 2013, p. 5). The classifications from this screening are low,
moderate, and high risk to re-offend, and the pre-screening immediately alerts officers to
the moderate and high risk juveniles, so that these juveniles can receive more
concentrated assistance (OPI, 2013, p. 5). The moderate and high-risk juvenile will then
undergo the full assessment in order to develop an elaborate analysis of his at-risk
behavior and characteristics that will be the basis of the case plan (OPI, 2013, p. 5). An
57
interview with the juveniles is essential for the pre-screening; however, most of the
factual (static) information about the juvenile, such as criminal history and family
background, can also be found in the police report and prior probation reports (OPI,
2013, p. 5). The full assessment adds to the pre-screen by providing a more elaborate
evaluation of the dynamic information, criminogenic needs, protective factors, and risk to
re-offend, which are all used in the development of the case plan for the higher-risk
juveniles (OPI, 2013, p. 6). The full assessment contains questions that focus on the
behavior of the juvenile that will lead to directions for treatment in the case plan (OPI,
2013, p. 6). For ease of understanding, the findings of the full assessment are exhibited
in a wheel graph, and users only have to click on a part of the wheel that corresponds
with a certain risk factor, which reveals gathered information on the juvenile
(OPI, 2013, p. 7).
The YASI provides another valued service that other assessments do not provide,
which is the reporting of all of the information gathered (OPI, 2013, p. 8). All of the
information provided by the full assessment and entered into the YASI software can be
made into a report that can be used to formulate a court report, or the YASI report can
simply be provided to the court itself (OPI, 2013, p. 8). The YASI report can also be
provided to other stakeholders and agencies assisting the juveniles, giving them the
information needed to render their services (OPI, 2013, p. 8). Finally, the YASI report
can also be used gather statistics for the agency as a whole (OPI, 2013, p. 8). The agency
would be able to show the population of juveniles being served, identify problems with
the services provided, and determine where continued funding would best be utilized
58
(OPI, 2013, p. 8). After all of the information has been provided in the software, the
YASI can be used to predict further criminality and service needs by pinpointing what the
juvenile’s criminogenic needs are and how they weigh against the strengths in his life
(OPI, 2013, p. 8).
Analysis of YASI
The YASI is a full service tool that forces probation officers to fully assess,
classify, and help treat the juveniles they serve. The pre-screen portion of the YASI is
used at the detention intake level to determine if a juvenile should be detained, placed on
a program of alternative detention, or released to the care and custody of his parents
pending court. It is also used to classify the juveniles that are detained in the facility.
The full-assessment allows the probation officer to gather more information about the
juvenile and his life, which can then be used for a court report or a report to other
agencies that will serve the juvenile and his family. This information is also placed in a
case plan that guides the field probation officer in understanding what type of treatment
needs to be completed by the juvenile and his or her family.
The YASI also determines the strengths of the juvenile, which is not addressed in
other assessment tools. Strengths include having a good home life, good community ties,
and a good education. This is weighed heavily against the criminogenic needs of the
juvenile in the YASI and displayed in the case plan. This counts as the risk to re-offend.
The YASI then gives a score of low, moderate, and high-risk to re-offend, and only the
moderate and high-risk juveniles will be eligible for detention and for the full assessment.
Assigning a risk level to the juveniles does not end the assessment process. The YASI
59
software continues to take all of the information and compile it into a report that can be
used as part of the court report. Reporting the outcome of the assessment is also an
aspect not seen in other assessment tools. The case plan suggests different treatment
options for the juvenile and serves as a follow up to the initial full-assessment.
Unfortunately, the YASI does not ask about or assess for head injury. As in the
DRAI, there are domains in the YASI that can be expanded to assess for head injury.
These domains are community/peers, substance abuse, mental health, violence, attitudes,
and skills. If the juvenile participates in sports in the community, a history of concussion
could be addressed. Also, if the juvenile abuses substances, finding the reason behind it
could uncover possible head trauma. Mental health and violence are definitely domains
that could encompass questions about head injury, as mental health changes can occur
after injury, including violence and aggression. Attitudes and skills can change
drastically after TBI, so if a parent indicates the juvenile’s attitude changed, an inquiry
into why the change happened could uncover possible head injury.
Positive Achievement Change Tool
The Positive Achievement Change Tool (PACT) is a complete assessment that
consists of 126 questions that are asked of the juvenile in an intake interview prior to the
juvenile appearing in court, and the answers to these questions will determine a risk score
that is used to measure the probability of the juvenile re-offending (Barnoski, 2013, p. 1).
The PACT is evidence-based and validated, and is a case management assessment
program that was developed by the Department of Juvenile Justice in Florida and
Assessments.com in 2005 (Barnoski, 2013, p. 1; Olson, 2007, p. 2). The PACT was
60
essentially based off of the Washington State Juvenile Court Assessment, which is what
birthed the YASI (Barnoski, 2013, p. 1; Olson, 2007, p. 2). The PACT was created to
provide a more precise way of accumulating crucial information to measure a juvenile’s
risks and criminogenic needs (Olson, 2007, p. 2). The PACT, much like the YASI,
reveals the strengths of the juvenile and what treatment services would work with those
strengths to improve the juvenile’s behavior (Barnoski, 2013, p. 1). There are 12 areas
of concentration in the PACT that have been proven to be indicators of future criminality:
-
Criminal History
Education
Free Time Activity
Employment
Current Relationships
Family Ties
Living Arrangements
Alcohol/Drugs
Mental Health
Attitudes and Behaviors
Violence
Skills (Barnoski, 2013, p. 1; Olson, 2007, p. 3)
The PACT is approximately a 45-minute interview, and the practitioners executing
the PACT are required to undergo training in motivational interviewing, a key factor in
the PACT, to get the most accurate and useful information from the juvenile (Barnoski,
2013, p. 1; Olson, 2007, p. 2). The PACT encourages and measures positive change, and
this all begins with the interview. The intake officer must begin motivating the juvenile
to desire to make positive changes; therefore, the interview must be more than the
exchange of questions and answers, it has to be insightful, uplifting, and rehabilitative.
The PACT software also has the capability of producing a case plan for the practitioner,
61
as all of the information put into the program indicates the needs of the juvenile, and is
distributed throughout the case plan (Barnoski, 2013, p. 1).
Other types of assessments before the PACT, especially in Florida, assessed
juveniles based on the alleged offense and their prior record, but the PACT considers
family strengths and dynamics, pro-social activities and skills, educational level, and
other mitigating factors before deciding the risk level of a juvenile and disposing of the
case (Olson, 2007, p. 3). The PACT is an evidence-based tool, and it has gained vast
approval due to the fact that focusing treatment on the particular needs of the juvenile has
been validated as a means to reduce recidivism, as opposed to just giving a punishment
for the crime committed and continued criminal behavior (Olson, 2007, p. 4). The risk
levels used in the PACT are based on the probability of the juvenile re-offending, and the
levels are:
-
Low
Moderate
Moderate-High
High (Olson, 2007, p. 4)
The questions asked in the PACT create scores displayed as percentages for each area
measured, and this percentage is used to determine the risk level of the juvenile (Olson,
2007, p. 2). The PACT aims to fit the recommended treatment and disposition of a case
to the risk-level of the juvenile (Olson, 2007, p. 3). If a juvenile is a low-risk to reoffend, he may receive few sanctions or none at all, as he is less likely to commit another
offense (“How to Read,” 2006, p. 2). However, a juvenile that is a high-risk to re-offend
may very well need more sanctions and interventions, as the likelihood of this juvenile
continuing his criminal behavior is high (“How to Read, “ 2006, p. 2).
62
The name of the PACT alone signifies positive change and rehabilitation, and it has
two purposes (Olson, 2007, p. 3). The first purpose for naming the PACT was to stress to
juveniles the importance of making a positive change in their lives and instilling in them
the desire to accomplish something positive (Olson, 2007, p. 3). The second purpose
surrounds the acronym, PACT, and it encourages a lawful agreement between everyone
in the juvenile justice system, the court, probation officer, juvenile, parent, and service
provider, to work together to aid the juvenile in making positive choices and decisions in
his life (Olson, 2007, p. 3). The PACT itself was created to achieve four goals, and they
are: identify the juvenile’s risk-level to re-offend to ensure services are provided to
juveniles that risk higher, determine the risks and strengths of the juvenile to be certain
treatment services are focused on the juvenile’s needs, concentrate on decreasing issues
that cause risk and increasing the juvenile’s strengths, and aid practitioners in following
up with the progress of the court’s treatment plan for the juvenile
(“How to Read,” 2006, p. 1).
Analysis of PACT
The Sacramento County Probation Department uses the PACT when writing
juvenile court reports and recommending dispositions in the cases. The PACT is only
used for disposition and not for detention decisions at the time of arrest. The PACT is
completed at the intake level; however, there are occasions where the PACT is not
completed, and the juvenile court report writer, who is also a probation officer, completes
the PACT by interviewing the juvenile’s parents, as the juvenile court report writer is not
allowed to speak with the juvenile without the permission of his attorney. If a juvenile is
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not detained at the time of arrest, but is cited, and he fails to appear for the citation
hearing, the juvenile court report writer will complete the PACT before the court report is
submitted for review.
The court wants to know what the PACT risk level is to help determine if the
juvenile should be committed to secure detention, committed to a placement facility,
placed on home supervision, and/or referred to counseling after being adjudicated. In
Sacramento County, low- and moderate-risk juveniles are not recommended for
commitment to the detention center or a placement facility post-adjudication, unless the
decision is overridden by a supervisor due to the nature of the offense or the juvenile not
having a parent or guardian available. The PACT lets the juvenile court report writer
know what, if any, type of counseling the juvenile and his family may need. If the
juvenile receives a certain score in family and relationships, functional family therapy
will be recommended. All of the information received and recorded in the PACT is autopopulated into a case plan, and the counseling and treatment plans are already chosen
based on the PACT percentage scores and determined risk-levels.
The PACT deals mostly with the juvenile’s risk to re-offend and the positive
changes the juvenile needs to make after adjudication. It is not used at the intake level
for detention decisions. Although the PACT interview is administered at the intake level,
the information is forwarded to the officer that prepares the court report to help them
determine a dispositional recommendation to the court. This is the difference between
the PACT and the previous two assessments discussed. The DRAI is only used for
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detention decisions, and the PACT is only used for post-adjudication. The YASI is the
only assessment that encompasses both aspects.
The PACT does not assess for, or even ask about, head injury. It is quite
interesting that the PACT is developed to positively affect change in the juvenile, but it
does not ask about something so important. TBI after head injury can dramatically
change a juvenile’s life, and to not consider the possibility of this contributing factor is
counter-productive. Every effort should be made to uncover the reasons why the crime
has been committed. The PACT considers the juvenile’s strengths and issues, but does
not ask about something so important. There are sections of the PACT that can also be
expanded to address possible head injury, and they are: current relationships, family ties,
living arrangements, alcohol/drugs, mental health, attitudes and behaviors, and violence.
Summary
All of the assessments reviewed in this chapter are unique, in that they measure
some of the same characteristics and risks, but are used quite differently. The DRAI is
strictly used to aid probation officers in determining if a juvenile should be securely
detained or not upon entering the detention center after arrest. The YASI is also used to
aid probation officers in making detention decisions, but it takes the risk assessment a
step further with the full assessment. The YASI also provides information to guide the
probation officer and the court in the final disposition of the case. The YASI identifies
and measures qualities, characteristics, and risks of each juvenile to make a prediction on
whether a juvenile will continue to re-offend and what services are available to assist that
juvenile. The YASI is a full service assessment. The PACT is an assessment much like
65
the YASI, but it is not used to make initial detention decisions. The PACT identifies and
measures risks and strengths of juveniles to determine which services would best help the
juvenile to reduce his risks and increase his strengths. The PACT is used to aid the court
in determining dispositions and sanctions.
Appendix A is a key that explains the codes and information in Appendix B.
Appendix B illustrates what basic topics these assessments address and do not consider.
Appendix B considered questions about health, sports, injuries, hospitalizations, abuse,
and head injury/TBI. It is evident that none of the above assessment instruments mandate
that an intake officer ask or assess for head or brain injury when receiving juveniles for
possible detention in their juvenile hall facilities. Unfortunately, the probation
department in which this researcher is employed does not specifically ask or know about
the offenders that have suffered a TBI, and offenders do not know the significance of
their injuries to alert their probation officers and/or therapists. This researcher has never
been trained to specifically ask or assess for TBI. The assessments guide the intake
officers in asking the juveniles basic questions about their health, but do not appear to
make it clear if they are asking about injuries outside of arrest at all, not to mention
whether they were recent and major or not.
As the research shows in Chapter Two, some individuals suffering from severe TBI
may not even believe they have an injury, problem, or disability. Therefore, simply
asking the juvenile or their parent a general question about their health or any injuries
may not be thorough enough to get the most accurate information and picture of what is
happening with the juvenile. Juveniles and parents could also believe that the
66
concussion(s) the juvenile sustained a year ago while playing sports is not worthy of
discussing now because the juvenile is no longer under a doctor’s care. They may not
know that the reason the juvenile steals and excessively curses may be indicative of
damage to his brain due to the concussion or head injury. It is also clear that informing
and training intake officers about the symptoms and significant impact of TBI can help
them be the information agents for the juveniles, parents, and the Court. The intake
officers need to be aware of the specific questions and wording they need to use and look
for in order to inquire about head or brain injury.
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Chapter 4
Assessment Tool and Protocol
Researcher’s Proposal
The purpose of this assessment tool and protocol, Assessment of Head Injury Tool
(AHIT), is to guide probation departments and their juvenile intake officers in asking the
questions necessary to thoroughly and accurately assess juveniles for entry into the
Juvenile Detention Facility, as well as the criminal justice arena. The previous chapters
in this project discussed how youth are more prone to head injury due to the many
activities in which they are involved, how TBI can affect cognitive functioning and
behavior, some of the available treatments, and how the assessments used by juvenile
intake staff do not assess for TBI. An accurate assessment and classification of the
juveniles entering detention facilities should decrease harm to the juvenile, other
juveniles in the housing units, staff supervising the housing units, and the liability on the
Department as a whole. AHIT should also increase the safety and security of detained
minors, staff, and the institution as a whole.
As the first contact in the criminal justice arena after arrest, it should be the
responsibility of the Probation Officer in the Juvenile Hall Intake Unit to use AHIT,
accompanied by their existing intake questionnaire, to assess the juvenile for possible
head injury or traumatic brain injury (TBI), past or present, and classify the juveniles
accordingly.
AHIT, shown on page 69, along with the existing intake questionnaire, should be
administered to every juvenile entering the Juvenile Detention Facility for detention and
68
every juvenile entering the intake process through law enforcement citation. The most
accurate information is necessary to make the best dispositional recommendations to the
court and the appropriate referrals for treatment.
69
Assessment of Head Injury Tool (AHIT)
1. Have you ever had an injury to your head in any of the following situations?
(Check all that apply):
O
O
O
O
O
O
O
Motor Vehicle Accident
Sporting Event
Fall
Gang confrontation, incident, or event
Shooting
Other specify: _______________________________
None (Do Not Continue AHIT Tool)
2. When did the injury occur?
__________________________________________________________________
3. Did you have any of the following symptoms immediately occur after the injury?
(Check all that apply):
O
O
O
O
O
Confused or Disoriented
Memory Loss
Loss of Consciousness/Pass Out for less than 20 minutes
Loss of Consciousness/Pass Out for more than 20 minutes
Other ___________________________________________________
4. Were you hospitalized?
O Yes
O No
5. If yes, what happened and how long were you there? _______________________
__________________________________________________________________
6. During the next few days, did you experience any of the following:
(Check all that apply):
O
O
O
O
O
O
O
Memory Loss
Headaches
Problems with balance
Insomnia
Irritability
Confusion
Other ____________________________________________________
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7. Did any of the above symptoms continue and/or get worse? __________________
__________________________________________________________________
8. Do you still have any symptoms today? __________________________________
___________________________________________________________________
9. Do you take any medication? If yes, what kind? ___________________________
___________________________________________________________________
10. Do you participate in treatment or therapy for this injury? What kind? __________
___________________________________________________________________
11. Is there anything you want to add about your injury or injuries?
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
71
Protocol
If the minor states he has had a previous head injury with multiple symptoms, but
the symptoms are no longer present, he may have suffered a mTBI, but this will not be a
diagnosis. The minor may no longer be suffering from any symptoms, but the
information should be logged in the intake report for review by the Court. If the minor
suffered an injury, was unconscious more than 20 minutes, was hospitalized, prescribed
medication, and suffered ongoing symptoms for six months after injury, he had a TBI. If
the symptoms are still present, especially dizziness, headaches, irritability, comments that
do not make sense, and medication, the minor needs to undergo a clinical interview for
possible severe TBI and possibly a medical clearance to be admitted into the juvenile
hall. An override can occur if the crime committed is a major index crime, and if the
safety and security of the minor, victim, and community are at risk. The Supervising
Probation Officer, or his designee, shall have the responsibility of the override.
The goal of AHIT is to gain as much insight into the life of the minor being
admitted for detention as possible. The safety of the juvenile and everyone else in the
facility is of great concern. If the individual has suffered one or more head injuries, it is
imperative that he not experience another. Detention facilities can have emergency
situations, such as fights and assaults, that would exacerbate the minor’s previous or
current symptoms. If a minor suffered a severe head injury, his behavior may be more
than juvenile hall staff can handle. He may consistently defy authority and become
aggressive with staff and other youth in the facility. This may cause an issue of restraint
and possible injury to the juvenile or staff, and force a liability issue. It is imperative that
72
probation departments uncover the real reason a person’s behavior is beyond control so
staff can make the best placement option that will suit the needs of the juvenile, staff, and
community.
The current research on TBI is clear. Injury to the head can cause mild to profound
damage to the brain, and the frontal lobe is most commonly damaged (Miura et al., 2005,
p. 662). Juveniles are at such great risk because of the amount of physical activity they
participate in such as sports, playful activity, and gang membership (Miller, 1999, p.158;
Miura et al., 2005, p. 662; Sonnenberg et al., 2010, p. 1003). This brain damage causes
people to lose consciousness, memory, and cognitive abilities, and an injured person can
also sustain permanent balance and physical impairments that alter his life (Miller, 1999,
p. 157). This individual could behave totally different from the way he behaved prior to
the injury. The worst part about TBI is that the injured person cannot and does not
understand the damage that has occurred to his brain, so the willingness to participate in
counseling, treatment, or therapy is not present (Matthes & Caples, 2013, p. 129). This
person may consistently defy authority due to his quick temper, inability to control his
impulses, and his inability to know how to behave in social situations, not to mention
detention facilities. This behavior may not be signs of a persistent criminal offender.
This behavior could be due to damage to the brain as a result of a sustained head injury.
Therefore, it is extremely important that agencies complete the AHIT assessment and
comply with the stated AHIT protocol to limit further injury and liability.
If it is discovered that a juvenile may have suffered or is currently suffering from a
possible head injury, a medical screen in the form of a clinical interview needs to be
73
completed. The individual will need to be medically cleared before admittance to the
detention facility. If the individual cannot be cleared, the Supervising Probation Officer,
or his designee, will have to do an override and determine if the alleged crime demands
the individual be detained. If the crime does not demand detention, the Supervising
Probation Officer shall determine whether the juvenile will be held at the detention
facility or released to the care and custody of his parent(s) with a recommendation to seek
immediate medical attention.
This information should be immediately shared with the minor’s attorney, the
District Attorney, and the Court. If the individual can be housed in the detention facility
with past or present head injury or TBI, he should be housed in the clinic, if possible, and
observed. If the individual is cleared by the clinic to be housed elsewhere in the facility,
the first choice should be isolation and not general population so that the individual does
not sustain further head trauma or cause harm or disruption for other juveniles or staff.
The mental health team in the facility should be immediately notified of the situation, and
treatment should begin while in detention, as research indicates treatment and
rehabilitation early on in recovery after a head injury can limit the symptoms and
consequences of the TBI. The attorneys and the Court should be made aware of the
injury so consideration can be given to the mitigating factors associated with the
commission of the crime.
After disposition and adjudication, if the minor is placed on probation, the
information about the TBI shall be shared with the Probation Officer supervising the
minor. A case plan and treatment goals should be formulated to assist the minor
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regarding the crime, but most importantly his TBI. Every effort should be made to assist
brain-injured juveniles in the completion of their case plan and treatment goals before
said juvenile can be returned to Court for a violation of their probation. The research
indicates that cognitive behavioral therapy has been a successful approach in the
rehabilitation of individuals suffering from TBI, as it makes them aware of their
impairment and encourages them to learn once again how to deal with certain social
situations and control their impulses. Therefore, counseling and treatment under the
cognitive behavioral therapy umbrella is recommended under AHIT, as said treatment is
evidence-based.
Implementation Concerns and Summary
During the implementation of the AHIT Protocol, this researcher anticipates
Probation Departments considering the issues of funding, liability, and becoming
involved in the medical treatment of possible injured juveniles that enter the criminal
justice system. These are concerns that any manager would have in implementing any
new rule, policy, or procedure. If a juvenile is confirmed to have suffered a TBI and
needs a clinical interview or continued treatment, the question will be who funds the
interview and treatment. However, the AHIT will be utilized with the detention risk
assessment immediately upon the juvenile entering the detention center to determine
whether the juvenile will be released or detained. If a clinical interview or medical
clearance is needed, the juvenile will not be accepted into custody. The law enforcement
officer will have to transport the juvenile to the hospital for clearance, or release the
juvenile to the custody of his or her parents with a citation to appear in court. The
75
probation department will not have to worry about liability, as custody was never
accepted.
Often times, juveniles are arrested and transported to the detention facility for
subsequent criminal offenses, and they are already on probation. If a juvenile is on
informal or six months court probation, they were never removed from the custody of
their parents, so their parents are responsible for the cost of the clinical interview and
possible treatment. If the juvenile is already a Ward of the Court, which is formal
probation, their parents can still be charged for the medical treatment, especially if the
juvenile still resides in the home with his or her parents. The probation department will
alert the parents to the need for the interview and possible treatment. If the juvenile is
adjudicated for the offense, his or her case plan should include cognitive-behavioral
counseling to address the TBI. The parents are responsible for the acquisition of
counseling, as well as payment.
If the juvenile was adjudged a Ward of the Court due to his or her parents being
unavailable, and the juvenile needs a clinical interview or medical clearance due to a
severe TBI, then the probation department will be responsible for funding. The juvenile
was committed to the care and custody of the probation officer, and the probation
department is responsible for maintaining the health and wellness of that juvenile. The
parents can still be billed and held financially responsible for extra treatment rendered,
just as they would be for any damage to the detention facility at the hands of the juvenile.
The final concern is the thought of becoming involved in the medical status of the
juvenile. The priority of the probation department at the time AHIT is utilized is to
76
merely determine if there is a need for clinical interview or medical clearance, and if so,
to alert the parents and the court about possible consequences and behavioral changes
that could exist with TBI. Ultimate treatment for TBI will fall on the parents, and the
probation department does not have to approve of the treatment, unless the parental rights
were removed. In this instance, the juvenile would be adjudged a Ward of the Court, and
committed to the care and custody of the probation officer, so the probation department is
obligated to provide medical care.
77
Chapter 5
Conclusion
Traumatic brain injury, as stated in Chapters One and Two can cause cognitive
impairments and severe behavioral changes, especially in youth, as they are involved in
more activities that could cause injury. Injured individuals can become violent and
disobedient due to the inability to control their anger and impulses, which poses liability
issues for probation staff supervising these individuals while detained in the detention
center or on probation in the community. Juveniles that have suffered severe TBI can
pose major problems for probation staff, as their behavior can be unpredictable, bizarre,
and uncontrollable. These individuals will need constant redirection, isolation, and
restraint to complete simple directives, which could compromise the safety and security
of the institution. These individuals can also flood the juvenile court system with
constant violations of probation, as they do not have the capacity to follow the conditions
of the court or directives of the probation officer with no knowledge of the consequences
of their impairment or ability to control their behavior.
Currently, probation departments may be unaware of TBI and the consequences of
such injury, so juveniles suffering from possible injury might be labeled as persistent
offenders and committed to detention and treatment facilities. Since their injury is never
considered, they graduate to the adult system as juvenile delinquents or career criminals.
The criminal justice system then continues to fail and becomes more overcrowded.
However, if juveniles suffering from TBI cannot control their behavior, they could be
considered victims of the criminal justice system, as no one attempted to uncover the real
78
reasons behind their actions. Also, the criminal behavior of these individuals continues
to terrorize and victimize the community. Liability issues could arise with the continued
victimization of society, as the public will want to know why was this juvenile not
properly assessed or treated.
The juveniles that suffer from TBI, along with their parents, may not know the
severity of the injury or the future problems that can arise. The probation department
could be the first agency to alert the parent to a severe medical condition and possibly
save the life of a juvenile or innocent member of society. As stated in Chapter Two,
some of the individuals that have suffered with head trauma have committed suicide due
to the deterioration of brain functions, which leads to physical impairment, such as
blindness, memory loss, inability to effectively communicate, and problems with
walking. Chapter Two also discussed how some adult athletes that have suffered
multiple concussions died sooner than others due to damage to the brain. TBI is an
extremely serious issue that goes beyond compliance with probation and orders of the
court. Detection and treatment of TBI could mean the difference between life and death.
The Sacramento County Probation Department is now using many evidencedbased treatment interventions for juvenile crime. One such program is the Aggression
Replacement Training (ART) program. ART is a multimodal intervention that was
designed to reduce anger and violence among adolescents involved with the criminal
justice system, and has recently been introduced to adults involved with said system
(Sacramento County Probation Intranet Site (SCPIS), 2011). This program attempts to
teach the offenders pro-social skills that will aid them in controlling their anger impulses
79
(SCPIS, 2011). However, if the Probation Officers, therapists, and offenders do not
know that the offender’s lack of impulse control and aggression is due to their previous
head injury, they may never be able to effectively use the skills the ART program
teaches. This can also lead to false failures in the program and frustration on the part of
the therapists (SCPIS, 2011). It may appear that the offenders are not taking the therapy
serious and not exhibiting sufficient effort. This may also frustrate the offenders because
they are exhibiting a great deal of effort, but it does not seem to work.
It is suggested that probation departments continue the ART therapy program and
others that aid offenders in dealing with impulse control and aggression, but add a
question or two to their intake assessments to determine if the offender suffered a head
injury at some point in their life where they were unconscious for 20 minutes or more. If
an offender states they have suffered a head injury, then the offender should be referred
to their physician for a MRI or CT scan to determine the severity of damage to
the brain. Once this information is known, the therapist and probation officer should
discuss the findings with the offender and his parent(s) to modify the offender’s case
plan to include the proper treatment. This will help the offender, the offender’s family,
and the legal system to fully understand the possible reasons for the criminal behavior
and aggression exhibited by the offender, thus relieving the system of the burden of
housing offenders that falsely appear to not respond to treatment or rehabilitation.
Traumatic brain injury can change the course of one’s life and the lives of their
families. The juvenile justice system consists of more than one victim. The juvenile,
more often than not, suffers from a poor home life or emotional problems, which causes
80
him or her to victimize someone else. The families of the victim and the juvenile usually
suffer as well. If more information was received and considered regarding TBI, the
suffering could be minimized for all parties concerned. This researcher strongly
recommends that probation departments throughout the United States utilize AHIT and
abide by the AHIT protocol to properly and effectively assess juveniles in their care
before their cases are resolved. The AHIT and AHIT protocol will only assist the
probation officer in becoming the most successful change agent they can be and improve
his or her ability to perform his or her duties, which is to protect the safety and security of
the community, as well as the injured juvenile.
81
APPENDIX A
Codification Key
SUBJECT
CODE
MEANING
Health
Y
Questions
N
Assessment specifically asks about health of
juvenile
Assessment does not ask about health
Sports
Y
Assessment asks if juvenile plays or played
Questions
N
Assessment does not ask about sports at all
Abuse
Y
Questions
N
Assessment specifically asks if juvenile has ever
been abused
Assessment does not ask about abuse of the
juvenile at all
(HQ)
(SQ)
(AQ)
Hospitalizations
Y
(HOSP)
N
Injury
Y
Questions
N
Assessment asks if the juvenile has spent more
than one day in the hospital
Assessment does not address hospitalization
Assessment asks if juvenile has had serious
injury
Assessment only asks if juvenile is currently
injured
(IQ)
Head
Y
Injury/TBI
N
(HI/TBI)
Assessment asks if juvenile has or has ever had a
serious injury to the head or suffered brain
damage
Assessment does not ask about injury to the
head or brain at all
82
APPENDIX B
Assessment Analysis
ASSESSMENTS
HQ
SQ
AQ
HOSP
IQ
HI/TBI
Y
Y
Y
N
N
N
YASI
Y
Y
Y
N
N
N
PACT
Y
Y
Y
N
N
N
DRAI
83
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