Intimate Partner Violence and Brain Injury Screening

Introduction

Intimate partner violence (IPV) is a serious, yet preventable public health issue that affects millions of people. Women who experience IPV are at high risk for injuries to their head, neck, and face—potentially resulting in a traumatic brain injury (TBI), as well as brain injury (BI) resulting from attempted strangulation (Kwako et al., 2011). A TBI is defined as a disruption in the normal function of the brain which results from a bump, blow, or jolt to the head, or penetrating head injury (Centers for Disease Control and Prevention, 2017; National Institute of Health, 2019). TBI severity can be categorized along the continuum of mild (mTBI), moderate, or severe (National Institute of Health, 2019).

BI can also result from hypoxic or anoxic events; strangulation can cause hypoxia and anoxia, when the oxygen supply to the brain is restricted or completely cut off, leading to brain tissue damage and/or death which can occur in a short period of time in IPV-related violence (Pritchard et al., 2015, 2018; E. M. Valera et al., 2019).

TBI is a major cause of death and disability in the United States (Jack et al., 2018; Peterson et al., 2019). TBI contributes to approximately 30% of all injury-related deaths in the United States (Faul et al., 2010). There is increasing interest in TBI, especially mTBI or concussions, resulting from sports injuries among athletes, combat injuries among military personnel, and falls among the elderly (Peterson et al., 2019). However, there is inadequate focus on BI among IPV survivors (E. M. Valera, 2018; E. M. Valera et al., 2019), despite increasing evidence of the high risk for BI in this vulnerable population (Baxter & Hellewell, 2019; Goldin et al., 2016; Haag et al., 2019; Kwako et al., 2011; St Ivany, Kools et al., 2018).

Research has shown that the rate of potential TBI among IPV survivors ranges between 35% and 80% (Kwako et al., 2011; E. M. Valera et al., 2019). Recent estimates show that about 31.5 million women in the United States experience at least one IPV-related TBI (E. M. Valera et al., 2019). One study found that about 75% of an IPV sample of 99 IPV survivors experienced BI, including strangulation-related anoxic and hypoxic episodes, and 50% of these women experienced repetitive TBI (E. M. Valera & Berenbaum, 2003). Another study of women in a domestic violence shelter reported that 92% of the women experienced a blow to the head or face, and 40% experienced at least one TBI that resulted in a loss of consciousness (Jackson et al., 2002).

As noted, survivors of IPV may also experience BI relating to strangulation. The rates of attempted strangulation were 68% among a domestic violence sample (Wilbur et al., 2001). A study of strangulation among 1,008 IPV survivors showed that about 80% experienced either attempted, completed, or multiple strangulation (Messing et al., 2018).

BI which includes both TBI and hypoxic/anoxic events can have long-term consequences on IPV survivors’ well-being and quality of life. Symptoms of BI can include problems concentrating, memory loss, irritability, nervousness, and anxiety (Baxter & Hellewell, 2019; Haag et al., 2019; T. Smith & Holmes, 2018). Research shows that the majority of BI that IPV survivors experience is mild TBI and is the most underreported type of BI (Campbell et al., 2018; Goldin et al., 2016). Among IPV survivors, these brain injuries are likely to be repeated (Goldin et al., 2016; Haag et al., 2019; St Ivany & Schminkey, 2019). One study showed that women may experience 3 to 4 hits to the head per week (E. Valera & Kucyi, 2017). Indeed, women may not be able to leave an abusive situation, which puts them at risk for further violence. Researchers have outlined a cycle of transmission over the life-course starting with TBIs that might be acquired in childhood from sports, an accident, or abuse. Women might enter into abusive relationships and acquire further TBIs and increasing TBI symptoms (St Ivany & Schminkey, 2019). Repeated mild BI, especially before the resolution of a previous BI, can result in result in severe deficits and long-term damage (E. M. Valera & Berenbaum, 2003; E. M. Valera et al., 2019).

Women may not seek medical care following a BI for several reasons. Women in an abusive relationship may not have the autonomy to seek medical help for their injuries (Goldin et al., 2016; Haag et al., 2019), and may also be concerned about shame, fear, and stigma associated with IPV (T. Smith & Holmes, 2018). Survivors might desire to stay safe by avoiding retaliation from their abuser resulting from disclosure of abuse to others (St Ivany et al., 2018). Due to the subtle nature of the symptoms and the lack of awareness of the issues, this injury is often missed (Centers for Disease Control and Prevention, 2017; Crowe et al., 2019). Also, symptoms such as dizziness, memory loss, and headaches may not always occur immediately after a BI, making it difficult to associate the injury with the symptoms (Monahan, 2019; Monahan & O’Leary, 1999). Without any immediate symptoms or loss of consciousness, women might minimize their injuries and not seek medical care (Campbell et al., 2018; Monahan, 2019; T. Smith & Holmes, 2018). A qualitative study of nine women who experienced a hit to the head and lost consciousness also experienced rape, and the interaction of extreme control of both psychological and physical abuse kept them from seeking medical care (St Ivany et al., 2018). There is some evidence that women are more likely to seek medical treatment for moderate to severe TBIs compared to mild TBIs (Centers for Disease Control and Prevention, 2017; Crowe et al., 2019; Hunnicutt et al., 2017; E. M. Valera et al., 2019). Furthermore, the symptoms of TBI can be difficult to diagnose and often overlap with other psychosocial sequalae of IPV such as depression and posttraumatic stress disorder (PTSD), thus preventing proper diagnosis, treatment, and recovery (Baxter & Hellewell, 2019; Haag et al., 2019; Smith & Holmes, 2018). For these reasons, BI among IPV survivors might be missed or overlooked by health care providers or advocates serving IPV survivors (Dicola & Spaar, 2016; Hunnicutt et al., 2017, 2019; Monahan, 2019).

Comprehensive screening among this vulnerable population and timely neurorehabilitation interventions have the potential to mitigate the impact of BI (Goldin et al., 2016; Monahan, 2019). However, despite the high risk of BI among IPV survivors either due to a hit to the head or strangulation, there are no standard guidelines for BI screening in this group of women. Also, there are no validated screening tools that have been created specifically for this population (Goldin et al., 2016). However, there has been use of the HELPS screen tool (Picard et al., 1991), that can be easily be administered by staff working with IPV populations and does not require expertise in BI (Goldin et al., 2016; Hunnicutt et al., 2019).

The purpose of this study is to use the modified HELPS screen tool to determine the extent of possible BI among IPV survivors to better understand the impact of these injuries. “HELPS” is an acronym for the key parts of screening: H = Hit in the head; E = Emergency room treatment; L = Loss of consciousness; P = Problem because of a hit to the head or due to strangulation; and S = other Sickness they might have experienced. The “S” question in the original HELPS screen tool pertaining to other sicknesses was removed in the modified tool at the request of staff in community-based organizations (CBOs) that participated in the study, and we shall refer to the tool as “HELP.”

The main research questions that framed this study were:

Methods

Results

Of the total 171 screenings, 58% (n = 100) screened positive and 42% (n = 71) screened negative for a possible BI, based on the HELP screen tool criteria (Figure 1).

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Figure 1.

Characteristics of participants who were ever hit in the head or strangled.

A lower proportion of participants in the 19-to-25 age group screened positive for HELP BI screenings when compared to those who screened negative (43% vs. 57%), while a higher proportion of participants in the age group 26 to 40 years old (61% vs. 39%) and age group >40 years old (75% vs. 25%) screened positive (p = .019; Table 1).

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Table 1.

Association Between Age Group and Characteristics of Hit in the Head or Strangled.

	≤25	26–40	>40	p value
Status (positive/negative) of HELP Brain Injury Screenings				.019 a
No	17 (57%)	33 (39%)	12 (25%)
Yes	13 (43%)	51 (61%)	36 (75%)
Ever hit in the head or strangled?				.59 a
No	3 (10%)	4 (5%)	3 (6%)
Yes	27 (90%)	80 (95%)	45 (94%)
Were you ever seen in the emergency room due to hit in the head or strangulation?				.21 a
No	18 (67%)	55 (69%)	24 (53%)
Yes	9 (33%)	25 (31%)	21 (47%)
If you were seen in the emergency room, were you given follow-up recommendation?				.69 b
No	3 (38%)	6 (25%)	4 (21%)
Yes	5 (62%)	18 (75%)	15 (79%)
Did you follow the recommendation you were given?
No	3 (60%)	4 (22%)	3 (20%)
Yes	2 (40%)	14 (78%)	12 (80%)	.18 b
Did you ever lose consciousness or experience blackout or dazed or confused due to hit in the head or strangulation?				.016 a
No	15 (56%)	28 (35%)	10 (22%)
Yes	12 (44%)	52 (65%)	35 (78%)

a

Pearson chi-square analysis. ^bFishers Exact test.

Of the total 171 women who were screened, 91% (n = 155) indicated that they had been hit in the head or strangled (Figure 1). The majority (52% n = 80) were in the age group 26 to 40 years. Age group was not associated with “ever hit in the head or strangled” (p = .59; Table 1). Also, 95% (n = 147) reported that it happened from an assault or fight, and 25% (n = 37) of these women reported that they were pushed, punched, shaken, or strangled during the assault of fight.

About 52% (n = 78) reported that they had been hit in the head or strangled more than four times in their life, of which 31% (n = 46) indicated that it happened more than six times in their life (Figure 1).

Of the 155 women who reported being hit or strangled, 35% (n = 55) stated that they were seen in the emergency room, hospital, or by a doctor due to a hit to the head or because of strangulation (Figure 2).

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Figure 2.

Characteristics of participants seen in the emergency room.

Of the 55 women who did receive medical treatment, 93% (n = 51) were seen by a doctor, 18% (n = 10) were seen by a nurse, and 11% (n = 6) were seen by other medical professionals (multiple response possible). About 75% (n = 38) were given follow-up recommendations, and 74% (n = 28) reported following the recommendations (Figure 2). Age group was not associated with “were you seen in the emergency room” (p = .21), “were you given follow-up recommendation” (p = .69) and “did you follow the recommendation you were given” (p = .18; Table 1).

Of the 155 women who reported being hit or strangled, 64% (n = 99) reported losing consciousness or experiencing a period of being dazed and confused because of a hit to the head or due to strangulation (Figure 3). Of the women who did lose consciousness, 65% (n = 62) reported feeling dazed or confused for hours versus days or months (Figure 3). Also, 53% (n = 42) indicated they felt this way 1 to 3 times, while 28% (n = 22) stated they felt this way more than six times (Figure 3).

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Figure 3.

Characteristics of participants who were confused, blacked out, or lost consciousness due to hit in the head or strangulation.

The majority of participants in the age group 26 to 40 years old (65%) and >40 years old (78%) blacked out or were confused due to a hit to the head or strangulation compared to 44% of the 19-to-25-year-old participants (p = .016; see Table 1).

About 88% (n = 121) reported experiencing the following problems due to a hit to the head or strangulation: headaches; dizziness; nausea; sensitivity to light; blurred or double vision; numbness or weakness in any of their limbs; insomnia, difficulty sleeping, or changes in their sleeping patterns; difficulty remembering; difficulty concentrating, and so on. The most frequent symptoms they experienced included anxiety, depression, headaches, insomnia, changes in relationships, and difficulty concentrating (Figure 4).

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Figure 4.

Experiences of participants ever hit in the head or strangled (multiple responses possible).

Among women who reported experiencing problems due to a hit in the head or strangulation, 43% (n = 49) stated that they believed the problems were due to the head injury. Only 44% (n = 4) of the women who responded to the question for support indicated that they would like resources or support to help with their problem. The most common support requested was to see a specialist.

Discussion

The results of this study show that IPV survivors had a high rate of probable BI, either due to a blow to the head or strangulation. Ninety-one percent indicated that they had been hit in the head or strangled. These findings are in keeping with previous research that have found that IPV victims are at high risk for a BI, including strangulation-related anoxic and hypoxic episodes (Kwako et al., 2011; Messing et al., 2018; E. Valera & Kucyi, 2017)

Research also shows that IPV survivors experience repeated blows to the head, resulting in loss of consciousness (Campbell et al., 2018; Dicola & Spaar, 2016; Mechanic et al., 2008; E. M. Valera & Berenbaum, 2003). Findings in our study showed that 72% of the women indicated that they had been hit in the head or experienced strangulation more than three times in their life. Indeed, research indicates that among IPV survivors, these brain injuries are likely to be repeated before an IPV survivor has a chance to recover from an injury (Baxter & Hellewell, 2019; Goldin et al., 2016; Haag et al., 2019; Hunnicutt et al., 2019). Also, these injuries can occur in close proximity to one another—as high as 3 to 4 times a week (E. Valera & Kucyi, 2017). People who experience repeated brain injuries, before the brain is able to recover from the initial trauma, experience what is known as “secondary trauma” (Monahan, 2019) or second-impact syndrome (Banks, 2007), and are at high risk for neurological deficits, depression, suicide, and Alzheimer-like symptoms (Campbell et al., 2018; McKee et al., 2013; Murray et al., 2016; Sahler & Greenwald, 2012; St Ivany & Schminkey, 2019).

In this study, about 75% of women experienced a possible BI in the past 2 years. One study showed that the higher the number of TBIs and the more recent the injury, the more likely that women did poorly on tests of cognitive functioning, memory, and learning. In addition, they had higher rates of posttraumatic symptoms including depression and anxiety (E. M. Valera & Berenbaum, 2003).

IPV often occurs in multiple relationships over the life course (Mummert, 2019; Oudekerk & Truman, 2017; Stein et al., 2019; St Ivany & Schminkey, 2019). In our study, while a higher proportion of women above age 25 scored positive for a possible BI, compared to those between 19 and 25 years, it is not known at what age they first experienced a hit to the head or were strangled. National data on abuse reveal that 71% of women (31 million) experience their first incident of physical violence, sexual violence, or stalking by age 25, and 26% of them, by age 18 (S. G. Smith et al., 2017). Indeed, women who are below age 25 are at a vulnerable time in their brain development—when violence first occurs. They are in an extremely stressful period in their lives, which might affect brain functioning as well. Social isolation and social deprivation in IPV might further exacerbate the stress they encounter. There is no research that elucidates how extreme stress affects the neuropsychological sequela of IPV-related BI.

Research indicates that IPV survivors might experience mild TBIs, and this is seen as the most underreported type of TBI (Campbell et al., 2018). While it is difficult to determine the exact severity of the brain injuries sustained by our participants, our findings revealed that the majority of the participants indicated severity that was at least great enough to cause a loss of consciousness or feeling of being dazed and confused. Furthermore, it is important to note that this was a repeated event, as almost half of them indicated having experienced loss of consciousness or confusion from being hit or strangled more than three times.

Using the HELP screen tool criteria (Gagnon & DePrince, 2017; Pritchard et al., 2015), about 58% of women tested “positive” for a possible BI. This is similar to another study that found 56% of IPV survivors screened, tested “positive” for a possible BI using the HELP tool criteria (Gagnon & DePrince, 2017).

As noted earlier, to test positive for a possible BI, women would need to experience three of the following: a hit to the head or strangulation; be seen in the emergency room or seek medical treatment; experience a period of loss of consciousness or confusion; and experience two or more chronic problems such as feeling anxiety, blurred or double vision, confusion, and lack of balance, resulting from the injury. While an absolute, definitive diagnosis for BI cannot be determined through screening measures, it is clear that the modified HELP screen tool utilizes more stringent criteria to ascertain a possible BI, beyond simply asking about an experienced hit to the head. Nonetheless, the majority of women in our study endorsed a possible BI based on the HELP screen tool criteria, which suggests with greater likelihood that IPV survivors have experienced a BI.

Our participants reported experiencing symptoms such as difficulty concentrating and focusing, memory, headaches, and dizziness. Research shows that symptoms of mild BI overlap with IPV-related psychological trauma such as depression, anxiety, and PTSD (Baxter & Hellewell, 2019; Hunnicutt et al., 2017, 2019), making IPV-related BI difficult to detect and, consequently, it might be missed by clinicians (Crowe et al., 2019). Women with a probable TBI have been shown to have neurological and central nervous system symptoms even after controlling for symptoms related to PTSD and depression (Campbell et al., 2018). These symptoms can impair the recovery process and complicate the ability of the survivor to make judgments and access the necessary social and mental health services (Gagnon & DePrince, 2017; Hunnicutt et al., 2019).

The help-seeking behavior of IPV-related BI is not well understood. In our study, despite their possible BI due to a hit to the head or strangulation, the majority of women did not seek medical treatment. A review article showed that between 30% and 74% of IPV survivors experiencing TBI seek care at an emergency room (Kwako et al., 2011). Research shows that women IPV survivors are less likely to seek medical care and this may be for several reasons. Women may not have the autonomy to seek medical care for their injuries, given the issues of power and control inherent in IPV (Goldin et al., 2016; Haag et al., 2019). They may not seek medical care due to the shame, fear, and stigma associated with IPV (T. Smith & Holmes, 2018) or to stay safe by avoiding possible retaliation by the abuser precipitated by revealing the abuse to others (St Ivany et al., 2018). In addition, they may not readily associate symptoms with a hit to the head or strangulation (Campbell et al., 2018) and seek medical care. In our study, 75% of these women who did seek care received follow-up recommendations.

Of the people who did seek medical care in our study, the majority were seen by a doctor, while others were seen by a nurse or other medical professionals. Indeed, participants at risk for TBI are also likely to seek help from different professionals including counselors or therapists, family physicians, domestic violence agency staff, and psychiatrists (Crowe et al., 2019; Hunnicutt et al., 2019). Hence, it is essential that the spectrum of health professionals and advocates for survivors with IPV be knowledgeable about BI, BI screening, and the overlap between BI and other related psychological symptoms of IPV survivors. Furthermore, in addition to the screening and detection of BI, service and health care providers need to be cognizant of rehabilitation approaches and community resources to make timely and appropriate referrals (Murray et al., 2016). It is important that a trauma-informed approach (Substance Abuse and Mental Health Services Administration, 2014) is used in screening/detection and rehabilitation. This approach takes into account the impact that trauma can have on people, their families, and communities; prioritizes the safety of survivors; and ensures that policies and practices of organizations avoid re-traumatizing survivors (Kulkarni, 2019; Substance Abuse and Mental Health Services Administration, 2014).

There were some limitations in our study. The data were from a nonrandomized sample, and data collection at the three organizations was episodic and not consistent over the period of 16 months. The data collection was based on staff availability and the presence of staff who had undergone training in BI and screening for such injuries. Future studies would do well to set up a trauma-informed protocol for data collection within organizations serving IPV survivors, after all staff in the organization have been properly trained. Our data were based on self-report and subject to possible symptom reporting bias (Armistead-Jehle et al., 2018; Zasler & Bender, 2019), and there was no corroborating medical record review to confirm their responses.

We do not have data to understand what impact, if any, a BI acquired as a child or as a youth might have on the psychological and cognitive sequela of an IPV-related BI as an adult. Our data show that 11 participants experienced BI as a child, and since it is not known if they also experienced BI as an adult, they were not excluded from our analysis. Gathering data on physical injuries to the head, as well as on adverse childhood experiences will provide useful information on whether these factors contribute to an increased risk for IPV and IPV-related BI in later life, and the neuropsychological sequela of such adult brain injuries. One study, for example, found that 60% of adults seeking care for a TBI had been abused as a child (Zieman et al., 2017).

In this study, information was gathered only from women; no men were included. Women compared to men are more likely to experience IPV, fatal injuries including strangulation and suffocation, and be killed by their current or former intimate partner (Ertl et al., 2019; S. G. Smith et al., 2017). Nonetheless, future research could focus on the impact of BI among male survivors compared to female survivors of IPV.

Finally, there are no validated screening tools to detect possible BI among IPV survivors. We used the HELP screen tool after modifications. Given that IPV survivors experience strangulation (Nemeth et al., 2019; E. M. Valera et al., 2019) in addition to being hit in the head, neck, or face, we gathered data on their experience with strangulation. Additional questions relating to the number of times and when they experienced a hit to the head or strangulation helped shed light on the repetitiveness and intensity of their possible BI. Also, we deleted the question on other health issues that participants might have experienced such as a brain tumor, strokes, and seizures; hence, we are unable to control for these extraneous factors that might have caused an acquired BI in our sample. Therefore, comparison of our data with previous studies that have used this screening tool may not be appropriate. The question asking women if they were hit in the head or strangled during an assault or fight needs to be revised to ascertain injuries associated with an assault.

Overall, the modified HELP tool was easy to use, can be administered in under 10 minutes, and is designed to be used by screeners such as staff at CBOs serving IPV survivors who may not be BI experts. The tool provides simple conversational cues for the screener to ask that prompt survivors to recall possible hits to the head or strangulation episodes. The tool clearly states that it is not a medical evaluation and does not provide a diagnosis of BI and advises for individuals at high risk to seek professional medical advice. It also includes a prompt at the end for any additional resources or support that survivors might need.

Future studies would do well to develop validated BI screening tools for IPV survivors that take into account brain injuries resulting from a hit to the head, neck, or face as well as hypoxic and anoxic injuries resulting from strangulation or suffocation. In developing the screen tool it would be important to obtain qualitative data on the perspectives of staff using the HELP screen. This information will help guide further modifications to tailor the tool to the context of CBOs serving IPV survivors.

Conclusion

Women survivors of IPV are at high risk for a BI caused by a hit to the head or strangulation. Health care and IPV advocates/clinicians need to be trauma responsive (Substance Abuse and Mental Health Services Administration, 2014) and routinely screen women for a possible BI. In addition, all organizations should implement and evaluate education/training programs for their staff on the intersection between IPV and BI and develop referral protocols for support services for IPV survivors who have experienced a BI. Future research should develop validated screening tools to detect a possible BI and screening guidelines to provide timely care for IPV survivors.