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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.

 

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Insight

Now is the time to embrace better ways of working

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By Merryn Dowson, assistant psychologist and part of the team behind rehab goal-setting platform Goal Manager

A stitch in time saves nine. Rome wasn’t built in a day. The best things take time.

We are all too aware that some of the most important parts of our lives have been crafted, carved and developed over months and years. Consider your education, for example: you may well have been to primary school, secondary school and then sixth form college. Perhaps you went on to do an undergraduate degree.

You may even have taken another leap and completed a Master’s degree or a Doctorate. This took years. You learned, revised, sat exams, sat resits, applied for places, got results, got rejected, got accepted, and made it here.

One thing is certain: compared to all of this expertise, someone who completed a two-hour online course on the same topic does not come close. We know that putting time and effort into something gives us better results than if we tried a quick approach.

We do not always lead by this example though. Despite the knowledge that great results are only achieved through hard work and perseverance, sometimes we decide just not to bother. Often, a room in our home might look cluttered, worn down and unloved and it could be made to look incredible.

The walls could be painted, clutter cleared, carpet cleaned, furniture patched up, curtains updated, but it is so much effort. We see the effort it would take and keep living with it. It does the job. It’s fine.

We heard this a lot when we began to develop our software. Goal Manager was designed from within a clinical neuropsychology service with young people with acquired brain injury, and we recognised how goal setting was becoming an intimidating concept within our service and our colleagues across the field.

To combat this, we developed an online goal-setting platform which streamlines the key processes of goal setting into one system and allows members of multi- disciplinary teams (MDTs) to collaborate on goal data remotely.

Crucially, it was designed to fill a hole. The more daunting goal setting became, the more it was shied away from, and the guidelines for goal setting that had emerged from the literature were falling to the wayside.

While we designed our platform to save time on completing all of the gold-standard processes of goal setting compared to doing them manually, we found that people had often not been completing them at all. It was all too complicated.

As a result, we recognise that adopting a software solution like Goal Manager can come with its own problems to solve. It requires relearning a lot of
what we know about a concept like goal setting, understanding properly how these key processes work and how they can be applied clinically to benefit clients.

It is only then that you can start to think of ways to make it more efficient. To help with this, our users are offered bespoke demonstrations, guided MDTs through meetings to help with the clinical application of the data, and training on assessments and goal attainment.

This takes time. Our users are often throwing out their previous guide and writing a new one. When surveyed, however, every single one who responded said that it was worth it.

This brings us back to where we started: the best things take time; Rome was not built in a day; a stitch in time saves nine. By taking time to develop an understanding of goal setting and being able to apply it to a software solution, users experience all of the benefits of best-practice goal setting outlined in the literature both for their clients and for their teams.

Clients are motivated, rehabilitation is meaningful, important areas to address are highlighted, MDTs are focussed, clinical practice is evidenced – the list continues. None of this would have been possible without the initial investment of time.

While simple enough to read, this is no doubt overwhelming to apply to your service or practice and, with this in mind, there are some key points to remember. The most significant is that there is no better time than now.

The world is slowly opening its eyes, sitting up in bed and having a good stretch after the darkness of the Covid-19 lockdown. It is not yet certain if we are going back to snooze or if we are leaping out of bed afresh.

What we do know, however, is that we are heading into a brand new day. Even for those of us who continued in practice throughout the pandemic, services have been slightly paused in one way or another, whether that be refraining from home visits or having fewer people in the office.

We are all very aware that we are heading into the “new normal” rather than our old ways. Use this time to bring new and innovative ways of working into your practice. You might completely change your filing system, consider how you approach your waiting lists, or change how you approach MDT meetings.

Whatever you have been wanting to do for you and your service for so long, now is that time.

Perhaps you decide that you are going to welcome change but not all at once. That works too! For users of Goal Manager, we often suggest that starting with one or two clients might feel more manageable than a whole caseload.

This can help get to grips with the new concepts and ways of working without feeling like everything is completely disrupted. This applies elsewhere too. If you are wary of integrating a system into your whole service, start with one corner of it, evaluate, take what you have learned and then look to apply it more widely.

Finally, remember that all time taken to improve and grow impacts more than just what you set out to do. When people lose weight, they rarely conclude
by saying they just lost weight: they often enthuse about how they feel more energised or move easier or feel more positive or experience less anxiety.

This applies to any time you invest in developing your clinical practice or your service.

While time spent learning how to use Goal Manager and establishing it within a caseload is designed to improve goal setting, that investment also leads to improved assessment processes, more effective meetings, improved digital literacy, increased patient involvement and so much more.

The potential is enormous. To motivate you to start the process, look at what you want to achieve and how that might trigger other improvements.

While the world is still trying to drag its head off the pillow to open up the lockdown curtains, look to invest in addressing those needs you have always been aware of but never felt like you could justify the time.

Walk around your “house” and look into each room: is this the best it can be or could I give it a lick of paint?

Is now the time to bring meaningful solutions into my practice? Maybe grab a tester pot and try a new shade on the walls. Sign up for a free trial. Plan to grow and improve. Start building Rome.

To invest in improving your goal setting, visit www.goalmanager.co.uk to register for a live demonstration, sign up for a free trial or request a bespoke tour through the platform and its features.

 

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Researchers unlock key prognostic tool for brain injured patients

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In 1974, leading neuroscientist Graham Teasdale co-created the Glasgow Coma Scale (GCS) while at the Institute of Neurological Sciences in Glasgow. This scale has since been used to assess coma and impaired consciousness in patients who have had a brain injury.

The scale is used to describe variations in a patient’s eye, motor, and verbal responses. Each feature is assigned numerical scores depending on the quality of the response, and total scores range from three, which is a deep coma, to 15, which is full consciousness.

The GCS is used in clinics all around the world by physicians, nurses, and emergency medical technicians; and is also applied more widely in other, more complex systems that are used in assessing acute brain damage.

However, all three features of the GCS can’t always be determined in patients. Most commonly, the verbal response can’t be tested, as it’s not possible to determine this response in patients with severe brain injury who are intubated.

When the verbal score cannot be measured, the GCS can still be used in routine assessment and communication about a patient’s condition.

“The GCS should be reported in its component parts, so there is still useful information in the motor and eye components, and the verbal score can simply be reported as not testable,” Paul Brenan, senior clinical lecturer in neurosurgery at the University of Edinburgh says.

“The missing verbal score is problematic, though ,when determining the GCS sum score (eyes + verbal + motor). The sum score is used in clinical prognostic tools, such as the GCS -pupils score, so until now, missing verbal data has prevented clinicians from using these tools.”

But now, Teasdale and Brennan, along with Gordon Murray at the University of Edinburgh, have created a tool to use to assess impaired consciousness when the verbal component of the GCS is missing.

The researchers first examined a database of GCS assessments, and found that the verbal component of GCS was missing in 12,000 patients with traumatic brain injury (TBI), which made up 11 per cent of GCS assessments. These verbal scores were most often missing in patients with low eye and motor scores.

Using GCS data recorded in a database of 54,000 patients, the researchers calculated the distribution of verbal scores for each combination of eye score and motor score. They then combined GCS eye and motor scores into EM scores, and determined the distribution of verbal scores for each EM score. Based on this, they identified a verbal score that clinicians could impute for every EM score.

“Without the verbal component of the GCS, the GCS sum score (eyes + Verbal + motor) cannot be determined, so we developed this imputation tool to enable clinicians to benefit from these prognostic tools for decision making in patients with the most severe brain injuries, where the verbal score is not testable,”  Brennan says.

To test these imputed verbal scores, the researchers substituted imputed verbal scores for actual verbal scores within the framework of prognostic charts, which the authors had previously developed.

These charts take into account the total GCS score, pupil response, age of the patient, and findings of abnormalities. The charts provide predictions about patient outcomes, and are designed to help clinicians make decisions and communicate across teams.

The authors outline in their paper, ‘A practical method for dealing with missing Glasgow Coma Scale verbal component scores,’ published in the Journal of Neurosurgery, that they found that the information gleaned from imputing verbal scores according to each EM score was similar to the variations between precise eye and motor scores, and from full information on verbal, eye, and motor responses.

Imputing verbal scores doesn’t add new information, but allows clinicians to use prediction and prognostic models by filling in verbal data needed for those systems to work.

“We have developed several tools related to the GCS that enhance its ease of use and clinical application, including the GCS Aid, the GCS-pupils score and the GCS pupils Age CT prognostic charts,” Brennan tells NR Times.

“These have been designed to address specific needs. For example, the GCS Aid was developed to support training in assessment of the GCS and to enhance reproducibility of assessment. The GCS pupils score and prognostic charts provide a simple but robust prognostic tool that can be used in the clinic.”

“Prognostic scores are helpful for clinicians to get a reliable prediction of patient outcome, to inform clinical decision-making and to support communication with a patient’s family.

“We know from previous research that clinicians can tend to predict overly pessimistic outcomes for patients, particularly those with severe brain injuries, so these prediction models are designed to prevent that. With our imputation tool, the sum score can be determined and prognostic models used in real-time in the clinic.”

The researchers believe that being able to add verbal scores will help clinicians quickly determine the severity of acute brain injury and estimate patient outcomes.

“We know from the enquires we get and from the number of downloads of materials from our website, that these are very popular and are having a positive impact on clinical care around the world.

“We are confident this missing verbal score imputation tool will be just as positively received,” Brennan says.

 

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Insight

Update:concussion in sport

A run through the latest developments in concussion in sport research and protocols.

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A study published in the May 27 in the medical journal of the American Academy of Neurology, looked at a biomarker called neurofilament light chain, a nerve protein that can be detected in the blood when nerve cells are injured or die.

Levels of the protein in the blood were measured and it was found that those with three or more concussions had an average blood levels of neurofilament light 33 per cent higher than those who had never had a concussion.

“The main finding in the study is that people with multiple concussions have more of these proteins in their blood, even years after the last injury,” said study author Kimbra L. Kenney, M.D of the National Intrepid Center of Excellence.

“Additionally, these proteins may help predict who will experience more severe symptoms such as PTSD and depression. That’s exciting because we may be able to intervene earlier to help lessen the overall effects of concussions over time.”

Following on from our article on the game changing tests into concussion in children it has been found that concussions sustained by high school athletes continues to increase.

Injury data collected from 100 high schools for sports including football, volleyball and wrestling found that, between the academic years 2015 and 2017, the average amount of concussions annually increased 1.012-fold compared to the previous four academic years.

Approximately 300,000 teens suffer concussions or mild traumatic brain injuries each year while playing high school sports.

Wellington Hsu, M.D, professor of orthopedics at Northwestern University’s Feinberg School of Medicine said: “It’s understandable to think that with increased awareness among practitioners who diagnose concussions, the incidence would naturally rise; however because we’ve studied and reported on concussions for a number of years now, I feel that enough time has passed and I would have expected to see the numbers start to level out.

“What we found was that the overall average proportion of concussions reported annually in all sports increased significantly, as did the overall rate of concussions.”

The data also revealed that in gender-matched sports, girls seemingly sustain concussions at a higher rate than boys.

The effects of concussion in young people continues to be a key concern, with links between concussion and football, specifically when heading the ball leading to some big changes when it comes to training guidelines.

Coaches have been advised to update their rules connected to heading the ball in training, with no heading at all in the foundation phase for primary school children and a “graduated approach” to introduce heading training at under-12 to under-16 level. This guidance is expected to be issued across the continent later this year.

These new guidelines were recommended following a FIELD study, joint-funded by the English FA and the Professional Footballers’ Association, published in October last year, finding that professional footballers were three-and-a-half times more likely to die of a neurodegenerative disease than members of the general population of the same age.

The study did not identify a cause for this increased risk, but repeated heading of a ball and other head injuries have been identified as possible factors.

Dr Carol Routledge, director of research at Alzheimer’s Research UK, said: “Limiting unnecessary heading in children’s football is a practical step that minimises possible risks, ensuring that football remains as safe as possible in all forms.

“As such, measures to reduce exposure to unnecessary head impacts and risk of head injury in sport are a logical step. I would, however, like to see these proposals introduced as mandatory, rather than voluntary as present, and a similar approach to reduce heading burden adopted in the wider game of football, not just in youth football.”

A similar stance, that also includes restrictions during matches, has been in place in the US since 2015 after a number of coaches and parents took legal action against the US Soccer Federation.

There is clearly a need to educate coaches and athletes about the concussion recovery process while equipping physicians with quick diagnostic tools.

A partnership between Neurotechnology and brain health analytics player SyncThink and concussion education technology specialist TeachAids aims to offer the latest concussion education combined with mobile, objective measurement technology.

EYE-SYNC, which allows a clinician to use analysis to decipher between brain systems to determine whether a patient may be performing poorly or impaired, will create a brain health education and evaluation system based on the implementation of CrashCourse, an interactive educational module that teaches athletes, parents and coaches about concussions.

This implementation will be available to all SyncThink partners which include top athletic organisations and clinical partners providing medical care and education for over 10,000 high school and college athletes.

This implementation could make tracking those who receive concussion education easier while complying with sport governing bodies educational requirements.

SyncThink founder and medical advisor to TeachAids, Jamshid Ghajar said: “Using the SyncThink platform to feature the CrashCourse educational technology for athletes and coaches is brilliant.

“Now clinicians can use the Eye-Sync tests and metrics alongside CrashCourse’s latest evidence-based information on concussion.”

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