Neurocognitive functioning among people accessing an addiction neuropsychology clinic with and without a history of offending behaviour

Effectiveness of interventions for violent behaviour may be undermined by the presence of neurocognitive impairment, which is known to be common among alcohol and other drug (AOD) users and violent offenders. The current study aimed to examine whether the cognitive functioning of individuals with AOD histories presenting to a specialist addiction neuropsychology service differed according to their offending history (i.e. non-offending, non-violent offending and violent offending), using a retrospective case file audit design. Data were extracted from 190 clients. Tests assessed a breadth of cognitive domains. Violent offenders demonstrated the lowest premorbid IQ out of the three groups, and a significantly higher proportion of violent offenders presented with impaired divided attention and impaired cognitive inhibition compared to non-violent offenders. Rates of impairment across groups were well beyond those expected within the general population. Delivery of both AOD and violence interventions should be adapted to accommodate individuals’ cognitive difficulties.Key words: alcohol and drug use, cognitive functioning, cognitive impairment, intervention, neurocognitive impairment, neuropsychology, offender, rehabilitation, treatment, violence

The number of people in prisons in Australia has increased by 25% between 2013 and 2018 (Australian Bureau of Statistics, 2019b), which is 2.6 times greater than the increase in the Australian population over that same period (9.6%; Australian Bureau of Statistics, 2019a). Of the prisoners released during 2015–2016, 43.7% returned to prison within two years (Justice & Regulation, 2018). This high rate of recidivism is despite the availability of programmes and psychological interventions during incarceration, community corrections orders or parole, and include those addressing alcohol and other drug (AOD) use and offending behaviour (Heseltine et al., 2011). However, the prevalence of AOD use remains a significant issue for the criminal justice system (Casey & Day, 2014), and is often associated with violent offending (Voce & Sullivan, 2019). For example, in 2018, 79% of police detainees across Australia who produced a positive urinalysis for drugs had committed a violent offence, and almost half of the sample (43%) attributed their violent offending to their AOD use (particularly alcohol and methamphetamine; Voce & Sullivan, 2019), which is consistent with international data (Bahr et al., 2012).AOD use and violent behaviour have been consistently associated with neurocognitive impairment (Boles & Miotto, 2003; Cadet & Bisagno, 2015; Crowe et al., 2020; Potvin et al., 2018; Potvin et al., 2014; Stavro et al., 2013). Neurocognitive impairment is an important factor to consider when selecting appropriate behaviour change interventions as it can affect people’s ability to make changes, and may limit engagement in, and response to, intervention (Rupp et al., 2012). Specifically, violent offenders have been found to have specific impairments in inhibitory control, emotional processing and divided attention (Bell & Polaschek, 2017; Bergvall et al., 2001; Yang & Raine, 2009), as well as more broad patterns of executive dysfunction (Broomhall, 2005; Hancock et al., 2010). These are similar impairments to those experienced by individuals with AOD use disorders, which also include aspects of executive functioning such as planning, use of environmental feedback, response inhibition, working memory and goal selection, in addition to learning and memory (Bates et al., 2002; Pitel et al., 2009). These skills are necessary for a successful response to interventions commonly used for aggression/violence, such as cognitive behaviour therapy (CBT), or motivational enhancement (Blume & Marlatt, 2009; Rupp et al., 2012).Importantly, neurocognitive impairments can persist for weeks or months after the cessation of AOD use, in some cases only returning to a normal range after lengthy periods (i.e. 12 or more months) of abstinence (Stavro et al., 2013), while in other cases deficits may persist (Crowe et al., 2020; Crowe & Stranks, 2018). Furthermore, populations with AOD use disorders often present with high rates of comorbid risk factors for cognitive impairment including educational disadvantage, trauma, mental health and head injury (Gooden et al., 2020; Jackson et al., 2011; Morisano et al., 2014).Given that cognitive impairment can be present in both AOD use disorder (Bates et al., 2002, 2013) and violent offending populations (Rosell & Siever, 2015), violent offenders with severe AOD use disorders may be more vulnerable to experiencing higher rates of, or more severe, cognitive impairment. This in turn may limit their ability to access or engage in treatment programmes. Furthermore, there is a risk that these impairments may go undetected or be underestimated despite their impact on intervention outcomes (Bernardin et al., 2014). As such, characterising the nature of these impairments and determining whether individuals in this group present with differing levels of cognitive impairment is the first step in ensuring these weaknesses can be considered and treatment programmes adequately adapted.This study aimed to explore and contrast the neuropsychological performance of (a) those with no offending history, (b) those with a history of non-violent offending and (c) those with a history of violent offending, who presented to a state-wide addiction neuropsychology service in Melbourne, Victoria, Australia. Specifically, we compared both mean scores and the proportion with scores in the impaired range across three groups defined by their history of offending behaviour. Based on existing literature, we predicted that violent offenders would demonstrate poor performance on tests of executive control (inhibition, divided attention and working memory) relative to that of non-violent offenders and non-offenders. Additionally, we aimed to determine the rates at which these groups differed from the normal range on domains of cognitive functioning and explore any differences between groups.     

Evaluation and management of dysmenorrhea in adolescents

Chronic pelvic pain is defined by the American College of Obstetricians and Gynecologists (ACOG) as noncyclic pelvic pain of at least 3 months duration or cyclic pain of 6-month duration, either of which interferes with one's normal activities of daily living. Dysmenorrhea, or painful menses, is the most common gynecologic complaint among adolescent and young adult females and is the leading cause of recurrent short-term school or work absenteeism. This chapter reviews the assessment, diagnosis, and treatment of some of the most common causes of pelvic pain in adolescents.     

Chronic venous ulcer treatment with fascial pedunculated graft

AIM: Chronic venous ulcer treatment is often time consuming and requires a high degree of compliance from the patient. This derives not only from venous hypertension but also from chronic structural and metabolic changes of underlying tissues which impair the healing process. It therefore becomes necessary to improve the ulcer tissue condition in order to accelerate the healing process. This is obtained mainly with the improvement of local haemodynamics and secondly by direct action on the ulcer. The aim of the study is to evaluate the efficacy of a treatment with a pedunculated flap of fascia as an additional treatment of chronic venous ulcer. METHODS: Four patients classified C6 according to the CEAP classification were treated for chronic venous ulcer with correction of venous hypertension (saphenectomy or ligature of incompetent perforating veins). The patients also underwent rotation of a fascial pedunculated flap transferred from the sural area to the perimalleolar area. After 7-15 days they had a free skin graft in the treated area. RESULTS: All patients were discharged on the 3(rd) postoperative day after the flap rotation. In 3 patients the ulcer healed within 30 days and in a 4(th) patient within 45 days. No recurrence was observed. CONCLUSION: With this method the healing time seems to be shortened compared to the typical evolution in patients treated with only reflux control followed by conservative therapy. Associating fascial flap in the treatment of chronic venous ulcers improves the bed on which the free skin graft is applied. We can also hypothesize that this procedure restores the aponeurotic barrier between deep venous circulation and superficial microcirculation with the ensuing improvement in local venous hypertension.