Adverse Childhood Experiences and Offending as a Function of Acquired Brain Injury Among Men in a High Secure Forensic Psychiatric Hospital

Abstract

Background Acquired brain injury (ABI) is a serious problem that disproportionately affects individuals in correctional services, but relatively little is known about ABI risks and correlates in forensic psychiatric services. Methods We conducted a retrospective chart review of all admissions to a high secure forensic hospital in Ontario, Canada from January 2009 to December 2012 ( n = 637) and collected data on ABI, psychiatric diagnoses, developmental disadvantage, criminal offending, and in-hospital aggression. A k-means cluster analysis was employed to assess risk factors by which men with ABI could be identified and multivariate general linear models were used to identify ABI-related differences in offending history and in-hospital aggression. Results One-fifth of the men had a documented ABI indicator. Based on our cluster analysis, ABI was more likely to be identified by greater adverse childhood experiences (ACEs), more health problems from pregnancy to childhood, and lower socioeconomic status, suggesting that ABI within the forensic context is associated with greater developmental disadvantage. Men with ABI had more serious pre-admission offences, but not more serious admission offences or in-hospital aggression. Men with ABI were more likely than those without to have higher scores on the Violence Risk Appraisal Guide or to be diagnosed with mood and personality disorders, and less likely to have a schizophrenia diagnosis, suggesting an association between ABI and general mental health pathologies but not with psychotic illness. Conclusions The disadvantage of ABI among men in forensic psychiatric hospitals is most likely evinced in antisocial behaviour rather than serious mental illness. Given that ACEs are likely to precede or co-occur with ABI, strategies that mitigate ACEs hold promise for ABI prevention.

Characteristics of forensic psychiatric patients with a neurocognitive disorder

“…We would argue that this implies that the behavioural problems that were a reason for admission, and that may be related to the neurocognitive disorder, are not likely to be mislabelled as psychotic behaviours in patients that are known to have a neurocognitive disorder. This lower prevalence also corroborates with the finding of Belfry et al, 23 who reported lower prevalence of schizophrenia in forensic patients with acquired brain injury. The question remains, however, how these behavioural problems are interpreted in patients with an undiagnosed neurocognitive disorder.…”

“…In summary, although at face value our study suggests that only 3.0% of prisoners in a PPC have a neurocognitive disorder, we hypothesise that the true prevalence of neurocognitive disorders in this population is higher, based on findings in the literature 20,23 and the relatively high prevalence of unspecified neurocognitive disorder. We call for increased attention to neurocognitive disorders in forensic psychiatry, both in clinical practice, as well as in research, including more attention for cross-cultural neuropsychological assessment.…”

“…This is remarkably lower than the 20-23% found in two earlier studies in similar populations. 20,23 Importantly, our study used real-world clinical data, whereas these two other studies used retrospective chart review to establish diagnoses of acquired brain injury themselves. A study by Fazel et al 26 mentions that prevalence numbers of psychiatric disorders in prisons are also much lower in studies that use real-world clinical data, compared with studies that use structured instruments.…”

“…22 Finally, in a recent study, 20% of a cohort of 638 men in a high-secure forensic unit in Canada were identified as having acquired brain injury. 23 The authors found that acquired brain injury was related to greater adverse childhood experiences, perinatal and childhood health problems and a lower socioeconomic status. They were also found to have a higher risk of violence and were more often diagnosed with mood and personality disorders, and less often with schizophrenia spectrum disorders.…”