Untreated Traumatic Brain Injury Keeps Youth in Juvenile Justice System

Traumatic brain injury (TBI) within youth, defined by the Centers for Disease Control and Prevention as an injury to the head that causes disruption of the normal function of the brain, is fast becoming an issue of concern for parents across the United States. High-profile incidents of TBI reported in professional athletes have sparked conversations on the safety of youth participation in a variety of sporting activities including hockey, boxing, soccer and full-contact football.

TBI that occurs during sporting events is only the tip of the iceberg. TBI also occurs frequently because of falls, motor vehicle accidents, fights and physical abuse perpetrated by adults. Hence, youth between the ages of 15 to 19 are one of the highest-risk groups to experience TBI, and the consequences of this high rate of TBI within youth are diverse and far reaching. TBI within youth have been shown to be associated with higher levels of anxiety, depression, attention deficit and hyperactivity disorder, attempted suicide, and abuse of alcohol and/or drugs.

Furthermore, TBI has also been shown to increase criminal behavior by youth and lead to their later involvement with law enforcement. A systematic review of research found that TBI is approximately three times more likely to occur within youth in the juvenile justice system relative to their nondelinquent peers. Therefore, we make an urgent call to action to all practitioners across the juvenile justice system to focus on TBI with evidence-driven assessment tools and interventions.

We believe, based on the prevalence of TBI and its known effects within youth in the juvenile justice system, that practitioners are increasing the likelihood for some of the most disadvantaged and marginalized youth to repeatedly fail by not adequately addressing TBI. Repeated failures will contribute to a destructive cycle of criminal behavior that causes harm both to the youth and society at large. For the youth with TBI adjudicated multiple times, instability and stigmatization accumulates with each encounter, thus further alienating the youth from pro-social opportunities. For society, the cost of additional crime and incarceration of youth with TBI contributes to the already high price that local and state government pay to ameliorate crime.

The first step to address TBI is the systematic assessment for it within all youth who enter the juvenile justice system. Practitioners must accurately assess for a problem in order to understand it, and TBI is no different. The traditional means of assessment has primarily included a single yes or no question asking the youth whether he or she has experienced any head injury that caused them to black out or lose consciousness. However, the use of a single question gives a very truncated view of an individual’s TBI history and it fails to differentiate the severity of lifetime TBI experiences.

Instead, practitioners in the juvenile justice system should adopt evidence-driven assessment tools that provide a systematic method to capture an individual’s TBI history. Two assessments that have been tested for accuracy are the Ohio State University TBI Identification (OSU-TBI-ID) method and the Traumatic Brain Injury Questionnaire (TBIQ). The OSU-TBI-ID is a structured interview process that guides a practitioner to probe all significant medical injuries experienced by a youth in their lifetime in order to identify and further elucidate those that involved the head, neck or high-velocity forces.

An important gap not adequately addressed by many of the assessments of TBI is how to capture the occurrence of mild TBI. Existing assessment tools primarily focus on head injuries that either led to the seeking of medical attention or a loss of consciousness.

However, it is estimated that approximately 85 percent of all TBIs are never documented because they do not result in a loss of consciousness or require medical attention. While any one mild TBI is likely to not result in anything worse than short-term headache or dizziness, the accumulation of multiple mild TBIs has the potential to result in similar consequences to that of a more severe TBI. Therefore, we believe that practitioners should supplement either the OSU-TBI-ID or the TBIQ with a question about injuries to the head or neck that resulted in disorientation, dizziness, confusion or a dazed state.

Beyond simply identifying a history of TBI with the systematic assessment of all youth in the juvenile justice system, practitioners also need to implement evidence-driven interventions to help youth be successful long term. In particular, interventions that focus on coping skills and executive functioning — or cognitive abilities that include cognitive flexibility, inhibition, working memory, problem solving and goal-directed behavior — have the potential to provide important benefits for youth in the juvenile justice system.

Interventions that have undergone evaluation and shown promising results are the Coping Skills Group, Goal Management Training and the Attention Improvement and Management Program. For example, Goal Management Training is a low-cost, straightforward intervention that provides a structure for youth with TBI to think about their thinking (i.e., metacognition) and execute goal-directed behaviors in their daily living. Each of these interventions could easily complement treatment modalities already shown to be effective with youth in the juvenile justice system, such as cognitive behavioral therapy.

Overall, the prevalence of TBI among youth in the justice system is an important issue that requires an urgent call to action for all practitioners who work with juvenile delinquents. There absolutely must be widespread implementation of evidence-driven assessment and intervention to address TBI throughout the juvenile justice system. Failure to act on this issue will continue to relegate thousands of youth every year to a lifetime of further hardship and disadvantage. We have the tools to address TBI and we must act.

Tanya Renn is a National Institute on Drug Abuse T32 postdoctoral fellow at the Brown School of Social Work and works with the Institute for Advancing Justice Research and Innovation.

Christopher Veeh is a research assistant professor working for the Institute for Advancing Justice Research and Innovation at the Brown School of Social Work.