A car accident, a rough tackle, an unexpected tumble. The number of ways to bang up the brain are almost as numerous as the people who sustain these injuries. And only recently has it become clear just how damaging a seemingly minor knock can be. Traumatic brain injury (TBI) is no longer just a condition acknowledged in military personnel or football players and other professional athletes. Each year some 1.7 million civilians will suffer an injury that disrupts the function of their brains, qualifying it as a TBI.

About 8.5 percent of U.S. non-incarcerated adults have a history of TBI, and about 2 percent of the greater population is currently suffering from some sort of disability because of their injury.

In prisons, however, approximately 60 percent of adults have had at least one TBI—and even higher prevalence has been reported in some systems. These injuries, which can alter behavior, emotion and impulse control, can keep prisoners behind bars longer and increases the odds they will end up there again. Although the majority of people who suffer a TBI will not end up in the criminal justice system, each one who does costs states an average of $29,000 a year.

With more than two million people in the U.S. currently locked up—and millions more lingering in the justice system on probation or supervision—the widespread issue of TBI in prison populations is starting to gain wider attention.

A few pioneering programs offering rehabilitation to prisoners—and education to families and correctional staff about TBI—are underway around the country. And several studies aim to ascertain the best ways to handle this huge population. "It's not as cut-and-dry as a lot of people think," says Elisabeth Pickelsimer, an associate professor at the Medical University of South Carolina. Some of the best options so far include cognitive therapy for prisoners and education for the people around them.

The kicker seems clear to many researchers: "If we don't help individuals specifically who have significant brain injuries that have impacted their criminal behavior, then we're missing an opportunity to short-circuit a cycle," says Peter Klinkhammer, associate director of services at the Brain Injury Association of Minnesota.

One hard knock
Concussions are the most common type of brain injury, and about 85 percent of people who suffer one will more or less fully recover within a year. But for those who do not, lingering symptoms, such as headaches or increased irritability, can get in the way of everyday functioning.

Many of the behavioral issues that result from a TBI are due to the nature of the impact itself. In an accident or altercation, the brunt of the blow is often borne by the front or top of the head—right around the frontal lobes where behavior is regulated.

Interactive by Ryan Reid

This sort of injury can be loosely compared with a computer glitch: "If something went wrong with the central processing unit, it might be slower—you couldn't save documents as easily—but it might chug along," says Wayne Gordon, a professor of rehabilitation medicine at Mount Sinai School of Medicine. Traumatic brain injury can lead to attentional and memory deficits as well as increased anger, impulsivity and irritability—which make for a poor match with the corrections world.

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.

Bad behavior
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.

The behavioral and other cognitive changes that TBI can bring, "if left unaddressed, are apt to provide challenges to the offender post-release as they attempt to reintegrate into their respective communities," notes Adam Piccolino, a neuropsychologist for the Minnesota Department of Corrections.

Bridge to the outside
Treating TBI in the broad adult population is not a perfect science. The goal is to "supply them with skills they need to better regulate their behavior and process information," Gordon explains. It often involves cognitive retraining and rehabilitation—and has imperfect results. And as he points out, these therapies have yet to be thoroughly tested on incarcerated populations.

Others argue that tools that seem to work in the broader population should be used in prisons as well. Cognitive rehabilitation therapy is one such tool that seems to be gaining traction in the TBI field. It aims to help those TBI sufferers make better-informed choices and to improve memory. And with such minimal knowledge about TBI and its symptoms, simply educating inmates about their—and others'—condition might go a long way in helping them cope with related challenges, Desrocher says.

Even with proper education and therapy, though, people with TBI will often experience behavioral issues. So many groups have put an emphasis on training staff—and even arresting officers—to handle these sorts of prisoners better in hopes that they "can recognize a behavior for what it is—and not defiance of an infraction of the rules," Maltman says. Resulting altercations can put law and corrections staff—and fellow prisoners—at risk for injury.

But knowing which prisoners might benefit from alternative approaches requires thorough screening processes that are either highly variable across institutions or entirely absent. "Additionally," Piccolino notes, "once an offender is identified with having incurred a TBI, the process of knowing whether they also experience ongoing complications related to their TBI is challenging."

Some organizations, such as the Brain Injury Association of Minnesota, have gone a step further and are also working with prisoners' family members, probation officers and outside support services to ready ex-convicts for release. Klinkhammer notes that for prisoners with TBI, returning to the outside world can be an extremely difficult transition. Once predictable prison routines disappear, he explains, it's almost like Dorothy going from her black-and-white reality in Kansas to the colorized world in Oz. Although that shift might sound like a blessing, for those with a brain injury who have difficulty managing their reactions or processing a lot of incoming information quickly, the new environment can be too much. "It can be very overwhelming, and it could result in one or more reason for a person to 'recidivize'"— do something that will land them back in jail, even if they had no intention of breaking the law— Klinkhammer says.

Much of his group's efforts come down to education and helping family and other community members learn how to support a prisoner with TBI returning to the outside world. And oftentimes just explaining to them that an old injury might be contributing to unpredictable behavior is a big help. "People know that their loved one's been knocked out" or were in a car accident years before, Klinkhammer says. "But the thought that the outcome of that may result in disinhibition or that it could be an aggravating factor to a person's criminal behavior gets lost."

The group does not yet have formal data on the success of the program, but from his observations, Klinkhammer says, "individuals are doing better when they are able to dovetail back into society in a way that they're supported." The key is "making sure that when people step out into the community they're not falling into an abyss," he says. And "in doing that, we're also helping society at large stay safer."

Earlier intervention
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."