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Professor Nathan Hughes
Faculty of Social Sciences, University of Sheffield, Sheffield, UK; 
Centre for Adolescent Health, Murdoch Childrens Research Institute, Melbourne, Australia.
Email: nathan.hughes@sheffield.ac.uk Web: https://sheffield.academia.edu/NathanHughes
 
Childhood neurodevelopmental impairments are functional difficulties resulting from problems in the development of the brain or nervous system related to genetics, birth trauma, traumatic brain injury, illness, or severe nutritional or emotional deprivation (1). Such difficulties may relate to:


  • Cognition: acquiring, understanding and applying knowledge, including skills related to learning, memory, attention, evaluation, or reasoning;

  • Emotional functioning: withdrawal, anxiety, impulsivity, regulating and expressing emotions, such as difficulties in restraining emotional reactions, or understanding the emotions of others;

  • Communication: speech, expressive language or receptive language.


Impairments are often experienced in combination, as clinically defined childhood neurodevelopmental disorders, such as: learning or intellectual disability; communication disorders; attention-deficit / hyperactivity disorder (ADHD); and fetal alcohol spectrum disorder (FASD) (2). The key diagnostic criteria for each of these disorders are presented below along with the high prevalence of neurodevelopmental disorders among young people in youth justice custodial institutions in various nation states, as summarised in two recent reviews (3, 4). In each case, the prevalence within such institutions appears disproportionate to rates reported by studies of comparable groups of young people in the general population.
 
Learning/intellectual disability: defined as deficits in cognitive capacity (measured by an IQ score of less than 70); and adaptive functioning (significant difficulties with everyday tasks). Prevalence rates among young people in the general population = 2-4%; prevalence rates among young people in custody = 23-32%
 
FASD: defined as Reduced height, weight, or head circumference; characteristic facial features; deficits in executive functioning, memory, cognition, intelligence, attention, and/or motor skills; resulting from prenatal alcohol exposure due to maternal consumption during pregnancy. Prevalence rates among young people in the general population = 0.1-5%; prevalence rates among young people in custody = 11-21%
 
Communication disorders: defined as problems with speech, language or hearing that significantly impact upon an individual's academic achievement or day-to-day social interactions. Includes expressive and receptive language; speech sound disorder; and stuttering. Prevalence rates among young people in the general population = 5-7%; prevalence rates among young people in custody = 60-90%
 
ADHD: defined as persistence in multiple symptoms of inattention, hyperactivity and impulsivity. Prevalence rates among young people in the general population = 2-9%; prevalence rates among young people in custody = 12%
 
This indicates that large numbers of young people in custody in various Western countries have one or more clinically defined neurodevelopmental disorder. What’s more, levels of need are even greater if we also consider those who may not meet tightly specified clinical diagnostic criteria, yet experience very real and significant impairments. This is illustrated by a systematic review of research regarding experiences of childhood traumatic brain injury (TBI) (5). Whilst TBI is not a neurodevelopmental disorder, it is associated with a wide range of related impairments in cognition, emotion, and communication, particularly where injuries lead to significant loss of consciousness. The review suggests 32-50% of young people in custody report experience of a TBI resulting in loss of consciousness, compared to 5-24% within the general population. This disparity is seemingly more pronounced as the severity of the injury increases.
 
This weight of evidence calls into question the extent to which impairment is recognised and effectively responded to within youth justice systems. Screening and assessment for such impairments appear rare, leading to the use of inappropriate interventions to address offending behavior, and a lack of support regarding difficulties with cognition and communication, causing significant barriers to engagement in police interviews or court procedures, and therefore inhibiting fair access to justice (6).
 
This evidence also illustrates that the youth justice custodial estate has become the primary service provider to a large number of young people with significant neurodevelopmental impairment. The suitability of such institutions to effectively meet the developmental needs of these vulnerable young people must surely be questioned. Furthermore, this suggests considerable challenges for practices and interventions within custodial institutions, given the potential impact of such impairment on: ‘interactions with staff and fellow prisoners, particularly in relation to conflict, bullying and victimization; the ability to understand and follow prison rules or particular commands; and engagement with interventions, particularly those intended to alter behaviour’ (7).
 
Our recent studies have also illustrated the range of complex health needs associated with neurodevelopmental impairment among young people in custody. Utilsing data collected through the Comprehensive Health Assessment Tool - a clinical assessment routinely undertaken with all young people entering custody in England – we have demonstrated that NDIs are associated with a greater risk of mental health difficulties when compared to peers in custody. This includes a greater risk of deliberate self harm (x2.2) and depression (x4.25) among young people with language impairments (8), and a greater risk of suicidal thoughts (x3.2) and deliberate self harm (x3.7) among young people who have experienced childhood TBI (9). We have similalrly identified higher levels of alcohol (x1.6) and other drug use (x1.5) among those with a language impairment (8), and higher alcohol use (x1.8) following a TBI (9). While this does not confirm any causal relationship, it demonstrates that signs of neurodevelopmental difficulties may indicate a need for comprehensive assessments of health behaviours and social functioning.
 
This recognition of the high levels of neurodevelopmental impairment and associated needs among young people in custodial populations clearly poses significant challenges for youth justice systems. However, a continued failure to recognize and respond to this evidence leaves these young people extremely vulnerable as a result of their experiences of disability, while also hindering our attempts to prevent future engagement in offending.
 
References
 
(1) Patel, D.P., Greydanus, D.E., Omar, H.A. & Merrick, J. (eds.) (2011) Neurodevelopmental Disabilities: Clinical Care for Children and Young Adults. New York: Springer
 
(2) American Psychiatric Association (APA) (2013) Diagnostic and statistical manual of mental disorders (5th ed.). Washington DC: APA.
 
(3) Hughes, N., Williams, H., Chitsabesan, P., Davies, R. and Mounce, L. (2012) Nobody Made the Connection: The prevalence of neurodisability in young people who offend. London: Office of the Children’s Commissioner for England. https://www.researchgate.net/publication/263162877_Nobody_Made_the_Connection_Neurodisability_in_the_youth_justice_system_Published_by_the_Office_of_the_Children%27s_Commissioner_for_England
 
(4) Hughes, N., Clasby, B., Williams, W.H. and Chitsabesan, P. (2016) ‘A systematic review of the prevalence of fetal alcohol spectrum disorders among young people in the criminal justice system’ Cogent Psychology, 3: 1214213 http://www.tandfonline.com/doi/full/10.1080/23311908.2016.1214213 
 
(5) Hughes, N., Williams, W.H., Chitsabesan, P., Walesby, R., Mounce, L.T.A. and Clasby, B. (2015) ‘The Prevalence of Traumatic Brain Injury Among Young Offenders in Custody: A Systematic Review’, Journal of Head Trauma Rehabilitation, 30(2): 94-105. https://www.researchgate.net/publication/273320578_The_Prevalence_of_Traumatic_Brain_Injury_Among_Young_Offenders_in_Custody_A_Systematic_Review
 
(6) Hughes, N. (2015) Neurodisability in the youth justice system: recognising and responding to the criminalisation of neurodevelopmental impairment, Howard League for Penal Reform, What is Justice? Series, Available at: www.academia.edu/15237699/Neurodisability_in_the_youth_justice_system_recognising_and_responding_to_the_criminalisation_of_neurodevelopmental_impairment
 
(7) Hughes, N. and Pierse-O’Bryne, K. (2016) ‘Disabled Inside: neurodevelopmental impairments among young people in custody’ Prison Services Journal, 226: 14-21https://www.crimeandjustice.org.uk/sites/crimeandjustice.org.uk/files/PSJ%20226%20July%202016.pdf
 
(8) Hughes, N., Chitsabesan, P., Bryan, K., Borschmann, R.  Swain, N., Lennox, C. and Shaw, J. (2017) Language impairment and comorbid vulnerabilities among young people in custody. Journal of Child Psychology and Psychiatry,58(10): 1106-1113 http://onlinelibrary.wiley.com/doi/10.1111/jcpp.12791/pdf
 
(9) Chitsabesan, P., Lennox, C., Williams, H., Tariq, O., and Shaw, J. (2015). Traumatic brain injury in juvenile offenders: findings from the comprehensive health assessment tool study and the development of a specialist linkworker service. Journal of Head Trauma Rehabilitation, 30(2), 106-115. https://www.ncbi.nlm.nih.gov/pubmed/25734841