Huw WilliamsHuw WilliamsGiray Cordan, Avril Mewse, Sarah Mills, Cris Burgess, James Tonks, Alex

Haslam

*School of Psychology*School of PsychologyUniversity of ExeterUniversity of Exeter

& & *Emergency Department*Emergency Department

Royal Devon & Exeter Hospital Royal Devon & Exeter Hospital

w.h.williams@exeter.ac.ukw.h.williams@exeter.ac.uk

NHS

Centre for Clinical Neuropsychological Research (CCNR)

Traumatic Brain Injury & Traumatic Brain Injury & Offending: Offending:

A modifiable factor for reducing A modifiable factor for reducing crime?crime?

Need for new policies to Need for new policies to influence practice re: TBI in influence practice re: TBI in

prison populationsprison populations mental health & drug/alcohol problems identified mental health & drug/alcohol problems identified ““relative to general population, relative to general population, [prisoners]…[prisoners]…

experience poorer physical, mental, and social experience poorer physical, mental, and social health…[more] mental illness and disabilityhealth…[more] mental illness and disability, drug, , drug, alcohol…suicide, self harm…lower life expectance alcohol…suicide, self harm…lower life expectance [etc.]…” Orme et al. BMJ editorial, 2005, 330. p 918[etc.]…” Orme et al. BMJ editorial, 2005, 330. p 918

and see Fazel & Danesh (2002a (Lancet))and see Fazel & Danesh (2002a (Lancet))

“…“…..delivery of servicesdelivery of services to prisoners with to prisoners with anxiety and anxiety and affective disorders, drugs and alcohol problems, affective disorders, drugs and alcohol problems, brain brain injuryinjury, learning disability, challenging behaviour and , learning disability, challenging behaviour and repetitive self-harm repetitive self-harm has changed little or worsenedhas changed little or worsened.” .” Dearbhla Duffy, et al. (2003) p. 242 (our emphasis)Dearbhla Duffy, et al. (2003) p. 242 (our emphasis)

TBI is TBI is largely neglected from policy documentslargely neglected from policy documents (Youth Crime Action Plan, 2008 and Bradley (Youth Crime Action Plan, 2008 and Bradley report 2009)report 2009)

http://www.loni.ucla.edu/http://www.loni.ucla.edu/~thompson/DEVEL/~thompson/DEVEL/

dynamic.htmldynamic.html

•dorsolateral prefrontal cortex•late to reach adult levels of cortical thickness•circuitry sub-serving control of impulses, judgment, and decision-making.•implications of late maturation of this area have entered educational, social, political, and judicial discourse

Brain development in children and adolescents: Insights from anatomical magnetic resonance imaging

Rhoshel K. Lenroota and Jay N. Giedd (2006)

Savage, 2009

0

20

40

60

80

100

120

140

160

180

200

00-0

4

05-0

9

10-1

4

15-1

9

20-2

4

25-2

9

30-3

4

35-3

9

40-4

4

45-4

9

50-5

4

55-5

9

60-6

4

65-6

9

70-7

4

75-7

9

80-8

4

85+

Age Group

Rate

per

100,0

00 p

op

n

MIXED RURAL - Female URBAN - Female MIXED RURAL - Male URBAN - Male

Yates, Williams et al. 2006, JNNP: Attendance rates for moderate to severe head injury per100 000 population for each 5 year age band by sex and area residence (GCS under 12).

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 Traumatic Brain Injury (TBI)(TBI)

(from: www.netmedicine.com/xray/ctscan/img_ct)(from: www.netmedicine.com/xray/ctscan/img_ct)

Traumatic brain injuriesTraumatic brain injuries::Penetrating injuryClosed Injury

Glasgow Coma Glasgow Coma ScaleScale

Loss of Loss of ConsciousnessConsciousness

Post Traumatic Post Traumatic AmnesiaAmnesia

MildMild 13-1513-15 <30 mins<30 mins < 24hrs< 24hrs

ModerateModerate 9-129-12 >1 to <7 days>1 to <7 days >30mins-<24 hrs>30mins-<24 hrs

SevereSevere 3-83-8 >7 days>7 days >24hrs>24hrs

frontal-tempo-limbic systemsfrontal-tempo-limbic systems are are crucial for crucial for Monitoring arousal level Monitoring arousal level & control of behaviour towards & control of behaviour towards “goal states”“goal states”

Moderate to Severe TBI Neuropsychological deficits, behavioural problems and poor social outcomes (Stambrook, Moore , Peters , Deviaene , & Hawryluk, 1990).

poor planning and inflexibility poor planning and inflexibility (Milders, Fuchs & Crawford, 2003)(Milders, Fuchs & Crawford, 2003)““poor anger managementpoor anger management ((irritability and impulse controlirritability and impulse control are are common” (Hawley et al. 2003)common” (Hawley et al. 2003)

Nb. Limbic systems more vulnerable in Nb. Limbic systems more vulnerable in childrenchildren

Brain Areas that typically Injured…

Mild TBI When “complicated”, or cumulative, there can be neuropsychological sequelae (15%?), esp. attention and executive systems (Williams, Potter & Ryland, 2010).

Childhood Brain Injury: long Childhood Brain Injury: long term effectsterm effects

Problems: Attention, working memory, executive control disinhibition etc. Problems: Attention, working memory, executive control disinhibition etc.

• lack of “moral” reasoning. lack of “moral” reasoning. ((Damasio 1996; Damasio 1996; Anderson, Bechara, Damasio, Tranel, & Damasio, 1999; Anderson, Bechara, Damasio, Tranel, & Damasio, 1999; Hanks, Hanks,

Temkin, Machamer & Dikmen 1999; Levin & Hanten, Powell, 2004).Temkin, Machamer & Dikmen 1999; Levin & Hanten, Powell, 2004).• Often there is Often there is inappropriate social behaviour inappropriate social behaviour

• the the most common and disruptivemost common and disruptive issue issue (Henry, Phillips, Crawford, (Henry, Phillips, Crawford, Theodorou & Summers, 2006).Theodorou & Summers, 2006).

• may not be evident until adolescencemay not be evident until adolescence (Lishman, 1998; Teichner & (Lishman, 1998; Teichner & Golden, 2000) Golden, 2000)

• point at which ‘delayed costs’ of earlier ABI are expressed (see point at which ‘delayed costs’ of earlier ABI are expressed (see Anderson 2008 re: neuroplasticity & crowding effects)Anderson 2008 re: neuroplasticity & crowding effects)

• may occur may occur in isolation from cognitivein isolation from cognitive deficits deficits (Anderson, (Anderson, Northam, Hendy & Wrennall, 2001Northam, Hendy & Wrennall, 2001

persisting personality and emotional deficits – due to persisting personality and emotional deficits – due to de-de-coupling of cognition and emotioncoupling of cognition and emotion - has been described by - has been described by Damasio (1994), as “acquired sociopathy”” – 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 MTBIWrightson, McGinn and Gronwall (1995)

pre-school children - MTBI tested after injury and then at 6 months and a year (V. orthopdeic control group). no differences after injury on a range of cognitive tasks. 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. 2009follow up of moderate-severe and (mostly) complicated MTBI showed persisting disabilities at 1 year – >lack of pro-social behaviour and emotional symptoms

Prevalence studies of TBI in Prevalence studies of TBI in adult offender groupsadult offender groups

Self-report prevalence studies of TBI - with 25% to 87% of Self-report prevalence studies of TBI - with 25% to 87% of inmates reportedly experiencing a head injury inmates reportedly experiencing a head injury (Schofield et al., 2006; (Schofield et al., 2006; Slaughter, Fann and Ehde, 2003; Morrell et al., 1998). Slaughter, Fann and Ehde, 2003; Morrell et al., 1998).

Slaughter et al (2003) - Slaughter et al (2003) - TBI in inmates in a county jail in the USA. TBI in inmates in a county jail in the USA. 87% lifetime prevalence and 36% in the previous year. 87% lifetime prevalence and 36% in the previous year. TBI in the previous year had worse anger and higher psychiatric TBI in the previous year had worse anger and higher psychiatric

disturbance. disturbance. Barnfield and Leathem (1998) Barnfield and Leathem (1998) New Zealand, had 118 respondents New Zealand, had 118 respondents

86.4% reported some form of “head injury” with 56.7% reporting 86.4% reported some form of “head injury” with 56.7% reporting more than one blow to the head. more than one blow to the head.

concomitant reports of difficulties with memory and socialization. concomitant reports of difficulties with memory and socialization. Analysis of medical records. Analysis of medical records.

De Souza (2003) De Souza (2003) Brazil -Brazil - Of 3233 offenders there were 133 cases of TBI reported (39 “mild” Of 3233 offenders there were 133 cases of TBI reported (39 “mild”

and 94 “moderate or severe”). and 94 “moderate or severe”). In the majority (111 cases) there was no account taken of the In the majority (111 cases) there was no account taken of the

injury by service providers. injury by service providers.

Prevalence studies of TBI Prevalence studies of TBI in young offender groupsin young offender groups

Huxx, Bong, Skinner, Belau, & Sanger (1998)Huxx, Bong, Skinner, Belau, & Sanger (1998) TBI in offending and non-offending youths (50% TBI in offending and non-offending youths (50%

versus 40%) versus 40%) greater biomechanical forces - such as fights greater biomechanical forces - such as fights

and road accidents versus sports injury and road accidents versus sports injury higher levels of immediate symptoms, such as higher levels of immediate symptoms, such as

headaches, dizziness and losses of headaches, dizziness and losses of consciousness.consciousness.

Perron and Howard (2008) Perron and Howard (2008) period prevalence and correlates of TBI – with a LOC of 20 period prevalence and correlates of TBI – with a LOC of 20

minutes or more - in 720 youth offenders. minutes or more - in 720 youth offenders. 18.3% reported such a head injury. 18.3% reported such a head injury. Male gender, co-morbid psychiatric diagnosis, Male gender, co-morbid psychiatric diagnosis, earlier onset earlier onset

of criminal behaviourof criminal behaviour and substance use were associated and substance use were associated with TBI.with TBI.

TBI a risk factor for TBI a risk factor for crime??...crime??...

Timonen et al (2002)Timonen et al (2002) population based cohort study in Finland involving more than 12,000 population based cohort study in Finland involving more than 12,000

subjectssubjects TBI during childhood or adolescence associated with TBI during childhood or adolescence associated with

fourfold increased risk of developing later mental disorder with fourfold increased risk of developing later mental disorder with coexisting offending in adult (aged 31) male cohort memberscoexisting offending in adult (aged 31) male cohort members (OR (OR 4.1)4.1)

TBI might have been a result of TBI might have been a result of high novelty seekinghigh novelty seeking and and low harm low harm avoidanceavoidance in people susceptible (for issues of genetics, family background, in people susceptible (for issues of genetics, family background, social forces etc.) to risky behaviours – coincidental to crime….BUTsocial forces etc.) to risky behaviours – coincidental to crime….BUT

TBI earlier than age 12 were found to have committed crimes significantly TBI earlier than age 12 were found to have committed crimes significantly earlier than those who had a head injury later earlier than those who had a head injury later

Therefore - temporal congruency suggests a causal linkTherefore - temporal congruency suggests a causal link

Fazel, Philipson, Gardiner, et al. 2009 Fazel, Philipson, Gardiner, et al. 2009 meta-analysis of studies relating to violence and meta-analysis of studies relating to violence and

neurological conditions indicated that TBI was neurological conditions indicated that TBI was a moderate a moderate risk factorrisk factor for violence whereas epilepsy was inversely for violence whereas epilepsy was inversely correlated with riskcorrelated with risk

McKinlay A., et al.McKinlay A., et al.““Are children who experience Traumatic Are children who experience Traumatic

Brain Injury more likely to engage in Brain Injury more likely to engage in criminal behaviour during their adult criminal behaviour during their adult

lives?” lives?” 3333rdrd ASSBI(Abstract) ASSBI(Abstract) Brain Brain ImpairmentImpairment. 2010. 2010

longitudinal epidemiological study of a birth cohort of 1265 children longitudinal epidemiological study of a birth cohort of 1265 children born in Christchurch (New Zealand) urban region in mid-1977. born in Christchurch (New Zealand) urban region in mid-1977. Groups: MTBI “hospitalised” “Not hospitalised” and “No-Injury”Groups: MTBI “hospitalised” “Not hospitalised” and “No-Injury”

Outcomes - ages 21-25 - self-reported arrests, violent offences and Outcomes - ages 21-25 - self-reported arrests, violent offences and property offences. property offences. adjustment for gender, SES...(BUT ?? Family issues)adjustment for gender, SES...(BUT ?? Family issues)

Adjusted rates - compared to non-injured individuals, Adjusted rates - compared to non-injured individuals, both TBI groups both TBI groups were more likely to be arrested (relative risk (RR)=2.03 and RR=1.68), 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 involved in property offences (RR=2.08 and RR=1.54) and violent offencesoffences (RR=1.35 and RR=2.29) (all p<0.01). (RR=1.35 and RR=2.29) (all p<0.01). ““clear evidence of ongoing problems for individuals who had clear evidence of ongoing problems for individuals who had

experienced a TBI compared to their non injured experienced a TBI compared to their non injured counterparts”. counterparts”.

Associations between TBI & Associations between TBI & CrimeCrime

Blake, Pincus and Buckner (1995) Blake, Pincus and Buckner (1995) assessed thirty-one individuals awaiting assessed thirty-one individuals awaiting

trial or sentencing for murder, and found trial or sentencing for murder, and found evidence of ``frontal'' dysfunction in 20 evidence of ``frontal'' dysfunction in 20 (64.5%). (64.5%).

Vietnam Head Injury Study (VHIS) Vietnam Head Injury Study (VHIS) (Grafman et al 1996) (Grafman et al 1996) rate of 14% for fighting and property rate of 14% for fighting and property

damage in head injured veterans compared damage in head injured veterans compared to 4% in non-head injured controls. to 4% in non-head injured controls.

TBI & Crime: Coincidence or TBI & Crime: Coincidence or causal?causal?

Turkstra et al. (2003)Turkstra et al. (2003) offenders with TBI against “true peers” without TBI offenders with TBI against “true peers” without TBI

20 individuals convicted of violent crime compared to 20 non 20 individuals convicted of violent crime compared to 20 non convicted controls (matched for convicted controls (matched for education, age and education, age and employmentemployment). ).

TBI NOT more common in the offender group BUT TBI NOT more common in the offender group BUT there was variance on there was variance on severityseverity of injury of injury non-offending group– typically – Milder TBI from (eg non-offending group– typically – Milder TBI from (eg

sports). sports). offending group injuries offending group injuries

More assaults (with probable longer lasting changes in More assaults (with probable longer lasting changes in behaviour). behaviour).

had more issue related to anger control.had more issue related to anger control.

TBI is not necessary for crime, but that TBI is not necessary for crime, but that TBI may TBI may contribute to “expression of violence”contribute to “expression of violence” - increase - increase the risk “threshold” in vulnerable people. the risk “threshold” in vulnerable people.

Rates of Mild – Severe TBI in Rates of Mild – Severe TBI in Prisoners Prisoners

Williams et al (2010) Brain InjuryWilliams et al (2010) Brain Injury

Other

Murder/manslaughter

Robbery

Sexual offences

Drugs offences

Fraud/deception

Driving offences

Violent offences

Shoplif ting/theft

Burglary

Missing

453 males held in 453 males held in HMP Exeter HMP Exeter

Pps:Pps:196 aged between 196 aged between 18 and 54 years 18 and 54 years (43% response rate)(43% response rate)

sentenced or sentenced or remandedremanded

Percentage of population Percentage of population reporting TBI & reporting TBI & type & TIME type & TIME

of injury of injury (Williams et al (2010))(Williams et al (2010))

Number of severe tbi

Number of moderate t

Number of mild tbi

“Any tbi?”No 39.6 %Yes 60.4%

we estimate that65% may have had a TBI.

• 10% Severe• 5.6 % Moderate • 49.4% Mild

Any tbi?

YesNoMissing

Cou

nt

140

120

100

80

60

40

20

0

Average age at 1st imprisonment:21 Years – Non-21 Years – Non-TBITBI16 years - TBI 16 years - TBI

Re-offendingRe-offending

The number of participants that were re-offenders differed significantly according to whether they had reported “head injuries” [Chi squ (1, N=195)=11.98, p = .001].

No

Yes

Any TBI?

Bars show counts

No Yes

Is this the first time in prison?

0

50

100

150

Co

un

t

Young Offenders & Young Offenders & brain injurybrain injury

192 young male offenders ranging from 11 to 19 years of 192 young male offenders ranging from 11 to 19 years of age (age (M M = 16.63, = 16.63, SD SD = 1.07 years) (response rate of = 1.07 years) (response rate of 98%).98%).

The mean number of convictions 6.95 (SD 4.56).The mean number of convictions 6.95 (SD 4.56). Offences of violence accounted: 27.1%Offences of violence accounted: 27.1% shoplifting, theft, and robbery: 25.5%shoplifting, theft, and robbery: 25.5% Burglary: 18.2%Burglary: 18.2% ““joyriding”: 14.7% joyriding”: 14.7% drug offences: 11.6%drug offences: 11.6% Fraud: 2.5%Fraud: 2.5% Offences: 0.4%Offences: 0.4%

Williams, Cordan et al (in press, Neuropsychological Rehabilitation):

Young offender population Young offender population and TBIand TBI

65% reported a history 65% reported a history of “head injury” of “head injury”

main category of injury main category of injury was violencewas violence (57.6%) (57.6%)

With falls “on drugs” With falls “on drugs” being second most being second most common “criminal cause”.common “criminal cause”.

MTBI with a LOC of up MTBI with a LOC of up to 10 minutes & to 10 minutes & Moderate - severe TBI Moderate - severe TBI made up made up 46%46% of the of the overall sampleoverall sample. .

Repeated MTBI were Repeated MTBI were also very frequentalso very frequent

nearly twice as many nearly twice as many multiple MTBI compared multiple MTBI compared to single MTBIsto single MTBIs

Conviction profilesConviction profiles Participants w/ TBIs Participants w/ TBIs

had an average of had an average of 2 more convictions2 more convictions (M = 7.23) (M = 7.23) compared to non-TBI (sig. after age effects etc.)compared to non-TBI (sig. after age effects etc.)

Those with Those with x3+ TBI with greater violencex3+ TBI with greater violence

Young Offenders, TBI Young Offenders, TBI and Drugsand Drugs

Frequency of cannabis use – (once a month –to – everyday)

TBI in Prisoners: TBI in Prisoners: Childhood injury Childhood injury

and rehabilitationand rehabilitation Leon-Carrion J, Ramos FJ. (Leon-Carrion J, Ramos FJ. (2003) (BI)2003) (BI)

Retrospective factor analytic study of links between Retrospective factor analytic study of links between head injuries (in childhood and adolescence) in adult head injuries (in childhood and adolescence) in adult violent and non-violent prisoners. violent and non-violent prisoners.

subjects in both groups had a history of academic difficulties. subjects in both groups had a history of academic difficulties. Trend for both groups to have had behavioural and academic Trend for both groups to have had behavioural and academic

problems at schoolproblems at school Head injury in addition to prior learning disability/school Head injury in addition to prior learning disability/school

problems increases chances of having a violent offending problems increases chances of having a violent offending profileprofile

Violent offending (noted) to be “associated with non-treated Violent offending (noted) to be “associated with non-treated brain injury”brain injury”

? ? rehabilitation of head injury may be a rehabilitation of head injury may be a measure of crime preventionmeasure of crime prevention

TBI and Crime – TBI and Crime – causal or co-incidental?causal or co-incidental?

The evidence The evidence is not clear cut there are many there are many confounding factors within the within the

relationships between injury and later offendingrelationships between injury and later offending the link between crime and TBI may be an the link between crime and TBI may be an

epiphenomenonepiphenomenon – whereby TBI is “marker” for – whereby TBI is “marker” for of various of various contextual factors associated with crime - indeed contextual factors associated with crime - indeed

criminal behaviourcriminal behaviour

““particularly violent crime, is particularly violent crime, is likely to likely to result from complex interaction of result from complex interaction of factors such as genetic pre-factors such as genetic pre-disposition, emotional stress, poverty, disposition, emotional stress, poverty, substance abuse and child abusesubstance abuse and child abuse” ”

Turkstra, 2004 (P 40). Turkstra, 2004 (P 40).

better better screening for head injury at pre-sentencingscreening for head injury at pre-sentencing and on and on admission to prison/custodial services –admission to prison/custodial services –

for for better understanding of risk, and for rehabilitative purposesbetter understanding of risk, and for rehabilitative purposes Esp. Esp. those with executive & socio-affective difficulties who those with executive & socio-affective difficulties who

may have difficulty in changing behaviour patterns in may have difficulty in changing behaviour patterns in response to contingenciesresponse to contingencies

““The person at risk of violence needs to The person at risk of violence needs to recognise his risk and take preventative steps…recognise his risk and take preventative steps…but [those with]…damage to…prefrontal cortex…but [those with]…damage to…prefrontal cortex…may not be able to reflect on their behaviour and may not be able to reflect on their behaviour and take responsibility…[as their] take responsibility…[as their] internal soul-internal soul-searchingsearching [is] damaged [is] damaged…” Raine (2002)…” Raine (2002)

rehabilitation interventions in custodial systems – rehabilitation interventions in custodial systems – Targeted at impulse control/socio-emotional Targeted at impulse control/socio-emotional processing (esp. ToM/Empathy etc.)processing (esp. ToM/Empathy etc.)

Screening & enhancing Screening & enhancing rehabilitation rehabilitation

Service development and Service development and community involvementcommunity involvement

Services – as NHS provision is moving “into” prison Services – as NHS provision is moving “into” prison groups:groups: Would also be helpful to have Would also be helpful to have TBI reported as a chronic TBI reported as a chronic

condition for which offenders condition for which offenders within and outside custodial within and outside custodial systemssystems would have support for managing would have support for managing consequences of consequences of injuryinjury

e.g. in line with Bradley report - via Primary care – Poly-e.g. in line with Bradley report - via Primary care – Poly-clinics – linked to specialist support in Neuro-rehabilitation clinics – linked to specialist support in Neuro-rehabilitation centrescentres

Community levelCommunity level Policing of “at risk” groups in communityPolicing of “at risk” groups in community (Youth Crime Action Plan, (Youth Crime Action Plan,

2008)2008) Eg role of Police Community Support Officers & inter-agency workingEg role of Police Community Support Officers & inter-agency working Esp. with early & intensive family interventionsEsp. with early & intensive family interventions

Alternatives to custodyAlternatives to custody – eg. – eg. restorative justice re: improving restorative justice re: improving empathyempathy

What can be done: What can be done: Younger groupsYounger groups

children are most likely to be injured & least likely to get children are most likely to be injured & least likely to get supportsupport

EVEN if TBI is a marker, it may be an important one to pick EVEN if TBI is a marker, it may be an important one to pick up!up!

Systematic neuro-rehabilitation Systematic neuro-rehabilitation MAY BE A MEASURE OF MAY BE A MEASURE OF CRIME PREVENTION IN IN ITSELF… CRIME PREVENTION IN IN ITSELF…

““sleeper effects” (“crowding” as part of sleeper effects” (“crowding” as part of neurplasticity)– esp. relevant to socio-emotional neurplasticity)– esp. relevant to socio-emotional functions at transition to adolescence – important to functions at transition to adolescence – important to monitormonitor

The delivery of services to such groups would The delivery of services to such groups would therefore require therefore require close cooperation between close cooperation between health, social and educational systemshealth, social and educational systems..

Particularly focus on Particularly focus on parenting of at risk children -parenting of at risk children -http://www.scmh.org.uk/pdfs/chance_of_a_lifetime.pdfhttp://www.scmh.org.uk/pdfs/chance_of_a_lifetime.pdfhttp://www.incredibleyearswales.co.uk/ & see Gardner, Hutchings, http://www.incredibleyearswales.co.uk/ & see Gardner, Hutchings,

Bywater & Whitaker, 2010 J. Clin Child & Adol Psych. – Bywater & Whitaker, 2010 J. Clin Child & Adol Psych. – use of <: in use of <: in multi agency workmulti agency work

ConclusionsConclusions Deputy Prime Minister Nick Clegg recently Deputy Prime Minister Nick Clegg recently

noted that the nation was "criminalising noted that the nation was "criminalising far too many young children". far too many young children". http://news.bbc.co.uk/1/hi/uk/8565619.stmhttp://news.bbc.co.uk/1/hi/uk/8565619.stm

Public safety and long term economic Public safety and long term economic advantage could be gained by better, advantage could be gained by better, earlier, targeted interventions to:earlier, targeted interventions to:

prevent injuryprevent injury reduce impact of injury reduce impact of injury enhance outcomesenhance outcomes

May be complicated to deliver – BUT:May be complicated to deliver – BUT:

“pessimist sees the difficulty in every opportunity; an optimist sees the opportunity in every difficulty”W. Churchill

Children’s brain need to be IN Society to be SOCIALISED… (as Vygotsky may have said)

“We have to understand the brain as part of a socio-cultural environment. Our brain is shaped by … interaction with other brains. The brain is essentially a social organ that we can not understand isolated from its environment.”

Wolf Singer (in Die Zeit, May 2008)

"Brains become minds when they learn to dance with other brains" W.J. Freeman

The brain NEEDS to be The brain NEEDS to be socialised...socialised...

Turkstra, L., Williams, W.H, Tonks, J and Frampton, I. (in press): Measuring Social Turkstra, L., Williams, W.H, Tonks, J and Frampton, I. (in press): Measuring Social Cognition in Adolescents: Implications for Students with TBI Returning to School. Cognition in Adolescents: Implications for Students with TBI Returning to School. NeuroRehabilitation.NeuroRehabilitation.

Wall, S., Williams, W.H., Morris, R. and Bramham, J. (in press): The Development of a Wall, S., Williams, W.H., Morris, R. and Bramham, J. (in press): The Development of a New Measure of Social-Emotional Functioning for Young Adolescents. New Measure of Social-Emotional Functioning for Young Adolescents. Clinical Child Clinical Child Psychology and PsychiatryPsychology and Psychiatry

Tonks. Tonks. J, Williams H. et al. J, Williams H. et al. (2009): (2009): The development of emotion and empathy skills The development of emotion and empathy skills after childhood brain injury." Developmental Medicine and Child Neurology. (2.4)after childhood brain injury." Developmental Medicine and Child Neurology. (2.4)

Tonks, J., Williams, W. H., Frampton, I., Yates, P., Slater, A. & Wall, S. (2008) Reading Tonks, J., Williams, W. H., Frampton, I., Yates, P., Slater, A. & Wall, S. (2008) Reading emotions after childhood brain injury: Case series evidence of dissociation between emotions after childhood brain injury: Case series evidence of dissociation between cognitive abilities and emotional expression processing skills. cognitive abilities and emotional expression processing skills. Brain Injury.Brain Injury.

Hooper, Williams, et al. (2007). Stress, parental style and coping in parents of children Hooper, Williams, et al. (2007). Stress, parental style and coping in parents of children with encephalitis. with encephalitis. Neuropsychological RehabilitationNeuropsychological Rehabilitation.(1.0).(1.0)

Tonks, J., Williams, W.H., Frampton, I.J. and Slater, A. (2007): Assessing emotion Tonks, J., Williams, W.H., Frampton, I.J. and Slater, A. (2007): Assessing emotion recognition in 9- to 15-year olds: preliminary analysis of abilities in reading emotion recognition in 9- to 15-year olds: preliminary analysis of abilities in reading emotion from faces, voices and eyes. from faces, voices and eyes. Brain Injury Brain Injury (1.2)(1.2)

Yates, P.J, Williams, W.H., Round, A., Jenkins, R. & Harris, A (2006) An epidemiological Yates, P.J, Williams, W.H., Round, A., Jenkins, R. & Harris, A (2006) An epidemiological study of head injuries in a UK population attending an Emergency Department. study of head injuries in a UK population attending an Emergency Department. Journal Journal of Neurology, Neurosurgery and Psychiatryof Neurology, Neurosurgery and Psychiatry.(3.6).(3.6)

Wall, SE, Williams, W.H., Cartwright-Hatton, S., Kelly, T.P., Murray, J., Murray, M., Wall, SE, Williams, W.H., Cartwright-Hatton, S., Kelly, T.P., Murray, J., Murray, M., Owen, A. & Turner, M. (2006). Neuropsychological dysfunction following repeat Owen, A. & Turner, M. (2006). Neuropsychological dysfunction following repeat concussions in jockeys. concussions in jockeys. Journal of Neurology, Neurosurgery and PsychiatryJournal of Neurology, Neurosurgery and Psychiatry..

Williams et al (In press) Traumatic Brain Injury in young offenders: a modifiable risk Williams et al (In press) Traumatic Brain Injury in young offenders: a modifiable risk factor for re-offending, poor mental health and violence. Neuropsychological factor for re-offending, poor mental health and violence. Neuropsychological RehabilitationRehabilitation

Williams, Mewse…et al. (in press) Traumatic Brain injury in a Prison Population: Williams, Mewse…et al. (in press) Traumatic Brain injury in a Prison Population: Prevalence, and Risk for Re-Offending, Brain Injury.Prevalence, and Risk for Re-Offending, Brain Injury.

Williams WHWilliams WH,, PotterPotter S and Ryland H (2010): S and Ryland H (2010): Mild Traumatic Brain Injury and Post Concussion Mild Traumatic Brain Injury and Post Concussion Symptoms: a Neuropsychological Perspective. Journal of neurology, Neurosurgery and Symptoms: a Neuropsychological Perspective. Journal of neurology, Neurosurgery and Psychiatry,0:200817129 doi: 10.1136/jnnp.2008.171298 Psychiatry,0:200817129 doi: 10.1136/jnnp.2008.171298

  JJames Tonks*, Phil Yates, Wames Tonks*, Phil Yates, W. Huw Williams. Huw Williams, Ian Frampton, and Alan Slater (pbl Online First), Ian Frampton, and Alan Slater (pbl Online First):: Peer-relationship difficulties in children with brain injuries: comparisons with children in mental Peer-relationship difficulties in children with brain injuries: comparisons with children in mental health services and healthy controls. health services and healthy controls. Neuropsychological Rehabilitation Neuropsychological Rehabilitation..

Williams, WHWilliams, WH (2010) Editorial: Advances in measuring outcome for Children and Adolescents (2010) Editorial: Advances in measuring outcome for Children and Adolescents with Brain Injury. Brain Impairment.with Brain Injury. Brain Impairment.