No Child Left Behind Goals (and more) are obtainablewith the Neurocognitive Approach: Vol. 1
by Kirtley E. Thornton, Ph.D.
Chapter 19 – Prisons, Drugs, and Special Education
We have a massive problem in the United States with our inability to reduce our prison population and drug abuse problem. Treatment interventions are, by and large, ineffective with these groups.
Size of the Problem
There were 2,268,000 people behind bars in the US in 2004, up1.9% from 2003.With an incarceration rate of 724 per 100,000 inhabitants, the United States is the unchallenged world leader in both raw numbers and imprisonment per capita.
With a global prison population estimated at nine million, the USaccounts for about one-quarter of all prisoners on the planet. The estimated U.S. population is 297,731,005 (population clock) or 5% of the world population, which is 6,480,917,568 and incarcerates 24% of the world’s prison population.
In terms of raw numbers, only China, with almost four times thepopulation of the US, comes close, with about 1.5 million prisoners. Ourcloser competitors in incarceration rates are Russia (638 per 100,000) andBelarus (554), according to the British government’s World Prison PopulationReport. The Federal Bureau of Prisons is now the largest prison systemin the land, with 180,000 inmates, followed by Texas (168,000), California(167,000), and Florida (86,000). The federal system is now at 40% overcapacity. (Profile of Jail Inmates, 2002) (State Prison Expenditures, 1996)
Criminal behavior and drug abuse behavior overlap considerably.The total number of people doing time for drugs in the United States in2003 exceeded 530,000, according to numbers from the Bureau of JusticeStatistics (Feature, 2005). People sentenced for drug crimes accounted for21% of state prisoners and 55% of federal prisoners.Drug abuse has a great economic impact on society-an estimated$67 billion per year. This figure includes costs related to crime, medicalcare, drug abuse treatment, social welfare programs, and time lost fromwork. Treatment of drug abuse can reduce those costs. Studies have shownthat from $4 to $7 are saved for every dollar spent on treatment. It costs approximately $3,600 per month to leave a drug abuser untreated in the community, and incarceration costs approximately $3,300 per month. In contrast, methadone maintenance therapy costs about $290 per month (NIDA info facts).
The Coalition for Juvenile Justice (CJJ) report shows that between 70and 87 percent of incarcerated youth suffer from learning disabilities (LD)or emotional disabilities (ED) that interfere with their education. Moreover,youth that drop out of school are three and a half times more likely to bearrested than high school graduates. In the adult criminal system, 82 percentof prison inmates dropped out of high school. (Leahy, 2001)Traumatic brain injuries have been correlated with violent behavioraltendencies like those observed in the behavioral topography of perpetratorsof serial homicides. (Lewis et al., 1986). A 1986 study examinedthe neurological histories of fifteen death row inmates and found that everymember of the experimental population had experienced severe head injuryprior to incarceration (Lewis et al., 1986). Galski et al. (1989) also documented the role of previous traumatic brain injuries in the violent offender. Brain damage in utero and in early childhood has been correlated with increased tendencies toward both youth and adult violence (Raine et al, 1997) (Prothow-Smith and Spivak, 1999)
Costs of Prisons
As the US has the largest prison business in the world, the costs associated with the business are also large. In its first analysis of state prison expenditures since 1990, the federal government’s Bureau of Justice Statistics reports that state correctional costs rose from $12 billion in 1990to $22 billion in 1996, an 83 percent increase. The state prison populationrose 52 percent during the same time period. Federal prison expendituresrose 160% from $946 million in 1990 to $2.5 billion in 1996, an averageof about 17% a year. Ninety-six percent of the state expenditures were forsalaries, wages, benefits and other operating expenses. The total operatingper inmate cost rose from $16,300 in 1984, to $18,400 in 1990 to $20,100(state inmates) and $23,500 (Federal inmates) in 1996. (Stephan, 1996)
On a per capita basis, it costs every man, woman and child in thecountry $103 to run state prisons in 1996, up from $53 per person in 1985.California had the largest state prison expenditure in 1996, spending $3billion and North Dakota had the smallest, $10.7 million. The figures comefrom an analysis of the 1996 Survey of Government Finances, conducted bythe U.S. Bureau of the Census. Bureau of Justice Statistics finance specialists contacted state budget and corrections officials to ensure the numbers were accurate and then made considerable corrections to the dataIn conclusion, the our drug and special education problems continueto grow in tandem with the size and cost of our prison population.
Costs to Victims
The costs of these crimes go beyond those to society’s prison costsand the perpetrator’s jail time. Crime victims in 1992 lost $17.6 billion indirect costs, according to the National Crime Victimization Survey. Thesecosts included losses from property theft or damage, cash losses, medicalexpenses, and amount of pay lost because of injury or activities related tothe crime. The crimes included in this figure are rape, robbery, assault,personal and household theft, burglary, and motor vehicle theft. Crimesinclude attempts as well as completed offenses. (Klaus, 1994)
Treatment – How has our society attempted to deal with these problems?
Due to the overlapping problem of criminal behavior and drug abuse,some studies have examined both of these behaviors following treatment.
The drug rehabilitation industry has been looking for effective solutions for decades. Substance Abuse and America’s Prison Population revealed that 80 percent of the men and women behind bars in the U.S. wereseriously involved with drugs and alcohol. That year, states spent nearly $30billion on the adult corrections system, $24.1 billion of which was spent onsubstance-involved offenders making substance abuse the number one contributor to crime in America.
The state of Texas released a report in 2005 that examined the recidivism rate among its prisoners during 2000 and 2001. They found anaverage recidivism rate of about 30%, with property (35%) and drug offenders (31%) having the highest rates followed by individuals initiallyconvicted of violent offenses (23%). The recidivism rate among other statesthat included California (2000- 60.5 %), Colorado (1999-47%), Pennsylvania(2000- 46%) and a national norm of 51% (1994). The Texas studyalso indicated that juveniles had a higher recidivism rate (about 51%). Thereport did not indicate whether any treatment was involved. Therefore, anyintervention must be compared to the naturally occurring recidivism ratewithout treatment. (Statewide Criminal Justice Recidivism rates and revocation rates, 2005)
DTAP – Residential/Therapy – Alcoholism
The National Center on Addiction and Substance Abuse (CASA)conducted a five-year research study (2/2003) through Columbia Universityon the Drug Treatment Alternative-to-Prison (DTAP) Program and foundthat positive results were achieved at about half the cost of incarceration.(DTAP, 2003)
The DTAP program provides 15 to 24 months of residential drugtreatment, vocational training, and social and mental health services to drug addicted, nonviolent repeat offenders who face mandatory punishment underNew York State’s second felony offender law. Participants are abusers of heroin, crack and powder cocaine, among other substances. They plead guilty to a felony, thereby ensuring a mandatory prison sentence if theyabscond from the program. Sentencing is deferred upon program participation; if participants complete the program, their guilty plea is withdrawn and the charges dismissed.
The five-year CASA evaluation found that participants who completedthe program and graduated were 33 percent less likely to be rearrested,45 percent less likely to be reconvicted, and 87 percent less likely toreturn to prison than the comparable prison group.
DTAP graduates were three and one half times more likely to beemployed after graduation than before their arrest. Before their arrest, 26percent were working either part-time or full-time. Following successfulcompletion of the program, 92 percent had found employment.
DTAP participants remain in treatment six times longer than individuals in other long-term residential treatment (a median of 17.8 monthscompared to three months). Retention rates are important because the longer an individual stays in treatment, the greater their chance of maintaining sobriety.
These results are achieved at about half the cost of incarceration.The average cost for each DTAP participant of residential drug treatment,vocational training, and support services was $32,975, compared to an average cost of $64,338 for the time spent in prison for DTAP participants who dropped out.
Psychotherapy – Individual / Group – Drugs and Criminal behavior
A review of treatment outcomes for drug addiction and criminalitywas reported by Simpson et al. (2002). Interviews were conducted at1 and 5 years after treatment for 708 subjects (from 45 programs in 8 cities)who met DSM-III-R criteria for cocaine dependence when admitted in1991-1993. Primary outcome measures included drug use and criminality.Self-reported cocaine use showed high overall agreement with urine (79%agreement) and hair (80% agreement) toxicology analyses. The results indicated that half (52%) had relapses to drug use: 23% to “weekly” cocaineuse; 19% to “occasional” cocaine; 10% to “other drugs”.
Additional conclusions noted that the percent of illegal activity declined from 40% before the intake for program participation to 25% in year 5 follow-up after discharge from the program (up slightly from 16% in year 1). The percent arrests in the past year dropped from 34% before the programintake to 18% in year 5 follow-up (down slightly from 22% in year 1).The group that received less treatment (i.e. “low treatment”) did not fare aswell. Low treatment usually meant less than 3-months of treatment – considered the minimum “threshold” for an effective length of stay. In addition, poorer long-term outcomes were related to higher problem severity at treatment admission and less treatment.
We need to look at these numbers for a moment to see exactly whatthe result of the treatment was. If illegal activity was at the 40% figure priorthe treatment, then 60% of the participants had stopped committing illegalactivity, a “spontaneous cure”. If the treatment program resulted in a posttreatment rate of illegal activity at year 1 of 16%, then the program was effective in reducing illegal activity by another 24%. Thus, of the 40% who were still committing illegal activity, 60% (24/40) were “cured” of theirillegal activities at the one year post treatment time assessment. Employingthis approach to the data results in a treatment effectiveness value of 70%for cocaine abuse, 73% for heroin abuse, 73% for alcohol abuse, and 35%for any arrests (which is not the same as a recidivism number). Thus the“recidivism” rate for drug abuse was about 30% and for criminal activitybetween 40% (illegal activity) and 65% (arrest) if the person was engagedin the program.
EEG Biofeedback – Neurotherapy and Criminal Behavior Initial Discovery
Dr. Von Helsheimer and Doug Quirk reported between 1970-1995 ona series of fascinating observations and research results that are particularlyrelevant to the prison population (Quirk, 1995, Quirk & Von Helsheimer).Mr. Quirk was interested in the prison population. As a psychologist he hadlearned to administer the Bender-Gestalt test which requires the subject tocopy geometric designs. A variant of this test is the Diagnostic DifferentialTest (DDT).
One of the neurologists on staff where Mr. Quirk worked gave him alist of 10 patients whose serial EEGs eventually demonstrated epilepsy butwho did not have seizures. He was asked what test to use to figure out howto recognize them more reliably than with the EEG. Doug found a file intowhich he had put the DDT’s those individuals’ had taken and found thoseparticular DDT’s as uninterpretable.
He had a casual conversation with a psychologist who told him ofsome work he had been doing with pigeons demonstrating that when anablation was made in the region of the brain’s septum the pigeons that hadbeen trained to respond to angular signs were post operation unable to differentiate the angles from curves. The performance of his 10 puzzling patients on the DDT indicated that they couldn’t handle angles as well as they could handle curves. So Quirk decided that he had found an indicator ofdeep diencephalic epilepsy. The first 70 patients he found with this sign onthe DDT were all diagnosed by a neurologist as epileptic. All but one hadtypical seizure spindles on the EEG.
Quirk applied the DDT to a large number of arsonists, assaultists andrapists. Forty per cent of the serious arsonists, 30% of the assaultists, and25% of the rapists demonstrated the sub-ictal sign on the DDT. This lastgroup, the rapists with anomalous DDT performance, also demonstratedvisible anomalies of the temporal lobe in CAT scans.
By way of contrast, fewer than 2% of the remaining ‘garden varieties’of less dangerous offenders exhibited this deep-brain epileptic syndrome.In several other studies we found that there was a consistent andstrong relationship between strong emotional reactivity or weak emotionalcontrol and dangerous criminal actions.
Some epilepsies whose focus lies in the deep recesses of the old brain are variously referred to as partial seizures with complex symptomatology (PSCS) or “complex partial seizures”. These are non-convulsive seizures, paroxysmal events, sub-ictal states, or seizure equivalents. The behaviors associated with these sub-ictal states tend to distract the observer because they are intense, gruesome, unappetizing, and usually criminal activities. If the epileptic discharge in these seizures involves the Olds and Milner ‘drive centre’, the person may exhibit uncontrolled paroxysms of rage, sexual drive, hunger, satiety, alcohol use, or other excitant automatisms such as fire setting. The individual may seem perfectly normal in just a few seconds after the explosion of aberrant behavior. There is a subclass of criminal which is floridly emotional and whose emotionality is almost always associated with grotesque and extreme acting out.
The most common prodrome in deep-brain complex partial seizuresseems to be heightened intensity of emotional arousal — perhaps sometimesdue to associated activation of the Olds and Milner ‘drive centre’. The difficulty encountered by most people in using strong emotional arousal as acue for behavior is that emotional arousal tends to distract attention fromconscious cortical self-regulatory habits. High emotional intensity tends todisengage the subject from such moderating habits. Distracted attention anddisengagement is intensified by alcohol and by recreational and medicaldrugs, all of which are often involved in scenes of intense emotionality. Itis generally agreed that some deep-brain complex partial seizures are facilitated by alcohol ingestion.
Developing the intervention
In 1970 Quirk went to a meeting in Boston and heard Barry Stermantalk about his work with cats and human epileptics. Dr. Sternman was employing the sensori-motor rhythm (SMR) frequency (12-15 Hertz) to successfully inhibit seizure activity in cats. He was training the 13 Hertz range along the Fissure of Roland (Sensorimotor Strip or sulcus centralis – top central portion of head) which resulted in resistance to epileptic seizure -even that produced by toxins such as hydrazine (an normally infallible producer of seizures of fatal intensity). The amplitude of 13 Hz is notoriouslysmall in epileptics over the Rolandic Fissure.
Quirk completed two preliminary studies of recidivism among OntarioCorrectional Institute felons who had been discharged. He compared55 pairs of high-risk felons, half of whom were treated by temperature biofeedback, a modified GSR technique called SCARS, and by Sterman’s EEG method, and half of whom received only counseling. These felons received 33 half-hour sessions of training. These violent felons demonstrated the sub-ictal pattern on the DDT (viz., they didn’t handle visual angles as wellas visual curves) and on the EEG. The treatment of the 55 felons includedvolunteer administered temperature biofeedback training, SCARS GSRtraining, and EEG training of the sensorimotor rhythm at C-3 and C-4 asdescribed by Sterman. Subsequently, he trained another group of 55 pairs offelons In the typical case, the percent of the time in which this SMR activityoccurred tended to average around 10% during the first few half-hour trainingsessions, and to rise to 45% to 55% during the last training sessions.
Two years after his initial study of 55 pairs of felons 22 or 40% of thetreated felons had been arrested again. Two years after the second study of55 pairs of felons 11 or 20% of the treated felons had been rearrested. Thisrate of recidivism compared to 85% and 65% rearrested among the matchedfelons who were not treated by biofeedback. In other words, 60% and 80%of the treated felons were still free, while only 15% and 35% of the untreatedfelons had managed to remain outside of prison.
The justice system records of the offenders accepted into this biofeedback treatment program were reviewed an average of a year and a half after release from their treatment sentences. Of the 17 offenders who received 0 to 4 half-hour training sessions (i.e., essentially no treatment), 65% had been re-convicted of criminal offenses. Of the 10 who had received 34 or more half-hour training sessions, only 2 or 20% had been re-convictedof criminal offenses. Intermediate amounts of training were found to be associated with intermediate recidivism rates. Among these subjects, neitherfollow-up interval nor age were related to recidivism rates.
Overall, from 1970 through 1995, Mr. Quirk trained 2776 felons bythis combined method (temperature, GSR, and EEG). Of those trained, 15%were rearrested in the 3 years following release. This compares well to therange of rearrest in studies summarized by Alter et al (1996) – 42 % to 78%.In a series of reports to corrections officials, Mr. Quirk indicated that thethree-year recidivism rate from the biofeedback (using these techniques)had never been more than 45%, and in some groups had fallen to 15%.Overall, the rate of recidivism was consistently close to 15%.
The common rate of recidivism in correctional institutions in theUnited States was generally, at the time, believed to be 98% within twoyears of discharge. To put the numbers in a different perspective, prisonswere so bad that it could be said that we were failing to criminalize only2% of the juvenile population enrolled in our higher institutions of learning(correctional institutes). (Quirk, 1995)
The Texas report indicated that, presently, in a normal prison population we can expect about a 51% recidivism rate presently without anyform of intervention.
The effectiveness, time and cost issues for these intervention methodsare summarized in Table 22 and compared to the national norm. Therefore,any intervention must be considered with reference to this base rate.An examination of the table quickly reveals that the EEG biofeedback approach is clearly the more effective mode of treatment for this condition, aswell as being the least expensive.
EEG Biofeedback and Seizure Activity
EEG biofeedback originally developed out of the discoveries of B.Sterman in the application of the approach to inhibit seizure activity. It wasfound as early as 1969 that after training for enhanced SMR (12-15 Hz)rhythm in cats, the threshold for seizure onset was increased for chemicallyinduced seizures (Fairchild, 1974, Sterman, 1976). Sterman and hisassociates (Sterman & Friar, 1972; Sterman et al., 1974) found by trainingepileptics to enhance the human EEG sensorimotor rhythm (SMR) of 12-15Hertz (Hz) that their seizure management could be improved. Sterman etal. (1974) achieved an average 66% reduction in seizure incidence in fourepileptics using SMR enhancement training in combination with inhibitionof excessive slow-wave activity in the 6-9 Hz regime. Lubar and Bahler(1976) found similar results when they trained epileptics to enhance theSMR frequency and suppress the theta (4-7 Hz) slow wave frequency. Wyler’s and Finley’s studies were the first to include such pseudo-conditioning and control periods (Wyler, 1976; Finley, 1976). Such sham training was also provided in a more exhaustive, double-blind study (neither the experimenter nor the patient was aware of the contingency of reward) undertaken by Lubar, et al. in 1981. Five of 8 patients exhibited seizure reduction with respect to baseline, the reduction being 35% for the entire group. Since the original research in this area, the evidence for the application of the technology to seizure activity has continued to amass as a reliable intervention method for seizure reduction. (Sterman, 2000) Alternateprotocols to address the seizure problem have been employed by Walker &Kozlowski (2005) who reported a 100% reduction in seizure activity in agroup of patients.
It has been documented that about 20% of the patients with epilepsymay exhibit ADHD symptoms. (Tan & Appelton, 2005). Electroencephalography has also been reported to be abnormal in children with ADHD, some showing epileptiform activity. The reported incidence ranges from 6.1% of 476 of children with ADHD (compared to 3.5% of 3726, normal, school age children) 18 to 30.1% of 176 children with ADHD.As EEG seizure activity (not necessarily behavioral seizure activity)is part of the picture in the learning disabled and ADHD population, theability of the intervention approach is self evident.