Addressing TBI in the juvenile justice system involves policies that cut across health, criminal justice, human services, education and other policy domains. State lawmakers play a critical role in overseeing and funding health care programs that may serve justice-involved juveniles and families, including TBI programs and Medicaid. State legislative responsibility for juvenile justice can include facilitating collaboration within justice systems, promoting public safety and improving outcomes for young people.
States have introduced or enacted legislation to appropriate funds to TBI prevention, rehabilitation and community-based services, including information and referral services and service coordination. They have also proposed or enacted laws requiring insurers, hospitals and health maintenance organizations to provide insurance coverage for cognitive rehabilitation for TBI survivors. In addition, between 2009 and 2019, all 50 states and the District of Columbia have passed “return to play” laws to address sports-related concussions for youth athletes. According to NASHIA, 23 states have passed laws to designate funding sources—e.g., traffic fines or vehicle registration surcharges—to support programs and services for individuals with TBI. A few states provide appropriations to supplement these funds or are the only source of TBI funding.
As shown in the four state examples that follow, state policymakers, officials and researchers have adopted a variety of approaches to study the prevalence of TBI among justice-involved juveniles, provide screening and assessment to better detect TBI, and provide services and interventions that help individuals with TBI attain their potential.
Colorado: Partnering to Identify and Treat TBI in Juvenile Justice
MINDSOURCE Brain Injury Network, Colorado’s brain injury program administered by the Department of Human Services, received funding from HHS’ ACL TBI State Partnership Grant. In 2014, MINDSOURCE partnered with University of Denver (DU), the Brain Injury Alliance of Colorado, county jails, the Colorado Judicial Branch and other stakeholders to develop and implement a screening, identification, support and referral protocol for adults and juveniles involved in the criminal justice system. The four-year project aimed to:
- Develop, implement, evaluate and disseminate a best-practice protocol for screening, identifying and assessing TBI within the adult and youth corrections populations.
- Provide professional training for corrections and judicial personnel.
- Provide information about TBI to the families of justice-involved youth with TBI.
- Develop, implement and evaluate strategies that provide access to service providers for corrections populations.
The project screened about 4,000 adults and juveniles for lifetime history of brain injury, with about 38% of all youth screening positive. Individuals screening positive for a brain injury were referred to DU for further neuropsychological screening, which identified a need for case management support for about 200 individuals who exhibited brain injury and serious cognitive deficits. The pilot highlighted several important lessons. For example:
- To address staff turnover in the juvenile corrections setting, it is important to provide ongoing training and consultation.
- The pilot’s step of delivering the secondary, neuropsychological screens is costly and may not always be necessary.
- When individuals connect with a case manager before they are released from the juvenile justice system, they are more likely to follow through with community-based supports after they are released.
Colorado’s legislature has helped partners sustain their efforts. In 2019, the General Assembly passed SB 114, which appropriated $450,000 in state general funds to support a probation pilot program administered by DHS’ brain injury program.
Minnesota: Leveraging Federal Funds to Improve TBI care
Minnesota was awarded the federal HHS’ ACL TBI State Partnership Grant in 2006, 2010 and 2018.
The 2006-2010 grant assessed the prevalence of TBI in the state’s correctional facilities and developed strategies to successfully transition individuals back to the community. Using the Traumatic Brain Injury Questionnaire (TBIQ) to survey offenders in adult correctional facilities and juvenile detention centers, researchers found that 49 of 50 juvenile males at one facility reported a TBI, according to the Brain Injury Alliance of Minnesota. The state developed three online training modules for corrections staff, including training on release planning and TBI resources.
The state’s 2010 award helped partner agencies build on their earlier efforts by hiring a project psychologist and release planner to support the needs of offenders with significant needs relating to TBI.
Medicaid Home and Community-Based Waivers
In 1992, Minnesota first received approval from the U.S. Centers for Medicare & Medicaid Services (CMS) for a home- and community-based services (HCBS) waiver, also known as a Section 1915(c) waiver, to provide services to people with brain injuries. The waiver must be renewed every five years, with current CMS approval valid through 2020. The HCBS waiver is used to obtain Medicaid matching federal funds to deliver long-term services and supports to people in community-based settings instead of institutions.
Minnesota is one of at least 22 states using a Medicaid HCBS waiver to extend benefits and services to children and adults who have an acquired, traumatic or degenerative brain injury. According to Minnesota DHS, an average of 1,190 people each month were served through the state’s brain injury waiver in 2018. In addition to services provided under the general Medicaid benefit package, the HCBS waiver makes available a wide range of services, including consumer-directed community supports, crisis respite and case management. Minnesota also administers a TBI trust fund program, from which the majority of the funds are used to contract with the Minnesota Brain Injury Alliance, a nonprofit organization, for a network of supports, including information and referral services and resource facilitation.
Pennsylvania: Improving TBI Screening and Treatment in Juvenile Detention Centers
To address the needs of youth in juvenile detention centers—as well as detention center staff who serve them—the Pennsylvania Department of Health partnered with the Brain Injury Association of Pennsylvania (BIAPA) in 2014. With a federal ACL TBI State Partnership Grant Program, DOH and BIAPA implemented the Brain Injury Education, Training and Consultation Project in two juvenile detention centers. The project sought to screen detainees, provide neurocognitive assessment for those screening positive, and connect juveniles with resources and supports, both in the detention setting and back in tehir community.
By 2017, more than half (53%) of juveniles screened in two detention centers were determined to have experienced an event that could have caused a brain injury. Of the 133 juveniles who went on to receive neurocognitive testing, 74—or 56%—showed evidence of impairment. One-quarter of youth in the Loysville Youth Development Center screened positive for TBI. The pilot project revealed several important lessons that inform the state’s ongoing work. For example, BIAPA learned that:
- Because there is not a single statewide system, implementation must be tailored to juvenile justice systems in each county.
- Youth may deny their head injury history because they are afraid of having to stay at the detention center longer, making it important to learn how to best engage youth.
- Obtaining partnerships with all stakeholders is difficult, but necessary for implementation. Future outreach should involve judges and county juvenile probation offices, as they play a key role in developing youth service plans.
- Youth are more likely to receive interventions if they are going back to the community than if they are being placed at another juvenile justice facility. Moreover, the privacy protections relating to the youth population can make it difficult to follow them through placement in services.
- Lack of knowledge, skepticism, and hesitation about TBI and its effects are challenges. Staff may not understand that a brain injury is causing impairments.
BIAPA and DOH adopted several strategies to sustain—and build upon—the education, training and consultation project. To promote long-term sustainability, project partners adopted a range of strategies by 2018, such as:
- Conducting TBI research and disseminating results to state and national audiences.
- Training nurses to take over screening if BIAPA no longer has funding to support screening. By 2018, screening had been incorporated within the nursing roles at one juvenile detention facility.
- Focusing on youth in probation rather than at detention sites.
- Providing technical assistance and guidance to support other interested counties.
Virginia: Supporting evidence-based interventions for juveniles with TBI
Virginia’s experience demonstrates the various ways that state lawmakers have initiated and supported TBI initiatives that address the needs and challenges within the juvenile justice population.
Virginia’s General Assembly in 2008 directed the secretary of public safety to analyze the incidence of TBI in the adult and juvenile offender populations. The director of the Department of Juvenile Justice (DJJ) convened a work group representing various state agencies, Virginia Commonwealth University (VCU) and TBI advocates. In its 2008 report, the work group found insufficient data to quantify the prevalence of TBI in Virginia’s offender populations; however, the available data suggested a “significant portion of the incarcerated population may have a history that suggests the possibility of TBI.”
The work group recommended funding to support research to examine the scope of the problem and to develop a best practices model with a focus on juveniles committed to the state’s juvenile correctional centers.
In 2010, the Commonwealth Neurotrauma Initiative (CNI) advisory board awarded a grant to VCU to study screening, evaluation and intervention programs for youth with brain injury in Virginia’s DJJ facilities. The project used grant funds to formulate guidelines for brain injury screening, evaluation and intervention. The grant provided the cash match to a federal grant.
Researchers from VCU and DJJ screened individuals entering the juvenile justice system using tests that measured memory, attention, concentration, visual perception and visual construction. They also conducted interviews and reviewed medical charts to gather additional information on lifetime incidence of TBI. Researchers found that more than half (53%) of youth admitted to the juvenile justice system reported a history of sustaining at least one TBI.
To increase awareness about the prevalence of TBI and its effects on individuals in the juvenile justice system, BIAV and VCU collaborated on a series of videos to educate DJJ front-line staff about brain injury.
A 2016 report by the Disability Law Center of Virginia noted that a positive outcome stemming from Virginia’s efforts with juveniles has included the development of a Brain Injury Screening Tool that reliably evaluates juveniles entering the DJJ system. More information on the development and use of the brain injury tool is available through a 2019 webinar.