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TBI Guide for Criminal Justice Professionals

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Traumatic Brain Injury:
A Guide for Criminal Justice Professionals
Many prison and jail inmates are living with
traumatic brain injury (TBI)-related problems
that complicate their management and
treatment while incarcerated. Because
most inmates will be released, these
problems also pose challenges when they
return to the community. The Centers for
Disease Control and Prevention (CDC)
recognizes TBI in prisons and jails as an
important public health problem.

What is Traumatic Brain
•	 A traumatic brain injury (TBI) is
defined as a blow or jolt to the head
or a penetrating head injury that
disrupts the function of the brain.1
•	 Not all blows or jolts to the head
result in a TBI. The severity of such
an injury may range from “mild,” with
a brief change in mental status or
consciousness, to “severe,” with an
extended period of unconsciousness
or amnesia after the injury.1
•	 A study of young adults found that
those with a TBI were at risk for
sustaining another,2,3 and that a
history of multiple TBIs is associated
with slower recovery.4

How many people have TBI?
•	 Each year, on average 1.4 million
people in the United States sustain
a TBI. Of this number, 50,000 die,
235,000 are hospitalized, and 1.1
million are treated and released from
an emergency department.5
•	 At least 5.3 million Americans are
living with TBI-related disabilities.6
•	 The number of people with TBI
who are not seen in an emergency
department or who receive no care
is unknown.7

What are the causes of TBI?
•	 The leading causes of TBI are falls,
motor vehicle-traffic crashes, struck
by or against events, and assaults.5
•	 Blasts are the leading cause of TBI
among active duty military personnel
in war zones.8

What are the long-term
consequences of TBI?
•	 A person with a TBI can experience
short- or long-term problems,
requiring help in performing activities
of daily living.1,6
•	 A TBI can cause a wide range of
problems in thinking, sensation,
learning, language, behavior, and/or
•	 Persons with TBI may experience
mental health problems such as
severe depression,12 anxiety,13
difficulty controlling anger14 and
alcohol or substance abuse.15,16

•	 TBI can also cause epilepsy and increase
the risk for both Alzheimer’s and Parkinson’s
diseases and other brain disorders associated
with increasing age.9

What is known about the extent
of TBI and related problems
within the criminal justice system?
•	 According to jail and prison studies, 25-87%
of inmates report having experienced a head
injury or TBI17-19 as compared to 8.5% in a
general population reporting a history of TBI.20
•	 Inmates who reported head injuries are more
likely to have disciplinary problems during
•	 Inmates with head injuries may have
seizures19 or mental health problems such
as anxiety22 or suicidal thoughts and/or
•	 Studies of inmates’ self-reported health
indicated that inmates with one or more
head injuries have significantly higher levels
of alcohol and/or drug use during the year
preceding their current incarceration.22
•	 The U.S. Department of Justice has
reported that 52% of female and 41% of
male offenders were under the influence of
drugs, alcohol, or both at the time of their
arrest,24 and that 64% of male arrestees
tested positive for at least one of five
illicit drugs (cocaine, opioids, marijuana,
methamphetamines, or PCP).25
•	 Although more than half of prison inmates
have a lifetime history of drug use disorders,26
fewer than 15% receive substance abuse
treatment services while in prison.27
Women and Families:
•	 Female inmates who are convicted of
a violent crime, are more likely to have
sustained a pre-crime TBI and/or some other
form of physical abuse.28
•	 Children and teenagers who have been
convicted of a crime are more likely to have
sustained a pre-crime TBI29 and/or some other
form of physical abuse.29-31

•	 Among male inmates, a history of TBI is
strongly associated with perpetration of
domestic violence and other kinds of violence
during their lifetimes.32
Corrections and Law Enforcement Officers:
•	 Corrections personnel and law enforcement
officers are at risk for head injury or fatal head
•	 Interactions with suspects prior to arrest and
with inmates during their incarceration are
considered high risk situations for injury or
death due to head trauma.35

How might inmates with TBI and
others be affected by TBI-related
Within the correctional setting, TBI can contribute
to situations that lead to disciplinary action. Here
are some common TBI problems and strategies for
•	 Attention deficits may make it difficult for
the inmate with TBI to focus on a required
task or respond to directions given by a
corrections officer. Either situation may be
misinterpreted, thus leading to an impression
of deliberate defiance on the part of the
o	 Management strategies:
	 Ask the inmate to repeat what
you have said to confirm that
he or she has heard and
understood your directions
	 Encourage the inmate to write
down steps for the task
	 Allow extra time for the task to
be done
	 Clear or reduce environmental
•	 Memory deficits can make it difficult to
understand or remember rules or directions,
which may lead to disciplinary actions by jail
or prison staff.21
o	 Management strategies:
	 Explain rules or directions
slowly, step-by-step

	 Ask the inmate to repeat
the steps and encourage
him or her to write down the
	 Provide examples and ask the
inmate to provide his or her
	 Teach the inmate to ask
questions when he or she
doesn’t understand
•	 Slowed verbal and physical responses may
be interpreted by corrections officers as
uncooperative behavior.36,37
o	 Management strategies:
	 Give directions, or ask
questions, slowly; repeat if
	 Allow the inmate additional
time to respond
•	 Irritability or anger may be difficult to control
which can lead to an incident with another
inmate or corrections officer. Such incidents
can lead to further injury for the inmate with
TBI and others.37,38
o	 Management strategies:
	 Avoid arguing with the inmate
	 Try re-phrasing the problem,
breaking it down into parts
	 Reinforce positive behaviors
•	 Uninhibited or impulsive behavior, including
unacceptable sexual behavior, may provoke
other inmates or result in disciplinary action
by jail or prison staff.36,39
o	 Management strategies:
	 Tell the inmate calmly that the
behavior is unacceptable
	 Seek assistance from mental
health professionals

How can the problem of TBI in
prisons and jails be addressed?
A recent report from the Commission on Safety and
Abuse in America’s Prisons recommended increased
health screenings, evaluations, and treatment for
inmates and development of partnerships with
community health providers to assure continuity of
care and case management for released inmates.40

In addition, TBI experts and some prison officials
have suggested the following:
•	 Routinely screen jail and prison populations to
identify a history of TBI.41,42
•	 Screen inmates with TBI for possible
alcohol and/or substance abuse and
provide treatment for these co-occurring
•	 Conduct additional evaluations to identify
specific TBI-related problems and determine
how they should be managed.41 Special
attention should be given to impulsive
behavior, including violence,39 sexual
activity,36 and suicide risk if the inmate is

How should TBI-related problems
be addressed after release from
jails and prisons?
Lack of treatment and rehabilitation for inmates
with mental health and substance abuse problems
while incarcerated increases the probability that
they will again abuse alcohol and/or drugs when
released.25,44 Persistent substance abuse can lead to
homelessness,46 return to illegal drug activities,47 rearrest,48 and increased risk of death49 after release.
As a result, criminal justice professionals and TBI
experts have suggested the following:
•	 Community re-entry staff should be trained
to identify a history of TBI and have access
to appropriate consultation with other
professionals with expertise in TBI. 29,41,42
•	 Transition services should be capable of
accommodating the effects of an inmate’s
TBI upon their release and return to the
•	 Released inmates with mental health and/or
substance abuse problems should receive
case management services and assistance
with placement into community treatment
CDC supports new research to develop better
methods for identifying inmates with a history of TBI
and related problems and for determining how many
are living with such injury.

Further information is available from these websites:
Traumatic Brain Injury (TBI):

CDC, National Center for Injury Prevention and Control
This site provides information for professionals and the general public regarding TBI. Topics include
prevention, causes, outcomes, and research. Data reports on TBI in the United States and many free
publications and fact sheets can be downloaded. Materials are available in English and Spanish.

Health Issues in Correctional Settings:

CDC, National Center for HIV, STD, and TB Prevention
This site provides information for public health and criminal justice professionals about health topics with an
emphasis on infectious diseases in the correctional setting. It also includes materials for the general public
with links to related organizations.

Intimate Partner Violence (IPV):

CDC, National Center for Injury Prevention and Control
This site provides information for professionals and the general public regarding IPV. The site contains
an overview and fact sheet about IPV, prevention strategies, links to other IPV organizations, and a list of
current CDC publications.

Legal Issues of Persons with TBI within Correctional Settings:
National Disability Rights Network

This site provides information about the laws protecting the civil and human rights of people with disabilities
including those with TBI. Inmates with disabilities or their families can receive help from the Network about
inmates’ legal rights, access to mental health services and/or medication, and restoration of benefits upon

Substance Abuse:

Substance Abuse & Mental Health Services Administration
This site provides information for professionals and the general public regarding treatment resources for
persons with, or at risk for, mental health and/or substance abuse problems. It also has materials for specific
populations and age groups and hotlines.

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