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Vital link in solving prison problem?

Offenders at every prison and probation setting in the UK should have access to a member of staff trained in brain injury signs and symptoms, experts have urged.

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“My head’s like a patchwork quilt under there,” says Wendy, an inmate at HM Prison Drake Hall in Staffordshire. “He beat me bad, bad, bad… I was just knocked out, unconscious, so many times.”

Before slipping into the criminal justice system, Wendy suffered domestic violence in a four-year relationship. She is now part of a damning statistic; more than six in 10 female offenders have a history of acquired brain injury (AB)).

This is according to research led by The Disabilities Trust, which found that of 173 female offenders at Drake Hall examined against the Brain Injury Screening Index, 64% had a history indicative of a brain injury.

The vast majority of injuries (96%) were traumatic, while a third were sustained before the individual committed their first known offence.

The Disabilities Trust’s findings follow the introduction of the charity’s Brain Injury Linkworker Service at the facility. The service provides support to women with a history of ABI, developing a “sustainable pathway” that supports rehab and helps prisoners to manage the transition between custody and the community.

From the women supported through the service, there were 196 reports of severe blows to the head – 62% of which were sustained through domestic violence.

Nearly half (47%) of the women with brain injuries had been in an adult prison five or more times and 33% sustained their first injury prior to their first offence.

Following its findings, The Disabilities Trust has called for linkworkers – or a similar role with a strong understanding of brain injury – to be accessible to all prisons and probation settings.

To date, the linkworker service has been rolled out into eight prisons, HMP Drake Hall, Preston, Leeds, Aylesbury, Bullingdon, Durham, Deerbolt and Cardiff.

An independent assessment of the charity’s research by Royal Holloway, University of London, found that women seen by the linkworker experienced improved mood and self-esteem, and enhanced confidence and positivity; key factors that have been previously identified as being essential for a woman to engage in rehabilitative programmes.

The linkworker service also offered practical guidance for staff working with women with a brain injury, and alleviated pressure from other service provision such as mental health.

It concluded that a brain injury linkworker service provides a strong framework which will benefit offenders and prisons by identifying and managing brain injury. Offenders helped by the service include ‘Sarah’ who says of her brain injury: “I was becoming very anxious about these problems that I was seeing …not remembering the names of the people I’d spoken to or not being able to express myself properly ‘cause I’m forgetting what I’m saying.”

Another, ‘Helen’, says: “When I was counting screws in the work area I had to count them three times. It gets me very stressed, like when people tell me ‘go and tell this person [something]’ and [I’m] forgetting it.”

As well as the rollout of a linkworker service, or something similar, The Disabilities Trust called for the inclusion of brain injury screening as a routine part of the induction assessment on entry to prison or probation services.

All prison and probation staff should also receive basic brain injury awareness training, it said. The charity also sought assurances that brain injury support would be aligned with “gender-informed” practice. It also recognised that further research is needed to examine the potential effect of brain injury on re-offending behaviour – as well as the role of neuro-rehab in contributing towards the reduction of re-offending behaviour.

The landmark Time for Change report, published in October, made similar recommendations. The report, by the All-Party Parliamentary Group for ABI, called for reforms to criminal justice procedures and processes to factor in the needs of people with ABI.

More ABI training for staff in the police, court, probation and prison services was also urged; as was brain injury screening for children and adults on entry to the criminal justice system. If a brain injury is identified, its impact, severity and related deficits should be measured and “appropriate interventions planned by a trained team”, the report said.

Also, it recommended that all agencies working with young people in the criminal justice system, schools, psychologists, psychiatrists, GPs and youth offending teams work together to ensure individual needs are addressed.

As the APPG report stated, evidence now emphatically links ABI to offending in young people, with prevalence rates for traumatic brain injury (TBI) as high as 60% in some studies (most recently, a 2018 comprehensive review published in The Lancet Psychiatry).

In comparison, UK brain injury charity Headway says only around one in 200 people in the general population has been admitted to hospital with a head injury.

But some experts have warned that it is misleading to suggest brain injury causes crime – and that crime/ABI links are highly complex and must be investigated further. Ryan Aguiar, consultant clinical neuropsychologist at Ashworth Secure Hospital in Liverpool, told the Guardian last year: “Brain injury does not lead to crime even though there are more prisoners with head injury and cognitive impairment per capita, or as a percentage, than there is in the general population.

“Crime is a much more complex condition that is brought about by a myriad of social, environmental, personality, mental health and situational circumstances.

“Head injury is only one among many and not even a first among equals.”

Similarly, Graeme Fairchild, a reader in psychology at the University of Bath, warned: “One of the main problems is that many of the risk factors for criminal offending and violence, eg. being male, coming from a low socioeconomic status background, having ADHD, being physically abused, and abusing alcohol and other substances, are also risk factors for sustaining head injuries, so it is very difficult to disentangle cause and effect here.”

Certainly there is an abundance of evidence of head injury prevalence in prison populations, even if studies unpicking the reasons for this link are lacking.

A 2015 study of 613 adult prisoners found that 47% reported a history of TBI when screened on admission to HMP Leeds.

It also found that 70% of those offenders reported their first injury before their first offence, backing up previous research linking TBI as a risk factor for offending.

In 2011, a 35-year Swedish population study led by psychiatrist Seena Fazel calculated that people with a head injury on their records had a 9% chance of becoming violent offenders. This compared to the general population average of 2.5%.

Recognising that brain injuries could be related to upbringing, the researchers also monitored the siblings of those with brain damage. They discovered a 4.5% chance of becoming offenders too.

There are numerous older studies linking head injury with the changing behaviour and lack of self-control that could theoretically lead to crime. Among them is a lengthy investigation into brain-injured Vietnam veterans in the US.

It evidenced increased aggression in many veterans who had damaged their frontal lobe in the conflict.

Public debate – and wild speculation – about ABI and crime has been fuelled over the decades by infamous examples of brain injured criminals.

Ian Brady and Fred West both reportedly had some experience of head trauma, while Ronnie Kray was almost killed at age nine by a head injury sustained in a fight with his twin brother Reggie.

No expert has ever suggested that their heinous crimes could be attributed to a brain injury but their medical history has at least raised questions about the impact of neurological injury on behaviour.

Aside from such conjecture, there is now hard evidence – and lots of it – to show a vastly disproportionate level of head injury in offender populations.

The criminal justice system and the many agencies that may interact with an individual on the slippery slope to prison have a series of recommendations they must address – and urgent action is needed.

A promising development in recent years has been Headway’s Brain Injury Identity Card scheme (read more on p20). It is designed to help the police identify brain injury survivors and ensure they are given appropriate support when they come into contact with the criminal justice system.

Brain-injured individuals carry a card which reads “My name is … I have a brain injury”. All the challenges they may experience as a result of the injury – such as fatigue, anxiety and information processing problems – are listed on the card.

The scheme was launched in 2017 with the backing of the NHS, the National Police Chiefs Council, the College of Policing, Police Scotland, The Police Service of Northern Ireland and the National Appropriate Adult Network.

Stories like that of ID card holder Dominic Hurley underline its practicality. He was arrested three times for being drunk and disorderly but in each case, he was simply showing symptoms of his brain injury. His card enables him to avoid these misunderstandings.

Meanwhile, events unfolding in the courtroom, particularly in the US, could potentially see brain injuries become a bigger consideration by jurors in years to come.

A number of papers, including that led by Owen D. Jones of Vanderbilt University in Tennessee, are recognising the growing role of neuroscientific evidence in court.

Jones references the story of Grady Nelson, who, in 2005, brutally murdered his wife Angelina. After stabbing her 61 times, he left a butcher’s knife embedded in her brain.

Later, his own life hung in the balance as the Florida jury that convicted him of murder next had to decide whether he would be executed or spend his life behind bars.

Nelson’s attorney offered to provide neuroscientific evidence, specifically quantitative electroencephalography (QEEG) introduced through the testimony of a neuroscientist, to suggest that Nelson had potentially relevant brain abnormalities.

The jury should hear this evidence, the attorney argued, because although it may not excuse Nelson’s behaviour, it should mitigate his punishment.

In order for wife-killer Grady Nelson to be sentenced to death, seven of the twelve jurors (a simple majority) had to vote in favour of executing him.

Only six did, so his life was spared by the narrowest possible margin. Following the vote, it appeared that the neuroscientific evidence had been crucial.

Two of the jurors who voted against executing Nelson told the press that the neuroscientific QEEG evidence had changed their minds, given that they had each initially favoured his execution.

One of them said: “It turned my decision all the way around. The technology really swayed me. After seeing the brain scans, I was convinced this guy had some sort of brain problem.”

The paper states: “It is becoming increasingly common for lawyers to offer neuroscientific evidence, particularly brain images, in both criminal and civil litigation. In our view, this development is both promising and perilous depending on whether and how well courts can come to distinguish, within the contours of distinctly adversarial proceedings, between justifiable and unjustifiable inferences.

“Neuroscientists have crucial parts to play in a legal system that needs to understand and interpret neuroscientific evidence and to separate the wheat from the chaff.

“The ability of neuroscientific techniques to shed light on important aspects of human cognition has generated hope that neuroscience can help to answer some perennial questions in courts of law.

However, one should keep in mind that it is easier to misunderstand or mis-apply neuroscience data than it is to under- stand and apply it correctly, and this is crucially important when lives and livelihoods depend on it.

Whether courts can successfully navigate these challenging waters will depend on the level of engagement by neuroscientists.”

Neuroscience in court is nothing new, but as brain mapping techniques and evidence on exactly how a brain injury can lead to crime becomes clearer, this development may well give ABI survivors a fairer deal in the criminal justice system.

 

Insight

Taking time to look back – so the way ahead is clearer

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Reflective practice within healthcare settings is widely talked about, but not always so easy to implement in the workplace. NR Times speaks to one neurological centre about how it benefits patients and staff there.

Reflective practice and discussion in healthcare settings is a professional requirement for nurses, as laid out by the Royal College of Nursing revalidation requirements as part of their continuous professional development.

It allows professionals to take time to pause and reflect, communicate and plan, which undoubtedly leads to better outcomes for patients and staff.

But in reality, reflective practice can often be left to the bottom of the pile, underneath many of the competing responsibilities facing staff who are often pressed for time.

It could be argued that this is also why reflective practice is so important – healthcare staff are facing so many pressures that it actually makes less sense to neglect the important work of individual and team reflection.

The Royal College of Nursing defines reflective practice as: A conscious effort to think about an activity or incident that allows us to consider what was positive or challenging and if appropriate
plan how it might be enhanced, improved or done differently in the future.

Staff at Elysium St Neots Neurological Centre in Cambridgeshire started doing regular, weekly reflective practices when its new hospital director, Fiona Box, came into the role a few months ago.

The nurses and healthcare assistants from a ward are invited into the meetings and in their absence the therapy staff monitor patients and provide activities.

“We thought it would be helpful for team members to give them the opportunity to think, learn, and to hear their opinions,” says charge nurse Jemima Vincent.

“If we have an incident with a patient, we discuss it in the session” she says.

Sessions are led by the management team, with added input from psychology teams on each ward.

They will talk through any strengths, weaknesses and opportunities, and work through an analysis to learn from the incident and create an action plan.

They talk about the worst-case scenario in relation to an individual situation and discuss how staff would manage that, so they’re better prepared in the event of it happening.

While they focus on one patient at a time, issues arise during conversations that bring in their wider experiences.

In an article* published in the Nursing Times in 2019, Andrea Sutcliffe, chief executive of the Nursing and Midwifery Council said: “In these challenging times for health and social care, it’s so important that collectively we do all we can to support our health and care professionals, and their employers, in devoting time to individual, reflective, personal and honest thinking.”

Fiona has received encouraging feedback from staff, who say the meetings help the staff feel much more involved in a patient’s care and allow the team to increase their knowledge and understanding resulting in a more consistent way of working.

“Healthcare workers often don’t fully understand patients’ diagnoses or why they’re reacting in a certain way, for example,” Jemima says.

“They know a patient presents with certain behaviours and may be taking medicine to help them cope but they’re not aware why the patient is showing signs of aggression and the best response to deescalate the situation,” she says.

“It’s a learning opportunity for staff, because reflective practice means that they can understand a patient’s diagnosis and why they behave how they do,” Jemima says.

“Reflective practice answers their ‘why’ questions, and gives them a more open mind.”

Jemima also benefits from the meetings; it’s a way for her to get to know staff better, especially when it comes to learning opportunities.

“I’m able to understand what level of support each member of the team requires, including training needs and if they need more knowledge on a specific topic.”

In her final year as a mental health nurse student on extended clinical placement at Elysium St. Neots, Jo took part in a reflective practice session.

She had just finished her dissertation, in which she looked at how settings can increase the opportunities and variety of reflective practices within hospital settings.

The aim of Jo’s session was to reflect on the recent deterioration in a patient’s mental state and the resulting impact on their well-being to ensure staff had a consistent approach to support the patient.

The hospital’s director Fiona asked the team about the patient’s care plan, diagnoses and needs and wishes.

Where staff were unsure of the answers to questions, Jo says Fiona gave them answers and encouraged the team to share their knowledge of the patient, problem solve and come up with an agreed plan to move forward with.

Jo found the session helpful and was impressed with how the healthcare assistants were so involved in the discussions about all aspects of the patient’s care, including the more clinical elements.

Healthcare assistants told her they found the session helpful too and that it made them feel like they had a better understanding of the patient’s changing mental state, behaviours and needs.

Jo says having the opportunity to reflect on practice is a crucial skill for all healthcare workers to help them learn from their experiences and increase self-awareness, which, in turn, can improve individual professional standards, strengthen teams and enhance patient-centred care and clinical outcomes.

For referrals to Elysium St Neots Neurological Centre or other Elysium centres visit: www.elysiumhealthcare.co.uk/neurological

Reference source: https://www.nursingtimes.net/news/ professional-regulation/nmc-highlights-importance-of-nurses- reflection-on-practice-18-06-2019/

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Robots and resilience at Askham Rehab

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NR Times reports on a new rehabilitation approach taking place in Cambridgeshire.

Despite a year of relentless change and upheaval for all involved in neuro-rehab, one provider in Cambridgeshire has been able to keep its ongoing development on track.

Askham Rehab, part of the Askham Village Community, is a recently-launched specialist rehabilitation service incorporating the latest in rehab robotics and sensor assisted technology.

While the firm has invested in state-of-the-art technology to do the heavy lifting, however, its rehab services remain person-centred, as director Aliyyah-Begum Nasser explains.

“We’re a specialist rehab centre in essence, and so, although the robotic technology helps us to get the most out of our patients and staff, we are very much family-focused.

The equipment is obviously fantastic but we know from experience that a person’s mindset, and their ability to sustain whatever improvements they make, comes down to the people who are supporting them – their family members.

“We’ve been on some real journeys with many of our family members who just didn’t understand the impact of a brain injury in terms of how it can impact behaviour or what it can do for cognition.

“Once they understand that, suddenly they become a lot more compassionate, and a lot more supportive; they become part of the recovery process, rather than being a frustrated observer.”

With recognition of the family’s paramount importance to recovery, Askham Rehab does everything within its power to harness this force – including by enabling families to stay together in specially-designed apartments on site.

Aliyyah-Begum says: “The flats are fully adapted, with cantilever cupboards, height-adjustable sinks in the bathroom and full wet room with turning spaces.

“We have the patients themselves participating in rehab, specifically to their programme, but relatives are also there from the beginning, seeing the improvement and being part of our process from the outset.

“We think of the centre as more of a rehab environment; it’s not a just care home with therapy as an added extra.

“So from the minute our patients wake up to the minute they go to bed, everything is based around their recovery goals, and everyone is working together towards achieving them.”

And robotics are an important tool in pursuing these goals through patient exercise. They help therapists to achieve the repetitions and intensity needed to progress their clients, as Aliyyah-Begum explains.

“The point of the robotics is that they respond to the patient. For example, if you set the machine on a left lower limb, but it senses that there is more pressure being exerted through the right limb than the left, it will automatically respond to make sure the patient is moving the correct part of their body.”

The centre’s head of rehab and nursing, Priscilla Masvipurwa, says: “This is a real a game changer in our approach to rehabilitation.

“Robotics help to bridge the gap, increasing the frequency and repetitiveness of treatment, something that’s an essential part of the process.

“We anticipate that this will enable us to support our patients in reaching their goals in a more efficient and sustainable way.

“The centre has so far invested in four items from robotic rehabilitation firm Tyromotion, but is looking to add more over time, as the benefit to both staff and patients becomes ever more evident.

Aliyyah-Begum says: “It’s really important to the team at the centre that the robotics aren’t just seen as an add on.

“There is a lot of nervousness about robots replacing therapists, but our service is still very much therapy-led.

“What this means in practice is that, where a resident would previously have had maybe an hour of therapy time in an afternoon, now you have an hour of therapy time, and then you can carry on exercising if you want to, or carry on playing games with other residents.

“For example, one of our machines, the Myro, enables patients to play games like bat and ball, or perform virtual tasks like sweeping leaves.

“However, because it is all sensor-assisted, if it senses that the patient needs to work a certain hand, it will alter what it is asking them to do accordingly, while they won’t even necessarily feel they’re having therapy – it’s all part of the game, and part of their socialising with other residents.”

Askham Rehab forms part of the Askham Village Community, on the edge of Doddington village, in Cambridgeshire.

It provides specialist care for people of all ages, offering day visits, respite care and continuing long-term support, both on-site or at home.

The site consists of five homes, three of which are specialist neurological facilities. In total, the neuro-rehab team can look after up to 52 patients at any one time, with 120 staff made up of rehab professionals and specialists.

The team comprises carers nurses, physiotherapists, occupational therapists, speech and language therapists and psychologists.

Aliyyah- Begum believes that the introduction of the robotic rehab services, combined with the patient-led therapy the group has been offering for 30 years, can only enhance the centre’s outcomes.

She adds: “We know that there is an increasing number of care homes that offer specialist therapy, but the difference with Askham Rehab is that we have embedded it into the whole culture of our setting – and the outcomes really speak for themselves.

“We often discharge people earlier than planned, and that’s a testament to the fact that the patients are really working hard with the team throughout their stay with us to achieve their goals – and that is the key.”

For more information about Askham Rehab, visit www.askhamrehab.com

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Astrocytes identified as master ‘conductors’ of the brain

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In the orchestra of the brain, the firing of each neuron is controlled by two notes – excitatory and inhibitory – that come from two distinct forms of a cellular structure called synapses.

Synapses are essentially the connections between neurons, transmitting information from one cell to the other. The synaptic harmonies come together to create the most exquisite music–at least most of the time.

When the music becomes discordant and a person is diagnosed with a brain disease, scientists typically look to the synapses between neurons to determine what went wrong. But a new study from Duke University neuroscientists suggests that it would be more useful to look at the white-gloved conductor of the orchestra – the astrocyte.

Astrocytes are star-shaped cells that form the glue-like framework of the brain. They are one kind of cell called glia, which is Greek for “glue.” Previously found to be involved in controlling excitatory synapses, a team of Duke scientists also found that astrocytes are involved in regulating inhibitory synapses by binding to neurons through an adhesion molecule called NrCAM. The astrocytes reach out thin, fine tentacles to the inhibitory synapse, and when they touch, the adhesion is formed by NrCAM. Their findings were published in Nature on November 11.

“We really discovered that the astrocytes are the conductors that orchestrate the notes that make up the music of the brain,” said Scott Soderling, PhD, chair of the Department of Cell Biology in the School of Medicine and senior author on the paper.

Excitatory synapses — the brain’s accelerator — and inhibitory synapses — the brain’s brakes — were previously thought to be the most important instruments in the brain. Too much excitation can lead to epilepsy, too much inhibition can lead to schizophrenia, and an imbalance either way can lead to autism.

However, this study shows that astrocytes are running the show in overall brain function, and could be important targets for brain therapies, said co-senior author Cagla Eroglu, PhD, associate professor of cell biology and neurobiology in the School of Medicine. Eroglu is a world expert in astrocytes and her lab discovered how astrocytes send their tentacles and connect to synapses in 2017.

“A lot of the time, studies that investigate molecular aspects of brain development and disease study gene function or molecular function in neurons, or they only consider neurons to be the primary cells that are affected,” said Eroglu. “However, here we were able to show that by simply changing the interaction between astrocytes and neurons — specifically by manipulating the astrocytes — we were able to dramatically alter the wiring of the neurons as well.”

Soderling and Eroglu collaborate often scientifically, and they hashed out the plan for the project over coffee and pastries. The plan was to apply a proteomic method developed in Soderling’s lab that was further developed by his postdoctoral associate Tetsuya Takano, who is the paper’s lead author.

Takano designed a new method that allowed scientists to use a virus to insert an enzyme into the brain of a mouse that labeled the proteins connecting astrocytes and neurons. Once tagged with this label, the scientists could pluck the tagged proteins from the brain tissue and use Duke’s mass spectrometry facility to identify the adhesion molecule NrCAM.

Then, Takano teamed up with Katie Baldwin, a postdoctoral associate in Eroglu’s lab, to run assays to determine how the adhesion molecule NrCAM plays a role in the connection between astrocyte and inhibitory synapses. Together the labs discovered NrCAM was a missing link that controlled how astrocytes influence inhibitory synapses, demonstrating they influence all of the ‘notes’ of the brain.

“We were very lucky that we had really cooperative team members,” said Eroglu. “They worked very hard and they were open to crazy ideas. I would call this a crazy idea.”

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