TYPE Systematic Review PUBLISHED 16 August 2023 DOI 10.3389/fpsyg.2023.1066474 Alterations in executive functions OPEN ACCESS in inmates convicted for violent behavior: a systematic review EDITED BY Fabio Giovannelli, University of Florence, Italy REVIEWED BY Shichun Ling, Maria Antonia Chaguendo-Quintero1† , California State University, Los Angeles, United States Daniela Quintero-Monjes1† , Maria Teresa Cuervo1* and Karen Lahm, Wright State University, United States Juan P. Sanabria-Mazo2,3,4* 1 *CORRESPONDENCE Department of Social Sciences, Pontificia Universidad Javeriana, Cali, Colombia, 2 Teaching, Research, Maria Teresa Cuervo and Innovation Unit, Parc Sanitari Sant Joan de Dèu, Barcelona, Spain, 3 Centre for Biomedical Research mtcuervo@javerianacali.edu.co in Epidemiology and Public Health (CIBERESP), Madrid, Spain, 4 Department of Basic, Developmental, Juan P. Sanabria-Mazo and Educational Psychology, Universidad Autónoma de Barcelona, Barcelona, Spain juanpablo.sanabria@sjd.es † These authors have contributed equally to this work and share first authorship Background: The growth of the prison population and the high recidivism rates of inmates represent a major public safety problem. SPECIALTY SECTION This article was submitted to Objective: This systematic review explored executive functions in inmates Forensic and Legal Psychology, convicted of violent behavior compared with inmates convicted of non-violent a section of the journal Frontiers in Psychology behavior and healthy controls (HCs). RECEIVED 10 October 2022 Methods: Systematic searches were carried out using five databases (PubMed, ACCEPTED 31 March 2023 Scopus, Web of Science, EBSCO, and Embase) until March 6th, 2023. Following PUBLISHED 16 August 2023 Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) CITATION guidelines, two reviewers independently performed the screening, data extraction, Chaguendo-Quintero MA, Quintero-Monjes D, Cuervo MT and Sanabria-Mazo JP (2023) and risk of bias assessment of the 8 studies included. The protocol of this study Alterations in executive functions in inmates was registered in Prospective Register of Systematic Reviews (PROSPERO), under convicted for violent behavior: a systematic registration number CRD42021252043. review. Front. Psychol. 14:1066474. doi: 10.3389/fpsyg.2023.1066474 Results: Consistently, inmates convicted of violent behavior exhibited a greater COPYRIGHT alteration in inhibition than inmates convicted of non-violent behavior (four out © 2023 Chaguendo-Quintero, of four studies) and HCs (two out of two studies). In addition, inmates convicted Quintero-Monjes, Cuervo and Sanabria-Mazo. This is an open-access article distributed under of violent behavior showed greater impairments in cognitive flexibility (two out of the terms of the Creative Commons Attribution three studies) and working memory (two out of three studies) than HCs. Although License (CC BY). The use, distribution or with limited evidence (only one study), they also showed worse performance in reproduction in other forums is permitted, provided the original author(s) and the set shifting and planning than HCs. copyright owner(s) are credited and that the Conclusion: This study provides evidence of alterations in inhibition in inmates original publication in this journal is cited, in accordance with accepted academic practice. convicted of violent behavior compared to inmates convicted of non-violent No use, distribution or reproduction is behavior and HCs. Even though inmates convicted of violent behavior showed permitted which does not comply with these greater impairments in planning and set shifting than HCs, these findings were terms. supported in only one study. In general, more robust evidence is needed to confirm alterations in inmates convicted due to violent behavior. These findings highlight the importance of designing and promoting specific cognitive interventions that contribute to the reintegration of inmates into society. Systematic review registration: https://www.crd.york.ac.uk/prospero/ display_record.php?ID=CRD42021252043, identifier CRD42021252043. KEYWORDS inmates, violent behavior, executive functions, inhibition, cognitive flexibility, working memory, systematic review Frontiers in Psychology 01 frontiersin.org Chaguendo-Quintero et al. 10.3389/fpsyg.2023.1066474 1. Introduction Recent research indicates that inmates convicted of sexual abuse or rape report greater alterations in executive functions Violence is a global public problem of great concern (Bureau than those convicted of non-sexual offenses (Pulido et al., 2017) of Justice Statistics, 2020). There are currently 6.5 homicides per and non-inmates (Burton et al., 2016; Guamán and Carballo, 100,000 inhabitants in the world (Institute for Economics and Peace 2019). This could be because these inmates present executive [IEP], 2021). A recent report indicate that more than 11 million dysfunctions involving high impulsivity and aggressiveness, as well people are imprisoned awaiting trial or convicted (World Prison as difficulty in planning, inhibition, and regulation, the latter being Brief, 2020). The growth of the prison population and the high a possible predictor of the frequency in which these individuals recidivism rates of inmates represent a major social and economic commit crimes (Burton et al., 2016; Pulido et al., 2017; Guamán burden on public safety (Navarrete and Austin, 2020). Specifically, and Carballo, 2019). In addition, this group of inmates reports since 2000 the inmate population in the world has grown by 24% poorer performance in cognitive flexibility and executive control (Bureau of Justice Statistics, 2020). Recidivism rates of inmates compared to non-inmates (Burton et al., 2016; Guamán and have ranged from 35% to 67% in different countries (Meijers et al., Carballo, 2019). 2015). Deprivation of liberty affects inmates’ physical and mental A previous review (Meijers et al., 2015) identified that inmates health and increases the development of maladaptive feelings and convicted of violent behavior showed greater impairments in behaviors that, in the long term, lead to inmate recidivism (Meijers inhibition and set shifting than non-inmates. Given the aim of et al., 2017; Wallinius et al., 2019; Cruz et al., 2020). the study and methodological approach, this narrative review Neuropsychology has contributed to the understanding used a less restrictive selection of articles, including those with of the biological basis of social behavior (Arioli et al., 2020). heterogeneous comparison groups (inmates for violent behavior, A meta-analysis (Ogilvie et al., 2011), in which 126 studies inmates for other types of behaviors, and HCs), or even without a involving 14,786 cases were analyzed, found that people with comparison group. Although this review represents an interesting antisocial behaviors presented greater impairments in executive scientific contribution, the results should be taken with caution due functions than healthy controls (HCs). In this comparison, limitations such as the small size of the samples of the included the groups with more alterations were those with antisocial studies and the lack of evaluation of several executive functions in behaviors, externalizing behavior disorders, and antisocial the same population. personality disorders. In this regard, some studies have indicated For this update, inclusion of new articles was sought using that people convicted of violent behavior with alterations an approach suggested by Meijers et al. (2015). Specifically, this in executive functions report higher levels of aggression consisted of exploring studies that evaluate groups of inmates for (Wallinius et al., 2019; Alvarado-Grijalba et al., 2020; Cruz violent behavior in comparison with different controls (e.g., non- et al., 2020) and others suggest that alterations in executive violent inmates or HCs). In addition, this made it possible to functions are related to social skills, impulsivity, foresight, and analyze the extent to which differences in executive function are judgment (Karlsson et al., 2016; Meijers et al., 2017; Cruz et al., specific to violent offenders (De Brito et al., 2013; Zou et al., 2013; 2020). Chen et al., 2014; Moreno, 2014; Vilà-Balló et al., 2014; Karlsson Executive functions are cognitive, emotional, and motivational et al., 2016; Meijers et al., 2017; Sedgwick et al., 2017; Slotboom processes essential for regulating behavior, developing adaptive et al., 2017; Baliousis et al., 2019). behaviors, and facilitating the social integration of individuals As far as it is known, this is the first study to systematically (Ogilvie et al., 2011). A systematic review (Tirapu-Ustárroz explore baseline executive functions in inmates convicted of violent et al., 2017), in which 33 studies were explored, indicated that behavior compared with inmates convicted of non-violent behavior executive functions are composed of cognitive processes that enable and HCs. To facilitate the interpretation of the findings, this control, self-regulation of behavior, processing speed, working study also assessed the risk of bias (RoB) of the studies explored. memory, verbal fluency, inhibition, dual execution, cognitive The identification of alterations in executive functions could flexibility, planning, and decision making. Specifically, there is help to increase the neuropsychological understanding underlying evidence that alterations in these functions generate cognitive and violent behaviors in this population (Santos-Barbosa and Coelho- behavioral manifestations that interfere in the functioning and Monteiro, 2008; Hanlon et al., 2010; Arana et al., 2013; Rocha et al., social adaptation of individuals (Arioli et al., 2020; Cruz et al., 2014; Pulido et al., 2017; Carreño et al., 2018; Delfín et al., 2018; 2020). Meijers et al., 2018; Cando-Pilatuña et al., 2019; Spenser et al., 2019; People with criminal records demonstrate worse performance Wallinius et al., 2019). in planning and monitoring (Seruca and Silva, 2015; Meijers et al., 2017; Delfín et al., 2018), cognitive flexibility (Meijers et al., 2015; Seruca and Silva, 2015; Karlsson et al., 2016; Wallinius et al., 2019), and inhibition (Meijers et al., 2017, 2018; Wallinius et al., 2019). 2. Materials and methods Inmates convicted of violent behavior showed deficits in prefrontal 2.1. Protocol and registration functioning, as well as greater impairments in inhibitory control, set shifting, attention, working memory, planning, and inhibitory This systematic review was performed following the Preferred responses -the latter being associated with aggressive behaviors- Reporting Items for Systematic Reviews and Meta-analyses than HCs or inmates convicted of non-violent behavior (Zou et al., (PRISMA; Page et al., 2021). The protocol was registered in 2013; Karlsson et al., 2016; Meijers et al., 2017; Wallinius et al., Prospective Register of Systematic Reviews (PROSPERO), under 2019). registration number CRD42021252043. Frontiers in Psychology 02 frontiersin.org Chaguendo-Quintero et al. 10.3389/fpsyg.2023.1066474 2.2. Sources of information and search 2.5. Data extraction and coding Systematics searches were performed using PubMed, Scopus, The first (MAC-Q) and second (DQ-M) reviewers synthesized Web of Science, EBSCO, and Embase. The selection of terms was all relevant information from the articles in a standardized record performed considering the Context, How, Issues and Population format. The data extracted were authors, year of publication, (CHIP) and search string of the previous review (Meijers et al., country, study design, mean age, and executive functions evaluated. 2015). The Boolean search was validated with the support of three The statistical parameters analyzed were sample size, means, external reviewers and a documentalist, using the Peer Review of standard deviations (SDs), significance, and effect size. Electronic Search Strategies (PRESS; McGowana et al., 2016). The search strategy combined terms related to the population (prisoner OR incarcerated OR criminal OR violent offenders 2.6. Risk of bias (RoB) OR offender) and executive functions (executive function OR executive dysfunction OR neurocognitive OR neuropsychological OR RoB was assessed for each eligible study using an adapted neuropsychology), found in titles, abstracts, and Medical Subject version of the Quality Assessment Tool for observational studies Headings (MeSH). The search strategies employed in each database from the National Heart, Lung, and Blood Institute (National, are detailed in the Supplementary File 1. If possible, the search Heart, Lung, and Blood Institute [NHLBI], 2018). This risk included the following filters: the period of publication (2007– of bias assessment tool helps reviewers focus on concepts 2023), type of document (article), field (Psychology, Psychiatry, that are key to the internal validity of a study, considering Neuroscience, Health Sciences, and Social Sciences), language aspects related to study designs and verifying possible bias in (English or Spanish), age ranges (≥18 years), and species (human). methods or research implementation (National, Heart, Lung, The search period was defined considering the results obtained and Blood Institute [NHLBI], 2018). The total score of the in the review by Meijers et al. (2015). The reference list of RoB scale composed of eight items was divided into low included studies was also examined by a reverse citation search for (6–8), medium (4–5), and high (≤3). Items were scored 1 further analysis. The database search was updated until March 6th , point when criteria were met and 0 when criteria were not 2023. met, unclear, or could not be determined. The procedure followed for the adaptation of this tool can be found on the Supplementary File 2. 2.3. Eligibility criteria Eligibility criteria were defined based on the Participants, 2.7. Data analysis Intervention, Comparison, Outcomes, and Study Design (PICOS; Perestelo-Pérez, 2013). Table 1 details the inclusion and exclusion Data were classified according to the sociodemographic criteria established in this systematic review. Forensic inmates characteristics of the sample, outcomes explored, and effect sizes (such as pedophilic inmates) were excluded from this study reported. Effect sizes were evaluated according to Cohen’s proposal since, according to the literature, they are associated with (Albers and Lakens, 2018): small (d ≥ 0.2), medium (d ≥ 0.5), and a psychiatric disorder (Berryessa, 2018) that could confound large (d ≥ 0.8). the results of the study. Additionally, juvenile inmates were excluded due to the changes in brain development that occur during this developmental period, which could also confound the findings of this systematic review (Maschi and Dasarathy, 3. Results 2019). 3.1. Selection of included studies Figure 1 displays the flowchart of the study selection process. 2.4. Data management and study selection The initial search yielded a total of 632 potential studies. In the first phase, after eliminating duplicates, the titles and abstracts of In the first phase, results of the database searches were 289 studies were reviewed, of which 19 were selected for full-text exported to Mendeley. In the second phase, duplicate articles were review. These studies were excluded because they reported results automatically detected and removed. In the third phase, titles that were not of interest for this review (n = 132); because they and abstracts were screened using the Rayyan QCRI Intelligent did not meet the criteria for population, study design, or types of Systematic Review tool. In the fourth phase, selected full articles publications (n = 130); and because they were not available (n = were reviewed for compliance with the eligibility criteria. In the 8). In the second phase, after reviewing the full texts, 11 studies fifth phase, data were extracted from the selected full articles in a were eliminated because they included samples with minors (n = standardized record format and RoB assessment was performed. All 4), no control group (n = 2), pedophilic inmates (n = 2), forensic these phases were performed by two independent reviewers (MAC- inmates (n = 1), variables measured with non-neuropsychological Q and DQ-M). Discrepancies in the process were agreed with the instruments (n = 1), or no variables of interest (n = 1). Finally, 8 third (MTC) and fourth reviewer (JPS-M). studies met the eligibility criteria for this systematic review. Frontiers in Psychology 03 frontiersin.org Chaguendo-Quintero et al. 10.3389/fpsyg.2023.1066474 TABLE 1 Eligibility criteria according to PICOS strategy. Inclusion criteria Exclusion criteria [P] Participants Adult inmates convicted for violent behavior: homicide, attempted homicide, Forensic population, juvenile delinquents, or minors. aggravated robbery, armed robbery, physical assault, kidnapping (or attempted), forcible confinement, domestic violence, sexual abuse, or rape (Harris et al., 2002). [I] Intervention Not applicable. Not applicable. [C] Comparison Adult inmates convicted for violent behavior compared with at least one control Other types of comparison groups. group: inmates convicted of nonviolent behavior or HC not deprived of their liberty and with no criminal record. [O] Outcomes Executive functions: inhibition, cognitive flexibility, working memory, decision Other types of measures. making, set shifting, and planning. [S] Study design Experimental, quasi-experimental, or observational studies in humans; published Non-original (systematic reviews, meta-analyses, case in peer-reviewed scientific journals; published in English or Spanish; and with a reports, editorials, guidelines, etc.), dissertations, or publication date between 2007 and 2023. qualitative studies. FIGURE 1 Preferred reporting items for systematic reviews and meta-analyses (PRISMA) flowchart from record identification to study inclusion. Frontiers in Psychology 04 frontiersin.org Chaguendo-Quintero et al. 10.3389/fpsyg.2023.1066474 3.2. Characteristics of the studies on the Stop-Signal Task test than those convicted of non- violent behavior (n = 45, p = 0.02). Levi et al. (2010) Table 2 presents the characteristics of the included studies. indicated that irritable inmates convicted of violent behavior These studies were published between 2007 and 2018. The sample (emotional violent crimes) performed significantly more poorly size ranged from 60 to 130 men. The age of the inmates ranged from (n = 34, M = 81.41, SD = 18.26) on the full impulsivity 18 to 85 years (M = 42.13, SD = 11.9). In total, four studies (50%) scale on The Integrated Visual and Auditory Continuous assessed the executive functions of inmates for sexual abuse, with Performance Test than predatory inmates (premeditated samples ranging from 20 to 68 participants (Becerra-García and non-emotional violent crimes; n = 25, M = 95.08, SD = Egan, 2014; Becerra-García, 2015; Rodriguez et al., 2017; Rodriguez 17.17, p = 0.001, d = −0.77) and those convicted of non- and Ellis, 2018); and the other four (50%) studies examined inmates violent behavior (n = 30, M = 96.40, SD = 15.29, p = 0.001, convicted of other types of violent crimes (assault, wounding, d = −0.89). attempted murder, homicide, manslaughter, and armed robbery, Rodriguez et al. (2017) and Rodriguez and Ellis (2018) found among others), with samples ranging from 20 to 85 participants significant differences in inmates convicted of sex offenses on the (Hoaken et al., 2007; Levi et al., 2010; Seruca and Silva, 2016; Hayling test. The Rodriguez et al. (2017) study identified that Meijers et al., 2017). The crimes considered to define an inmate both first-time sex offender inmates (n = 32; M = 3.1, SD = convicted of violent behavior were homicide, attempted homicide, 1.6) and inmates with a record of sexual offenses (n = 36; M = aggravated robbery, armed robbery, physical assault, kidnapping 3.5, SD = 1.9) had significantly higher dysfunction (p < 0.001, (or attempted), forcible confinement, domestic violence, sexual in both cases) on the total scale of the Hayling test than inmates abuse, or rape. Three studies (Hoaken et al., 2007; Levi et al., 2010; convicted of non-sexual offenses (n = 32; M = 5.2, SD = 1.5), Becerra-García, 2015) used the criteria established by Cornell et al. with a large effect size (d = 1.4 and 1.0, respectively). However, (1996) and Harris et al. (2002) to define violent behavior. Criteria in this same study, there were no significant differences between for classifying nonviolent inmates included crimes such as theft, the sex offense groups. In the Rodriguez and Ellis (2018) study, burglary (nonviolent), drug dealing/possession, or fraud. inmates with a history of sexual offenses (n = 34; M = 3.6, SD = 1.9) presented significantly poorer performance on this same test (p = 0.002; d = 0.9) than inmates for non-sexual offenses (n = 32; M = 5.2, SD = 1.5). In addition, no statistically significant 3.3. Risk of bias assessment and effect sizes differences were displayed between sex offense and non-sex offense inmates. As seen in Table 3, 62.5% of the studies obtained a moderate Regarding the COWAT test, the study by Rodriguez et al. (2017) RoB. Effect sizes were reported in 2 out of the 8 studies (Rodriguez evidenced that inmates convicted for the first time of sexual offenses et al., 2017; Rodriguez and Ellis, 2018). In the studies where all (M = 31.9, SD = 13.2) presented significantly worse performance necessary information was included (Levi et al., 2010; Becerra- on inhibitory responding (p < 0.05; d = 0.43) than inmates with a García and Egan, 2014; Seruca and Silva, 2016), effect sizes were history (M = 37.4, SD = 12.3) and non-sexual inmates (M = 43.9, calculated manually. Due to lack of data, it was not possible to SD = 10.5; p < 0.001; d = 1.00). Despite using the same test, no calculate this information in three studies (Hoaken et al., 2007; significant results between comparison groups were presented in Becerra-García, 2015; Meijers et al., 2017). the Rodriguez and Ellis (2018) study. Becerra-García (2015) compared 10 domestic violence inmates, 20 sex offense inmates, 9 violent crime inmates, 8 non-violent 3.4. Evidence on executive functions inmates, and 31 control group inmates using the Trail Making Test. This study identified that the sex crime and domestic violence The executive functions measured across these eight studies groups performed significantly poorer on inhibitory ability than the were: inhibition (n = 6), cognitive flexibility (n = 5), working control group (p = 0.001). In contrast, non-violent inmates did not memory (n = 4), decision making (n = 4), set shifting (n = 2), and show significant differences compared to the control group. planning (n = 2). Table 4 shows the scoring in each task. 3.4.2. Cognitive flexibility (five studies) 3.4.1. Inhibition (six studies) Seruca and Silva (2016) found that the general inmate group (n Seruca and Silva (2016) reported that inmates convicted of = 38) performed significantly worse on the Trail Making Test than violent behavior (n = 13; M = 60.15, SD = 36.42) presented the control group (n = 28, p = 0.008; d = 0.61). Becerra-García significantly poorer performance on the Porteus Mazes Test Q score (2015) found that on the Trail Making Test the domestic violence than the control group (n = 28, M = 32.57, SD = 20.42; p = 0.01), and sexual offenses groups (n = 30) performed significantly worse with a large effect size (d = 0.99). In the Stroop test, no significant on the post-hoc tests than the control group (n = 31, p = 0.001). differences were found between inmates for violent behavior and Rodriguez et al. (2017) identified that there were no statistically the control group (p = 0.73), as well as between inmates in general significant differences on the Trail Making Test-B between the (including non-violent inmates) and the control group (p = 0.95). first-time sexual violence group (n = 32, M = 111.7, SD = 59.2) Meijers et al. (2017) found that inmates convicted of and the repeat sexual violence group (n = 36, M = 124.8, SD = violent behavior (n = 85) performed significantly worse 45.9), although both sexual offender groups performed significantly Frontiers in Psychology 05 frontiersin.org Chaguendo-Quintero et al. 10.3389/fpsyg.2023.1066474 TABLE 2 Synthesis of the main characteristics of the studies. Authors Country Inmate population sample (mean Control population Executive functions (year) age) sample (mean age) evaluated Rodriguez and Ellis Australia 11 inmates convicted for the first time for child 32 inmates for non-sexual Inhibition, decision making, (2018) exploitation material (61 years) and 34 inmates offenses (57 years). cognitive flexibility, or set shifting. with a history of sexual offenses against children (62 years). Rodriguez et al. Australia 32 inmates convicted for the first time for sexual 32 inmates for non-sexual Inhibition, decision making, (2017) offenses (63 years) and 36 inmates convicted for offenses (55 years). cognitive flexibility, or set shifting. sexual offenses with record (62 years). Meijers et al. (2017) Netherlands 85 inmates for violent behavior (31 years). 45 non-violent inmates (35 Inhibition, planning, working years). memory, set shifting, and decision making. Seruca and Silva Portugal 13 inmates for violent behavior and 25 non-violent 28 healthy control group (36 Inhibition, planning, cognitive (2016) (34 years). years). flexibility, and working memory. Becerra-García Spain 10 inmates for domestic violence (42 years), 20 for 8 non-violent inmates (41 Inhibition, cognitive flexibility, and (2015) sexual offenses (37 years), and 9 for violent crimes years). 31 healthy control set shifting. (30 years). group (38 years). Becerra-García and Spain 21 incestuous (child molesters) inmates (47 years) 28 healthy control group (45 Cognitive flexibility and working Egan (2014) and 11 non-incestuous (child molesters) inmates years). memory. (49.09 years). Levi et al. (2010) Canada 25 predatory inmates (31 years) and 34 irritable 30 non-violent inmates (38 Inhibition and decision making. inmates (29 years). years). Hoaken et al. (2007) Canada 20 inmates for violent behavior (35 years). 20 non-violent inmates (33 Working memory. years). 20 healthy control group (25 years). 100% of the studies evaluated were cross-sectional. TABLE 3 Risk of bias assessment using an adapted version of the NHLBI. Studies Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Score RoB Rodriguez and Ellis (2018) 1 1 1 0 0 1 1 1 6 Low Rodriguez et al. (2017) 1 1 1 0 0 1 1 1 6 Low Meijers et al. (2017) 1 1 1 0 0 1 0 1 5 Medium Seruca and Silva (2016) 1 1 1 0 0 1 0 0 4 Medium Becerra-García (2015) 1 1 1 1 0 1 1 0 6 Low Becerra-García and Egan (2014) 1 1 1 0 0 1 1 0 5 Medium Levi et al. (2010) 1 1 1 0 0 1 1 0 5 Medium Hoaken et al. (2007) 1 1 1 0 0 1 0 1 5 Medium Score ranges from 1 to 8. Low (6, 7, 8), medium (4, 5), and high (1, 2, 3) risk of bias. Q1. Was the research question or objective in this paper clearly stated? Q2. Was the study population clearly specified and defined? Q3. Were all the subjects selected or recruited from the same or similar populations (including the same period)? Were inclusion and exclusion criteria for being in the study prespecified and applied uniformly to all participants? Q4. Was a sample size justification, power description, or variance and effect estimates provided? Q5. For exposures that can vary in amount or level, did the study examine different levels of the exposure as related to the outcome (e.g., categories of exposure, or exposure measured as continuous variable)? Q6. Were the outcome measures (dependent variables) clearly defined, valid, reliable, and implemented consistently across all study participants? Q7. Were key potential confounding variables measured and adjusted statistically for their impact on the outcome(s)? Q8. The proportion of participants with missing data in the variable is irrelevant (or is adequately justified to be irrelevant) or it is justified that statistical techniques to deal with missing data are appropriate (e.g., weighting adjustments or imputation methods). worse on this task than non-sexual inmates (n = 32; M = 86.8, SD all tasks of the Trail Making Test than the control group (n = 28, M = 28.5; p < 0.05, in both cases; d = 0.6 and d = 1.00, respectively). = 70.04, SD = 26.66, p < 0.01), with large effect sizes (d = 1.60 and Even though in the Rodriguez and Ellis (2018) study both the 1.44, respectively). However, there were no significant differences group of inmates first convicted of sexual offenses (n = 11, M = between inmate groups. 38.8, SD = 12.3) and group with history (n = 34, M = 37.7, SD = 12.6) presented poorer performance on the FAS-COWAT test than non-sexual inmates (n = 32, M = 43.9, SD = 10.5), no significant 3.4.3. Working memory (four studies) differences were found between the two sexual offender groups. Seruca and Silva (2016) evidenced no statistically significant Becerra-García and Egan (2014) indicated that incestuous inmates differences in the Digit Span-Backwards test between inmates (n (n = 21, M = 155.14, SD = 70.24) and non-incestuous inmates (n = 38, M = 5.97, SD = 1.71) and the control group (n = 28, M = 11, M = 145.09, SD = 68.71) presented inferior performance on = 6.25, SD = 1.53; p = 0.39). Meijers et al. (2017) also found no Frontiers in Psychology 06 frontiersin.org Chaguendo-Quintero et al. 10.3389/fpsyg.2023.1066474 TABLE 4 Scoring in each task. Study Measures/tasks Executive function Scoring Higher score Lower score Rodriguez and Ellis (2018) Inhibition Hayling test Better performance Poor performance Controlled oral word association test Better performance Poor performance Decision making Iowa gambling task Better performance Poor performance Cognitive flexibility Trail making test (score) Better performance Poor performance Trail making test (time) Poor performance Better performance Rodriguez et al. (2017) Inhibition Hayling test Better performance Poor performance Controlled oral word association test Better performance Poor performance Decision making Iowa gambling task Better performance Poor performance Cognitive flexibility Trail making test (score) Better performance Poor performance Trail making test (time) Poor performance Better performance Meijers et al. (2017) Inhibition Stop-signal task (reaction time) Poor performance Better performance Planning Stockings of Cambridge Better performance Poor performance Working memory Spatial working memory task Poor performance Better performance Set shifting Intra-extra dimensional set-shift task Poor performance Better performance Decision making Cambridge gambling task Better performance Poor performance Seruca and Silva (2016) Planning Porteus mazes test (TA) Better performance Poor performance Inhibition Porteus mazes test (Q score) Poor performance Better performance Stroop color and word test Better performance Poor performance Cognitive flexibility Trail making test (score) Better performance Poor performance Trail making test (time) Poor performance Better performance Working memory Digit span backwards Better performance Poor performance Becerra-García (2015) Cognitive flexibility, Trail making test (score) Better performance Poor performance inhibition, and set shifting Trail making test (time) Poor performance Better performance Becerra-García and Egan Cognitive flexibility Trail making test (score) Better performance Poor performance (2014) Trail making test (time) Poor performance Better performance Working memory Digit span Better performance Poor performance Levi et al. (2010) Inhibition Integrated visual and auditory continuous Better performance Poor performance performance test Decision making Iowa gambling task Better performance Poor performance Hoaken et al. (2007) Working memory Conditioned non-spatial association test Poor performance Better performance Concrete subject-ordered working memory test Poor performance Better performance Abstract subject-ordered working memory test Poor performance Better performance significant differences on the Spatial Working Memory Task test 6.46; SD = 1.85). Non-incestuous inmates did not show significant between violent inmates (n = 85) and non-violent inmates (n = 45). differences compared to the control group. In contrast, Becerra-García and Egan (2014) detected significantly Hoaken et al. (2007) transformed executive performance lower scores on section DF of the Digit Span test in incestuous measures (Conditioned Non-Spatial-Association Test, Concrete inmates (n = 21, M = 6.4, SD = 1.56) than the control group (n = Subject-Ordered Working Memory Test and Abstract Subject- 28, M = 9.39, SD = 1.95; p < 0.01; d = −1.67). Similarly, incestuous Ordered Working Memory Test) to construct a single variable inmates (M = 4.05, SD = 1.49) demonstrated poorer performance measuring working memory. In this study, no statistically on the DB section of the post-hoc than non-incestuous (n = 11, M = significant differences were found between violent (n = 20) and 5.82, SD = 1.83; p = 0.02; d = −1.06) and the control group (M = non-violent (n = 20) behavior inmates, but significantly poorer Frontiers in Psychology 07 frontiersin.org Chaguendo-Quintero et al. 10.3389/fpsyg.2023.1066474 performance in these two groups compared to the control group alterations in executive functions than inmates convicted of non- (n = 20, p < 0.01) was observed. violent behavior, and non-inmates (De Brito et al., 2013; Zou et al., 2013; Chen et al., 2014; Vilà-Balló et al., 2014; Karlsson et al., 2016; Meijers et al., 2017; Sedgwick et al., 2017; Slotboom et al., 2017; 3.4.4. Decision making (four studies) Baliousis et al., 2019). Similarly, inmates convicted exclusively of Levi et al. (2010) found significantly superior performance on sexual offenses showed more alterations in executive functions than the Iowa Gambling Test (IGT) in non-violent inmates (n = 30, M inmates convicted of non-sexual offenses or HCs (Burton et al., = 9.23, SD = 7.90) than in irritable (n = 34, M = 2.53, SD = 10.08; 2016; Guamán and Carballo, 2019). p = 0.009; d = 0.73) and predatory (n = 25, M = 3.68, SD = 7.93; These findings indicated that inmates convicted of violent p = 0.057; d = 0.70) inmates. Although no significant differences behavior presented greater impairments in inhibition (Levi et al., were present between the two violent groups, irritable inmates 2010; Becerra-García, 2015; Seruca and Silva, 2016; Meijers et al., performed worse than non-violent inmates. Rodriguez et al. (2017) 2017; Rodriguez et al., 2017; Rodriguez and Ellis, 2018) than and Rodriguez and Ellis (2018) used the IGT for the assessment of inmates convicted of non-violent behavior (Levi et al., 2010; decision-making and Meijers et al. (2017) the Cambridge Gambling Becerra-García, 2015; Seruca and Silva, 2016; Meijers et al., Task; however, in none of these three studies were significant 2017; Rodriguez et al., 2017; Rodriguez and Ellis, 2018) and differences found between their comparison groups. HCs (Becerra-García, 2015; Seruca and Silva, 2016). Four out of the six studies that evaluated this function (Levi et al., 2010; Becerra-García, 2015; Seruca and Silva, 2016; Meijers et al., 3.4.5. Set shifting (two studies) 2017; Rodriguez et al., 2017; Rodriguez and Ellis, 2018) reported Meijers et al. (2017) found no statistically significant differences large (Levi et al., 2010; Seruca and Silva, 2016; Rodriguez in performance on the Intra-Extra Dimensional Set-Shift Task test and Ellis, 2018) or moderate (Rodriguez et al., 2017) effect between inmates for violent behavior (n = 85) and inmates for sizes. In addition, these studies obtained a low to moderate non-violent behavior (n = 45). In contrast, Becerra-García (2015) risk of bias. found significantly worse performance on the Trail Making Test The systematic review by Meijers et al. (2015) reported between the domestic violence inmate groups (n = 10) and the inconsistent evidence on alterations in inhibition (Munro et al., control group (n = 31, p = 0.004); and between the sexual behavior 2007; Schiffer and Vonlaufen, 2011) in inmates convicted of violent inmates (n = 20) and the control group (p = 0.004). behavior and inmates convicted of non-violent behavior. This inconsistency could be since the two studies that explored this function included inmates convicted of different types of violent 3.4.6. Planning (two studies) offenses (instrumental in one study and reactive in another). In the Seruca and Silva (2016) indicated significantly poorer current systematic review, in contrast, the evidence on inhibition performance on the Porteus Maze Task in inmates for violent analyzed were consistent (Levi et al., 2010; Becerra-García, 2015; behavior (n = 13, M = 15.57, SD = 2.277) than in the control Seruca and Silva, 2016; Meijers et al., 2017; Rodriguez et al., group (n = 28, M = 18, SD = 2.09; p = 0.040; d = 11.18). In 2017; Rodriguez and Ellis, 2018). Similarly, greater alterations in contrast, Meijers et al. (2017) evidenced no statistically significant inhibition were identified in inmates convicted of violent behavior differences in performance on the Stockings of Cambridge test than in inmates convicted of nonviolent behavior (Levi et al., 2010; between their study groups. Meijers et al., 2017; Rodriguez et al., 2017; Rodriguez and Ellis, 2018) and HCs (Becerra-García, 2015; Seruca and Silva, 2016). As several studies have pointed out, alterations in inhibition could explain the difficulty of inmates to control their impulses 3.5. Alterations in executive functions (Levi et al., 2010; Becerra-García, 2015; Seruca and Silva, 2016; Meijers et al., 2017; Rodriguez et al., 2017; Rodriguez and Ellis, Tables 5, 6 compares the evidence identified between inmates 2018), as well as predict recidivism and the emission of aggressive convicted of violent behavior and inmates convicted of non-violent behaviors (Zou et al., 2013; Karlsson et al., 2016; Wallinius et al., behavior or HCs, respectively. 2019). It is important to intervene in inhibitory control in inmates because this executive function allows them to regulate impulsive or automatic responses that may be harmful to themselves or 4. Discussion others (Becerra-García, 2015). Inhibitory control also promotes cognitive flexibility, working memory, and emotional regulation Inmates have historically been a stigmatized, neglected, and (Seruca and Silva, 2016; Rodriguez et al., 2017), which are necessary underserved population in need of interventions that promote skills for environmental adaptation and social reintegration. By their wellbeing and reintegration into society. This systematic improving inhibitory control, inmates can act in a specific and review provided up-to-date evidence, with a considerable temporal socially appropriate manner when faced with different situations range of studies (2007 to 2018) including comparisons with other (Becerra-García, 2015). In this sense, the assessment of inhibition groups (i.e., inmates convicted of non-violent behavior and HCs) impairment could be critical for predicting criminal or violent on executive function alterations in inmates convicted of violent behavior in new and recidivist inmates. behavior. Consistent with previous research, it was identified that, None of the studies included in this systematic review in general, inmates convicted of violent behavior displayed more found statistically significant alterations in working memory Frontiers in Psychology 08 frontiersin.org Chaguendo-Quintero et al. 10.3389/fpsyg.2023.1066474 TABLE 5 Synthesis of the identified evidence of VI vs. NV. Executive Studies (n) VI (N) NV (N) Directionality VI vs. Significant differences VI vs. functions NV (n, %) NV (n, %) Inhibition 4 257 139 ↓ Lower levels (4/4, 100%) (4/4, 100%) Cognitive flexibility 4 165 97 = Equal levels (3/4, 75%) (1/4, 25%) ↓ Lower levels (1/4, 25%) Working memory 3 118 90 = Equal levels (3/3, 100%) (0/3, 0%) Decision making 4 257 139 = Equal levels (3/4, 75%) (1/4, 25%) ↓ Lower levels (1/4, 25%) Set shifting 1 85 45 = Equal levels (1/1, 100%) (0/1, 0%) Planning 2 98 70 = Equal levels (2/2, 100%) (0/2, 0%) Significant differences were determined using p ≤ 0.05. VI, inmates convicted of violent behavior; NV, inmates convicted of nonviolent behavior; N, number of total individuals; n, number of studies. The study by Becerra-García and Egan (2014) was not included in this comparison, as it did not include a control group of inmates convicted of non-violent behavior. TABLE 6 Synthesis of the identified evidence of VI vs HC. Executive Studies (n) VI (N) HC (N) Directionality VI vs. Significant differences VI vs. functions HC (n, %) HC (n, %) Inhibition 2 52 59 ↓ Lower levels (2/2, 100%) (2/2, 100%) Cognitive flexibility 3 84 87 = Equal levels (1/3, 33.3%) (2/3, 66.6%) ↓ Lower levels (2/3, 66.6%) Working memory 3 65 76 = Equal levels (1/3, 33.3%) (2/3, 66.6%) ↓ Lower levels (2/3, 66.6%) Set shifting 1 39 31 ↓ Lower levels (1/1, 100%) (1/1, 100%) Planning 1 13 28 ↓ Lower levels (1/1, 100%) (1/1, 100%) Significant differences were determined using p ≤ 0.05. VI, inmates convicted of violent behavior; NV, inmates convicted of nonviolent behavior; HC, healthy control group (i.e., individuals with no criminal record). N, number of total individuals; n, number of studies. (Hoaken et al., 2007; Seruca and Silva, 2016; Meijers et al., 2017), (Meijers et al., 2018; Molleman et al., 2022). Moreover, improved set shifting (Meijers et al., 2017), and planning (Seruca and cognitive functioning can lead to better decision-making skills and Silva, 2016; Meijers et al., 2017) in inmates convicted of violent increased self-control, which are crucial for successful reintegration behavior compared to those convicted of nonviolent behavior. into society. Statistically significant differences in cognitive flexibility (Seruca In the present systematic review, half of the articles included and Silva, 2016; Rodriguez et al., 2017; Rodriguez and Ellis, 2018) evaluated several executive functions at the same time, which and decision-making (Meijers et al., 2017; Rodriguez et al., 2017; allowed for a greater exploration of the results of each sample. Rodriguez and Ellis, 2018) were also not identified in three out of In addition, these studies showed the common characteristic of four studies. being recently published. In particular, the need to explore a larger In two out of the three studies explored, inmates convicte set of executive functions in each study was noted within the d of violent behavior presented greater alterations in cognitive recommendations of the previous review (Meijers et al., 2015). flexibility (Becerra-García and Egan, 2014; Becerra-García, 2015; In accordance with the above, it can be observed that not only Seruca and Silva, 2016) and working memory (Hoaken et al., 2007; has research on this topic continued, but it has been gradually Becerra-García and Egan, 2014) than HCs. Although with evidence developing, improving its methodologies, and broadening the supported by the results of a single small-sample study, greater spectrum of assessment of executive functioning (Richter, 2010; alterations in planning (Seruca and Silva, 2016) and set shifting Larrota et al., 2018). Although the tendency of the articles to explore (Becerra-García, 2015) were identified in inmates convicted of a greater number of executive functions seems evident, the possible violent behavior than in HCs. Nevertheless, these studies obtained role of confounding variables has been little explored in the studies a low to moderate risk of bias. included in this systematic review. Improvements in cognitive flexibility, working memory, and Confounding is a systematic error that occurs frequently in planning may have a significant impact on reducing violent observational studies (Viswanathan et al., 2013). The distortion behavior among inmates (Vadini et al., 2018; Molleman et al., introduced by an unexplored confounding factor can be a 2022; Romero-Martínez et al., 2022). Specifically, enhancing these fundamental aspect for the proper interpretation of an effect executive functions could help prisoners regulate their emotions, (Arah, 2017). In this sense, it is important to explore the inhibit impulsive behavior, and plan and execute non-violent role of confounding variables in studies included in systematic problem-solving strategies (Seruca and Silva, 2016; Valizadeh reviews considering they can affect the validity and precision et al., 2020). As a result, prisoners may be less likely to engage of estimates of the effect of an exposure on an outcome in violent behavior, both within prison and after their release (Metelli and Chaimani, 2020). If not adequately controlled, they Frontiers in Psychology 09 frontiersin.org Chaguendo-Quintero et al. 10.3389/fpsyg.2023.1066474 can introduce bias into the analysis and lead to erroneous degrees of dangerousness of inmates, nor psychological or social conclusions (Arah, 2017; Metelli and Chaimani, 2020). Therefore, circumstances. Identifying them with a subculture of violence the risks of bias and confounding that may be present in the and illegality that apparently does not present ways to overcome. studies included in the review should continue to be considered This systematic review serves as an input to consider the need (Viswanathan et al., 2013). for prevention programs, as well as the importance of designing Specifically, exploring the possible confounding role of and promoting specific cognitive interventions rather than general sociodemographic and clinical characteristics (i.e., sex, age, executive function interventions for inmates. Stronger evidence is education level, occupation, socioeconomic status, marital status, needed to confirm the magnitude of alterations in other executive place of residence, diagnosis of mental disorders, psychoactive function processes in inmates convicted of violent behavior to substance use, frontal circuit maturity, type of cognitive task, understand the role of executive functions in violent behavior. degree of development of executive function, diagnoses of mental In the future, longitudinal studies with representative samples disorders, head injury or history of stroke) in the comparison of comparing groups of inmates convicted for different types of crimes executive functions between the inmate population and control are suggested. This will allow to deepen the knowledge about groups (Álvis et al., 2014; Mercado et al., 2014; Arana-Medina et al., the phenomenon of executive function, the possible differences 2019) is an aspect of great relevance for future lines of research. between inmate populations, and the development of a differential profile according to the crime. This research could contribute to develop of interdisciplinary programs for the prevention 4.1. Study limitations and strengths of executive dysfunctions, as well as for the promotion and intervention in the executive function of inmates, which are The findings of this systematic review should be analyzed so necessary for reintegration into society and to contemplate considering the following limitations: (a) differences in establishing public policies to guide the processes of change in this conceptualizations of executive functions; (b) variety of situation. Finally, considering the scientific interest generated by instruments used to measure executive functions; (c) small the exploration of executive functions in this population in recent sample sizes; (d) limited quantity of evidence for each outcome; years, systematic reviews are suggested to be updated when more (e) moderate risk of bias of the included studies, which could evidence is published. imply inaccuracies in the conclusions; and (f) only cross-sectional studies were assess. In contrast, the strengths of this review were: 5. Conclusions (a) expanding the inclusion criterion to include studies with non-violent inmates and/or HCs as a control group; (b) updating This systematic review presented evidence of impaired of the evidence by including studies until 2023, a range that had executive functioning in inmates sentenced for violent behavior not been explored previously; (c) inclusion of studies that assessed compared with inmates sentenced for non-violent behavior or HCs. more than one executive function, which facilitates a more accurate Although previous studies found differences in executive functions exploration of the findings for each sample; and (d) inclusion of such as inhibition, cognitive flexibility, working memory, and the quality assessment tool to estimate the RoB. planning, among others, compared to heterogeneous groups (i.e., inmates for violent behavior, inmates for other types of behavior, and/or HC), the current systematic review suggests that inmates 4.2. Reflections and recommendations for convicted of violent behaviors compared exclusively with inmates future research convicted of non-violent behaviors and healthy controls (HCs) had greater deficiencies in inhibition, which is responsible for stopping, This study provided a broader picture of the development of controlling, and modifying impulsive behaviors and executing research on executive functions in the inmate population. It also more socially appropriate behaviors. These findings reaffirms the highlights the need for further research on executive functions importance of focusing on inhibition, as well as continuing research beyond neuropsychological assessments. Expanding knowledge on other specific cognitive processes (e.g., cognitive flexibility, about this phenomenon and conducting targeted interventions in working memory, set shifting, and planning, among others), in this population could have a direct or indirect impact on crime neuropsychological interventions. and recidivism rates. This is especially critical in populations that have been poorly studied, where the knowledge gap about Data availability statement executive functions is unquestionable, such as inmates in American countries, whose rates of crime and recidivism continue to increase. The original contributions presented in the study are included This is an aspect that has overflowed the capacity of the prison and in the article/Supplementary material, further inquiries can be penitentiary system. directed to the corresponding authors. The failure of prison as a resocialization system and recidivism potentiates a dangerous spiral. The problems attributed to crime encourages legal initiatives that, instead of decreasing Author contributions criminality, strengthen the identification of inmates with the criminal environment, promotes recidivism, and generates more MC-Q and DQ-M conceived the idea for this article, skilled criminals. This makes it easier not to differentiate between conducted the search for studies, evaluated the articles, and Frontiers in Psychology 10 frontiersin.org Chaguendo-Quintero et al. 10.3389/fpsyg.2023.1066474 drafted the manuscript, tables, and figure. MC and JS-M that could be construed as a potential conflict resolved discrepancies, guided, reviewed, and proofread the entire of interest. process. All authors contributed to the article and approved the submitted version. Publisher’s note Acknowledgments All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated We are grateful to the Pontificia Universidad Javeriana Cali organizations, or those of the publisher, the editors and the for supporting this review. JS-M has a PFIS predoctoral contract reviewers. Any product that may be evaluated in this article, or from the ISCIII (FI20/00034) and grateful to the CIBER of claim that may be made by its manufacturer, is not guaranteed or Epidemiology and Public Health (CIBERESP CB22/02/00052; endorsed by the publisher. ISCIII) for its support. Supplementary material Conflict of interest The Supplementary Material for this article can be found The authors declare that the research was conducted online at: https://www.frontiersin.org/articles/10.3389/fpsyg.2023. in the absence of any commercial or financial relationships 1066474/full#supplementary-material References Albers, C., and Lakens, D. 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