Keeping Children in Society:
Youth offending and
aquired brain injury.
Dr James Tonks & Prof. Huw Williams.
*School of Psychology
University of Exeter
Centre for Clinical Neuropsychological Research (CCNR)
Brain development in children and adolescents: Insights from anatomical
magnetic resonance imaging
Rhoshel K. Lenroota and Jay N. Giedd (2006)
•dorsolateral prefrontal cortex
•late to reach adult levels of
•circuitry sub-serving control of
impulses, judgment, and
•implications of late maturation of
this area have entered
educational, social, political, and
Yates, Williams et al. 2006, JNNP:
Attendance rates for moderate to severe head injury per
100 000 population for each 5 year age band by sex and area
residence (GCS under 12).
Rate per 100,000 popn
MIXED RURAL - Female URBAN - Female MIXED RURAL - Male URBAN - Male
Nb. Rates of TBI (across all severities) in males across severities are given as between 5% to 24%
250-450 per 100,000 across all severities (US/UK) - 80% approx are MILD
Traumatic Brain Injury (TBI)
Glasgow Coma Scale Loss of Consciousness Post Traumatic
Mild 13-15 <30 mins < 24hrs
Moderate 9-12 >1 to <7 days >30mins-<24 hrs
Severe 3-8 >7 days >24hrs
Traumatic brain injuries:
Closed Injury Penetrating injury
Brain Areas that typically Injured…
frontal-tempo-limbic systems are crucial for
Monitoring arousal level & control of behaviour
towards “goal states”
Moderate to Severe TBI
Neuropsychological deficits, behavioural
problems and poor social outcomes (Stambrook,
Moore , Peters Deviaene & Hawryluk, 1990).
poor planning and inflexibility (Milders, Fuchs
& Crawford, 2003)
“poor anger management (irritability and
impulse control are common” (Hawley et al.
Nb. Limbic systems more vulnerable in children
When “complicated”, or cumulative, there
can be neuropsychological sequelae (15%?),
esp. attention and executive systems
(Williams, Potter & Ryland, 2010).
Childhood Brain Injury: long term effects
Problems: Attention, working memory, executive control disinhibition etc.
• lack of “moral” reasoning.
(Damasio 1996; Anderson, Bechara, Damasio, Tranel, & Damasio, 1999; Hanks, Temkin, Machamer & Dikmen
1999; Levin & Hanten, Powell, 2004).
• Often there is inappropriate social behaviour
• the most common and disruptive issue (Henry, Phillips, Crawford, Theodorou &
• may not be evident until adolescence (Lishman, 1998; Teichner & Golden, 2000)
• point at which ‘delayed costs’ of earlier ABI are expressed (see Anderson 2008 re:
neuroplasticity & crowding effects)
• may occur in isolation from cognitive deficits (Anderson, Northam, Hendy &
persisting personality and emotional deficits – due to de-coupling of cognition and
emotion - has been described by Damasio (1994), as “acquired sociopathy”” –
Max et al, 2001: prospective study of 94 children with TBI aged 9 at time of injury
OPC in 57% of severe TBI sample (22/37) & 5% mTBI (3/57)
labile and aggressive OPC subtypes most common - 3-4 x more
Problems MIGHT also occur post
Wrightson, McGinn and Gronwall (1995)
pre-school children - MTBI tested after injury and
then at 6 months and a year (V. orthopdeic control
no differences after injury on a range of cognitive
But, at 6 months and then at 1 year, the MTBI
children less good on visual problem solving and
association with further injury.
Limond et al. 2009
follow up of moderate-severe and (mostly) complicated
MTBI showed persisting disabilities at 1 year –
>lack of pro-social behaviour and emotional symptoms
Hessen et al, 2007 (BI) – 23 year follow up study of MTBI –
role of (longer) PTA as a predictor of outcomes – SUBTLE neuropsych impairments
Long-term behavioural outcomes of pre-school mild
traumatic brain injury
A. McKinlay1,*, R. C. Grace1, L. J. Horwood2, D. M.
Fergusson2, M. R. MacFarlane (2010)
longitudinal epidemiological study of a
birth cohort of 1265 children born in
Christchurch (New Zealand) urban region
Groups: MTBI “hospitalised” “Not
hospitalised” and “No-Injury”
• data obtained yearly from age 7 to 13
• evidence of deficits after inpatient
MTBI (n = 21) compared to ctrls
• increasing deficits over years 7–13.
• Mother/teacher ratings for: attention
deficit/hyperactivity disorder and
oppositional defiant/conduct disorder
The Role of Theory of Mind and Empathy
Theory of Mind (ToM):
to attribute mental states to others, to
know they have beliefs, desires and
intentions that are different from one's
(? Cognitive empathy (see Shamay-Tsoory,
2009 - VPC) )
to recognise or understand another's state
of mind or emotion & “co-experience”
their outlook or emotions within oneself
"putting oneself into another's shoes”
“I feel what you feel” (IFG)
Sophisticated levels achieved during
Pre-requisite – processing of other’s basic
Emotion reading skills are developed across the span of childhood into late adolesecence.
From birth Intrinsic bipolar emotional
related to arousal - distress and pleasure
6? months - primary emotions - surprise,
interest, anger, sadness and fear
From 1 yr Girls ‘empathising’ , by 3 Theory
of Mind - boys slightly later
By 7-9 Complex theory of mind (e.g. We were both, in our own
Detecting faux pas) (see Baron-Cohen et al, way, manipulators — good
1999). at grasping the feelings of
others and instinctively
Continues to develop in late adolescence playing on them.
(14-17 yrs (ToM) (Dumontheil et al in press)
Tony Blair, as reported in
Development is non-linear - rapid the Guardian, 1/9/10
development associated with growth of the
prefrontal cortex, (see Tonks et al. 2009)
Theory of Mind (complex) & Critical age of injury
Theory of Mind mean score
25 young adolescents (10 to
Boys 15yrs) with a history of ABI,
50 typically-developing (TD)
10 Global impairments
Poorer empathic responding
BI TD Less accurate ToM
Parental reports of poor
emotion recognition and
Self-reports of poor emotion
recognition and empathy
+ executive impairments
40 (DEX-C + EF measures),
increased daily difficulties and
Birth to 2 2 to 6 6 to 12 +
Age at injury (years) Borderline/impaired
The National Picture
No common agreed pathways
Little parity or standardisation of
Paucity of research studies
Absence of a needs-based approach
Marginalisation of mild brain injury
and paediatric injuries
National Service Framework &
Every child matters (2005)
Problems typically emerge at
around 10 years of age. (Perna, 2002).
This age is a stage of transition, when children have to adapt to
meet the demands of ever-more complex social situations as they
become more adult-like in their social functioning. (Turkstra, 2000).
Brain growth spurts, characterised by significant alterations in neural functioning,
coincide roughly with the Piagetian stages of development (Kolb & Whishaw,
Piaget’s Four Stages Of Cognitive Epstein’s Growth Spurts In Brain
Birth to 18-24 months. Sensorimotor Stage 30% increase in brain weight by 1 ½ years.
Approx 2 to 6 years. Preoperational Stage. Approx 2 to 4 years, 5 to 10%
Approx 7 to 11 years Concrete Operational Stage. Approx 6 to 8 years, 5 to 10%
12 years + Formal Operational Stage 12 to 14 years 5 to 10 % .
At 10 years- Improvement in
visual structural elements.
Between ten and eleven the
difference was highly significant
(F(1,61) = 9.573 p<.003). No
other significant differences
Brain injury will affect lots of
. What emotion is this?
Is she happy, sad, angry,
Frightened, or normal/ neutral?
How do ABI children compare to
76 F(1,84)=10.992 p<.001
Reading emotion/mind in the eyes .
How do ABI children compare to healthy
children on the eyes task?
60 ANCOVA (FAS):
How do ABI children compare
to non-injured children (“Mind
in the Eyes”)?
Mean mind in th e eyes test
50 40 Healthy
ABI Healthy up to 11 11 to 12 12 Plus
Peer relationships after ABI?
Peer relationships – critical for
positive peer relationships are an
essential component of well-being
social isolation from peers poses a
considerable threat to children’s mental
health in both the short and long-term
absence of peer relationships
undermines self-esteem and deprives
children of important pleasurable
experiences, contributing to depression
Impairments will impact upon
peer relationships after ABI.
Impairments in recognizing and responding to
emotional expressions are correlated with emotional
distress and peer-relationship difficulties. (Tonks, Williams,
Frampton, Yates & Slater, 2007).
impairments in self-regulation associated with executive
dys-function have a negative effect upon social
competence. Ganesalingham et al. (2006)
poor social competence = peer-relationship
difficulties (Caspi et al., 1995)
Peer relationship difficulties and emotional distress
Tonks, Yates, Williams, Frampton, & Slater (2010).
137 Healthy Childen (controls), 27 children using the Child and Adolescent Mental
Health Services (CAMHS), 40 children with ABI, (All children aged 8 to 17 years old).
Strengths and Difficulties Questionnaire (SDQ) Parent version (Goodman, 1999)
•control group compared to
CAMHS was significant (p<. 001)
• difference between the controls
and the ABI children (p<. 001).
•There was no significant difference
in reported peer difficulties between
CAMHS and ABI children (or for
Controls CAMHS ABI Children
Mean SDQ parent scores for emotional distress for healthy age-matched controls,
CAMHS children and children with ABI.
•control group compared to
CAMHS was significant
• controls and the ABI
children (p<. 001).
•There was no significant
difference in reported
CAMHS and ABI children.
James & Huw’s equation
Impairment to social skills + Loss of peer relationships= Vulnerability.
Vulnerability and Resilience
Family disruption, Depression & Anxiety
Measures Controls ABI Group t-test
Family Function M =17.7 M=24.2 t(89) = -4.729,
(FAD 12) SD =4.5 SD=5.8 p < 0.001
BYI Depression M=46.9 M=54.0 t(89)= -2.518,
T-Score SD=7.2 SD=12.2 p = 0. 019
BYI Anxiety M=47.2 M=53.2 t(89) = -2.645,
T Score SD=7.3 SD=9.6 p = 0.013
There is emerging evidence of link between ABI and Youth
Even when children are known to have an ABI we’re
really poor at serving their needs/ their injury history is
Impairments to social skills are detrimental to peer
relationships and increase vulnerability to a range of
difficulties (familial, mental health, etc.).
We are currently testing clinical interventions- working
with schools, peers and families of children with ABI.
Problems of Empathy & ToM –
o psychosocial risks for poor empathic responding
o harsh or inconsistent parenting , abuse “empathy poor” environments (Patterson,
o angry, coercive responding role models for emotional regulation rather than pro-
social empathic models (see Robinson 2007).
o Young offenders have been found to have less empathic responses compared to no-
offending groups (Robinson, 07).
o persistent offenders are described as impulsive and lacking affective empathy (see
Williams et al 2010)
o Such anti-social behaviours = rejection by peers and gravitation towards those with
additional neurological injury may contribute to poorer
& Risk of Crime...
Timonen et al (2002)
population based cohort study in Finland involving more than 12,000 subjects
TBI during childhood or adolescence associated with
fourfold increased risk of developing later mental disorder with coexisting
offending in adult (aged 31) male cohort members (OR 4.1)
TBI might have been a result of high novelty seeking and low harm avoidance in
people susceptible (for issues of genetics, family background, social forces etc.) to risky
behaviours – coincidental to crime….BUT
TBI earlier than age 12 were found to have committed crimes significantly earlier than those
who had a head injury later
Therefore - temporal congruency suggests a causal link
McKinlay A., et al.
“Are children who experience Traumatic Brain Injury
more likely to engage in criminal behaviour during
their adult lives?” 33rd ASSBI(Abstract) Brain
longitudinal epidemiological study of a birth cohort of 1265 children born in
Christchurch (New Zealand) urban region in mid-1977.
Groups: MTBI “hospitalised” “Not hospitalised” and “No-Injury”
Outcomes - ages 21-25 - self-reported arrests, violent offences and property
adjustment for gender, SES...(BUT ?? Family issues)
Adjusted rates - compared to non-injured individuals, both TBI groups were more
likely to be arrested (relative risk (RR)=2.03 and RR=1.68), involved in property offences
(RR=2.08 and RR=1.54) and violent offences (RR=1.35 and RR=2.29) (all p<0.01).
“clear evidence of ongoing problems for individuals who had
experienced a TBI compared to their non injured counterparts”.
Prevalence studies of TBI in
young offender groups
Huxx, Bong, Skinner, Belau, & Sanger (1998)
TBI in offending and non-offending youths (50% versus
greater biomechanical forces - such as fights and road
accidents versus sports injury
higher levels of immediate symptoms, such as
headaches, dizziness and losses of consciousness.
Perron and Howard (2008)
period prevalence and correlates of TBI – with a LOC of 20 minutes
or more - in 720 youth offenders.
18.3% reported such a head injury.
Male gender, co-morbid psychiatric diagnosis, earlier onset of
criminal behaviour and substance use were associated with TBI.
Rates of Mild – Severe TBI in
Williams et al (2010) Brain Injury
453 males held in Other
HMP Exeter Murder/manslaughter Missing
Pps: Sexual offences
196 aged between
18 and 54 years
(43% response rate) Drugs offences
sentenced or Fraud/deception
Percentage of population reporting TBI
& type & TIME of injury (Williams et al (2010))
“Anytbi?” we estimate that Average age at 1st
No 39.6 % 65% may have had a TBI. imprisonment:
Yes 60.4% • 10% Severe
• 5.6 % Moderate 21 Years – Non-TBI
• 49.4% Mild 16 years - TBI
Number of severe tbi
Number of moderate t
Number of mild tbi
Missing No Yes
Young Offenders & brain
Williams, Cordan et al (in press,
192 young male offenders ranging from 11 to 19 years of
age (M = 16.63, SD = 1.07 years) (response rate of 98%).
The mean number of convictions 6.95 (SD 4.56).
Offences of violence accounted: 27.1%
shoplifting, theft, and robbery: 25.5%
drug offences: 11.6%
Young offender population and TBI
65% reported a history of “head
main category of injury was
With falls “on drugs” being
second most common “criminal
MTBI with a LOC of up to 10
minutes & Moderate - severe
TBI made up 46% of the
Repeated MTBI were also very
nearly twice as many multiple
MTBI compared to single MTBIs
Participants w/ TBIs
had an average of 2 more convictions (M = 7.23) compared to non-TBI (sig.
after age effects etc.)
Those with x3+ TBI with greater violence
Young Offenders, TBI and Drugs
Frequency of cannabis use – (once a month –to – everyday)
TBI in Prisoners:
Childhood injury and
Leon-Carrion J, Ramos FJ. (2003) (BI)
Retrospective factor analytic study of links between head injuries (in
childhood and adolescence) in adult violent and non-violent
subjects in both groups had a history of academic difficulties.
Trend for both groups to have had behavioural and academic problems at
Head injury in addition to prior learning disability/school problems increases
chances of having a violent offending profile
Violent offending (noted) to be “associated with non-treated brain injury”
? rehabilitation of head injury may be a measure of
TBI and Crime –
causal or co-incidental?
The evidence is not clear cut
there are many confounding factors within the
relationships between injury and later offending
the link between crime and TBI may be an epiphenomenon –
whereby TBI is “marker” for of various contextual factors
associated with crime - indeed
“particularly violent crime, is likely to result
from complex interaction of factors such as
genetic pre-disposition, emotional stress,
poverty, substance abuse and child abuse”
Turkstra, 2004 (P 40).
Tom McMillan – Head Injury & Offending
What can be done: Younger groups
children are most likely to be injured & least likely to get support
EVEN if TBI is a marker, it may be an important one to pick up!
Systematic neuro-rehabilitation MAY BE A MEASURE OF
CRIME PREVENTION IN IN ITSELF…
“sleeper effects” (“crowding” as part of neurplasticity)–
esp. relevant to socio-emotional functions at transition to
adolescence – important to monitor
The delivery of services to such groups would therefore
require close cooperation between health, social and
Particularly focus on parenting of at risk children -
http://www.incredibleyearswales.co.uk/ & see Gardner, Hutchings, Bywater &
Whitaker, 2010 J. Clin Child & Adol Psych. – use of <: in multi agency work
Deputy Prime Minister Nick Clegg recently
that the nation was "criminalising far too many
Public safety and long term economic advantage
could be gained by better, earlier, targeted
reduce impact of injury
May be complicated to deliver – BUT:
“pessimist sees the difficulty in every
opportunity; an optimist sees the
opportunity in every difficulty”