One of the big challenges in addressing TBI in prison populations, and beyond, is that it is not as easy to diagnose as a broken bone or a blood-borne illness. Symptoms are by no means unique to the injury and can be co-occurring with other mental health conditions. To make things even tougher for those hoping to track the disability, no two brain injuries are alike. "Two people can have the same injury and have a totally different set of impairments," Gordon says. "One can be fine, and one can be not so fine—but we don't know why that is yet." He suggests that differential responses could be due to a combination of physical, genetic, contextual and social factors, such as skull thickness, the magnitude of g-forces involved in the impact or past history of more minor, sub-concussive injuries.
Due in part to these variables, not all TBIs result in a medical paper trail. Doctors treating people with serious wounds might miss diagnosing a brain injury, and hospitals do not always code for every presenting condition. Also, many people who suffer a head injury, especially a milder one, such as a concussion, might not seek medical attention at all.
Researchers have started using detailed interviews with prisoners to get a better sense of how many have suffered from a brain injury. In a recent South Carolina survey of 636 prisoners, some 65 percent of males and 73 percent of females reported having sustained TBIs at some point in their lives. Injury counts are likely underestimated. Many people, for example, are unaware of injuries that they might have sustained when they were babies or young children. And even adulthood injuries were not entirely clear to prisoners. "They were told they had their bell rung—they got knocked out," says Rebecca Desrocher, assistant program director at the U.S. Department of Health and Human Services's Federal Traumatic Brain Injury Program.
The very nature of brain injuries can also make tracking them—and figuring out how many an individual might have suffered—especially difficult. As Pickelsimer points out, "after you've had some, you don't remember them as clearly." These injuries are additive, with each assault to the brain compounding damage from the previous ones. The average reported number of TBIs for an individual prisoner was about four, Pickelsimer says. And some reported up to a dozen.
Through these interviews, Pickelsimer says, another thing became clear: prisoners were often not aware that a single event—or a series of them—could be making it harder for them to earn a ticket out of jail, or avoid being sent back in the future.
As much as TBI seems to increase the likelihood that a person will wind up in prison, it also seems to make the corrections environment that much more difficult to navigate. In prison, "there's so much that goes on a day-to-day basis: 'Line up over here; do this; do that,'" says David Maltman, a policy analyst at the Washington State Developmental Disabilities Council. When a prisoner with TBI is misremembering rules or is slow in responding to instruction, many prison staff are likely to see a prisoner as noncompliant or intentionally defiant, provoking situations that can lead to further injury—or at least poorer chances at an early release.
Brian injury also increases the likelihood that people will have other mental health troubles, including substance abuse, and can also make it more difficult to overcome additional conditions. In a survey of adults enrolled in a New York State substance abuse program, about half had a record of TBI, Gordon says. The screening that Pickelsimer and her colleagues have done in South Carolina found that for both men and women, alcohol and crack cocaine were among the most common substances to which TBI prisoners were addicted. And these habits can cloud a person's memory of brain injuries they might have suffered in accidents, altercations or other incidents, which makes accurate diagnosis even more challenging. For those getting substance abuse treatment, a TBI can also make traditional rehab programs less effective. With the "reduced processing speed and their memory challenges," Gordon says, lessons might need to be altered or even repeated for enrolled prisoners with a history of TBI.