1. Jacquelyn C. Campbell, PhD, RN, FAAN Johns Hopkins University School of Nursing Jessica Gill, PhD, RN, NINR, NIH Akosoa McFadgion, MSW, PhD©, Howard University

2. Team Members United States Jacquelyn Campbell, PhD, RN, FAAN - PI Phyllis Sharps PhD, RN, FAAN – Co-I Richelle Bolyard, MHS Jamila Stockman, PhD, MPH Marguerite B. Lucea, PhD, MSN, MPH, RN Bushra Sabri, PhD, LMSW, ACSW Akosoa McFadgion, MS, MSW, PhD student Kaitlan Gibbons, PsyD(c) Mary Paterno, MSN, CNM, RN, PhD student Sharon O’Brien, PhD Sachi Mana-ay, BSN student Jessica Draughon, MSN, RN, PhD student Charmayne M. Dunlop-Thomas, MS Callie Simkoff, BSN, RN Gyasi Moscou-Jackson, MHS, BSN, RN Chris Kunselman Ayanna Johnson, MPH Ashley Chappell, BSN, RN Lucine Francis, BSN, RN Naa Ayele Amponsah, MPH Hossein Yarandi, PhD US Virgin Islands Doris Campbell, PhD, ARNP, FAAN – Co-PI Gloria Callwood, PhD, RN, FAAN – Co-I, PI of CERC Desiree Bertrand, MSN, RN Lorna Sutton, MPA Tyra DeCastro Alexandria Bradley, RN Sally Browne, RN Edris Evans, RN Yvonne Francis, RN Naomi Joseph, BSN student Jennifer King, RN Suzette Lettsome, MSPHN, RN Julie Matthew, RN Kenice Pemberton, ASN student J'Nique Smith, BSN student Jaslene Williams, MSW Research supported by a subcontract with Caribbean Exploratory NIMHD Research Center of Excellence (CERC), USVI Grant # P20MD002286, PI Gloria Callwood, PhD, RN, FAAN

3. TBI’s A TBI occurs when an external force injures the brain; resulting in neuronal injury in the area of contact, as well as diffuse neuronal damage It is the secondary injury mechanisms including blood brain barrier disruption, neuronal edema, and inflammatory activation that results in many of the neurological consequences A TBI can be classified as penetrating or closed head Damage can be caused by the direct contact, or by acceleration/deacceleration Also a category of “head or brain injury,” that also includes anoxic injuries such as strangulation or drowning, which deprives oxygen to neurons

4. TBI’s are common 500,000 deaths in the U.S. per year 2% of the U.S. population (60 million Americans) have a TBI related disability (Thurman, 1999; Pullkrat, 2007) Physical: Gait, balance, muscle weakness Cognitive: concentration, memory, executive functioning, processing speed. Behavioral: Irritability, fatigue, erratic actions Emotional: Depression, anxiety, and personality changes Sensory: olfactory, vision, and taste Substantial impact on family and social supports Estimated annual expenditure of 60 Billion dollars related to medical care and lost productivity (Finkelstein, 2006)

5. Individuals with Repeated TBI’s at the Highest Risk In athletes, mild TBI’s within one week place individuals at high risk for PCS symptoms (Wall, 2006; Master, 2001) “Cumulative Concussions” TBIs that occur within 3 days result in an additive effect that places the individual at high risk for prolonged recovery (Gusiweisak, 2003) Not enough time to allow for neuronal recovery

6. Injuries from IPV Often Includes TBI’s but Only Recently Recognized  Unexplained longterm CNS Sx associated with IPV (Coker, 2002; Campbell 2002)  TBI’s resulting from physical contact to the head (Blunt Force): 68% of women reporting at least one mild TBI & 10% abused women reporting a moderate to severe TBI from head injury (Monahan & O'Leary 1999)  Strangulation one or more times:  54- 68% of women in two domestic violence shelter samples (Wilbur, Higley et al. 2001; Sutherland, Bybee et al. 2002)  56% of IP femicide victims vs. 10% urban abused women - 12 city femicide study (Glass, Koziol-McLain, Campbell ‘08)

7. TBI’s in Abused Women Linked to Post-Concussive Symptoms Strangulation: memory problems, depression, insomnia, headaches, dizziness, and loss of sensation with far greater symptoms in women who reported five or more strangulation events compared to abused women who reported two or fewer events (Smith, Mills et al. 2001). Blunt force: TBI often have PCS symptoms including: headaches, dizziness, memory loss, insomnia, depression apathy, and fatigue. (Monahan and O'Leary 1999; Smith, Mills et al. 2001; Wilbur, Higley et al. 2001) No clinical assessment of all PCS symptoms No linking with neurological impairments Do not examine the cumulative impact of TBI’s Do not control for PTSD and depression symptoms No neuronal imaging or biomarkers

8. Image of a Severe TBI Primary BBD BBD = Blood Barrier Disruption – neuronal damage

9. Traumatic Brain Injury in ACAAWS  ACAAWS operationalization of TBI with questions from PASS (MAPSAIS) & SVAWS - one or more instances in the past year of the following  Head injury with loss of consciousness  Broken Jaw  “Choked” you  CNS Sx from PASS (MAPSAIS) - Dizzy spells, memory loss, difficulty concentrating, headaches, blacking out

10. TBI: Head Injury &Choking, % Broken Jaw: significant difference between cases/controls (χ 2 =6.12, p<0.05) & by site (χ 2 =8.92, p<0.05) Head Injury with Loss of Consciousness (HI + LOC) significant difference between cases & controls (χ 2 =14.39, p<0.01); & by site (χ 2 =6.12, p<0.05) Choking (past year) significantly different between cases & controls (χ 2 =83.54, p<0.01); no significant difference by site among cases (χ 2 =2.58, p=0.28) Percent (N=905)

11. Frequency of Choking Among Cases (SVAWS, past 12mo, %) (N=159 cases) (N=380 cases)

12. All significant at p <.01 except headaches N=901

14. NEVER EVER N=510 Mean number of CNS Symptoms Among Abused Women

15. N=899

16. Multivariate Logistic Regression – OUTCOME - CNS SYMPTOM FREQUENCY VariableDF Parameter Estimate Standard Errort ValuePr > |t| TBI10.794820.398032.000.046 Age1-0.000030040.01869-0.000.99 Site1-0.763160.35690-2.140.033 PC- PTSD10.404850.135183.000.003 DANGER ASSESSMENT 10.011630.005142.260.024 DEPRESSION10.208910.028967.21<.0001 Significantly Associated with CNS Sx Frequency Outcome Among Abused Women

17. Potential Long-term Consequences IPV (HI & Choking ) CF TBI Mothering practices Employment/ school Active Strategies for IPV CF = Cognitive Functioning Prior Injury PTSD/ Depres- sion Suicidality

18. Specific Recommendations for Health Care System Immediate aftermath of injury – HI & strangulation – assessment for TBI - Tx if indicated – protocols – for post concussion If we see her after ED – check to see if done, send back Later - important to consider history – both strangulation & HI Immediate treatment of either HI &/or attempted strangulation Careful assessment for history of both – from IPV & non- violent sources Thorough Neurological Examination if indicated – make sure gets to right provider – knows TBI possibilities

19. Screening Options for Traumatic Brain Injury HELPS Brain Injury Screening Questionnaire (BISQ) Defense & Veterans Brain Injury Center (DVBIC)

20. Assessing for Acute Strangulation Injuries – Excellent Protocols Available – www.forensichealthcare.com – Ruth Downing & familyjusticecenter.org/strangulation www.forensichealthcare.com Strangulation: skin abrasions or reddening of the skin on the neck – use enhanced light Petechiae – due to venous congestion Subconjunctival hemorrhage Severe strangulation: damage to the larynx indicated by one of the following: swollen tongue, sore throat, difficulty swallowing, or hoarseness/problems talking, Anoxia - Mental status change: restlessness, combativeness, and confusion Urinary incontinence (sometimes bowel)

22. Strangulation discharge instructions Return for difficulty breathing trouble swallowing swelling of neck or throat increased hoarseness or voice change blurred vision severe headache weakness, numbness NZ group – Miranda Richie vipmanager@ymail.com, Faye Clark faye@aztec.co.nz, Denise Wilson, Jane Koziol-McLain – www.nnvawi.org–vipmanager@ymail.com faye@aztec.co.nzwww.nnvawi.org

23. Overall summary Intimate partner violence encompasses many aspects of violence; ranging from threats/coercion to physical and sexual abuse – most abused women experience multiple forms Women who experience IPV at increased risk for multiple injuries and health problems – that may be misdiagnosed and/or inadequately treated without knowledge of IPV Traumatic Brain Injuries may be one of missing links between what we know about IPV and some of longterm issues for abused women Must consider interplay of neurological & psychological - American Association of Neurology 2011 position statement – supporting routine screening – IOM report on women’s health – routine screening & brief counseling for IPV – Sec Sebelius adopted for AHA – OWH implementing|

24. Primary Care -protocols Follow up questions after discloses IPV – about choking & head injuries Neurological Sx – assess Full neurological work-up if indicated? MRI, CT Scans TBI rehabilitation guidelines from VA & DoD? – need to be tested to see if appropriate for IPV survivors

25. Moving Forward  Equity in health care access not enough  Competent care for women in all health care settings necessitates assessing for IPV – among all women  In order to make an accurate diagnosis  In order to give appropriate treatment  “Trauma informed” interventions – both emotional and physical trauma  More research to differentiate TBI’s and related Sx from Post Traumatic Disorders & Depression also related to IPV  Collaboration with community resources  Collaboration with whole community

26. Making Women & Children Safer & Healthier