Intimate Partner Violence & Brain Injury. Understanding the Hidden Consequences.

IPV-TBI is one of the top ten priorities in brain injury Brain Canada identified as part of a lengthy multi-step pan-Cana-dian stakeholder engagement exercise.

“By providing researchers with funding in this area, as well as stakeholder-informed direction on where the greatest impact can be achieved, we are helping to build much-needed evidence-based solutions that will improve brain health in Canada,” said Dr. Viviane Poupon, President and CEO of Brain Canada.

Creating a sustainable ecosystem of care for women with TBI.

Dr. Carolina Bottari, a professor in Université de Montréal’s School of Rehabilitation and researcher at the Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal is a recipient of the Innovation Grant who has been raising awareness of the consequences and outcomes for women who have traumatic brain injuries (TBI) as a result of domestic violence.

Grounded in her expertise as an occupational therapist, Dr. Bottari and her team will take a unique approach that involves working closely with staff at second-stage women’s shelters in Quebec where the priority for admission is given to women with children.

In contrast to first-stage women’s shelters (i.e., emergency shelters), where women may stay post-separation for a maximum of three months, second-stage shelters provide transitional housing for one to two years. This extended period provides some stability and presents an opportunity for shelter workers to screen for TBI and create post-screening assistance that is sensitive to their needs and circumstances.

A brain injury is a brain injury, whether it happens in the context of intimate partner violence or sports or a fall, and the consequences are the same, but the responses to similar injuries with different causes couldn’t be more different.
Dr. Bottari

Women who experience intimate partner violence are at very high risk of having repetitive brain injuries that can lead to scarring in the brain.

In sports injuries, protective equipment and concussion protocols are in place to prevent brain injuries and ensure a safe return to play.

In the context of women with violent partners, there is no protective equipment, often no medical team, and generally no opportunity to be guided on the path to recovery by a rehabilitation team, shared Dr. Bottari.

Although evidence highlights the importance of early TBI diagnosis and intervention to minimize adverse outcomes, women who have experienced partner violence do not typically go to the hospital for diagnosis or to rehabilitation clinics for treatment and only seek help after repeat trauma, if ever.

In many cases, a woman who has had a brain injury from partner violence is not able to seek medical treatment, noted Dr. Bottari. She may have memory loss and trouble organizing her thoughts, and damage to the parts of the brain involved in decision-making. All of this poses challenges for her to assess the severity of the situation in which she finds herself and to seek help, over and above the fear and need to ensure her own survival and that of her children if she is a parent.

Another key consideration is that there is rarely a witness of concern in cases of domestic violence.

“If you see your child get kicked in the head in a soccer game, you are a positive witness and you will take them for medical attention. If an aggressor is the only witness to the brain injury, there is no witness of concern to seek help for the victim,” said Dr. Bottari.
Women in shelters are going through a number of physical, emotional, and social challenges, and there is currently no clear path to knowing what to do next if there is a positive screen for TBI.

“We are beginning to understand that we need to be slow and careful in our approach to women victims of violence. What we really don’t want is for a positive screen for brain injury to be weaponized against the women,” said Dr. Bottari. “We need to consider whether having a positive screen will help women get the services they need or increase their risks – including losing custody of their children if they are a parent. We want to make sure that we don’t do more damage than good by putting TBI screening and post-screening interventions in the shelters.”

By mapping out a network of care that includes members of the criminal justice system, social justice system, and healthcare system, Dr. Bottari and her team hope that this work will serve as a first step to compel members to form an “ecosystem of services” and think about their potential roles and opportunities to support recovery for women who have experienced partner violence.

A natural extension of Dr. Bottari’s project is advocating to address this service gap. Occupational therapists analyze people’s ability to carry out everyday activities in a real-world environment and propose interventions to facilitate their overall autonomy. For example, if the TBI has caused increased sensitivity to light and noise, the occupational therapist can help identify strategies, like dimming the lights and scheduling rest periods and supervised child care, so that the women can recover better from their injury.
Preliminary explorations by students in Dr. Bottari’s group have demonstrated that occupational therapists can help women in shelters understand the repercussions of their injuries and learn new strategies.

“The goal of an occupational therapist is to increase someone’s independence in their everyday activities secondary to any sort of injury,” shared Dr. Bottari. For women in these shelters, these strategies can provide hope and a way forward to rebuild their lives.

“As a society, we need to be more cognizant of the consequences of brain injuries on women experiencing physical violence. What we’re trying to do in our research work is to sort out a way to bring TBI rehabilitation to these women and integrate more knowledge about TBI throughout the shelters to improve their awareness of both TBI and strategies to limit the impact of these injuries on their everyday activities” said Dr. Bottari.

Improving the detection of brain injury in IPV patients.

Dr. Sandy Shultz, a neuroscientist and professor in the Faculty of Health Sciences and Human Services at Vancouver Island University in British Columbia and the Director of the newly established Centre for Trauma and Mental Health Research, was awarded an Innovation Grant in collaboration with Island Health, a forensic nursing examiner team, researchers at the University of British Columbia, and an outpatient clinic for IPV survivors.

“Through this program, we are committed to advancing TBI research, knowledge translation, awareness, and support. Our work will improve our understanding and treatment of TBI, bridging the gap between research and medical practice,” said Dr. Matthew Galati, founder of Brain Changes Initiative.

Funds from the grant will be used to develop a two-pronged screening approach for detecting TBI in people who have experienced IPV. As a first step, his team will develop
a screening tool that is easy to use by a wide range of individuals, including first responders, clinicians in emergency departments, community workers, and shelter workers.

In the second step, this tool will be validated against a blood test that looks at elevated proteins associated with a brain injury for people who have experienced IPV to ensure that the screening tool is reliable for detecting TBI.

As blood tests are not always feasible to administer in community settings, having a validated screening tool will improve the detection of tbi so that more resources and supports can be mobilized.

The screening tool will be developed as part of a larger collaborative research program. “We have consulted and will continue to consult with people with lived experience so that they can give us input on whether they would be willing to answer these questions and how we can ask them so that they are not triggering,” explained Dr. Shulz. “We will also consult with people who will be administering the test to know whether it is practical and something they can do in their work.”

When looking at brain injuries, both male and female brain cells release the same proteins that can be detected with a blood test; however, there may be differences in willingness to report symptoms that could be relevant to the screening tool. For now, Dr. Shultz’s work will focus on women, as they are the primary group affected by IPV, but he hopes to have representation from all gender identities as the research program grows.

“Strangulation is different than a trauma to the head because it restricts oxygen and blood supply. We might be able to detect new changes in the blood that are specific to IPV strangulation that reflects a hypoxic type of injury,” said Dr. Shultz.

If blood changes related to strangulations can be detected, this would have a significant impact as it would create objective evidence that is useful in a court of law. With future improvements in blood analysis technology, it may even be possible to retrospectively analyze frozen samples or small blood samples stored on paper, and trace brain injury that is attributed to violence rather than other mechanisms.

Having this knowledge can also provide another benefit, noted Dr. Shultz.

A common thread that has emerged in our interactions with individuals who have experienced IPV is that understanding that the brain injury could be causing some of their symptoms seems to have a therapeutic impact. There is almost a sense of relief or validation when someone becomes aware that some of the issues that they are struggling with are because of a brain injury.

The team plans to implement the screening tool once it is validated, for immediate benefit while waiting for subsequent research elements to be completed.

Periods of increased stress, whatever the cause (e.g., economic stress, environmental stress, stress from COVID-19 lockdown), align with an increase in cases of intimate partner violence. Increasing awareness of the triggers for IPV, improving detection of TBI, and ramping up subsequent services will help to reduce the impact of brain injuries for people experiencing intimate partner violence.

“We know that brain injuries have long-term repercussions that impact a person’s ability to function and impact their quality of life. Everything we are doing in care right now is reactionary, but it would be great to be able to harness the knowledge that we gain on prevalence from this project and use that to advocate for more prevention, more education, and more resources,” said Dr. Shultz.

An unequal impact

According to a review by Drs. Kellianne Costello and Brian Greenwald published in Brain Sciences in 2022, IPV disproportionally affects women, with one in three women experiencing IPV in their lifetime compared to 14% of men.

Studies they looked at in the review have also shown that there is a cyclical relationship between TBI and domestic violence. Someone with a TBI from domestic abuse may suffer from mood irregularities, cognitive dysfunction, and memory loss, which further frus-trates the aggressor, triggering subsequent abuse and repetitive head injuries.

Moreover, the true prevalence of TBI for those who experience domestic violence is unknown, as many cases go unreported. Even so, research cited by Drs. Costello and Greenwald estimates that 11–12 times more women have had a TBI from domestic violence when compared to TBIs documented in military personnel and athletes combined.