The majority of survivors of domestic violence suffered a head injury and 83% were strangled

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Domestic violence survivors commonly suffer repeated blows to the head and strangulation, trauma that has lasting effects that should be widely recognized by advocates, health care providers, law enforcement and others who are in a position to help, according to the authors of a new study.

In the first community-based study of its kind, researchers from The Ohio State University and the Ohio Domestic Violence Network found that 81 percent of women who have been abused at the hands of their partners and seek help have suffered a head injury and 83 percent have been strangled.

The research suggests that brain injury caused by blows to the head and by oxygen deprivation are likely ongoing health issues for many domestic violence survivors.

Because of poor recognition of these lasting harms, some interactions between advocates and women suffering from the effects of these unidentified injuries were likely misguided, said the authors of the study, which appears in the Journal of Aggression, Maltreatment & Trauma.

“One in three women in the United States has experienced intimate partner violence.

What we found leads us to believe that many people are walking around with undiagnosed brain injury, and we have to address that,” said lead researcher Julianna Nemeth, an assistant professor of health behavior and health promotion at Ohio State.

The study included 49 survivors from Ohio and 62 staff and administrators from five agencies in the state.

Previous research has acknowledged brain injury as a product of domestic violence. But this is the first study to gather this kind of detailed information from the field.

It’s also the first to establish that many survivors have likely experienced repeated head injury and oxygen deprivation – a combination that could contribute to more-severe problems including memory loss, difficulty understanding, loss of motivation, nightmares, anxiety and trouble with vision and hearing, Nemeth said.

“Nobody really knows just what this combination of injuries could mean for these women,” she said.

“When we looked at our data, it was an ‘Oh my gosh’ moment.

We have the information we need now to make sure that people recognize this as a major concern in caring for survivors.”

Almost half of the women in the study said they’d been hit in the head or had their head shoved into another object “too many times to remember.”

More than half were choked or strangled “a few times” and one in five said that happened “too many times to remember.”

In some cases, the survivors lived through both experiences multiple times.

The reports from women in domestic violence programs throughout Ohio already have prompted changes to how the statewide advocacy group and the programs it works with are helping the survivors they serve.

They’ve created a model called “CARE” for “Connect, Acknowledge, Respond and Evaluate.”

They’ve adjusted their training and developed materials that address the “invisible injuries” to the brain.

They’re encouraging providers at agencies to tailor care plans to the specific needs of women who’ve had traumatic brain injury, and to help them seek medical care to get an appropriate diagnosis and treatment.

Currently, the team is working on an evaluation to see how well that new programming is working.

“Brain injury was not something we really talked about much until now.

It wasn’t part of any routine training and we’re trying to address that now because of what we learned from these survivors,” said Rachel Ramirez, a study co-author and training director for the Ohio Domestic Violence Network. She’s been exploring ways to ensure better diagnosis and treatment for women with brain injuries, and said there’s a long way to go.

“Almost all of the best-practice recommendations for TBI are focused on athletes and soldiers, and some of the guidance is impractical for our population,” she said.

“These women could be having trouble being able to plan for the future, to make decisions about their safety, to come to appointments, to do their jobs. Many have likely been wondering for years what’s going on with them.”

Emily Kulow, accessibility project coordinator for the Ohio Domestic Violence Network, said that it’s likely some of the survivors who’ve suffered from severe head trauma and oxygen deprivation have been slipping through the cracks because their symptoms aren’t well-understood.

For instance, someone who can never remember to show up for counseling at the right time or who is combative with a roommate might be seen as a troublemaker when she’s really at the mercy of her brain injury, Kulow said.

“Regardless of why we’re seeing these behaviors, we should be serving all the women who have survived domestic violence and a one-size-fits-all approach won’t work.”

Added Nemeth, “The survivors who have severe brain injury are likely some of those with the greatest unmet need.”

In addition to memory problems and cognitive impairment, poor mental health may arise or be exacerbated by brain injury – and addressing the mental health needs of survivors is an ongoing challenge for agencies, Kulow said.

The researchers also authored another study, recently published in the Journal of Family Violence, that documents challenges that agency employees face when dealing with the complex mental health needs of survivors.

The study authors, led by Ohio State Assistant Professor of Social Work Cecilia Mengo, call for care models tailored to survivors who have a mental health disability.

But they also recognize the challenges faced by advocates and survivors, particularly in areas where residents have poor access to counselors, psychologists and psychiatrists.

“It’s not that they don’t recognize the need for mental health services, but that need is difficult to meet in a state with inadequate mental health services,” Ramirez said.

Added Kulow, “We also heard from programs that there’s a lack of understanding of the more-serious mental health disorders that people have, such as bipolar disorder.”


The Centers for Disease Control and Prevention (CDC) defines a traumatic brain injury as a disruption in the normal function of the brain caused by either a bump, blow, or jolt to the head, or a penetrating head injury. TBI can range from mild (including a concussion) to severe.

Research on abused women shows that between 40 to 92 percent of victims of domestic violence suffer physical injuries to the head; nearly half of these women report that they have experienced strangulation, according to research published in October 2017 in the Journal of Women’s Health

“If anyone applies pressure to your neck by any means, it is strangulation,” says Gael Strack, CEO of Alliance for HOPE International and the National Training Institute on Strangulation Prevention.

Barrow Neurological Institute, the world’s largest neurological disease treatment and research institution, conducted a study on TBI and domestic violence that included 115 victims. According to this research, published in February 2017 in the Journal of Neurotrauma, 81 percent of patients reported a history of loss of consciousness associated with their injuries and only 21 percent of patients sought medical help at the time of injury.

Glynnis Zieman, MD, a neurologist in the Concussion and Brain Injury Center at the Barrow Neurological Institute and lead author of the study, explains that there are multiple reasons why victims don’t get help.

Further symptoms of TBI, such as confusion, amnesia, and loss of consciousness, may make it difficult for victims to realize a brain injury has occurred.

Glynnis Zieman, MD Tweet 

“Victims are often alone after they are injured and often cannot seek medical care for injuries due to safety, isolation, or economic reasons.”

There’s also a misconception that a hit on the head isn’t problematic unless you lose consciousness.

A study published in October 2017 in the Journal of Women’s Health suggests that a mild TBI like a concussion is the most underreported type of TBI.

“The lack of awareness of the cumulative effect of mild TBI in this population [victims of domestic violence] might be a barrier to people getting the services that they need. We just aren’t used to thinking about this population in that context,” says Ashley Bridwell, a social worker and rehab program coordinator in the Barrow Outpatient Neuro-Rehabilitation Center and the Barrow Concussion and Brain Injury Center at the Barrow Neurological Institute.

Screening and the Importance of Asking Specific Questions

If you are the victim of domestic violence and you’re exhibiting symptoms of brain injury, David Cifu, MD, senior TBI specialist in the Department of Veterans Affairs, advises paying a visit to your primary care physician before seeking a specialist.

“Ninety-eight percent of these problems can be managed by primary care physicians,” he says.

HELPS, a universal, five-question screening tool originally developed by the International Center for the Disabled in 1991, is also used to help identify TBI among domestic violence victims. The screening tool, which was updated recently by project personnel to reflect the CDC’s recommendations for TBI, asks:

Were you HIT in the head?

Did you seek EMERGENCY room treatment?

Did you LOSE consciousness.

Are you having PROBLEMS with concentration or memory?

Did you experience SICKNESS or other physical problems following the injury?

“We have discovered that if you don’t ask specific questions they won’t tell you,” says Strack. “You have to really pull this information out of people because of lack of memory, they might be embarrassed, they might be afraid that if someone finds out, or there might be retaliation.”

Jacquelyn Campbell, PhD, RN, the Anna D. Wolf chair and professor at the Johns Hospital University’s School of Nursing, agrees.

She has been working to raise awareness of domestic violence victims in her facility.

“Whenever an abused woman comes into the system we ask about potential head injury, brain injuries from strangulation, and or punches to the head or face,” she says.

Campbell trains interdisciplinary audiences (healthcare, domestic violence advocates, criminal justice system professionals) all over the country on how to use the Danger Assessment, which helps to determine the risk of being killed by an intimate partner.

She also educates these professionals about the possible effects of TBI and how to refer victims to the appropriate care.

Helping to Educate Facilities That Care for Victims of Domestic Violence

Education and awareness of TBI in victims of domestic violence has been lacking in domestic violence shelters. Also, provided medical services vary by shelter so there’s no standard of care.

Four years ago, Bridwell collaborated with Javier Cárdenas, MD, director of the Barrow Concussion and Brain Injury Center at the Barrow Neurological Institute, to create a domestic violence program that provides free neurological care for women who screen positive for TBI. Bridwell, Dr. Cárdenas, and Dr. Zieman, who is also involved in this project, started educating case managers and shelter intake staff at a homeless shelter in Phoenix. Since then, the Barrow Neurological Institute has expanded the program to six shelters and has served over 300 men and women.

Another component of the Barrow Neurological Institute’s domestic violence program is the “BRAINS” club, which meets once a month at partnering shelters.

These free classes, which are only available at select shelters, teach victims of domestic violence about their neurological health by using specific modules that address memory, cognition, and executive function.

Treatment Options for People With TBI

Treatment for TBI is different for every patient. Victims of domestic violence diagnosed with a TBI often require a multidisciplinary approach, says Zieman.

“Migraines and headaches often respond well to early treatment, while symptoms such as imbalance and vision changes often warrant physical and occupational therapies.

Mood symptoms often improve with time, but depression and anxiety warrant appropriate psychiatric intervention. Finally, cognitive deficits are often improved significantly with speech cognitive therapy,” she says, adding that the earlier people seek medical care, the easier it is for them to recover fully and quickly.

If you or someone you know is suffering from domestic violence, first call 911 if you are in danger or have been injured, says Zieman.

The national domestic violence hotline, 800-799-7233, is available 24/7.

Most major cities also have shelters to help victims of domestic violence.

“Please come forward. Please know that help is available,” says Strack. “There are people out there who can and want to help you.”


More information: Julianna M. Nemeth et al, Provider Perceptions and Domestic Violence (DV) Survivor Experiences of Traumatic and Anoxic-Hypoxic Brain Injury: Implications for DV Advocacy Service Provision, Journal of Aggression, Maltreatment & Trauma (2019). DOI: 10.1080/10926771.2019.1591562

Cecilia Mengo et al. Knowledge and Perspectives of Domestic Violence Service Providers about Survivors with Mental Health Disability, Journal of Family Violence (2019). DOI: 10.1007/s10896-019-00053-3

Provided by The Ohio State University

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