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2014 apa convention_presentation_08-07-14
This document summarizes a study that examined the relationship between traumatic brain injury (TBI) and substance abuse among prison inmates in a therapeutic community (TC). The study hypothesized that inmates with a history of moderate or severe TBI would have poorer health, cognitive performance, and program compliance compared to inmates without TBI. It assessed 213 inmates and found that those with moderate/severe TBI reported worse physical and mental health, and performed slightly worse on a simple cognitive test, but showed similar program compliance. It also found higher rates of reported TBI using a structured interview compared to prison records. The study provides initial evidence on the interactions between TBI and substance abuse in prisoners.
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2014 apa convention_presentation_08-07-14
- 1. TBI and SubstanceAbuse Correlates Within a Prison Therapeutic Community 2014 APA Convention Washington, D.C. Paper Session Scott R. La Point, MA, Doctoral Candidate Joseph Francis, Psy.D. and Linda Baum, Ph.D. 8/7/2014 1
- 2. Acknowledgments: Lakeview NeuroRehabilitationCenter American Psychological Association Regent University Joseph Francis, Psy.D. Linda Baum, Ph.D. John Corrigan, Ph.D. George Parkerson, Ph.D. James Brockington, Ph.D. My family - wife Amy and our three sons (Luke, Joshua & Samuel) 8/7/2014 2
- 3. Introduction • Between1.5 million to 2 million individuals are presently incarcerated in U.S. prisons and jails. (Bureau of Justice Statistics, 2012; Torrey et al., 2010) • TBI is an unrecognized problem in prisons and jails nationwide, with 25% to 87% of offenders reporting a history of TBI as compared to 8.5% of the general population. (Slaughter, Fann, & Ehde, 2003) • An estimated 155.9 million individuals identify as illicit drug users or drinkers of alcohol. (National Survey on Drug Use and Health, 2011) 2 8/7/2014 3
- 4. New Mexico 2Million New Hampshire 1.3 Million Wyoming 0.5 Million 8/7/2014 4
- 5. 1.7 Million 9Million Nebraska Georgia 8/7/2014 5
- 6. Background on TBI,SA • Alcohol and accidents – 50% of all TBI-related accidents involve alcohol use (Allen et al., 2010; Sparadeo, Strauss, and Barth, 1990) • TBI and Substance Abuse – Cognitive decline; TBI or SA? (Iverson, Lange, and Franzen, 2005) • Comorbidity – Major Depressive Disorder, anxiety, substance use disorders, impulsivity, and problems with executive functions (attention, memory, initiation) (CDC, 2010; Rimel et al.,1981) • Screening for TBI < SA or psychiatric disorders • Affect of TBI on functioning in a TC population 3 8/7/2014 6
- 7. Background on TBI • Controversies about TBI – Level of impairment not always representative of injury severity • mTBI and PCS – Small percentage of individuals with mTBI experience long-term deficits (McCrea, 2008) • Technology not the answer – Advancements have not led to better identification (Zhou et al., 2013) • Study rationale – Group parings: mTBI and no TBI 4 8/7/2014 7
- 8. Purpose of theStudy • The lack of research among offenders within a prison therapeutic community means that an exploratory study could yield important findings with implications on the importance of screening for TBI. • Improved identification of offenders with a history of TBI could enhance understanding of TBI-related problems within a prison TC. • This study sought to explore if having a TBI has an effect on offenders’ health, cognition, and prison performance. 5 8/7/2014 8
- 9. Hypotheses • Hypothesis1: Among offenders with a history of substance-related problems, measures of program compliance will be higher for those without a history of moderate/severe TBI. • Hypothesis 2: Among offenders with a history of substance-related problems, offenders with moderate/severe TBI will show evidence of greater problems with physical health and mental health as measured by the Duke Health Profile (DUKE) than will offenders without a history of moderate/severe TBI. • Hypothesis 3: Among offenders with a history of substance-related problems, offenders with moderate/severe TBI will perform less well on the Trail Making Test (TMT) than will offenders without a history of moderate/severe TBI. 6 8/7/2014 9
- 10. Hypotheses (cont.) •Hypothesis 4: Offenders who lack both a diagnosis of substance abuse/dependence and moderate/severe TBI will show better health indices on the DUKE, better program compliance, and perform better on the TMT than offenders with history of moderate/severe TBI and/or substance abuse/dependence. • Hypothesis 5: A higher percentage of offenders with a history of TBI will be identified through the use of a structured interview (Ohio State University TBI Identification Method) than indicated by self-report methods upon admission to the prison TC. 7 8/7/2014 10
- 11. Methodology • Participants – 213 offenders aged 18 to 65 • Procedures • Measures – Demographic Form – Prison TC Compliance Rating – Duke Health Profile (DUKE) – Trail Making Test (TMT) – Ohio State University TBI Identification Method (OSU TBI-ID) – Addiction Severity Index (ASI) 8 8/7/2014 11
- 12. Demographics • Age – Mean: 37 years • Date of birth • Ethnicity • Educational level • Marital status 8/7/2014 12
- 13. Data Analysis •Between-group design • SPSS Statistics 20 for Windows • Prior to Analysis – Preliminary examination included assessment of normality, outlier analysis, and descriptive statistics. – All assumptions met • Eager participants – Unexpected number 10 8/7/2014 13
- 14. Results • Hypothesis1 – Level of TBI not predictive of TC compliance • Virtually the same TC performance rating • Hypothesis 2 – Level of TBI predictive of physical and mental health • Moderate/severe TBI reported more problems • Hypothesis 3 – Level of TBI significantly affected less cognitively demanding task but not more difficult one • Moderate/severe TBI accounted for 3.4% of variance on TMT-A 11 8/7/2014 14
- 15. Results (cont.) •Hypothesis 4a – Cognitive Processing Speed (TMT) • Level of TBI significantly affected TMT-A but not TMT-B • Level of SA significantly affected TMT-B but not TMT-A • Hypothesis 4b – Physical and Mental Health (DUKE) • Level of TBI predictive of health problems – Moderate/severe TBI reported more problems • Level of SA not predictive of health problems • Hypothesis 4c – TC Compliance • TBI and SA not predictive of program participation 12 8/7/2014 15
- 16. Results (cont.) TC,DUKE and TMT Performance by Substance Use and TBI Status Substance Use History of TBI SU Problem (n = 165) (n = 151)1 No SU Problem (n = 48) (n = 43)1 Moderate/ Severe (n = 54) (n = 50)1 No Moderate/ Severe (n = 159) (n = 144)1 Domain M SD M SD F p η² M SD M SD F p η² TC Compliance 2.78 .433 2.75 .438 .25 .62 .001 2.76 .432 2.77 .435 .15 .69 .001 DUKE Physical 70.42 21.31 70.83 21.31 .097 .76 .00 65.00 22.38 72.52 21.77 4.21 .04* .020 DUKE Mental 68.24 23.50 71.04 22.99 .005 .95 .00 63.15 25.24 70.82 22.45 5.14 .02* .024 TMT-A 49.56 10.21 49.79 10.47 .020 .89 .00 46.40 10.13 50.72 10.08 4.75 .03* 0.24 TMT-B 47.62 9.48 44.42 11.78 3.94 .048* .02 44.82 9.82 47.64 10.12 3.38 .07 .017 TBI: Traumatic Brain Injury; TC: Therapeutic Community; DUKE: Duke Health Profile; TMT: Trail Making Test; 1Results for TMT-A and TMT-B only include participants whose ethnicity is African American and Caucasian; Note: * p < .05 13 8/7/2014 16
- 17. Results (cont.) •Hypothesis 5 – TBI identification • Higher percentage of offenders reported history of TBI on structured interview than indicated in prison records – 69.5% on OSU TBI-ID – 84.5% indicated “possible TBI,” “mild TBI,” and “moderate/severe TBI” 14 8/7/2014 17
- 18. Discussion • PrisonTC Compliance – Regardless of TBI history or substance abuse, rating virtually the same • Physical and Mental Health – TBI severity predictive of lower estimates of physical and mental health • Individuals with more severe TBI may experience long-term comorbid disorders or lifelong physical, cognitive, behavioral, and emotional disturbances. (Cohen, et al., 1999; Lucas & Addeo, 2006) 15 8/7/2014 18
- 19. Discussion (cont.) •Cognitive Processing Speed – Group differences; unexpected directions – Substance Abuse • No ready explanation for why offenders with SA performed better on the more demanding task • Practice effect? Concept formation practice (Corrigan, 2012) • TBI identification – Findings congruent with previous research – Prison records revealed only 11.3% of offenders indicated a history of TBI 16 8/7/2014 19
- 20. Limitations • Volunteerparticipants – Results cannot be generalized as broadly – “I’ve had a concussion, but…” – Participants in better health • Reliability of Duke Health Profile – Evidence of actual health problems? • Accuracy of offenders’ self-reporting – Health, TBI history (Schofield et al., 2010), and addiction severity • Validity and reliability of ASI – Systemic bias of ISRs 17 8/7/2014 20
- 21. Future Research •mTBI as its own category – Results possibly distorted by study’s grouping – A “no” TBI group? • PCS among offenders with moderate/severe TBI – Cognitive rehabilitation as an alternative treatment • Studying female offenders – Insights into prevalence, health of incarcerated women • More specific measure to rate offender compliance – Organic factors vs. personality characteristics 18 8/7/2014 21
- 22.
- 23. References Allen, D.,Frantom, L., Forrest, T., & Strauss, G. (2006). Neuropsychology of Substance Use Disorders. In P. Snyder (Ed.), Clinical neuropsychology: A pocket handbook for assessment (p. 649-673). Washington, DC: American Psychiatric Publishing. Bigler, E., & Maxwell, W. (2012). Neuropathology of mild traumatic brain injury: Relationship to neuroimaging findings. Brain imaging and behavior, 6(2), 108- 136. Bureau of Justice Statistics (2012, December). Prisoners in 2011. U.S. Department of Justice, Office of Justice Programs. Centers for Disease Control and Prevention (2010). Traumatic brain injuries in prisons and jails: An unrecognized problem. Retrieved November 13, 2010, from Centers for Disease Control and Prevention Web site: http://wwww.cdc.gov/traumaticbraininjury/pdf/Prisoner_TBI_Prof-a.pdf Cohen, R., Rosenbaum, A., Kane, R., Warnken, W., & Benjamin, S. (1999). Neuropsychological correlates of domestic violence. Violence and Victims, 14(4), 397- 411. Corrigan, J., & Bogner, J. (2007). Initial reliability and validity of the Ohio State University TBI Identification Method. Journal of Head Trauma Rehabilitation, 22(6), 318-329. 20 8/7/2014 23
- 24. References (cont.) Heaton,R., Miller, S., Taylor, M., & Grant, I. (2004). Revised Comprehensive Norms for an Expanded Halstead-Reitan Battery: Demographically Adjusted Neuropsychological Norms for African American and Caucasian Adults Scoring Program. Lutz, FL: Psychological Assessment Resources. Iverson, G., Lange, R., & Franzen, M. (2005). Effects of mild traumatic brain injury cannot be differentiated from substance abuse. Brain Injury, 19(1), 15-25. Lucas, J., & Addeo, R. (2006). Traumatic brain injury and postconcussion syndrome. In P. Snyder (Ed.), Clinical neuropsychology: A pocket handbook for assessment (p. 351- 380). Washington, DC: American Psychiatric Publishing. McCrea, M. (2008). Mild traumatic brain injury and postconcussion syndrome. New York: Oxford University Press. McLellan, A., Luborsky, L, Woody, G., & O’Brien, C. (1980). An improved diagnostic evaluation instrument for substance abuse patients: The addition severity index. The Journal of Nervous and Mental Illness, 168(1), 26-33 Parkerson, G., Broadhead, W., & Tse, C. (1990). The Duke Health Profile: A 17-item measure of health and dysfunction. Medical Care, 28(11), 1056-1072. 21 8/7/2014 24
- 25. References (cont.) Rimel,R., Giordani, B., Barth, J., Boll, T., & Jane, J. (1981). Disability caused by minor head injury. Neurosurgery, 9(3), 221-228. Schofield, P., Butler, T., Hollis, S., Smith, N., Lee, S., & D’Este, C. (2010). Are prisoners reliable survey respondents? A validation of self-reported traumatic brain injury (TBI) against medical records. Brain Injury, 20(5), 1-9. Slobounov, S., Gay, M., Zhang, K., Johnson, B., Pennell, D., Sebastianelli, W. … & Hallett, M. (2011). Alteration of brain functional network at rest and in response to YMCA physical stress test in concussed athletes: rsFMRI study. NeuroImage, 55(4), 1716- 1727. Sparadeo, F., Strauss, D., & Barth, J. (1990). The incidence, impact, and treatment of substance abuse in head trauma rehabilitation. Journal of Head Trauma Rehabilitation, 5(3), 1-8. Zhou, Y., Kierans, A., Kenul, D., Ge, Y., Rath, J., Reaume, J. … & Lui, Y. (2013) Mild traumatic brain injury: Longitudinal regional brain volume changes. Radiology. 22 8/7/2014 25
Editor's Notes
- #2 TBI and Substance Abuse Correlates within a Prison Therapeutic Community: While previous research has assessed offenders in a prison population, this is the first known study that examined the problem of TBI and substance abuse within a prison therapeutic community (TC).
- #3 TBI and Substance Abuse Correlates within a Prison Therapeutic Community: While previous research has assessed offenders in a prison population, this is the first known study that examined the problem of TBI and substance abuse within a prison therapeutic community (TC).
- #4 Between 1.5 million to 2 million individuals are presently incarcerated in U.S. prisons and jails. TBI is an unrecognized problem in prisons and jails nationwide, with 25% to 87% of offenders reporting a history of TBI as compared to 8.5% of the general population. Of the close to 2 million prison offenders, a half million to 1 and a quarter million report a history of TBI. In regards to substance use, according to the National Survey on Drug Use and Health, an estimated 155.9 million individuals identify as illicit drug users or drinkers of alcohol. What makes this figure noteworthy is the fact that problems with memory and nonverbal learning resolve slowly after cessation of drinking. However, difficulties with abstraction and problem-solving, perceptuomotor abilities, visual learning/visual memory, and contextual memory often persist. Furthermore, various drugs have different long-term effects on people, but whatever problems they experience are usually reversible.
- #5 Between 1.5 million to 2 million individuals are presently incarcerated in U.S. prisons and jails. TBI is an unrecognized problem in prisons and jails nationwide, with 25% to 87% of offenders reporting a history of TBI as compared to 8.5% of the general population. Of the close to 2 million prison offenders, a half million to 1 and a quarter million report a history of TBI. In regards to substance use, according to the National Survey on Drug Use and Health, an estimated 155.9 million individuals identify as illicit drug users or drinkers of alcohol. What makes this figure noteworthy is the fact that problems with memory and nonverbal learning resolve slowly after cessation of drinking. However, difficulties with abstraction and problem-solving, perceptuomotor abilities, visual learning/visual memory, and contextual memory often persist. Furthermore, various drugs have different long-term effects on people, but whatever problems they experience are usually reversible.
- #6 Between 1.5 million to 2 million individuals are presently incarcerated in U.S. prisons and jails. TBI is an unrecognized problem in prisons and jails nationwide, with 25% to 87% of offenders reporting a history of TBI as compared to 8.5% of the general population. Of the close to 2 million prison offenders, a half million to 1 and a quarter million report a history of TBI. In regards to substance use, according to the National Survey on Drug Use and Health, an estimated 155.9 million individuals identify as illicit drug users or drinkers of alcohol. What makes this figure noteworthy is the fact that problems with memory and nonverbal learning resolve slowly after cessation of drinking. However, difficulties with abstraction and problem-solving, perceptuomotor abilities, visual learning/visual memory, and contextual memory often persist. Furthermore, various drugs have different long-term effects on people, but whatever problems they experience are usually reversible.
- #7 Before getting into the study, I want to provide more background on TBI and SA, Among people with TBI, alcohol use is involved in more than 50% of all accidents. In fact, individuals with TBI are often intoxicated at the time of injury and have more chronic problems with alcohol than the general population. In regards to TBI and Substance Abuse, Iverson et al. (2005) reported that brain injuries are “two-to-four times more prevalent in alcohol abusers than in the general public and reflect a significant risk factor for cognitive decline independent of the effects of alcohol” In short, this study asks: Are offenders’ problems because of mTBI or Substance Abuse – or both? There is a High rate of comorbidity among people with TBI and/or substance abuse. Associated disorders that are more prevalent in the offender population than the general population include Major Depressive disorder, an anxiety disorder, impulsivity, Substance Abuse, and problems with Executive functions, such as attention, memory, initiation, judgment. It’s interesting that Problems being identified today by the CDC are the same ones that were first talked about by Rimel et al. as well as others more than 30 years ago. In regards to screening offenders for problems, Screening for psychiatric problems is routinely done, while screening for TBI is not. In light of the prevalence of TBI in prison, A central question becomes: How much does TBI affect areas of functioning in a prison TC, and will offenders with a history of TBI in addition to substance abuse perform less well on outcome variables than those with SA alone?
- #8 In the literature, controversies about TBI exist. For example, the level of impairment is not always consistent with the degree of an individual’s injury severity. Someone does not need to lose consciousness to have sustained a TBI of mild severity. Also, psychiatric problems typically follow those with moderate/severe TBI and less frequently following mTBI; and yet, someone with mTBI can have lasting deficits while someone with a moderate/severe TBI does not have any mTBI and PCS A small percentage of individuals with mTBI go on to experience long-term deficits or post-concussion symptoms, a condition commonly referred to postconcussive syndrome. McCrea reported that only 1% to 5% of individuals with mTBI end up having a neurologic explanation for their deficits. Other factors explain these problems better. Environmental, individual, familial, and the way someone was raised, among others, interact with neurologic factors to effect outcome from mTBI. Technology not the answer Advancements in neuroimaging have not always led to better identification of TBI. Zhou et al. (2013) found measurable global and regional brain atrophy in a small sample of concussed individuals one year after injury following a single concussion. MRI results revealed structural changes to the brain in regions associated with cognitive changes in attention, memory, and anxiety. Slobounov et al. (2011) reported that the brain might remain injured even after symptoms of a concussion have resolved and that neuropsychological tests might not detect these putative injuries. All of this bring us to a rationale for the groupings of the Predictor Variables for the Present Study Because of the fact that approximately 90% to 95% of individuals with mTBI do not suffer long-term deficits or dysfunction, this study separated those offenders with mTBI from those with moderate/severe TBI. In other words, the mTBI was group included those offenders who did not report a history of TBI, as it was believed that this group would not report more problems than those with a history of moderate/severe TBI.
- #9 The lack of research among offenders within a prison therapeutic community means that an exploratory study could yield important findings with implications on the importance of screening for TBI. Numerous studies have examined the prevalence of TBI within a prison population and called for better screening of TBI among offenders because of the emotional-behavioral challenges associated with brain injury. There has been no research, however, into how TBI affects an offender’s program compliance within a Prison TC. Thus, a study examining offenders with TBI could enhance understanding of TBI-related problems within a prison TC. Does having a TBI have an effect on health, cognition, and prison performance? That’s what this study attempted to find out.
- #10 It should be noted that the first three hypotheses have to do with substance-related problems, as opposed to substance abuse or dependence. For purposes of this study, offenders with a history of substance-related problems refers to those convicted of committing a drug-involved crime (1) while under the influence of a substance, such as driving under the influence, (2) that involved an illegal substance, such as possession, or (3) in order to obtain an illegal substance (i.e., breaking and entering). In short, these 3 groups included those both with and without substance abuse or dependence.
- #11 Hypothesis 5: A higher percentage of offenders with a history of TBI will be identified through the use of a structured interview (Ohio State University TBI Identification Method (OSU TBI-ID) than indicated by self-report methods upon admission to the prison TC. With Hypothesis 5, it was a qualitative study of a structured interview (Ohio State University TBI Identification Method) vs. recording of TBI history in prison records.
- #12 Participants In regards to participants, 21% of ICCC prison population volunteered to participate; 213 male offenders, aged 18 to 65 Procedures Regent Human Subjects Review Committee and the Virginia Department of Corrections Human Subjects Research Review Committee After the author obtained HSRC and DOC approval, offenders were solicited in groups of 60+ from the six housing units. Self-report measures were administered individually. The process of data collection took place over a six-month period. Consent was obtained and participants were told that they would not be paid and that their sentences would not be reduced. They were also informed that they could withdraw from the study at any time. Lead researcher trained eight assistants, all of whom were doctoral students in clinical psychology at Regent University. They were trained on how to conduct the various assessments and record the information on the data collections sheet. Measures A Demographic questionnaire was created to obtain data on participants’ age, date of birth, ethnicity, educational level, and marital status. Prison TC Compliance Rating: The Southeastern Virginia Prison TC uses a five-point Likert Scale to rank offenders’ compliance within the TC program. The ratings range from 1 (active resistance) to 5 (most favorable). Duke Health Profile: a 17-questions instrument that assesses six health domains; the present study utilized the physical and mental health indices; high scores indicate good health status. OSU TBI-ID: a semi-structured interview to assess lifetime history of TBI. It asks about events that involved a blow to the head or a brain-related trauma or medical event. It also asks about loss of consciousness, alterations in mental status, and age of each injury. Trail Making Test: A popular and brief test commonly used to measure psychomotor speed, visual scanning, and executive ability. It consists of two parts, with part A consisting of 25 encircles numbers, and Part B consisting of 25 encircled numbers and letters. It requires participants to connect the circles in an ascending pattern as quickly as possible. Raw scores (time to complete) are converted to T-scores based on norms addressing sex, education, age, and ethnicity (Heaton, Miller, Taylor, & Grant, 2004). Addiction Severity Index: Is an instrument administered as a semi-structured interview and uses a 10-point scale from 0 to 9. It provides two scores: the Interviewer Severity Ratings score and the Composite Score. The IRSs incorporates an Interviewer Rating Scale and a Client Rating Scale, which reflects offenders’ self-report of problems in various areas. In this study, the ASI drug and alcohol indices were used to denote whether offenders had a substance-use problem. Both Prison TC Compliance Rating and Addiction Severity Index scores were taken from prison records. The TC rating was the most recent, and the ASI scores for the drug and alcohol indices were used.
- #13 Demographic data indicated that 131 of the 213 male participants (61.5%) were aged 26 to 45. 212 or 60% identified as African American/Black, and 76 (35.7%) identified as Caucasian/White. Regarding education level, 3.3% attended only primary school to middle school, while one participant reported not having received any schooling. More than 50% received either their high school diploma (113) or General Equivalency Diploma (GED). Twenty six (12.2%) received some college. In regards to marital status, a majority was single (135: 63.3%), while 40 (18%) were married and 9 were separated (4.2%).
- #14 A between-group subjects design was used in the current study – Moderate/severe TBI and substance-related problems and those without; Moderate/severe TBI and substance-use problems (abuse/dependence) and those without (Hypothesis 4) Hypotheses were tested using quantitative data obtained through SPSS Statistics 20 for Windows. Preliminary examination included assessment of normality, outlier analysis, and descriptive statistics. All assumptions were met
- #15 Hypothesis 1 Level of TBI not predictive of TC compliance The presence of TBI did not significantly affect program compliance; offenders with moderate/severe TBI received almost the same TC performance rating as did offenders without moderate/severe TBI Hypothesis 2 Level of TBI predictive of physical and mental health Offenders with moderate/severe TBI reported more physical and mental health problems than offenders without severe/moderate TBI. Hypothesis 3 Level of TBI significantly affected less cognitively demanding task but not more difficult one History of moderate/severe TBI did not significantly affect the TMT-B scores, but it did have a significant effect on the TMT-A scores, accounting for 3.4% of variance on TMT-A Results indicated that offenders with moderate/severe TBI performed less well on TMT-A than offenders without moderate/severe TBI.
- #16 Hypothesis 4a Cognitive Processing Speed (TMT) Level of TBI significantly affected TMT-A but not TMT-B Level of SA significantly affected TMT-B but not TMT-A 4a: Results indicated that history of TBI had a significant effect on TMT-A, but did not significantly affect TMT-B. Substance use did not have a significant effect on TMT-A, but it did significantly affect TMT-B. Hypothesis 4b Physical and Mental Health (DUKE) Level of TBI predictive of health problems Moderate/severe TBI reported more problems Level of SA not predictive of health problems 4b: Results indicated that history of TBI had a significant effect on both physical and mental health. Substance use did not have a significant effect on physical health or mental health. The interaction between history of TBI and substance use did not have a significant effect on either one of the dependent variables individually. Hypothesis 4c TC Compliance -- Level of TBI and Substance Use not predictive of program participation Regardless of TBI history and history of substance use or abuse, rating was virtually the same.
- #17 Hypothesis 4: It was hypothesized that offenders who lack both a history of substance abuse or dependence and a moderate/severe TBI will perform better on a measure of processing speed/executive functioning, report better health, and receive better TC program-performance rating, than offenders with a history of moderate/severe TBI and/or substance abuse or dependence problems. Table of results for Hypothesis 4: 2X2 MANOVA with TBI and Substance Abuse as the independent or predictor variables with TC Compliance, DUKE, and TMT as outcome or dependent variables.
- #18 TBI Identification Higher percentage of offenders reported a history of TBI on the OSU TBI-ID than were found in prison records 69.5% vs. 11.3% Possibly as many as 84.5% if those with a “possible” (dazed and confused) were included
- #19 Prison TC Compliance Regardless of TBI history or substance abuse, rating virtually the same The five-point rating scale showed little variation among offenders, and as a result, most offenders either with or without moderate/severe TBI were rated similarly. With the general nature of rating criteria, staff may be less able to capture any significant differences between offenders by using the current measurement tool. Another potential reason for the obtained findings is the possibility that offenders with lower compliance ratings did not volunteer for the study. Perhaps they did not volunteer because they were not interested, or were already struggling with demands of the program and did not want to call further attention to their non-compliance. While it was unclear why offenders with moderate/severe TBI appeared to be performing as well as those without moderate/severe TBI, it is possible that the structure provided within a prison TC helps to ameliorate some of the problems that offenders experience, and that any difficulty they are having socially and/or psychologically is being addressed by the TC’s treatment approach (De Leon, 2000). Physical and Mental Health Research supports the finding of more physical and mental health problems among individuals with TBI. Although effect sizes were small, results indicated that offenders with a history of moderate/severe TBI and substance-related problems evidence greater problems with physical and mental health than do offenders without. As Cohen, et al. and Lucas & Addeo, reported, individuals with more severe TBI may experience long-term comorbid disorders or lifelong physical, cognitive, behavioral, and emotional disturbances.
- #20 Regarding Cognitive Processing Speed, there were Group differences BUT IN unexpected directions Moderate/severe TBI: Better on TMT-A but not TMT-B: Unknown why those with moderate/severe TBI did as well as those without moderate/severe TBI on a measure requiring greater cognitive flexibility Moderate/severe unexpectedly did not perform worse In regards to Substance Abuse and TBI Better performance on TMT-B by SA group No ready explanation for why offenders with SA performed better on the more demanding task A possible rationale for this is that offenders experienced a form of “rehearsal” effect on the simpler task. Perhaps they were “Primed” for the more complex task by the relatively easier and unfamiliar portion preceding it. If offenders can’t grasp what you are saying/explaining when telling them the directions seeing the actual paper with the letters on it can help a lot. Perhaps the novelty of the assessment artificially lowers the Part A score because they are trying to “wrap their head around” the concept. They learn the concept and get some visual feedback from doing the Trails A. So their score on Trails B is not as poor – delayed concept formation. TBI identification Findings congruent with previous research Prison records revealed only 11.3% of offenders indicated a history of TBI A disproportionate number of offenders are failing to report a history of TBI using the current system A more structured assessment tool is likely to capture a significantly higher number of offenders who sustained a TBI sometime in their lifetime.
- #21 Volunteer participants Results cannot be generalized as broadly because the participants did not come from a random sample; they signed up to participate It is also possible that many declined to participate, because, as one offender noted, “I’ve had a few concussions, but I’ve never had a brain injury.” Participants in better health than non-participants. They didn’t believe the study pertained to them. It’s also possible that Participants in better health than non-participants It is also possible that those who did not participate actually had a history of TBI or diagnosis of substance abuse/dependence Reliability of DUKE Aside from mixed findings for test-retest reliability, the DUKE has strong psychometric support. Still, perhaps a question on the physical health indices, which asked about “physical trouble or difficulty walking up a flight of stairs” is not suitable in an environment where walking up a flight of stairs is not an option of everyday life. An instrument designed for a prison setting might include content that is more specific to the offender population. Accuracy of Offender’s self-reporting As with any psychological assessment in which self-reporting is utilized, there is always the question of reliability of offenders’ reporting of problems. However, Schofield at al., indicated that offenders’ reporting of TBI is highly accurate when compared to medical records. Systemic Bias It’s worth noting that Several of the offenders’ ASI scores on the alcohol and drug indices were rated “0,” an indication that the interviewer rated the offender as having no substance-use problem. While such a finding could be accurate, a review of the literature calls into question the validity of the Interviewer Severity Ratings score (ISRs). Because of its subjective nature, the ISRs has been shown to be less valid than the objective Composite Scores.
- #22 1 mTBI as its own category Results possibly distorted by study’s grouping New groupings might produce different results Bigler & Maxwell reported that Because of the variability in functional outcomes among individuals with mTBI, some of these individuals may present with symptoms congruent with a more severe injury. 2 It would be worth studying post-concussion symptoms among offenders with moderate/severe TBI Although not without its critics, cognitive rehabilitation has shown some promise for individuals suffering with memory deficits and other cognitive problems (i.e., impairments of executive functioning, poor impulse control, and communication difficulties). Studying female offenders It is possible that they experience prison life differently and experience different problems with men Also varying Prevalence rates More specific measure to rate offender compliance Problems that are brain related vs. personality characteristics