Head Injury and the Criminal Justice System in Scotland

Thank you very much for that introduction. I'm very pleased to be with you all today. I'm going to give a bit of context and background and then talk about head injury in prisoners in Scotland, head injury and criminal justice social work, and then talk about training and education.

Let's start off with some context and talk about the program on head injury in Scotland and why head injury is relevant. The Cabinet Secretary for Justice in Scotland asked for a working party report on brain injury and offending in 2015. I chaired that working party, and we produced the report the following year. We made the report as evidence-based as we could. Our recommendations included getting more evidence about head injury and offending in Scotland and to develop education and training, two things I've been involved with since then.

Regarding evidence-based practice, we have looked at representative samples of prisoners in three studies covering men, women, and young men. We have looked at hospital attendance with head injury of everyone who was in prison on a particular day in Scotland. We have looked at police custody, attendees for social work pre-sentencing reports, and we have done some work on the education of prisoners about head injury and the knowledge and training needs of professionals.

Why is head injury relevant? The prevalence is very high in people who are involved in the criminal justice system, and it is associated with crime and recidivism. Disability is often hidden in head injury generally; it is particularly hidden in people in the criminal justice system. Staff and people with head injury aren't aware of the effects very often. It is also linked with other health problems and is associated with the risk of further brain injury.

What about the case in principle? Why might head injury be linked to offending? If you look at theories of offending, you find that a core element of many of these theories is impaired self-control. The idea is that people who have a tendency to act on impulse, be aggressive, and not care about consequences for others are more likely to commit antisocial acts. As we know, these are also effects of head injury. So, in principle, it might be that head injury will increase the risk of offending in some people.

You will be aware of the emotional and cognitive effects of head injury. Emotionally, people can be more impulsive, their threshold for being aggressive can be reduced, and they may be less concerned about the consequences of their actions. Thinking can be rigid, and people may see things in black and white. Together with other cognitive problems, this may make it more likely that people will commit antisocial acts.

How common is head injury in practice in people who offend? In our prison studies, we assessed 500 men, women, and young males. In each study, about 80% of the sample had a history of head injury likely to have significant long-term effects. Our census of all prisoners in Scotland found that hospitalization with head injury was more than twice as likely in the prisoner population than in a sample of the general population matched for age and deprivation.

Is there evidence that a history of head injury is linked to offending? It is difficult to establish clear cause and effect, but prisoners with significant head injury had spent more time in prison and had more convictions than prisoners without a history of head injury. Adults in prison with significant head injury were three to five times more likely to have convictions for violence than prisoners without such a history.

Does head injury differ in prisoners compared to the general public? The prevalence is much higher. In the general public, the most common cause of head injury is a fall. In prisoners, it is assault. In adults and young men, this often arises during fighting, and in women, it results most commonly from domestic abuse. Almost all the prisoners had suffered mild head injuries, mostly with brief or no loss of consciousness. However, an important difference is that two-thirds of those had mild head injury that was repeated over long periods. Repeated head injury can have cumulative effects over time.

We found that disability was associated with head injury in a third of the adults, mostly related to social function, which makes the disability somewhat hidden. Despite the high occurrence of head injuries, 38% had never been to hospital, meaning they wouldn't be getting any professional input or information about head injury or its effects.

I call the health challenges of prisoners the weave of multimorbidity. They have high levels of health morbidity related to drug and alcohol use, mental health, history of trauma and abuse, repeated exposure to head injury, deprived backgrounds, and limited attendance at school. These strands interact, and head injury is a critical strand. Our research shows that if you have a history of significant head injury, you are even more likely to have psychological trauma, mental health problems, and substance use problems.

Regarding women prisoners, more often than not, head injury occurred during abuse. PTSD was twice as likely in women with head injury. Many women were so used to being hit that they had normalized this and were not aware of the potential cumulative effects, so they didn't know they should ask for help.

In our study of people referred for a court report prior to sentencing, three-quarters had a lifetime history of significant head injury. Despite this, no criminal justice social work report noted the history of head injury. This highlights the need for training about head injury for criminal justice social work and the need to establish links with community brain injury services.

In police custody, we estimated that about 13% of detainees report having had a head injury in the past 48 hours. This equates to 12,000 to 14,000 people a year in Scotland. It needs to be considered.

Regarding training and education, I have developed four training modules with NHS Education Scotland. These take people through an introduction to head injury in the criminal justice system, theoretical perspectives, evidence on head injury and crime, and how to assess and manage it. Police Scotland and the Scottish Prison Service are also interested in slimmed-down versions for their staff.

We also developed a single group psycho-education session for prisoners and found it was effective in improving knowledge. We are hoping to develop an online system in the prisons in Scotland so this can be provided either in a group format or through the prison internet.

I am Chris Marriott, the Justice Program Manager for Headway UK. I manage the brain injury identity card and our prison, probation, and police projects. The brain injury identity card is issued to survivors to help explain their symptoms. It has a 24-hour legal assistance helpline for anybody that has interaction with the criminal justice system.

We are looking to digitalize the identity card, which will reduce lost cards and give people the ability to share their information with a safe person. We are also working with police regions to put cardholder information on a crisis and care database, providing officers with specialist information and in-depth history before they arrive on the scene.

For police, we provide training packages built around a basic understanding of brain injury and managing behaviors that challenge. Our prison project is the most advanced, and by April 2026, we should have reached 11 prisons for training. We tailor the training to the needs of each prison estate. We are also looking to build a contract with Prison Industries so that products created by prisoners can be sold in our retail shops, providing an end result and sense of achievement for the prisoners.

In probation, we are seeking funding for staff training. We also plan to build a five-module rehabilitation course for people with brain injuries leaving prison and adjusting back into society. This will be lived-experience led to help authenticate the training. Everything we are doing is centered around education because once we have educated justice professionals, we can look at effective rehabilitation.