Once a person with TBI is behind bars, arguing for a chunk of shrinking budgets to help them out is not always an easy sell. In South Carolina, for example, once a person is identified as having TBI, the department of corrections is obligated to provide extra resources for them. "It's cheaper for them to just lock them up," Pickelsimer says.
In her estimation, "the intervention has to be when they are much younger"—before they commit a crime, by encouraging teenagers to stay in school and not have children until they are prepared to provide and care for them. By doing that, she says, the next generation will be less likely to fall into a cycle of injury and crime.
Gordon would extend this early intervention to screening, too. In his research on TBI in substance abusers, participants who had multiple brain injuries tended to be in their 30s. But, he says, "the average age when they had their first injury was 14." If their injury had been identified—and they had received any necessary assistance—earlier, future substance abuse and behavioral issues might have been avoided altogether. This, he says, is an example of "using screening and identification as prevention—and what you're preventing is social failure." That social failure due to TBI is not limited to the corrections world, he notes: "In any group of folks who are failing—substance abuse, the hardcore unemployed—I would say, the prevalence of TBI is very high." Early diagnosis does not necessarily require expensive intervention, he says.
Treatment for those already in trouble can also start younger. An experimental program in El Paso, Texas, adapted a TBI cognitive treatment program for juvenile offenders. The goal was "to try to teach them how to be in touch with their own sensations and activities so they can learn to stop and think before they act—and then consciously choose a choice and evaluate whether that was the right choice," Gordon explains. When administered to kids—both those who had a history of TBI and those who did not—there was a fivefold reduction in recidivism, he reports.
The Traumatic Brain Injury Act of 1996 carried provisions to help reduce the incidence of TBI and improve psychological treatment, and in 2000 it was expanded to include education about prevention—especially to parents. A 2008 reauthorization of the act added a mandate to study TBI prevalence among institutionalized populations, which includes prisons but also nursing homes and other institutions where people reside. But studies have been slow to materialize. Minnesota is currently assessing data from their prison population to determine how much TBI affects substance abuse treatment completion, use of medical and mental health resources, and rates of recidivism.
One of the first steps to better understanding TBI in these populations, however, is to boost screening—as well as ensure that such monitoring is scientifically sound and widespread. And just demonstrating the value of screening might take years, Desrocher says. Her hope is that down the road, the data show that it is "not only [of] clinical value for the individual—but also a value for society."