Neurocognitive disorders are defined in the DSM-5 as disorders that are acquired later in life, rather than as part of the developmental process. Neurocognitive disorders thus represent a decline from a previous level of functioning (American Psychiatric Association, 2013). The two examples discussed in this section – traumatic brain injury and dementia –  are often encountered by professionals working in the criminal justice field.

2.6.1 Traumatic Brain Injury

Traumatic brain injury (TBI) is a brain injury that occurs when a sudden trauma causes damage to the brain. A TBI can result if a person hits their head suddenly, violently hits an object, or when an object pierces the skull and enters brain tissue (National Institute of Neurological Disorders and Stroke). Anyone can get a TBI, but certain groups of people are more likely to experience a TBI, including racial and ethnic minorities, veterans, people who are homeless, and survivors of intimate partner violence. These groups are also less likely to receive proper medical followup and rehabilitation – leading to greater problems from the TBI (Centers for Disease Control and Prevention, 2023).

TBI is a major cause of death and serious injury in the United States. Survivors’ symptoms vary depending on the severity of the TBI, but moderate to severe injuries come with a vastly shortened life expectancy and a seriously reduced quality of life. Symptoms typically include difficulty understanding and thinking clearly, loss of self-control, personality changes, feelings of anger and aggression, impulsivity and depression (Centers for Disease Control and Prevention, 2023).

People in the criminal justice system have often survived multiple violent encounters, including childhood abuse, violent victimization, physical fights, and prison violent encounters – any of which can be a cause of TBI. Falls or car accidents are also frequent causes of TBI, as are gunshot wounds (such as from attempted suicide). Regardless of cause, incidence of TBI is startlingly high in the criminal justice system. According to the U.S. Centers for Disease Control and Prevention (the CDC), up to 87 percent of jail and prison inmates report a head injury or TBI – in contrast to just about 8-9 percent of the general population (Centers for Disease Control and Prevention, n.d.). Additionally, symptoms of TBI, like so many mental disorders discussed in this text, are likely to impair a person’s ability to succeed in the incarceration or rehabilitation environments that would allow them to move out of the criminal justice system (Chan et al., 2023).

TBIs are commonly undiagnosed or misdiagnosed among people involved in the criminal justice system, which can greatly impact people getting the proper support needed to successfully exit the criminal justice system. For instance, agitation, confusion, behavioral changes, and mood changes can all be symptoms of a TBI. If not properly diagnosed, these symptoms can easily be misdiagnosed as someone being defiant or unwilling to follow societal norms (National Advisory Neurological Disorders and Stroke, 2022).

It is best practice for a mental health clinician to ask during a clinical assessment if someone has ever experienced a loss of consciousness for a few seconds or a few minutes. Although this question is routinely asked in the behavioral health field, it is not always followed with comprehensive care where indicated. Oftentimes, a person will go untreated for potential TBIs and be incorrectly diagnosed with a behavioral disorder. There is a need to have more comprehensive screening tools for potential TBI diagnosis for people involved in the criminal justice system to more accurately diagnose and treat this disorder.

2.6.2 Dementia

Dementia is the loss of cognitive functioning — thinking, remembering, and reasoning — to such an extent that it interferes with a person’s daily life and activities. Some people with dementia cannot control their emotions, and their personalities may change. Dementia ranges in severity from the mildest stage, when it is just beginning to affect a person’s functioning, to the most severe stage, when the person must depend completely on others for basic activities of living.

Dementia is more common as people age (about one-third of all people aged 85 or older may have some form of dementia) but it is not a normal part of aging. Many people live into their 90s and beyond without any signs of dementia (National Institute on Aging, 2021). However, the vulnerable and marginalized groups that make up the U.S. prison populations appear to have greater health problems overall, including a tendency to develop dementia:

“[T]he high risk is because of challenges faced in prison life—and inmates’ experiences before incarceration. Prisoners are often marginalized members of society with less access to health care, poorer diet, issues with alcohol or drug misuse, mental health problems and potential traumatic brain injuries—all factors that increase the likelihood of developing the condition” (Novak, 2022).

Dementia is predicted to be a problem of growing enormity as inmates with this disorder increase in number in the coming years – still facing long sentences but extremely vulnerable to abuse and in need of significant care (Novak, 2022). Prisons are turning to various solutions to manage this growing population, from creating memory-care type wards within prisons to allowing fellow prisoners to serve as caregivers to affected patients (figure 2.16) (Belluck, 2012).

Figure 2.16 shows James Evers, an inmate at the California Men’s Colony, shaving fellow inmate Joaquin Cruz, 60, a convicted killer with Alzheimer’s disease.

2.6.3 Neurocognitive Disorders Licenses and Attributions

“Neurocognitive Disorders” by Kendra Harding is licensed under CC BY 4.0. Modifications:Copied some paragraphs verbatim and reworded others from National Institute of Aging and copied some paragraphs verbatim and reworded others from National Institute of Neurological Disorders and Stroke

Figure 2.16. Image of prison inmates © Todd Heisler/The New York Times is included under fair use.