Eighteen years later, she is still experiencing symptoms such as headaches, memory loss, post-traumatic stress disorder, and hormonal issues. Pamela, now 51, was diagnosed with post-concussion syndrome several years after the incident. She believes that the traumatic brain injury (TBI) she sustained from domestic violence is what’s causing her problems today. Like many victims of domestic violence, Pamela did not seek medical care right after her injury. She said she was primarily focused on fleeing the abuse. She also felt a deep level of shame. “I had no idea the potential long-term results of trauma to the back of the head. If I were to do it all over again, I certainly would have sought help just to make sure I didn’t have a concussion,” says Pamela, who encourages other survivors of domestic violence to seek medical help.
Why Does TBI Often Go Unreported in Victims of Domestic Violence?
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. “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.”
