Brain Injury

ISSN: 0269-9052 (Print) 1362-301X (Online) Journal homepage: https://www.tandfonline.com/loi/ibij20

Pediatric traumatic brain injury and antisocial

behavior: are they linked? A systematic review

Giulia Bellesi, Edward D. Barker, Laura Brown & Lucia Valmaggia

To cite this article: Giulia Bellesi, Edward D. Barker, Laura Brown & Lucia Valmaggia (2019):
Pediatric traumatic brain injury and antisocial behavior: are they linked? A systematic review, Brain
Injury, DOI: 10.1080/02699052.2019.1641621

To link to this article: https://doi.org/10.1080/02699052.2019.1641621

Published online: 21 Jul 2019.

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BRAIN INJURY
https://doi.org/10.1080/02699052.2019.1641621

Pediatric traumatic brain injury and antisocial behavior: are they linked? A
systematic review
Giulia Bellesia,b, Edward D. Barkera, Laura Browna,b, and Lucia Valmaggiaa,b
a
King’s College London, Institute of Psychology, Psychiatry, and Neuroscience, Department of Psychology, London, UK; bSouth London and
Maudsley NHS Trust, London, UK

ABSTRACT ARTICLE HISTORY

Purpose: Despite growing evidence supporting a link between pediatric traumatic brain injury (TBI) and Received 12 October 2018
antisocial behavior, little work has rigorously evaluated this. This review aimed to explore systematically Revised 12 May 2019
previous literature on the association between TBI before the age of 19 and severe behavioral problems Accepted 4 July 2019
such as violence, aggression and assault. KEYWORDS
Methods: All articles published from 1990 to 2018 were searched using four major databases, alongside Traumatic brain injury;
manual searching and cross-referencing. children; antisocial behavior;
Results: Sixteen articles met the eligibility criteria. Overall, they supported an association between crime; outcomes
pediatric TBI and antisocial behavior. Factors were identified that might influence this link, such as, for
example, TBI severity and substance use.
Conclusions: The review identified several issues in the current literature, highlighting key areas for
improvement. It is imperative that more attention is paid to gathering detailed information regarding
the temporal sequencing of events and TBI severity; evaluating the contribution of biopsychosocial
variables co-occurring with TBI and antisocial behavior; disentangling which outcomes are specific to TBI
versus any injury. The review has implications for the health and justice systems; regardless of whether
TBI is the cause versus a contributing factor to antisocial behavior, increased awareness of their
association could lead to more comprehensive assessments, tailored interventions and effective
sentencing.

Introduction
Traumatic brain injury (TBI) is the leading cause of disability and
death in young adults worldwide (1). An area of particular interest
is the impact of pediatric TBI on subsequent development and
functioning. Although it was previously thought that youth reco-
vermore speedily from brain injury than adults, due to the brain’s
higher degrees of neuroplasticity, more recent work has countered
this (2). The child brain is increasingly recognized to be uniquely
vulnerable to external insults, and disruption in the development
of key processes responsible for cognitive and emotional regula-
tion (3). Pediatric TBI has been linked to several adverse outcomes
later in life, including lower educational attainment (4), increased
rates of substance use (5), and internalizing and externalizing
conditions (6,7). Youth with history of TBI also shows less sophis-
ticated interpersonal skills (8,9), lower levels of prosocial behavior
and increased rates of aggression (10,11).
The existence of a link between pediatric TBI and antisocial
behavior, an umbrella term encompassing nuisance behavior,
intimidation and vandalism, has recently become a topic of
pressing concern. Antisocial behavior is associated with high
interpersonal and financial costs, at individual, community and
societal level (12). Official estimates of its scale are hard to obtain
reliably; a formal report indicates that only in 2013, 2.3 million
incidents were formally recorded by the police in England and
Wales (13). Previous reviews have noted remarkably high rates
of TBI history in individuals accused of antisocial acts. In the
non-injured population, TBI incidence is approximately 10%,
with 85–90% of injuries being mild, and about 10–15% moderate
to severe (14). Within adult and youth offenders, instead, TBI
rates are approximately 60% and 30%, respectively (15,16).
Hughes et al., in a review of previous studies with youth offen-
ders from various national contexts, identified that when TBI
severity is considered, the disparity in incidence between non-
injured and injured individuals is even larger (17). Early child-
hood and adolescence are both peak periods for suffering from
a TBI (18); it is also well established that most prolific offenders
typically start their criminal career at a young age, in adolescence
or young adulthood (19). A UK charity, Centre for Mental
Health, recently completed an economic analysis estimating
the long-term costs of early TBI, with specific reference to its
link with crime (15). They predicted that, on average, a TBI in
a 15-year-old representative of the general population leads to
a lifetime cost of approximately £155,000 per case; of these,
£95,000 are spent on “non-crime” costs (e.g. hospital care),
whereas £60,000 on the consequences of additional offending.
For youth of the same age suffering from a TBI but who already
had a history of offending, estimated costs increased to around
£345,000 per case (15).
Although previous findings are suggestive of a causal relation-
ship between earlier TBI and problem behaviors, since these

CONTACT Giulia Bellesi giulia.bellesi@kcl.ac.uk King’s College London, Institute of Psychology, Psychiatry, and Neuroscience, Department of Psychology,
Addiction Sciences Building, 4 Windsor Walk, Denmark Hill, London SE5 8BB, UK
© 2019 Taylor & Francis Group, LLC
2 G. BELLESI ET AL.
focused exclusively on prisoner populations, it cannot be ruled out
that other mechanisms may be at work; for instance, TBI and
offending may have other common underlying determinants (15).
Studies following community populations, especially those with
longitudinal designs, may be more appropriate for elucidating the
etiology of the relationship between pediatric TBI and antisocial
behavior. Previous reviews of the evidence have predominantly
focused on the link between TBI a broader range of behavioral
outcomes, such as psychopathology, social skills and internalizing
and externalizing conditions (20–22). A recent systematic review
by Kennedy et al. (23) assessed whether pediatric TBI was asso-
ciated with “risk behaviors”, such as substance use, criminal
behavior and behavioral difficulties. Although informative, the
review examined different types of outcomes, meaning that only
a limited number of search terms related to antisocial behavior.
Moreover, in the review TBI had to have occurred by age 13;
although this allows to link outcomes to an injury occurring in
a narrower developmental phase, it also means that the final pool
of available studies was very small. It is also worth noting that
several different factors, such as for instance lower socioeconomic
status (24,25), substance abuse (26,27), and emotional dysregula-
tion (28,29) have been linked to both TBI and antisocial behavior;
nonetheless the literature on whether and how these variables
influence their relationship has yet to be evaluated as a whole.
It is therefore critical to examine systematically the recent
empirical evidence to provide an overview of the ongoing
progress. The need for more attention towards this area of
research has been recently highlighted by the Office of the
Children Commissioner, a national organization led by the
Children’s Commissioner for England. In line with the find-
ings outlined above by Hughes et al. (17), they highlighted
how high percentages of young people living in custody are
being increasingly found to have undiagnosed or untreated
neurological issues. They advocated for more time and effort
to be dedicated to an increase in our understanding of the
consequences of pediatric brain injury and whether these
might contribute to explain offending (30). This might, in
turn, guide the development of measures to prevent or mini-
mize future occurrence of severe behavioral issues.
Based on this, the present systematic literature review
aimed to address the following questions:
(I) Is pediatric TBI associated with increased engagement
in antisocial behavior?
(II) What biopsychosocial factors have been found to
influence the association between pediatric TBI and
antisocial behavior?
Method
The review was carried out according to the PRISMA guide-
lines (31).
Eligibility criteria
To be included in the review, articles had to meet the follow-
ing criteria: the study populations were human participants;
participants had sustained a TBI before 19 years of age; they
had been published as original articles in peer-reviewed
journals; they were written in English; TBI and antisocial
behavior were conceptualized as described below; the articles
had been published from 1990 to September 2018. Nineteen
years of age has frequently been used as a cut-off by previous
studies examining pediatric TBI (32,33); it is the age at which
individuals transition from pediatric to adult services in sev-
eral European countries, and the cut-off used by the World
Health Organisation to refer to the end of adolescence (34).
Articles which did not provide with information regarding
participants’ age at TBI or where this was unclear were not
included. The year 1990 has been chosen as start year also by
previous systematic reviews on pediatric TBI outcomes (22);
this is due to a surge in clinical and research interest in the
area since then, leading to more studies. Moreover, since TBI
occurrence and investigation methods have changed in the
last two decades (35), using this cut-off aimed to maximize
the overlap in methodologies and outcome measures.
Although population-based longitudinal designs are more
adequate than cross-sectional studies in establishing the direc-
tionality of the relationship between variables of interest,
preliminary searches had indicated that only a limited amount
of longitudinal research had been published. To maximize the
amount of evidence available, it was decided to include both
types of designs. All decisions regarding inclusion and exclu-
sion were made by at least two researchers.
Definitions
TBI and antisocial behavior were conceptualized as follows.
TBI
Definitions and classifications of TBI vary widely across stu-
dies, specialties and countries (36). In the present review,
conceptualizations needed to be consistent, as an absolute
minimum, with the definition provided by the Centres for
Disease Control and Prevention (37), also adopted by pre-
vious systematic reviews (17). This operationalizes TBI as “a
bump, blow, or jolt to the head or a penetrating head injury
that disrupts the normal function of the brain”.
Antisocial behavior
Antisocial behavior also has no single definition (38).
Typically, it refers to a wide spectrum of activities considered
unacceptable by one’s cultural standards, and disrespectful of
others’ rights (39). Specific labels, classifications, and assess-
ment methods vary often depending on discipline, context,
and country. For the purpose of the present review, “antisocial
behavior” was used to refer to activities on the most severe
end of the spectrum of socially unacceptable behavior, such as
for instance rule-breaking, delinquency, nuisance behavior,
vandalism, physical and verbal aggression.
Search sources and strategy
The searches were conducted using the search engines: Ovid
MEDLINE, PsycINFO, Embase, Web of Science. The final
search strategy was developed following an examination of
published and prospective reviews and meta-analyses. Three
key concepts were identified: TBI, childhood, and antisocial

behavior. Terms and synonyms relating to each were com-
bined using Boolean operators. Limiters and filters were used
to apply the inclusion and exclusion criteria. The list of search
terms used is available as a Supplemental File. Manual search-
ing for additional manuscripts was also conducted by consult-
ing reference lists and previous literature. A librarian at Reay
House Library in London with specialist expertise in systema-
tic reviews provided the first author with an hour-long train-
ing session, supporting with respect to refining the list and
combination of search terms and databases selection.
Quality assessment
The information gathered from the final selection of articles
(including: sample characteristics, design, methodology, find-
ings robustness) was assessed for methodological quality and
risk of bias. There are no recognized “gold standard” tools for
the quality assessment of cross-sectional or longitudinal stu-
dies. Previous evidence suggested that the NIH Quality
Assessment Tool for Observational Cohort and Cross-
Sectional Studies (40) and the Cohort Study Checklist (41)
are often adopted for cross-sectional and longitudinal studies,
respectively. These were therefore used, with each article
Figure 1. Pictorial representation of the study selection process.
BRAIN INJURY 3
being evaluated by two independent researchers. Depending
on the score obtained on the checklist, they were classified as
either “poor”, “fair” or “good”.
Results
Information extraction
The initial search yielded 2509 articles. Sixteen additional
articles were identified via manual searching. Removal of
duplicates reduced the number to 2319. Subsequent selection
involved four main phases (Figure 1):
Phase 1: Preliminary screening of titles to exclude articles
with ostensibly no relevance to the review aims (e.g. no
reference to TBI). This process reduced the number to 779.
Phase 2: Screening of abstracts; this reduced the number
to 96.
Phase 3: Full-text screening; this reduced the number to 39.
Phase 4: Examination of whether the remaining articles
met the inclusion criteria. This process was completed with
the aid of an extraction grid, summarizing key information
from each article against eligibility criteria. Following this
phase, 16 articles were considered suitable for the review.
4 G. BELLESI ET AL.
It is important to note that in three articles from the final
selection, mean age at TBI was either above 19 years of age
(42), or below this threshold but with high degree of variance
(43,44), meaning that not all participants had suffered from
their TBI in pediatric age. It was decided to still include these
articles as the authors had conducted additional, separate
analyses for participants who had their injury before age 19,
consistent with inclusion criteria. To keep the review focused
on outcomes of pediatric TBI, only the findings relevant to
these sub-groups of participants are reported and discussed.
Analysis of the articles
Table 1 provides key features of the final list of articles. They
were all published between 1998 (55,56) and 2018 (45), across
eight countries. Largest contributions were from the UK (four
articles) (47,48,52,55), US (43,44,51), and New Zealand
(5,49,50) (three articles each).
Samples characteristics
Populations with TBI were offenders (43,44,48,51,52) (five
articles), patients (5,45,53,55,56) (five articles), individuals
recruited from the community (42,46,47,54) (four articles),
and a mixture of patients and individuals from the commu-
nity (49,50) (two articles).
Sample sizes for participants with TBI were not always
reported. When this was the case, they varied widely, from
26 (53) to over 22,000 (42). Information regarding sex ratio in
TBI samples was not available for all articles; overall the
proportion of males ranged from 53% (50) to 100%, with
two articles comprising male participants exclusively (48,52).
Participants with TBI were predominantly compared to
individuals with no history of TBI (5,42–44,46,48,51–55). In
three articles, they were compared to individuals with history
of orthopedic injury (49,50,56). Pastore et al. (45) also
included a group of participants with brain lesions of vascular
or infectious origin. Kennedy et al. (47) were the only study to
include both a no injury group and a negative exposure group
(orthopedic injury). Orthopedic injury has a similar con-
founding structure to TBI, but no plausible biological connec-
tion to antisocial behavior; comparing outcomes between
these groups can help to ascertain whether the association
might be explained by potentially unobserved or unaccounted
for biases (e.g. the traumatic experience of suffering from an
injury).
It is likely that there was a degree of overlap with respect to
samples. Fishbein et al. (43) and Brewer-Smyth et al. (44)
examined an inmate population in the same institution and
time period. Scott et al. (49) and McKinlay et al. (50) both
assessed clinical and non-clinical participants recruited in
New Zealand in the same time frame. These publications
were still included as they assessed different, although related,
outcomes.
Designs and methodological considerations
Seven articles had a cross-sectional design (43–45,48,51,52,55)
and nine had a longitudinal design (5,42,46,47,49,50,53,54,56).
Cross-sectional articles present with intrinsic limitations with
respect to elucidating the temporal ordering of exposure and
outcome variables; however longitudinal research also varied
in the extent to which pre-injury antisocial behavior was
accounted for. For instance, in Timonen et al. (54) and
Fazel et al. (42), pre-injury antisocial behavior was not
recorded. This was because the outcome variable (number of
crimes) was extracted by national registers in countries where
crimes are only recorded after people’s 15th birthday (age by
which all participants had already had their TBI). Scott et al.
(49) and McKinlay et al. (50) did not collect information
regarding pre-injury behavioral problems. Ong et al. (56)
collected parental retrospective ratings at the time of injury.
A shift was noted in more recent articles towards account-
ing more accurately for pre-injury difficulties. McKinlay et al.
(5) examined parental reports of behavioral problems from
one to five years of age. Buckley & Chapman (46) collected
information regarding violent behavior at both time points of
testing (Time 1 and 2) and controlled for antisocial behavior
at Time 1 when examining outcomes at Time 2.
Assessment tools
TBI. TBI was assessed either through self-report (43,44,46–
48,51,52) (seven articles), examination of clinical records
(42,45,49,50,53–56) (eight articles) or both (5) (one article).
As it can be noted in Table 1, there was high heterogeneity
in how TBI was measured and classified. In articles relying
on self-report, participants could be included in the TBI
group if they had sustained a head injury that led to an
alteration or loss of consciousness, to a skull fracture, and/
or that “required medical attention”; specific definitions and
combinations of criteria varied in each article. Most articles
based on self-report did not explore TBI severity, most
likely due to difficulties assessing this reliably. There were
three exceptions, with Chitsabesan et al. (48) enquiring
about history of loss of consciousness and post-concussion
symptoms, and Brewer-Smyth et al. (44) and Davies et al.
(52) capturing information about the length of loss of con-
sciousness (LOC).
Most articles based on clinical records always included at
least one indicator of TBI severity and defined their groups
according to this. There was, however, significant variation in
relation to the assessment criteria used. Pastore et al. (45), for
instance, relied on the Glasgow Coma Scale (GCS) score only;
Ong et al. (56) on GCS score and coma length. Some articles
relied on more comprehensive sets of criteria. Scott et al. (49)
and Andrews et al. (55) relied on GCS score, Post-Traumatic
Amnesia (PTA) and LOC duration. McKinlay et al. used
information about computed tomography findings, PTA and
LOC length in one article (50); in another, they relied on the
same set of information as well as GCS score at admission (5).
However, in this participants were not divided into groups
depending on TBI severity, but rather on whether they had
been admitted to hospital as inpatients or outpatients (5); this
might also be an approximate indicator of severity.
Only two articles relying on medical records did not exam-
ine severity. In Luukenainen et al. (53), TBI data were
extracted from hospital registers, and authors did not have
access to detailed case notes. Timonen et al. (54) also relied on
pre-existing medical records and information indicative of
severity had not been entered or was missing.
Table 1. Key features of studies examining the association between pediatric TBI and antisocial behavior.

TBI Samples n (% Mean age at Time since TBI TBI definition and Antisocial behavior
Authors Year Country population male) Design TBI (years) TBI (years) assessment classification assessment Main findings Additional findings Rating
V. Pastore, S. Galbiati, M. Recla, 2018 Italy Clinical 57 participants CS M = 12, M=2 Clinical Severe traumatic (non- Aggression and ● Participants with TBI ● Participants Fair
K. Colombo, E. Beretta and with severe TBI SD = 4 records acquired) injury to the delinquent showed higher with TBI did
S. Strazzer (45) (61%), 33 control brain (GCS <9) behavior scales of degrees of delin- not differ sig-
participants (brain the CBCL (parent- quent (F = 6.05, nificantly from
lesions of vascular completed p = .003, d = .68) those with
or infectious questionnaire) and aggressive acquired brain
origin; 45%), 48 (F = 4.66, p = .01, injury; partici-
control d = .59) behavior pants with
participants (no than those with no acquired brain
brain injury; 45%) injury. injury did not
differ signifi-
cantly from
control (no
brain injury)
participants.

L. Buckley and R.L. Chapman (46) 2017 Australia Community Total sample of LT <14 1 Self-report Head injury involving Research-specific ● TBI at time 1 pre- ● Number of Good
734; 91 reporting (E-AIC) “concussion” or “being question regarding dicted violent beha- TBIs was not
a TBI at time point knocked out” violent behavior vior after one year included; it is
1 (58%) (getting in a fight) (OR = 2.28, 95% CI thus unclear if
1.11–4.73, p < .05) violent beha-
● This finding vior was
remained significant linked with
when controlling for higher num-
sex, violence and ber of injuries.
risk-taking beha-
viors (alcohol use,
truancy, unlicensed
driving and passen-
ger risks) at time 1
(OR = 2.34, 95% CI
= 1.07–5.16,
p < .05).

(Continued )
BRAIN INJURY
5
Table 1. (Continued). 6

TBI Samples n (% Mean age at Time since TBI TBI definition and Antisocial behavior
Authors Year Country population male) Design TBI (years) TBI (years) assessment classification assessment Main findings Additional findings Rating
E. Kennedy, J. Heron, and 2017 UK Community 800 participants LT 0–16 >1 Parental and Head injury resulting in Self-report ● Compared to parti- ● Participants Good
Munafò M. (47) with TBI (57%); (antisocial self- report “loss of consciousness” or questionnaire cipants with no with TBI
2305 control behavior (research- “cracked or broken skull” assessing injury, individuals showed
participants assessed at specific offending and with TBI were at increased
(orthopaedic age 17) question) trouble with the higher risk of odds of hazar-
injury; 55%); 8307 police offending (unad- dous alcohol
control justed OR = 1.72, use than the
G. BELLESI ET AL.

participants (no 95% CI 1.32–2.23), no injury

injury; 49%) and being in trouble group (OR =
with the police 1.51, 95% CI
(unadjusted OR 1.21–1.90) and
1.62, 95% CI the orthopedic
1.21–2.17). injury group
● The TBI-offending (OR 1.34, 95%
remained robust CI 1.05–1.72)
after adjusting for ● They also
pre-birth and early showed
childhood confoun- increased
ders (related to odds of pro-
socioeconomic sta- blematic use
tus and family of tobacco (OR
adversity), OR = = 1.47, 95% CI
1.67, 95% CI 1.12–1.94) and
1.24–2.24. The asso- cannabis
ciation with being in (OR = 1.54,
trouble with the 95% CI
police was instead 1.22–1.94)
significantly attenu- compared to
ated (OR = 1.44, those with no
95% CI 1.03–2.01). injury.
● Further adjusting for
substance use in
adolescence wea-
kened significantly
the link between TBI
and offending (OR =
1.29, 95% CI
.09–1.88) and
between TBI and
trouble with the
police (OR = 1.17,
95% CI .77–1.77)
● Participants with TBI
did not differ from
participants with
orthopedic injury for
either offending (OR
= 1.16, 95% CI
.87–1.54) or trouble
with the police
(OR = 1.14, 95% CI
.83–1.57).

(Continued )
Table 1. (Continued).

TBI Samples n (% Mean age at Time since TBI TBI definition and Antisocial behavior
Authors Year Country population male) Design TBI (years) TBI (years) assessment classification assessment Main findings Additional findings Rating
D. Fishbein, J. K. Dariotis, 2016 US Offenders Total sample of CS M = 17, SD Mean age at Self-report “A blow to the head or BPAQ (self-report ● 67.8% offenders ● Participants Fair
P. L. Ferguson and 636; 149 (N.R.) had =9 assessment (modified neck, resulting in an questionnaire reported history of with history of
E. E. Pickelsimer (43) a TBI before 13 Further of antisocial version of the alteration of measuring TBI, and 23% of the TBI before age
years of age analyses behavior OSU TBI-ID) consciousness (i.e. aggression) whole sample had it 13 had higher
conducted (across dazed or confused, or before age 13. aggression
for groups): forgetting what ● Compared to unin- scores (LS
participants M = 35, SD happened before or jured controls, those mean = 85)
who had =9 after the injury)” with a TBI by age 13 than those who
their TBI reported higher had a TBI at or
before age total aggression after that age
13 scores (β = 8.65, (LS mean = 82).
p < .001). ● The lower the
age at first
drug use, the
greater the
total aggres-
sion score,
regardless of
TBI age (β =
−.25, p < .01)
● When emo-
tional dysre-
gulation was
added as
mediator, TBI
age was no
longer
a predictor of
aggression, for
either TBI age
group.
Significant
indirect (med-
iation) effect
of emotional
dysregulation
for both age
groups.
● Partial media-
tion effect for
cognitive dys-
regulation for
participants
who had a TBI
before age 13.
BRAIN INJURY

(Continued )
7
 8

Table 1. (Continued).

TBI Samples n (% Mean age at Time since TBI TBI definition and Antisocial behavior
Authors Year Country population male) Design TBI (years) TBI (years) assessment classification assessment Main findings Additional findings Rating
R.K. Brewer-Smyth, 2015 US Offenders Total sample of CS M = 16, SD = Mean age at Self-report “A blow to the head or Research-specific ● Committing ● When adjust- Poor
M. E. Cornelius and 636; sample size N. 9 for those assessment (modified neck, resulting in an questions asking if a violent crime was ing for child-
G. BELLESI ET AL.

E. E. Pickelsimer (44) R. for people who who of antisocial version of the alteration of participants had associated with hood sexual
had a TBI before committed behavior OSU TBI-ID) consciousness (i.e. ever committed a higher average abuse, child-
age 15 violent (across dazed or confused, or a violent crime in number of TBIs by hood emo-
crimes; groups): forgetting what their lifetimes (e.g. age 15 (M = 1.4, SD tional abuse,
M = 17, M = 34, SD happened before or physical or sexual = .8) compared to childhood
SD = 9 for = 10 for after the injury)” assault) committing a non- neighbor
those who participants violent crime adversity, age,
committed who (M = 1.2, SD = .4), and sex, TBI by
non-violent committed p = .04. the age of 15
crimes violent ● However, no signifi- years was
Further crimes, cant group differ- negatively
analyses M = 37, SD ence in magnitude, associated with
conducted = 9 for as essentially one violent crime
for participants TBI on average (OR = .54, 95%
participants who CI .30 − .97).
who had TBI committed
before age non-violent
15 crimes
P. Chitsabesan, C. Lennox, 2015 UK Offenders Total sample of 93; CS 0–18 Mean age at Self-report Head injury that Criminal records ● Eighty-two percent ● RPQ mean Poor
H. Williams, O. Tariq and 76 participants assessment (CHAT and “caused them to be (violent offences) participants score = 12.2
J. Shaw (48) with TBI (100%) of antisocial RPQ knocked out or dazed” reported at least (SD = 12),
behavior questionnaire) A score of 25 or above one TBI. range 0–49.
(across on the RPQ was used to ● Sixty-four percent of ● Fourteen par-
groups) = identify participants participants with TBI ticipants
17, SD = .6 with moderate to severe reported violent (18%) met
post-concussion offenses threshold for
symptoms. moderate to
The CHAT also assessed severe post-
whether individuals concussion
presented with “a need” symptoms on
following their TBI (at the RPQ.
least 3 separate ● A similar
episodes of LOC or number (n =
a single episode of LOC 14; 18%) were
longer than 30 minutes, also identified
in addition to ongoing by the CHAT
symptoms) as experien-
cing “a need”
following the
TBI.

(Continued )
Table 1. (Continued).

TBI Samples n (% Mean age at Time since TBI TBI definition and Antisocial behavior
Authors Year Country population male) Design TBI (years) TBI (years) assessment classification assessment Main findings Additional findings Rating
C. Scott, A. McKinlay, T. McLellan, 2014 New Mixed 65 participants LT Moderate/ >5 Clinical Moderate TBI: GCS = Research-specific ● Significant group Fair
E. Britt, R. Grace Zealand (clinical and with moderate/ severe Moderate/ records 9–12 or higher if structured difference in
and M. MacFarlane (49) community) severe TBI (66%), TBI: M = 10, severe accompanied by interview offending (χ2 =
61 participants SD = 4; TBI: M = 12, radiological (assessing e.g. 10.57, p < .006),
with mild TBI Mild SD = 5 abnormalities, PTA history of assault, with participants
(54%), 43 control TBI: M = 7, Mild length = less than one drunk and with moderate/
participants SD = 4 TBI: M = 15, week, LOC length = less disorderly severe TBI having
(orthopaedic SD = 4 than 6 hours; behavior, the highest rates (χ2
injury; 41%) Severe TBI: PTA length vandalism) = 2.42, p < .12), fol-
= greater than 1 week, lowed by those with
or LOC length = greater mild TBI (χ2 = 3.64,
than 6 hours, or GCS p < .06), and those
score < 9 with orthopaedic
injury (χ2 = .17,
p = .68).

A. McKinlay, R. C. Grace, T. 2014 New Mixed 62 participants LT 0–17 >5 Clinical Moderate/severe TBI: Research-specific ● Compared to people ● The strongest Fair
McLellan, D. Roger, J. Clarbour Zealand (clinical and with moderate/ Moderate/ records clinical diagnosis of structured with orthopedic predictors of
and M. R. MacFarlane (50) community) severe TBI (66%), severe moderate or severe TBI, interview injury, the moder- offending
62 participants TBI: M = 11, skull fracture or (assessing e.g. ate/severe TBI behavior were
with mild TBI SD = 4; evidence of lesion on history of assault, group was more TBI status (OR
(53%), 43 control Mild computed tomography; drunk and likely to have = 4.23, 95% CI
participants TBI: M = 15, cerebral haemorrhage disorderly a history of offend- 1.33–13.48,
(orthopaedic SD = 5 or PTA length = more behavior, ing (OR = 20.35, p < .02),
injury; 44%) than 24 hours; vandalism) 95% CI 2.5–162.8, higher levels
Mild TBI: clinical p < .01), and con- of malevolent
diagnosis of mild TBI; victions (OR = 8.88, aggression
LOC length <20 95% CI 1.1–73.3, p < (OR = 1.23,
minutes; PTA length < .05), to have been 95% CI
one hour, no evidence arrested (OR = 1.06–1.42, p <
of skull fracture or 12.07, 95% CI .01), and
lesion on computed 1.8–98.4, p < .05), treatment age
tomography fined (OR = 6, 95% (OR = 1.27,
CI 1.6–22.1, p < .01), 95% CI 1.08 −
and to have 1.50, p < .01).
a history of petty
crime (OR = 8.88,
95% CI 1.1–71.4, p <
.05).
● The mild TBI group
was at increased risk
of offending (OR =
8.66, 95% CI 1–72.1,
p < .05)
BRAIN INJURY

(Continued )
9
 10
Table 1. (Continued).

TBI Samples n (% Mean age at Time since TBI TBI definition and Antisocial behavior
Authors Year Country population male) Design TBI (years) TBI (years) assessment classification assessment Main findings Additional findings Rating
A. McKinlay, J. Corrigan, 2014 New Clinical Total sample of LT 0–5 or 6–15 For those Parental Mild TBI: no evidence of ● SRDI (self- Co-variates: sex, family Additional co- Good
L. J. Horwood and Zealand 1265; 55 who had interview, skull fracture, and report ques- socio-economic status at variates: alcohol
D. M. Fergusson (5) outpatients (N.R.) their TBI parental individuals “did not tionnaire, birth, and parental reports
dependence and
and 22 inpatients before age diaries, and exceed” any of these assessing, of behavioral problems age
drug dependence
(N.R.) with a TBI 0–15, clinical criteria: (1) 20-minutes e.g. prop- 1–5 TBI between age 0–5:
between age 0–5; antisocial records LOC; (2) two-days erty and TBI between age 0– 5: No significant
G. BELLESI ET AL.

55 outpatients (N. behavior hospitalization (3) two- violent ● The inpatient group associations
R.) and 35 examined hours PTA; (4) GCS score offenses in was at increased remained for any
inpatients (N.R.) between on admission = 14 or the last 12 relative risk of outcome of interest.
with a TBI age 16–25 15. months) arrests (IRR = 4.33, TBI between age
between age 6–15 Moderate/severe TBI: ● Research- p < .01) and prop- 6–15:
symptoms of the TBI specific erty offenses (IRR = ● Both the inpa-
exceeded any of the question 2.24, p < .01). tient and out-
above criteria. regarding ● Both the inpatient patient groups
the number and outpatient remained
of arrests. groups were at more likely to
increased relative be arrested
risk of violent (IRR = 2.46,
offenses (IRR = 2.72, p < .01; IRR =
p < .01, IRR = 1.47, 2.35, p < .01,
p < .05, respec- respectively)
tively). ● The inpatient
group
TBI between age 6–15: remained at
● Both the inpatient significant risk
and outpatient of violent
groups were at offenses (IRR
increased relative = 1.95,
risk. The inpatient p < .01)
group was at ● The outpatient
increased relative group was
risk of violent significantly
offenses (IRR = 1.50, less likely to
p < .05) of arrests have com-
(IRR = 2.67, p < .01, mitted violent
IRR = 2.45, p < .01, offenses
respectively) (IRR = .52, p <
● The inpatient group .01)
was at increased ● The other
relative risk of vio- associations
lent offenses (IRR = were no
1.5, p < .05) longer
● The outpatient significant.
group was at higher
risk of property
offenses (IRR = 1.44,
p < .05), but not
violent offenses (IRR
= .98, p> .05).

(Continued )
Table 1. (Continued).

TBI Samples n (% Mean age at Time since TBI TBI definition and Antisocial behavior
Authors Year Country population male) Design TBI (years) TBI (years) assessment classification assessment Main findings Additional findings Rating
M. G. Vaughn, C. P. Salas-Wright, 2014 US Offenders Total sample of CS 0–18 Mean age at Self-report Head injury “which Research-specific ● Thirty percent parti- Poor
M. Delisi and B. Perron (51) 1354; 411 assessment (research- caused unconsciousness questions cipants reported
participants with of antisocial specific or needed medical regarding violent a history of TBI.
TBI (91%) behavior question) attention” and non-violent ● Compared to parti-
(TBI group) delinquency, cipants with no TBI,
= 16, SD = 1 lifetime adolescent the TBI group
gang involvement, reported more
bullying behavior, delinquency
peer delinquency (t = 5.41, p < .001,
and antisocial d = .32), bullying
influence (χ2 = 10.07, p < .01,
φ = .09), peer
delinquency
(t = 4.50,
p < .001, d = .26),
and peer antisocial
influence (t = 4.49,
p < .001, d = .25).

(Continued )
BRAIN INJURY
11
 12

Table 1. (Continued).

TBI Samples n (% Mean age at Time since TBI TBI definition and Antisocial behavior
Authors Year Country population male) Design TBI (years) TBI (years) assessment classification assessment Main findings Additional findings Rating
R. C. Davies, W. H. Williams, 2012 UK Offenders Total sample of 61; CS 0–18 Mean age at Self-report Head injury that Research-specific ● Seventy-two per- ● No significant Fair
D. Hinder, C. N. W. Burgess 44 with TBI (100%) assessment (research- “caused to be knocked structured cent participants main effect of
and L. T. A. Mounce (52) of antisocial specific out and/or dazed and interview assessing
G. BELLESI ET AL.

reported history of either fre-

behavior question) confused for a time” history of violent TBI. quency or
(across Severity assessed offending severity of TBI
groups) = relying on LOC length of on violent
17, SD = N. the worst injury. offending
R. Minor TBI: “feeling ● Near signifi-
dazed and confused” cant contrast
but no LOC. indicating that
Mild TBI: LOC length violent offend-
<10 minutes ing score (fre-
Complicated mild TBI: quency &
LOC length = 10–30 severity) was
minutes. higher in
Moderate/severe TBI: those with
LOC length = 30–60 more than
minutes four TBIs than
Very severe TBI: LOC in those with
length > 60 minutes. four or fewer
Post-concussion TBIs (F1,57 =
symptoms measured 3.02, p = .088,
using a modified Observed
version of the RPSQ. Power = .40)
● Near signifi-
cant contrast
indicating that
people with
no or mild TBI
reported the
age of their
first conviction
as older (M =
13, SD = 2)
than those
who had
experienced
TBI with any
LOC (M = 12,
SD = 2), F1,57
= 3.49, p =
.067, Observed
Power = .45

(Continued )
Table 1. (Continued).

TBI Samples n (% Mean age at Time since TBI TBI definition and Antisocial behavior
Authors Year Country population male) Design TBI (years) TBI (years) assessment classification assessment Main findings Additional findings Rating
S. Luukkainen, K. Riala, M. 2012 Finland Clinical Total sample of LT M = 15, SD Antisocial Clinical Diagnosis of either Criminal records ● Adjustment for sex, Good
Laukkanen, H. Hakko and P. (psychiatric 508; 26 =1 behavior records fracture of skull bones (violent and non- age, family type,
Rasanen (53) inpatients) participants with assessed (excluding facial violent crimes) and parents’
TBI (69%) after age 15 traumas), intracranial employment status
injury or injury of cranial ● TBI was significantly
nerves according to the associated with
ICD-9 or ICD-10 criminality (OR =
diagnostic criteria, and 4.89, 95% CI
requiring hospital 1.95–12.25,
admission. p = .001).
● Compared to parti-
cipants without TBI,
individuals with TBI
had committed
more violent (OR =
5.86, 95% CI
1.99–17.28, p =
.001) and non-
violent crimes (OR =
3.85, 95% CI
1.18–12.55, p =
.026).

(Continued )
BRAIN INJURY
13
 14

Table 1. (Continued).

TBI Samples n (% Mean age at Time since TBI TBI definition and Antisocial behavior
Authors Year Country population male) Design TBI (years) TBI (years) assessment classification assessment Main findings Additional findings Rating
S. Fazel, P. Lichtenstein, M. Grann 2011 Sweden Community 22,914 participants LT M = 25, SD Antisocial Clinical Diagnosis of TBI Criminal records ● Participants were ● After adjusting Good
N. Långström (42) with TBI (71%), = 12 behavior records according to the ICD-8 divided into two for age, sex,
266,709 with Further assessed (diagnostic codes groups: TBI before socio-
“concussion” only analyses after age 16 851–852), ICD-9 (codes versus after 16 years demographic
(N.R.), 229,118 conducted 851–854), or ICD-10 of age. confounders,
G. BELLESI ET AL.

(71%) general for (codes S06.01–S06.09) ● Participants first and substance

population participants criteria diagnosed with TBI abuse, partici-
controls who had it Diagnosis of before age 16 were pants with TBI
5,310 participants before 16 “concussion” only made at lower risk of vio- were at
had their TBI according to the ICD-8/ lent crime than increased risk
before 16 years of 9 (diagnostic code: 850) those who were first of violent
age (N.R.) or ICD-10 (diagnostic diagnosed after 16 crime than the
code: S06.0) criteria years of age (χ2 = general popu-
35.7, p < .001) lation (aOR =
2.3, 95% CI
2.2–2.5) (NB:
in this analysis
TBI might
have occurred
at any age,
including after
age 16)
● TBI was
a significantly
stronger pre-
dictor of vio-
lent crime
than concus-
sion only (χ2 =
21.9, p < .001)

M. Timonen, J. Miettunen, 2002 Finland Community Total sample of LT <15 Antisocial Clinical Diagnosis of skull Criminal records ● TBI was associated ● Criminals who Good
H. Hakko, P. Zitting, J. Veijola, 10934; 256 behavior records fracture, cerebral with a four-times sustained the
L. von Wendt and P. Rasanen participants with assessed contusion and increased risk of TBI before the
(54) TBI (59%) after age 15 concussion and mental disorder age of 12
intracranial injuries with coexisting started their
sustained as a result of offending in adult- criminal career
trauma, using the ICD-9 hood (OR = 4.3, significantly
diagnostic criteria 95% CI 1.3–14.5), earlier than
(codes 800–801, 803, even after adjusting those who
804 except for facial for marital status of had the TBI
traumas, 850–854 and the mother and after age 12
950–951). social class of the (log–rank =
father at the time of 6.67, p =
birth, dwelling place .0098)
in 1980 (urban/
rural) (OR = 4.1 95%
CI 1.2–13.6)

(Continued )
Table 1. (Continued).

TBI Samples n (% Mean age at Time since TBI TBI definition and Antisocial behavior
Authors Year Country population male) Design TBI (years) TBI (years) assessment classification assessment Main findings Additional findings Rating
T. K. Andrews, F. D. Rose and 1998 UK Clinical 10 with severe TBI CS Severe > 0.5; M = Clinical Diagnosis of TBI DAABS (assessing ● Children with TBI ● No significant Fair
D. A. Johnson (55) (N.R.), 9 with TBI: M = 13, 1.5 for the records according to the ICD-9 aggressiveness and showed higher difference
moderate TBI (N. SD = 3; severe TBI criteria (codes 800 ± antisocial levels of aggressive/ between TBI
R.), 8 with mild TBI Moderate group, M = 804, 850 ± 854). behavior) antisocial behavior groups in
(N.R.), 27 control TBI: M = 12, 1.4 for the Mild TBI: LOC length = than those with no terms of
participants (no SD = 3; moderate 20 minutes or less, history of TBI (t = aggressive/
TBI; N.R.) Mild and mild TBI admission GCS score = −19.3, p < .05) antisocial
TBI: M = 13, groups 13–15, PTA length = behavior
SD = 3 maximum 1 hour, “no
apparent subsequent
deterioration of
consciousness and no
evidence of mass lesion
or brain swelling”;
Moderate TBI: LOC
length> 20 minutes,
admission GCS score =
9–12, PTA length =
maximum 1 day;
Severe TBI: LOC length>
24 hours, admission
GCS score = 8 or less,
PTA length = at least 7
days.
L. C. Ong, V. Chandran, 1998 Malaysia Clinical 29 participants LT Severe TBI 0.5 Clinical Severe TBI: GCS score Aggression and ● Group effect for ● The severe TBI Fair
S. Zasmani and M. S. Lye (56) with severe TBI (N. group: M = records <9, coma duration = 24 delinquent delinquency (F = group had sig-
R.); 29 participants 9, SD = 1; + hours. behavior scales of 4.32, p = .002) and nificantly lower
with mild-to- Mild-to- Mild-to-Moderate TBI: the CBCL (parent- aggressiveness (F = delinquency
moderate TBI (N. moderate “head injury”, GCS score completed 3.69, p = .007), (p = .005) and
R.); 29 control TBI: M = 9, >9, coma length = from questionnaire) explained by signifi- aggression (p =
participants SD = 1 a few minutes to six cant differences .012) pre-injury
(orthopaedic hours. between the severe scores than
injury; N.R.) TBI group and both orthopedic
the moderate TBI controls (col-
group and orthope- lected
dic controls. retrospectively)
● No pre/post-injury
differences between
the moderate TBI
and orthopedic
group.

N.R. = not reported; LT = longitudinal; CS = cross-sectional; GCS = Glasgow Coma Scale (57); CBCL = Child Behavior Checklist (58); E-AIC = Extended Adolescent Injury Checklist (59); OSU TBI-ID = Ohio State University TBI
Identification tool (60); BPAQ = Buss-Perry Aggression Questionnaire (61); CHAT = Comprehensive Health Assessment Tool Study (62); RPQ = Rivermead Post-Concussion Symptoms questionnaire (63); PTA = Post-Traumatic
Amnesia; LOC = Loss of Consciousness; SRDI = Self-Report Delinquency Inventory (64); ICD-8/ICD-9/ICD-10 = International Classification of Diseases, Eight/Ninth/Tenth Revision; DAABS = Aggressive and Antisocial Behavior
BRAIN INJURY

Scales (65).
15
16 G. BELLESI ET AL.
Across articles, TBI groups were formed heterogeneously,
ranging from including only participants with a severe injury
(45), to participants with two or three different severity types
(49,50,55,56) (e.g. moderate versus severe), to up to five sub-
groups (minor, mild, complicated mild, moderate/severe, and
very severe) (52).
Antisocial behavior. Twelve articles relied on self-report in
assessing antisocial behavior, comprising a mixture of ques-
tionnaires and research-specific questions, enquiring about
delinquency, aggression, history of violent and non-violent
delinquency, and arrests (5,43–47,49–52,55,56). Only four
articles examined participants’ criminal case records, obtained
through national registers (42,48,53,54), reporting history of
non-violent and/or violent offenses and convictions.
Summary of main findings
Cross-sectional research. Overall, cross-sectional research
supported a link between pediatric TBI and antisocial beha-
vior, in all populations examined. Pediatric TBI history was
markedly common among offenders. For instance, both
Chitsaseban et al. (48) and Davies et al. (52) found that
more than half inmates (82% and 72%, respectively) reported
this. Offenders with TBI showed higher levels of delinquency,
bullying, and peer antisocial influence (51) and higher levels
of aggression (43) than uninjured controls. Within clinical
and community populations, aggression and delinquency
levels were higher in child patients with TBI than uninjured
controls (45,55).
Longitudinal research. In adults, pediatric TBI was associated
with more offending, compared to people with history of
orthopedic injury (49,50). Timonen et al. (54) found an
increased lifetime risk for criminal offending following
a TBI. McKinlay et al. (5) further corroborated the findings,
showing some differences in outcomes depending on age at
TBI and admission as outpatients versus inpatients.
Specifically, all inpatients were at increased relative risk of
arrests and violent offenses. Inpatients injured between 0 and
5 years of age were also at increased relative risk of property
offenses. Outpatient participants injured between 0 and 5
years were at increased risk of violent offenses, whereas
those injured between 6 and 15 years were at higher risk of
arrests and property offenses. In Ong et al. (56), children with
TBI presented with higher delinquency and aggressiveness
than the orthopedic injury group, compared to the pre-
injury baselines.
More recently, Buckley and Chapman (46) and Kennedy
et al. (47), in their community-based research, showed that
children with TBI had higher rates of offending, being in
trouble with the police, and violent behavior than those with
no history of injury. Buckley & Chapman (46), however, did
not include data on the number of previous TBIs; it is, there-
fore, unclear whether more violent behavior may have been
a function of this. Both Buckley and Chapman (46) and
Kennedy et al. (47) relied on self-report in assessing TBI;
this might have also reduced sensitivity with respect to iden-
tifying injury groups effectively compared to the other long-
itudinal research relying on medical records.
Additional factors
TBI severity. TBI severity emerged as a potentially important
factor in influencing outcomes. Ong et al. (56), found that the
children with milder TBI and those with orthopedic injury did
not differ in outcomes, with only those with severe TBI showing
more problem behaviors than control participants. In Scott et al.
(49), a significant effect of TBI severity was found, with partici-
pants with moderate/severe TBI having the highest offending
rates, followed by those with mild TBI, and the control group. In
the two articles by McKinlay et al. (5,50) people with severe TBI
or who had been admitted to hospital as inpatients had overall a
broader range of adverse outcomes than individuals with milder
TBI or outpatients respectively.
Andrews et al. (55) found no significant difference in out-
comes between three groups of patients differing in injury
severity. Their study had relatively small sample sizes; it is
possible that statistical power might have not been sufficient
to detect group differences. Davies et al. (52), who also had
relatively smaller sample sizes, found no significant main
effect of injury severity; however, participants with more
severe TBI reported the age of their first conviction to be
significantly younger than those with mild TBI.
TBIs number. There was tentative evidence linking greater
number of TBIs with increased levels of antisocial behavior.
Davies et al. (52) found a near significant contrast indicating
that violent offending score was higher in those with more
than four TBIs than those with four or fewer. In Brewer-
Smyth et al. (44), within inmates, committing a violent
crime was associated with a higher average number of TBIs
by age 15 compared to committing a non-violent crime.
Age at TBI. Some articles examined whether earlier age at
TBI may be linked to more adverse outcomes, with their
findings support this notion. Fishbein et al. (43) found that
offenders who had their TBI before the age of 13 had higher
aggression scores than those who had it later. In McKinlay
et al. (50), age at injury strongly predicted offending. In
Timonen et al. (54), individuals who had their TBI before
the age of 12 started their criminal career significantly earlier
than those who had it after then.
The longitudinal research by Fazel et al. (42), however,
showed a different picture, as individuals diagnosed with
TBI before the age of 16 were at lower risk of convictions
than participants who had it later. A possible explanation for
this discrepancy might relate to differences in health services
provision across countries. The study by Fazel et al. was
conducted in Sweden, which has a strong, treatment-
oriented approach in managing youth offending. In Sweden,
criminal responsibility begins at age 15; before this criminal
behavior is usually regarded as a social welfare problem (66).
Social services will usually assess the individual and their
circumstances, to evaluate the possible reasons that may
have led them to offend, to guide the provision of treatment
and rehabilitative measures (e.g. talking therapies, enhanced
care), with the aim of decreasing risk of further criminality.
This is a possible reason as to why Sweden has among the
lowest rates of recidivism worldwide (67). Participants in the

Fazel et al. research might have thus received interventions
that prevented their behaviors from escalating further.
Substance use. McKinlay et al. (5) found that, when they
accounted for history of alcohol and drug dependence during
adolescence and early adulthood, there was no longer
a significant association between TBI and offending for
those injured up to five years of age. However, outcomes for
those injured later remained substantially the same. Kennedy
et al. (47) also showed that, when substance use in adoles-
cence was controlled for, the TBI-antisocial behavior associa-
tion diminished substantially.
Of note, the article by Buckley & Chapman (46) found that
even after accounting for alcohol use the link between TBI
and violence remained significant. Their participants, how-
ever, were only followed up for one year, and were younger
on average than those in the article by Kennedy et al. (47), as
mean age was 13; it is likely that at that age, alcohol con-
sumption was still relatively uncommon for most participants.
Emotional and cognitive dysregulation. Fishbein et al. (43)
examined whether emotional and cognitive dysregulation can
explain the relationship between age at TBI (before versus at
or after 13 years of age) and aggression. Emotional dysregula-
tion significantly mediated the association between TBI and
aggression, regardless of age at TBI. There was no mediation
effect for cognitive dysregulation for participants who had
their TBI at or after 13. However, there was a partial media-
tion effect for those injured before then. These findings sug-
gest that emotional regulatory deficits might contribute to
explain the TBI-antisocial behavior relation; cognitive regula-
tion deficits might be of more relevance for those injured
earlier in life.
Adverse life events. Several authors controlled for environ-
mental stressors and/or parental factors, typically focusing on
socio-economic status, parental criminality and parental sub-
stance use (5,42,47,51,53,54); pediatric TBI continued to
remain linked with antisocial behavior, although the associa-
tion typically weakened slightly. An exception was the article
by Brewer-Smyth et al. (44). In this, after accounting for
several childhood adverse life events, such as sexual and
emotional abuse, TBI before the age of 15 years became
negatively, rather than positively, associated with committing
a violent crime.
Quality of evidence
Three articles were classified as “poor” (44,48,50), seven as
“fair” (43,45,48,50,52,55,56) and six as “good”
(5,42,46,47,53,54). “Poor” articles had the largest number of
methodological weaknesses; they all relied on cross-sectional
designs, self-report for TBI assessment, and biased popula-
tions (offenders). Moreover, research questions or objectives
were not as clearly specified, and there was limited considera-
tion of statistical factors such as power or samples sizes. Other
limitations included no statistical comparisons in Chitsabesan
et al. (48), limited information about gender ratio in Brewer-
Smyth et al. (44), and participants being all or almost exclu-
sively male in Chitsabesan et al. (48) and Vaughn et al. (51).
BRAIN INJURY 17
Articles classified as “fair” had a mixture of important
strengths, but also significant weaknesses reducing the overall
score. The article by Pastore et al.’s (45) main strengths were
the use of clinical records to assess TBI, standardized outcome
measures, inclusion of two control groups, and of effect sizes.
However, samples sizes were relatively small, and the cross-
sectional design and limited control of confounders limited
interpretations. The research by Fishbein et al. (43) had large
samples and relevant mediating factors; however, lack of
information about gender ratio, the cross-sectional design
and biased population of offenders limited quality. The arti-
cles by McKinlay et al. (50) and Scott et al. (49) had strengths
relative to the longitudinal designs and more thorough TBI
assessment. However, quality was downgraded by using
mixed group of clinical and community participants, the
lack of a no injury group, and limited sample sizes. Davies
et al. (52) included clearly outlined objectives, detailed TBI
characterization and important statistical information.
However, their population was highly biased and TBI,
although better defined than in similar articles, was still
assessed through self-report, reducing reliability of the diag-
nosis. Andrews et al.’s (55) and Ong et al.’s (56) strengths
included reliance on clinical records, TBI characterization,
and inclusion of a control group. Their quality was predomi-
nantly reduced by small sample sizes, limited consideration of
confounding variables and provision of demographic
information.
Although articles classed as “good” still presented with
methodological flaws, it was felt that these had shown greater
effort in overcoming some of the more common limitations of
previous research; overall they had the smallest numbers of
issues compared to other articles. Combinations of main
strengths were the use of longitudinal designs, recruitment
of more representative populations, clearly outlined research
questions, inclusion of important confounders and more than
one control group.
Discussion
The present systematic review aimed to enhance current under-
standing of whether pediatric TBI is associated with antisocial
behavior, and what factors might influence this link. Sixteen
articles met eligibility criteria, published from 14 studies in total.
Are TBI and antisocial behavior linked?
Overall, pediatric TBI was linked to higher rates of aggression,
arrests, offenses, and violence, across both longitudinal and
cross-sectional studies. This finding expands on previous
research examining short- and longer-term outcomes in
pediatric TBI. Studies following participants from one to
four years post-injury indicate that pediatric TBI is linked
with increased risk for psychopathology, reduced social and
adaptive functioning, and increased rates of disruptive beha-
vior (9,10,22,23).
Damage to the frontal and temporal areas of the brain is
typically considered the basis for the cognitive and neurobe-
havioral sequelae of TBI (68). These regions and their con-
nections are the most commonly damaged after these types of
18 G. BELLESI ET AL.
events (69) and are linked with key perceptual, cognitive and
emotional processing skills responsible history for positive
social functioning, including executive function, social cogni-
tion and emotional regulation (68). There is evidence that,
compared to uninjured counterparts, children with TBI strug-
gle reading people’s emotions, taking others’ perspectives, and
display neuropsychological impairments relative to impulsiv-
ity, attention, and self-regulation (70–73). All these impair-
ments are also often implicated in poor-decision-making,
increased sensation-seeking and engagement in risk-taking
behaviors such as antisocial behavior and criminality
(16,74,75). It will be important for future work to further
explore the neurobiological and neuropsychological mechan-
isms underpinning the pediatric TBI-antisocial behavior link
evidenced in this review; this will be essential for informing
preventative and rehabilitative strategies.
The present review indicated that, so far, only a small amount
of research has examined individual and environmental factors
that might directly or indirectly influence the pediatric TBI-
antisocial behavior. Some studies were indicative of a dose–
response relationship, whereby levels of antisocial behavior var-
ied as a function of number and severity of TBIs. These findings
could be explained in the context of previous literature, showing
that more frequent and severe TBIs are linked to more severe
disruption in brain development; this, in turn, can lead to
greater consequences on behavioral, cognitive and psychosocial
function (76–80).
Interestingly, some review findings indicated that earlier
age at injury might also be indicative of poorer outcomes. The
traditional view that children exposed to brain injury at earlier
age have better prognostic functional outcomes has been
increasingly challenged in recent years, with more empirical
evidence showing the opposite (2). More difficult recovery
when TBI occurs at younger age might relate to the nervous
system being more immature at the time of injury, hindering
subsequent developmental trajectories (81). Only one article
contradicted this notion, showing that individuals injured
before the age of 16 were at a decreased risk of criminality
than those injured after (42). However, as discussed above, the
study was conducted in a country with a strong focus on
rehabilitative approaches for youth offenders. It will be inter-
esting for future work to further explore the influence of early
interventions in moderating the TBI-antisocial behavior link.
Substance abuse was also identified as a key intersecting factor
by more than one article, with the TBI-antisocial association
weakening significantly when this was controlled for. Substance
use is a well-known risk factor for antisocial and criminal acts (82),
with history of alcohol and drug misuse being highly prevalent
within inmates (83). There are different ways in which substance
use might influence the TBI-antisocial behavior pathway. One
possibility is that neurocognitive and psychosocial impairments
related to early TBI increase later vulnerability to substance mis-
use. Use of substances might then exacerbate pre-existing deficits,
for example, by further decreasing one’s ability to self-monitor,
plan or problem-solve effectively, and thus increase the risk of
antisocial behavior (84). Due to the limited pool of research avail-
able, these interpretations remain tentative; more work is war-
ranted to clarify the nature of the relationship between these
variables.
Strengths and weaknesses of available research, and
recommendations
The notion that pediatric TBI can have severe implications for
long-term functioning has only begun to be more widely
acknowledged in recent years (81,85). Although the current
review included only 16 articles, 10 of these were published in
the last 5 years (5,43–51); this is a promising finding, indica-
tive of growing interest in the area.
A key concern emerging from the available research is the
lack of precision in establishing the temporal sequencing of
the events. For this reason, from the present findings, it is not
possible to draw definite conclusions regarding the direction-
ality of the pediatric TBI – antisocial behavior relationship:
whereas TBI might have led to increased risk of antisocial
behavior, it cannot be excluded that individuals might have
also presented with precursors of this prior to the injury.
Conduct and behavioral difficulties in pediatric age are
a likely risk factor for incurring in TBIs, as children present-
ing with these may often be more prone to falls and injuries
(86). It is essential that future research employs designs that
can elucidate the temporal sequencing of different events
more clearly to be able to draw causality links.
Another critical issue relates to how TBI was assessed. Clinical
records are usually considered more valid and reliable than self-
report (87). However, not all those who incur in a TBI always
present to medical services (30,88); thus, both methods can be
associated with a degree of misrepresentation. The significant
variation in assessment and classification methods, as well as the
heterogeneity in TBI groupings, also limited the ability to make
detailed comparisons across studies, and precluded the possibility
of completing a quantitative synthesis of the findings. This great
heterogeneity is likely due to the lack of international consensus
on TBI assessment and classification (35,36). Recent models pro-
pose that a sensitive way to assess TBI relies on structural imaging
findings, GCS score after resuscitation, PTA length, and duration
of alteration and loss of consciousness (89). More harmonization
among studies in classification and groupings needed to allow for
a meta-analysis of the results.
It was interesting to note that Kennedy et al. (47) found
limited differences between adolescents with TBI versus
orthopedic injury. Although inclusion of TBIs of different
degrees might have diluted group differences, it is also possi-
ble that both groups share risk factors that make them more
vulnerable to both injuries and problem behaviors (e.g. sensa-
tion-seeking). Similarly, in Pastore et al. (45) children with
TBI did not differ from those with an acquired brain injury.
The authors suggested that shared experiences such as stress
and estrangement from family and peers might account for
this. These studies raise questions regarding the specificity of
adverse outcomes to TBI, indicating that the role of these
factors needs to be better understood.
Finally, for most studies, the sample comprised predomi-
nantly or exclusively male participants, although a recent shift
towards more population-based studies was noted. Recruitment
of offenders or clinical populations can bias estimates of the
TBI-antisocial behavior relationship. Longitudinal studies fol-
lowing more representative samples participants for longer per-
iods of times will be essential for this purpose.

Clinical implications
Concerns have been raised about limited understanding
within public and professionals regarding the long-term
effects of pediatric brain injuries (90,91). Although it is not
possible to establish with certainty whether pediatric TBI
directly causes antisocial behavior, it is still worthwhile con-
sidering its potential role as at least a contributing factor in
the context of planning and implementing preventative
actions and interventions. Awareness of the issues associated
with TBI is likely to be important for all professionals who
have an oversight to children and young people’s health,
within healthcare, forensic and also community settings.
Increased linkage and collaboration between health-care pro-
fessionals and schools, for example, might play a pivotal role
towards identifying earlier on in the process which children
are at risk, and working towards monitoring and managing
early evidence of problem behaviors more effectively.
Awareness and monitoring of the adverse consequences asso-
ciated with early TBI are likely to be particularly important
when youth are undergoing phases of transition from more to
less structured schooling or types of environments (e.g. from
primary to secondary school), as changes in level of demands
might lead to their difficulties becoming more evident (14,85).
These approaches might also support in reducing the chances
of later school failure, including exclusion and isolation.
History of TBI is seldom assessed within forensic settings,
and neurorehabilitation rarely offered (14,91). Consideration
of TBI history and consequences on functioning may have
important implications for drawing up holistic formulations
of people’s needs and presentations, developing more tailored
rehabilitation programs as well as formulating more effective
sentences. These changes in the long-term might have several
benefits at individual and societal levels, including better
management of the factors increasing the risk for problem
behaviors as well as reduced burden and costs on criminal
justice, social and health-care services.
Acknowledgments
We would like to thank Mr Paul Lee, librarian at Reay House Library, for
his help and assistance in conducting the review.
Declaration of interest
The authors declare that there are no conflicts of interest.
References
1. World Health Organisation. Neurological disorders: public health
challenges [Internet]. Who.int. 2006. [cited 12 October 2018]. http://
www.who.int/mental_health/neurology/neurodiso/en/index.html.
2. Anderson V, Catroppa C, Morse S, Haritou F, Rosenfeld J.
Functional plasticity or vulnerability after early brain injury?
Pediatrics. 2005;116:1374–82. doi:10.1542/peds.2004-1728.
3. Ryan NP, Catroppa C, Godfrey C, Noble-Haeusslein LJ, Shultz
SR, O’Brien TJ, Anderson V, Semple BD. Social dysfunction after
pediatric traumatic brain injury: a translational perspective.
Neurosci Biobehav Rev. 2016;64:196–214.
4. Sariaslan A, Sharp DJ, D’Onofrio BM, Larsson H, Fazel S. Long-
term outcomes associated with traumatic brain injury in child-
hood and adolescence: a nationwide Swedish cohort study of
BRAIN INJURY 19
a wide range of medical and social outcomes. PLoS Med.
2016;13(8):e1002103. doi:10.1371/journal.pmed.1002103.
5. McKinlay A, Corrigan J, Horwood LJ, Fergusson DM. Substance
abuse and criminal activities following traumatic brain injury in
childhood, adolescence, and early adulthood. J Head Trauma
Rehabil. 2014;29:498–450. doi:10.1097/HTR.0000000000000001.
6. Bloom DR, Levin HS, Ewing-Cobbs L, Saunders AE, Song J,
Fletcher JM, Kowatch RA. Lifetime and novel psychiatric dis-
orders after paediatric traumatic brain injury. J Am Acad Child
Adolesc Psychiatry. 2001;40:572–79. doi:10.1097/00004583-
200105000-00017.
7. Schachar R, Levin H, Max J, Purvis K, Chen S. Attention deficit
hyperactivity disorder symptoms and response inhibition after
closed head injury in children: do preinjury behaviour and injury
severity predict outcome? Dev Neuropsychol. 2004;25(1–2):179–-
98. doi:10.1080/87565641.2004.9651927.
8. Ganesalingam K, Sanson A, Anderson V, Yeates K. Self-regulation
as a mediator of the effects of childhood traumatic brain injury on
social and behavioral functioning. JINS. 2007;13(2):298–311.
doi:10.1017/S1355617707070324.
9. Gerring J, Grados M, Slomine B, Christensen J, Salorio C, Cole W,
Vasa RA. Disruptive behaviour disorders and disruptive symp-
toms after severe paediatric traumatic brain injury. Brain Inj.
2009;23(12):944–55. doi:10.3109/02699050903285531.
10. Cole WR, Gerring JP, Gray RM, Vasa RA, Salorio CF, Grados M,
Christensen JR, Slomine BS. Prevalence of aggressive behaviour
after severe paediatric traumatic brain injury. Brain Inj. 2008;22
(12):932–39. doi:10.1080/02699050802454808.
11. Stoddard SA, Zimmerman MA. Association of interpersonal vio-
lence with self-reported history of head injury. Pediatrics.
2011;127:1074–79. doi:10.1542/peds.2010-2453.
National Institute for Health and Care Excellence. Antisocial
12.
behaviour and conduct disorders in children and young people:
recognition and management. [Internet]. Nice.org.uk. 2017. [cited
6 Jan 2019]. https://www.nice.org.uk/guidance/cg158.
13. Anti-Social Behaviour. Crime and Policing Act 2014. [Internet].
Legislation.gov.uk. 2014 [cited 6 Jan 2019]. https://www.legisla
tion.gov.uk/ukpga/2014/12/notes/division/3/1?view=plain
14. Williams H. Repairing shattered lives: brain injury and its impli-
cations for criminal justice. Transition to adult alliance. Barrow
Cadbury Trust; 2012 Nov.
15. Parsonage M. Traumatic brain injury and offending: an economic
analysis:Centre for Mental Health, Barrow Cadbury Trust; 2016 Jul.
16. Farrer TJ, Frost RB, Hedges DW. Prevalence of traumatic brain
injury in juvenile offenders: a meta-analysis. Child Neuropsychol.
2013;19(3):225–34. doi:10.1080/09297049.2011.647901.
17. Hughes N, Williams WH, Chitsabesan P, Walesby RC, Mounce LT,
Clasby B. The prevalence of traumatic brain injury among young
offenders in custody: a systematic review. J Head Trauma Rehabil.
2015;30(2):94–105. doi:10.1097/HTR.0000000000000124.
18. Yates PJ, Williams WH, Harris A, Round A, Jenkins R. An
epidemiological study of head injuries in a UK population attend-
ing an emergency department. J Neurol Neurosurg Psychiatry.
2006;77(5):699–701. doi:10.1136/jnnp.2005.081901.
19. Piquero AR. Taking stock of developmental trajectories of crim-
inal activity over the life course. In: Liberman AM, editor. The
long view of crime: a synthesis of longitudinal research.
New York, NY: Springer; 2008. p. 23–78.
20. Anderson V, Brown S, Newitt H, Hoile H. Educational, voca-
tional, psychosocial, and quality-of-life outcomes for adult survi-
vors of childhood traumatic brain injury. J Head Trauma Rehabil.
2009;24(5):303–12. doi:10.1097/HTR.0b013e3181ada830.
21. Emery CA, Barlow KM, Brooks BL, Max JE, Villavicencio-Requis A,
Gnanakumar V, Robertson HL, Schneider K, Yeates KO. A systematic
review of psychiatric, psychological, and behavioural outcomes follow-
ing mild traumatic brain injury in children and adolescents. Can
J Psychiatry. 2016;61(5):259–69. doi:10.1177/0706743716643741.
22. Li L, Liu J. The effect of paediatric traumatic brain injury on
behavioural outcomes: a systematic review. Dev Med Child
Neurol. 2013;55(1):37–45. doi:10.1111/j.1469-8749.2012.04414.x.
20 G. BELLESI ET AL.
23. Kennedy E, Cohen M, Munafo M. Childhood traumatic brain
injury and the associations with risk behavior in adolescence
and young adulthood: a systematic review. J Head Trauma
Rehabil. 2017;32(6):425. doi:10.1097/HTR.0000000000000289.
24. Amram O, Schuurman N, Pike I, Yanchar NL, Friger M,
McBeth PB, Griesdale D. Socio-economic status and traumatic
brain injury amongst paediatric populations: A spatial analysis in
greater Vancouver. Int J Environ Res Public Health. 2015;12
(12):15594–604. doi:10.3390/ijerph121215009.
25. Piotrowska PJ, Stride CB, Croft SE, Rowe R. Socioeconomic status
and antisocial behaviour among children and adolescents:
A systematic review and meta-analysis. Clin Psychol Rev.
2015;35:47–55. doi:10.1016/j.cpr.2014.11.003.
26. Bjork JM, Grant SJ. Does traumatic brain injury increase risk for
substance abuse? J. Neurotrauma. 2009;26(7):1077–82. doi:10.1089/
neu.2008.0849.
27. Robins LN. The intimate connection between antisocial person-
ality and substance abuse. Soc Psychiatry Psychiatr Epidemiol.
1998;33(8):393–99.
28. Aboulafia-Brakha T, Allain P, Ptak R. Emotion regulation after
traumatic brain injury: distinct patterns of sympathetic activity
during anger expression and recognition. J Head Trauma Rehabil.
2016;31(3):E21–E31. doi:10.1097/HTR.0000000000000171.
29. Davidson RJ, Putnam KM, Larson CL. Dysfunction in the neural
circuitry of emotion regulation: a possible prelude to violence.
Science. 2000;289(5479):591–94. doi:10.1126/science.289.5479.591.
30. Hughes N, Williams H, Chitsabesan P, Davies R, Mounce L.
Nobody made the connection: the prevalence of neurodisability
in young people who offend. London: Office of the Children’s
Commissioner, 2012.
31. Moher D, Liberati A, Tetzlaff J, Altman DG, the PRISMA Group,
Preferred reporting items for systematic reviews and
meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):
e1000097. doi:10.1371/journal.pmed.1000097.
32. Lumba-Brown A, Yeates KO, Sarmiento K, Breiding MJ,
Haegerich TM, Gioia GA, Turner M, Benzel EC, Suskauer SJ,
Giza CC, et al. Diagnosis and management of mild traumatic
brain injury in children: a systematic review. JAMA Pediatr.
2018;172(11):e182847. doi:10.1001/jamapediatrics.2018.1273.
33. Lloyd J, Wilson ML, Tenovuo O, Saarijärvi S. Outcomes from
mild and moderate traumatic brain injuries among children and
adolescents: A systematic review of studies from 2008–2013. Brain
Inj. 2015;29(5):539–49. doi:10.3109/02699052.2014.1002003.
34. World Health Organisation. Adolescent mental health. [Internet].
Who.it. 2018. [cited 6 Jan 2019]. http://www.who.int/news-room
/fact-sheets/detail/adolescent-mental-health.
35. Thurman DJ. The epidemiology of traumatic brain injury in
children and youths: a review of research since 1990. J Child
Neurol. 2016;31(1):20–27. doi:10.1177/0883073814544363.
36. Thurman DJ, Coronado V, Selassie A. The epidemiology of TBI:
implications for public health. In: Zasler ND, Katz DI,
Zafonte RD, editors. Brain injury medicine: principles and prac-
tice. New York, NY: Demos; 2007. p. 45–55.
37. Centers for Disease Control and Prevention. Traumatic brain
injury. [Internet]. Cdc.gov. 2014. [cited 12 Oct 2018]. http://
www.cdc.gov/TraumaticBrainInjury.
38. Carr H, Housing CD. Governance and antisocial behaviour. In:
Flint J, editor. Labelling: constructing definitions of antisocial
behaviour? Bristol: Policy Press; 2006. p. 57–78.
39. Frick P. Conduct disorders and severe antisocial behaviour.
New York: Springer US; 1998.
40. U.S. Department of Health. Quality assessment tool for observa-
tional cohort and cross-sectional studies. [Internet]. 2013. [cited
12 Oct 2018]. http://www.nhlbi.nih.gov/health-pro/guidelines/in-
develop/cardiovascular-risk-reduction/tools/cohort.htm.
41. Critical Appraisal Skills Programme. Cohort study checklist
[Internet]. Media.wix.com. 2016. [cited 12 Oct 2018]. http://media.
wix.com/ugd/dded87_e37a4ab637fe46a0869f9f977dacf134.pdf.
42. Fazel S, Lichtenstein P, Grann M, Långström N. Risk of violent
crime in individuals with epilepsy and traumatic brain injury: a
35-year Swedish population study. PLoS Med. 2011;8(12):
e1001150. doi:10.1371/journal.pmed.1001150.
43. Fishbein D, Dariotis JK, Ferguson PL, Pickelsimer EE.
Relationships between traumatic brain injury and illicit drug use
and their association with aggression in inmates. Int J Offender
Ther Comp Criminol. 2016;60(5):575–97. doi:10.1177/
0306624X14554778.
44. Brewer-Smyth K, Cornelius ME, Pickelsimer EE. Childhood
adversity, mental health, and violent crime. J Forensic Nurs.
2015;11(1):4–14. doi:10.1097/JFN.0000000000000062.
45. Pastore V, Galbiati S, Recla M, Colombo K, Beretta E, Strazzer S.
Psychological and behavioural difficulties following severe TBI in
adolescence: a comparison with a sample of peers with brain
lesions of other origin and with a control group. Brain Inj.
2018;32(8):1011–20. doi:10.1080/02699052.2018.1469041.
46. Buckley L, Chapman RL. Associations between self-reported con-
cussion with later violence injury among Australian early
adolescents. J Public Health. 2016;39(1):52–57.
47. Kennedy E, Heron J, Munafó M. Substance use, criminal beha-
viour and psychiatric symptoms following childhood traumatic
brain injury: findings from the ALSPAC cohort. Eur Child
Adolesc Psychiatry. 2017;26(10):1197–206. doi:10.1007/s00787-
017-0975-1.
48. Chitsabesan P, Lennox C, Williams H, Tariq O, Shaw J. Traumatic
brain injury in juvenile offenders: findings from the comprehen-
sive health assessment tool study and the development of
a specialist linkworker service. J Head Trauma Rehabil. 2015;30
(2):106–15. doi:10.1097/HTR.0000000000000129.
49. Scott C, McKinlay A, McLellan T, Britt E, Grace R,
MacFarlane M. A comparison of adult outcomes for males com-
pared to females following paediatric traumatic brain injury.
Neuropsychol. 2015;29(4):501. doi:10.1037/neu0000074.
50. McKinlay A, Grace RC, McLellan T, Roger D, Clarbour J,
MacFarlane MR. Predicting adult offending behaviour for indivi-
duals who experienced a traumatic brain injury during childhood.
J Head Trauma Rehabil. 2014;29(6):507–13. doi:10.1097/
HTR.0000000000000000.
51. Vaughn MG, Salas-Wright CP, DeLisi M, Perron B. Correlates of
traumatic brain injury among juvenile offenders: A multi-site
study. Crim Behav Ment Health. 2014;24(3):188–203.
doi:10.1002/cbm.1900.
52. Davies RC, Williams WH, Hinder D, Burgess CN, Mounce LT.
Self-reported traumatic brain injury and postconcussion symp-
toms in incarcerated youth. J Head Trauma Rehabil. 2012;27(3):
E21–E27. doi:10.1097/HTR.0b013e31825360da.
53. Luukkainen S, Riala K, Laukkanen M, Hakko H, Räsänen P.
Association of traumatic brain injury with criminality in adoles-
cent psychiatric inpatients from Northern Finland. Psychiatry Res.
2012;200(2):767–72. doi:10.1016/j.psychres.2012.04.018.
54. Timonen M, Miettunen J, Hakko H, Zitting P, Veijola J, von
Wendt L, Räsänen P. The association of preceding traumatic
brain injury with mental disorders, alcoholism and criminality:
the Northern Finland 1966 Birth Cohort Study. Psychiatry Res.
2002;113(3):217–26.
55. Andrews TK, Rose FD, Johnson DA. Social and behavioural
effects of traumatic brain injury in children. Brain Inj. 1998;12
(2):133–38.
56. Ong LC, Chandran V, Zasmani S, Lye MS. Outcome of closed
head injury in Malaysian children: neurocognitive and beha-
vioural sequelae. J Paediatr Child Health. 1998;34(4):363–68.
57. Teasdale G, Jennett B. Assessment of coma and impaired con-
sciousness: a practical scale. Lancet. 1974;304(7872):81–84.
doi:10.1016/S0140-6736(74)91639-0.
58. Achenbach TM. Manual for the youth self-report and 1991 profile.
Burlington: Department of Psychiatry, University of Vermont; 1991.
59. Chapman RL, Buckley L, Sheehan M. The development of the
extended adolescent injury checklist (E-AIC): a measure for injury
prevention program evaluation. Youth Stud Aust. 2011;30:49.
60. Corrigan JD, Bogner J. Initial reliability and validity of the
Ohio State University TBI identification method. J Head

Trauma Rehabil. 2007;22(6):318–29. doi:10.1097/01.
HTR.0000300227.67748.77.
61. Diamond PM, Wang EW, Buffington-Vollum J. Factor structure
of the Buss-Perry Aggression Questionnaire (BPAQ) with men-
tally ill male prisoners. Crim. Justice Behav. 2005;32(5):546–64.
doi:10.1177/0093854805278416.
62. Chitsabesan P, Lennox C, Theodosiou L, Law H, Bailey S, Shaw J.
The development of the comprehensive health assessment tool for
young offenders within the secure estate. J Forensic Psychi Ps.
2014;25(1):1–25. doi:10.1080/14789949.2014.882387.
63. King NS, Crawford S, Wenden FJ, Moss NE, Wade DT. The
rivermead post concussion symptoms questionnaire: a measure
of symptoms commonly experienced after head injury and its
reliability. J Neurol. 1995;242(9):587–92.
64. Elliott DS, Huizinga D. Improving self-reported measures of
delinquency. In: Klein M, editor. Cross-national research in self-
reported crime and delinquency. Dordrecht: Springer; 1989. p.
155–86.
65. DeBlois CS, Stewart MA. Aggressiveness and antisocial behaviour
in children: their relationships to other dimensions of behaviour.
Res Commun Psychol Psychiatr Behav. 1980;5:303–13.
66. Anderrson S Alternatives to custody for young offenders. National
report on juvenile justice trends. [Internet]. Sweden. Oijj.org.
2012. [Cited 6 Jan 2019]. https://www.oijj.org/sites/default/files/
baaf_sweden1.pdf.
67. Deady C. Incarceration and recidivism: lessons from abroad.
Newport, IR: Pell Center for International Relations and Public
Policy; 2014.
68. Bigler ED. Anterior and middle cranial fossa in traumatic brain
injury: relevant neuroanatomy and neuropathology in the study of
neuropsychological outcome. Neuropsychol. 2007;21(5):515.
doi:10.1037/0894-4105.21.5.515.
69. Bigler ED. The lesion(s) in traumatic brain injury: implications
for clinical neuropsychology. Arch Clin Neuropsychol. 2001;16
(2):95–131.
70. Babikian T, Asarnow R. Neurocognitive outcomes and recovery
after pediatric TBI: meta-analytic review of the literature.
Neuropsychol. 2009;23(3):283. doi:10.1037/a0015268.
71. Sinopoli KJ, Dennis M. Inhibitory control after traumatic brain
injury in children. Int J Dev Neurosci. 2012;30(3):207–15.
doi:10.1016/j.ijdevneu.2011.08.006.
72. Rosema S, Crowe L, Anderson V. Social function in children and
adolescents after traumatic brain injury: A systematic review
1989–2011. J Neurotrauma. 2012;29(7):1277–91. doi:10.1089/
neu.2011.2144.
73. Turkstra LS, Politis AM, Forsyth R. Cognitive–communication
disorders in children with traumatic brain injury. Dev Med
Child Neurol. 2015;57(3):217–22. doi:10.1111/dmcn.12600.
74. Ogilvie JM, Stewart AL, Chan RC, Shum DH. Neuropsychological
measures of executive function and antisocial behavior: A meta-
analysis. Criminology. 2011;49(4):1063–107. doi:10.1111/j.1745-
9125.2011.00252.x.
75. Williams WH, McAuliffe KA, Cohen MH, Parsonage M,
Ramsbotham J. Traumatic brain injury and juvenile offending: com-
plex causal links offer multiple targets to reduce crime. J Head Trauma
Rehabil. 2015;30(2):69–74. doi:10.1097/HTR.0000000000000134.
76. Anderson VA, Catroppa C, Dudgeon P, Morse SA, Haritou F,
Rosenfeld JV. Understanding predictors of functional recovery
BRAIN INJURY 21
and outcome 30 months following early childhood head injury.
Neuropsychol. 2006;20(1):42. doi:10.1037/0894-4105.20.1.42.
77. Sariaslan A, Sharp DJ, D’Onofrio BM, Larsson H, Fazel S. Long-
term outcomes associated with traumatic brain injury in child-
hood and adolescence: a nationwide Swedish cohort study of
a wide range of medical and social outcomes. PLoS Med.
2016;13(8):e1002103. doi:10.1371/journal.pmed.1002103.
78. Bryan CJ, Clemans TA. Repetitive traumatic brain injury, psycho-
logical symptoms, and suicide risk in a clinical sample of deployed
military personnel. JAMA Psychiatry. 2013;70(7):686–91.
doi:10.1001/jamapsychiatry.2013.1093.
79. Gaetz M, Goodman D, Weinberg H. Electrophysiological evidence
for the cumulative effects of concussion. Brain Inj.
2000;14:1077–88. doi:10.1080/02699050050203577.
80. Guskiewicz KM, Marshall SW, Bailes J, McCrea M, Cantu RC,
Randolph C, Jordan BD. Association between recurrent concus-
sion and late-life cognitive impairment in retired professional
football players. Neurosurgery. 2005;57:719–26.
81. Forsyth R, Kirkham F. Predicting outcome after childhood brain
injury. Can Med Assoc J. 2012;184(11):1257–64. doi:10.1503/
cmaj.111045.
82. Arseneault L, Moffit T, Caspi A, Taylor PJ, Silva PA. Mental
disorders and violence in a total birth cohort: results from the
Dunedin Study. Arch Gen Psychiatry. 2000;57:979–86.
83. Fazel S, Yoon IA, Hayes AJ. Substance use disorders in prisoners:
an updated systematic review and meta-regression analysis in
recently incarcerated men and women. Addiction. 2017;112
(10):1725–39. doi:10.1111/add.13877.
84. Brady KT, Myrick H, McElroy S. The relationship between sub-
stance use disorders, impulse control disorders, and pathological
aggression. Am J Addict. 1998;7(3):221–30.
85. Chapman SB. Neurocognitive stall, a paradox in long term recov-
ery from paediatric brain injury. Brain Inj Prof. 2006;3(4):10–13.
86. Max JE, Lindgren SD, Knutson C, Pearson CS, Ihrig D,
Welborn A. Child and adolescent traumatic brain injury: corre-
lates of disruptive behaviour disorders. Brain Inj. 1998;12
(1):41–52.
87. McKinlay A, Horwood LJ, Fergusson DM. Accuracy of self-report
as a method of screening for lifetime occurrence of traumatic
brain injury events that resulted in hospitalization. JINS. 2016;22
(7):717–23. doi:10.1017/S1355617716000497.
88. Theadom A, Parag V, Dowell T, McPherson K, Starkey N, Barker-
Collo S, Jones K, Ameratunga S, Feigin VL, BIONIC Research
Group, Persistent problems 1 year after mild traumatic brain
injury: a longitudinal population study in New Zealand. Br
J Gen Pract. 2016;66(642):e16–23. doi:10.3399/bjgp16X683161.
89. Department of Veteran Affairs, Department of Defense. VA/DOD
clinical practice guideline for the management of concussion-mild
traumatic brain injury. [Internet]. healthquality.va.gov. 2016.
[cited 6 Jan 2019]. https://www.healthquality.va.gov/guidelines/
Rehab/mtbi/mTBICPGFullCPG50821816.pdf.
90. McKinlay A. Long-term outcomes of traumatic brain injury in
early childhood. Aust Psychol. 2014;49(6):323–27. doi:10.1111/
ap.12084.
91. Williams W, Chitsabesan P, Fazel S, McMillan T, Hughes N,
Parsonage M, Tonks J. Traumatic brain injury: a potential cause
of violent crime?. Lancet Psychiatry. 2018;5(10):836–44.
doi:10.1016/S2215-0366(18)30062-2.