Domestic Violence: Improved Data Needed to Identify the Prevalence of Brain Injuries among Victims
Released: 2020-06-12T00:00:00

Letter

Background

Intimate Partner Violence

Data from CDC’s 2015 NISVS indicate that about 43.6 million women (36.4 percent) and 37.3 million men (33.6 percent) in the United States have experienced sexual violence, physical violence, and stalking by an intimate partner. Approximately 21.4 percent of women and 14.9 percent of men in the United States experienced severe physical violence by an intimate partner. About 30 million women (25.1 percent) and 12 million men (10.9 percent) reported experiencing some effect from the violence. (See fig. 1 for the most commonly reported effects of intimate partner violence, as reported by NISVS.)

Intimate partner violence can also result in death. Data from U.S. crime reports suggest that 16 percent of homicide victims (about one in six) are killed by an intimate partner. Strangulation victims, in particular, are at greater risk for being killed, according to the Training Institute on Strangulation Prevention.

Research has shown that certain factors increase the risk that someone may experience intimate partner violence. For example, a review of research on risk factors for women who experience intimate partner violence identified younger age, less education, unemployment, pregnancy, childhood victimization, and mental illness as being associated with higher rates of intimate partner violence. Exposure to intimate partner violence between a child’s parents or caregivers is also associated with a greater risk of intimate partner violence in adulthood, according to CDC. Adults with disabilities are also at a higher risk of violence than those without disabilities.

However, research indicates that victims of intimate partner violence may be less likely than others to obtain medical or other services. Even when services are obtained, victims may be less likely than others to identify the source or extent of their injuries out of fear for their safety or reprisal.

Brain Injuries

Brain injuries, including those that may result from intimate partner violence, can have several causes, including physical trauma and strangulation; range in severity; and can result in a number of health consequences.

TBI refers to a brain injury caused by external physical force, such as a blow to the head or shaking of the brain.

Anoxic (a complete disruption of oxygen to the brain) or hypoxic (a partial disruption of oxygen to the brain) brain injury may result from strangulation or other pressure applied to the neck that restricts blood flow and air passage.

TBIs and anoxic or hypoxic brain injuries may result in irreversible psychological and physical harm. Specifically, people who suffer from TBI and anoxic or hypoxic brain injuries may experience cognitive symptoms, including depression and memory loss, as well as behavioral symptoms, such as changes in mood, or difficulty sleeping, among others. The symptoms individuals experience can also vary. The signs and symptoms of an anoxic or hypoxic brain injury from strangulation can be similar to those of mild TBI, which is often referred to as a concussion. (See fig. 2.)

According to the Brain Injury Association of America, a severe brain injury can be clearly identified by reviewing an individual’s symptoms, but when the brain injury is mild or moderate, providers may need to conduct further assessments or screening to diagnose the brain injury. According to NIH, providers have several options for assessing brain injury that can help determine the severity of the injury. For example, providers may evaluate a person’s level of consciousness and the severity of brain injury by attempting to elicit body movements, opening of the eyes, and verbal responses. Providers may also evaluate an individual’s speech and language skills or cognitive capabilities.

Role of HHS and DOJ in Addressing Intimate Partner Violence

Both HHS and DOJ support activities for individuals affected by intimate partner violence through several of their agencies. Within HHS, for example, ACF provides federal funding to support emergency shelter and services for the victims of domestic violence and their dependents, as well as the National Domestic Violence Hotline. CDC provides grants to state and local entities to develop programs aimed at preventing intimate partner violence. Additionally, HRSA—which provides funding to federally qualified health centers—provides funding to develop educational materials for health care workers, in partnership with ACF, to increase the number of individuals screened for intimate partner violence and referred to treatment services, among other things.

DOJ, through its Office of Justice Programs and Office on Violence Against Women, conducts research and provides funding to help states, local governments, and nonprofit organizations’ develop programs to reduce violence against women. Many DOJ programs aim to strengthen responses at the local, state, tribal, and federal levels to domestic violence, dating violence, sexual assault, and stalking. Further, the Violence Against Women Reauthorization Act of 2013 amended federal laws to establish criminal penalties for strangulation or suffocation. Additionally, DOJ increased its support of activities focused on training to recognize and prosecute strangulation.

Role of HHS in Addressing TBI

HHS agencies also conduct work related to recognizing and responding to TBI. For example, NIH funds research aimed at developing knowledge about the brain and nervous system in order to reduce the effect of brain- related diseases on individuals. In addition, CDC conducts research on the prevention of TBIs, and ACL provides grants to states to help them to support individuals with brain injuries and to promote the rights of, and provide advocacy support to, those living with TBI.

Efforts to Provide Education, Screen for, or Treat Brain Injuries Resulting from Intimate Partner Violence

We identified 12 initiatives led by non-federal entities that focused on (1) education on brain injuries resulting from intimate partner violence by developing materials or offering training; (2) screening victims of intimate partner violence for potential brain injuries; or (3) treatment involving individuals with brain injuries resulting from intimate partner violence. Our list represents initiatives identified during the course of our review and may not be exhaustive. Some of these initiatives focus on only TBI or strangulation, while others focused on both. See appendix II for additional information on the initiatives.

Training for Domestic Violence Program Staff Domestic violence program advocates we spoke to told us that before they participated in the Ohio Domestic Violence Network training, they knew their clients were having a hard time remembering things or getting their thoughts across; however, they did not know this could be the result of a brain injury. The training helped advocates identify signs and symptoms in their clients and make others aware of these symptoms. For example, advocates told us they may inform a prosecutor that a client may have a brain injury and may have difficulty remembering or sharing their experiences.

The Ohio Domestic Violence Network—as a part of its Connect, Acknowledge, Respond, Evaluate (CARE) initiative—trained staff at five domestic violence programs on brain injuries, and developed educational materials for shelter staff to share with intimate partner violence victims, according to network officials. For example, we spoke to staff at a domestic violence program in Ohio who told us how the education they received from the network helped them identify the signs and symptoms of brain injury in their clients. Staff from another domestic violence program in Ohio told us as a result of CARE training they now suggest strategies to clients to assist them with their memory issues, such as writing appointment information on a whiteboard or in a planner.

The Swedish Hospital Violence Prevention Program, in Illinois, provided education to physicians, medical residents, and hospital staff to increase health care provider and staff awareness of and ability to respond to brain injuries among victims of intimate partner violence, according to officials with the initiative.

The Safe Futures initiative, in Connecticut, developed strangulation training materials for emergency medical personnel, law enforcement, prosecutors, and providers, as well as hosted trainings throughout Connecticut on intimate partner violence and brain injuries, according to officials with the initiative.

Screening. Six of the 12 initiatives used screening tools to identify potential brain injuries among intimate partner violence victims, according to officials. Based on our review of documentation from these initiatives, we found that the screening tools generally had a series of questions about injuries to the head, the loss of consciousness, or behavior changes—symptoms that may indicate a potential brain injury. For example:

Officials from three initiatives that screened victims for potential brain injuries reported using a version of the HELPS screening tool. (See fig. 4 for an example of a modified version of this screening tool used by one initiative.) Officials from one initiative told us that screening typically occurred at domestic violence shelters where staff and advocates receive training on how to screen intimate partner violence victims.

Officials from the other three initiatives told us they developed their own screening methods. For example, staff at the Maricopa County Collaboration on Concussions in Domestic Violence in Arizona screen victims using a tool that measures near point of convergence, which refers to an individual’s ability to focus both eyes on a target, an approach that can be used to detect a concussion. Police officers from two participating departments in Arizona have used this tool to screen individuals when they respond to a domestic violence call, according to officials with the collaboration.

Treatment. Two of the 12 initiatives included a treatment component. Officials with the Barrow Concussion and Brain Injury Center in Arizona and the Northside Hospital Duluth Concussion Institute in Georgia told us they provided treatment to victims who were referred by local domestic violence shelters. Providers affiliated with one of these initiatives told us that treatment for brain injuries resulting from intimate partner violence does not differ from treatment for other brain injuries. A provider with one of these initiatives said that treatment could include exercises and movements that decrease dizziness, vertigo, and imbalance; occupational, physical, or speech therapies; or treatment for pain management.

An Intimate Partner Violence Victim’s Brain Injury Treatment Jane Doe was abused by her partner. An advocate at a domestic violence shelter screened Jane for a brain injury and referred her for assessment. She was diagnosed and began treatment for a brain injury. Jane Doe told us that the treatments she received, which included nerve blockers—often used by neurologists to lessen chronic pain—helped to relieve the persistent headaches and debilitating migraines she experienced in the aftermath of her abuse. She told us that as a result of the treatment she received, she feels better able to function.

Officials from the Barrow Concussion and Brain Injury Center told us that individuals with brain injuries resulting from intimate partner violence may face a longer period of recovery compared to others with brain injuries, in part, because of living in unsafe home environments. As a result, special considerations are sometimes needed due to additional barriers faced by domestic violence victims. For example:

Victims may need safety planning and housing. As a part of the Barrow Concussion and Brain Injury Center’s domestic violence initiative, a social worker will help ensure that victims’ other needs are met.

Officials from the Northside Hospital Duluth Concussion Institute noted that transportation could also be a barrier for victims of intimate partner violence. As such, the Georgia Department of Public Health’s Injury Prevention Program, which partnered with the Northside Hospital Duluth Concussion Institute, planned to use CDC grant funding to provide domestic violence victims transportation from area shelters to the concussion institute for treatment.

Officials from the Barrow Concussion and Brain Injury Center also told us about other considerations, such as the need to have a flexible appointment policy to account for the possibility of victims missing or canceling appointments.

Of the 12 initiatives we identified, eight received federal grants from HHS or DOJ, while officials from the other four initiatives told us they were funded with state, local, or private dollars. According to HHS and DOJ officials, the grants did not have specific requirements to address the intersection of brain injuries and intimate partner violence. However, based on our review of documentation, the eight initiatives used the federal funds to focus on the intersection of these two issues. Six of these eight initiatives received funding from HHS. Of them, four were funded by HRSA or ACL grants that focused on TBI-related services and activities, and two were funded by CDC grants focused on injury and violence prevention activities. The other two initiatives were funded by DOJ’s Office of Justice Programs through grants that provide funds to support victims of crime.

In addition to the federal funding received by some of the 12 initiatives, we identified other efforts and grants funded by HHS and DOJ. These efforts made educational materials on intimate partner violence and brain injuries accessible online, made ad-hoc or internal trainings available to external parties, or provided education that touched on the connection between intimate partner violence and brain injury, according to HHS and DOJ officials. For example:

ACF has funded the National Resource Center on Domestic Violence and Futures Without Violence’s National Health Resource Center on Domestic Violence, which provide information related to intimate partner violence and brain injuries via websites.

ACF, in collaboration with HRSA, funded an effort led by Futures Without Violence, which includes some information on TBI and strangulation in trainings for select state leadership teams working to address intersections of health, intimate partner violence, and human trafficking.

DOJ’s Office on Violence Against Women provided grant funds to support the Training Institute on Strangulation Prevention, which offers training to individuals and outside entities to help them understand, recognize, and appropriately serve strangulation victims, as well as investigate and prosecute strangulation cases.

DOJ’s Office on Violence Against Women has also provided grant funds used by local organizations, such as police departments, to provide ad-hoc or internal training activities on brain injuries and to serve victims with brain injuries, including those caused by strangulation.

Data on the Overall Prevalence of Brain Injuries Resulting from Intimate Partner Violence Are Limited; Improved Data Could Help Target HHS Public Health Efforts

Based on our review of the literature, as well as interviews with HHS officials and other non-federal stakeholders, we found that data on the overall prevalence of brain injuries resulting from intimate partner violence are limited.

Specifically, available data do not provide an overall estimate of the prevalence of brain injuries resulting from intimate partner violence nationwide. While there are studies that estimate the prevalence of these injuries, these studies are also limited. Specifically, among the 28 articles we reviewed, six included an objective to estimate the prevalence of brain injuries resulting from intimate partner violence, while the remaining 22 articles examined other areas, such as health effects or awareness of brain injuries resulting from intimate partner violence, but did not have an objective to estimate prevalence. The six articles are also specific to a certain subpopulation or certain geographic locations and used different approaches to identify individuals with brain injuries. As a result, the range of reported prevalence rates on victims of intimate partner violence with brain injuries (brain injuries caused by trauma or strangulation) varied greatly (from 11 percent to about 79 percent) and were based on a range of sample sizes, from 95 people to about 1,000 people.

HHS agencies also have some data collection and research efforts related to this issue; however, these efforts are limited as well. For example, CDC and NIH have efforts that may assist in better understanding the connection between brain injuries and intimate partner violence, but CDC’s efforts do not account for all causes of brain injuries and NIH has only one study focused on this connection. Further, HHS agencies treat brain injuries and intimate partner violence as separate public health issues and pursue their efforts separately—which limits their ability to better understand the connection between the issues and the overall prevalence of brain injuries that result from domestic violence.

CDC officials told us that the agency’s data on the connection between brain injuries and intimate partner violence are limited, but the agency plans to address some of the limitations. For example, the officials said CDC analyzes health care claims data from emergency department visits to determine the causes of TBI. However, CDC officials told us that these data likely underestimate TBI among victims of intimate partner violence, because many do not seek medical care; for domestic violence victims who seek care, providers are unlikely to designate the individual as a victim of intimate partner violence.

CDC also collects data on intimate partner violence through its NISVS. According to CDC reports, NISVS data are a key source of information on intimate partner violence, but the survey does not collect data on all types of brain injuries related to intimate partner violence. For example, the NISVS estimates the prevalence of victims of intimate partner violence who have been “knocked out after getting hit, slammed against something, or choked.” However, published estimates are based on responses to a survey question that asks individuals about being “knocked out,” which is a colloquial term commonly used to indicate a loss of consciousness. CDC officials stated that in most known incidents of mild brain injury, people do not lose consciousness. As a result, NISVS data likely understate the number of intimate partner violence victims who may have brain injuries.

In order to better estimate TBIs resulting from intimate partner violence, CDC officials told us they plan to add a survey question to the NISVS to ask respondents about whether they have experienced a concussion—a common term for mild forms of TBI—due to a current or ex-partner. CDC officials told us that they have begun initial testing on several aspects of the survey, including on the additional question with the goal to begin data collection by the end of 2022, plans which are pending approval. Once the NISVS data are collected and analyzed, CDC officials said the data could help them provide a nationally representative prevalence estimate of intimate partner violence victims’ who experienced a TBI in their lifetimes.

However, adding the question to the NISVS may not ensure that these data can provide a comprehensive estimate of the prevalence of brain injuries resulting from intimate partner violence. In particular, The NISVS question will focus on TBIs, and will not account for individuals with brain injuries caused by strangulation. According to educational materials developed by the Training Institute of Strangulation Prevention and used by HRSA in the training of providers and advocates, more than two-thirds of intimate partner violence victims are strangled at least once. CDC officials told us that they are able to measure acts of choking or suffocation through the NISVS, but this measure cannot be used to account for brain injuries resulting from strangulation. Additionally, CDC officials told us that the agency’s priority is to focus on TBI specifically rather than accounting for other brain injuries.

Despite the focus on TBIs, CDC officials told us the NISVS data are not designed to examine whether intimate partner violence is a leading cause of TBI in comparison with other causes, such as sports or motor vehicle crashes. CDC officials said that some research and NISVS data suggest that intimate partner violence is not as large a contributor of TBIs when compared to other contributors. However, they noted that they do not have data on the proportion of TBIs resulting from intimate partner violence. Absent the ability to compare intimate partner violence as a cause of TBI against other contributors through the NISVS or other representative studies, CDC officials will continue to lack an understanding of the full scope of TBIs, their primary causes, and who is affected by them.

NIH officials identified two agency efforts that could help improve what is known about the connection between brain injuries and intimate partner violence.

NIH began funding a study in September 2019 that will use advanced brain imaging, blood analyses, and cognitive and psychological testing to study the effects of multiple brain injuries on women subjected to intimate partner violence. The objectives of the study are not to measure prevalence, but to examine the health effects of brain injuries resulting from intimate partner violence. NIH officials told us that this is the first study funded by NIH using brain images to investigate brain injuries resulting from intimate partner violence.

NIH is also developing blood biomarkers—which are clinical diagnosis tools—for identifying mild TBI. Currently, mild TBI is generally diagnosed by taking an inventory of symptoms, but symptoms can lead to misdiagnoses, including for mental illness or a substance use disorder. NIH officials said they are in the initial stages of developing these biomarkers, which could take the place of screening tools in diagnosing a brain injury. While this effort was not initiated to better understand brain injuries among victims of intimate partner violence, biomarkers have the potential to improve the identification of TBIs, provided they are applied to domestic violence victims.

Two other HHS agencies—ACL and HRSA—also have efforts that address brain injuries or intimate partner violence. However, these agencies’ efforts are generally not focused on the connection of the two issues, so they are not likely to result in more complete data on the prevalence of brain injuries resulting from intimate partner violence. Specifically: ACL provides grants to states to establish support services for individuals with brain injuries through its TBI State Partnership Program. As part of these efforts, ACL officials told us that they have begun to gather information to determine how many TBI grant recipients are using the funds to support particular populations, including individuals with TBI resulting from intimate partner violence. As of December 2019, ACL officials told us that two states (Idaho and Iowa) have used the grants to focus on individuals with TBI as a result of intimate partner violence.

HRSA has proposed an effort to collect data that may assist in further understanding the health consequences of intimate partner violence. As part of its strategy to address intimate partner violence, HRSA officials recently began requiring federally qualified health centers to capture International Classification of Diseases-10 codes for intimate partner violence on health care claims beginning in 2020. This effort is not aimed at the intersection of intimate partner violence and brain injuries; the purpose of this data collection is to better understand the effect of intimate partner violence on victims’ health outcomes. While these data may currently underestimate the number of individuals affected by intimate partner violence, HRSA officials told us that their goal in collecting these data is to underscore the significance of intimate partner violence and help position providers to assist victims. Further, knowing the prevalence of brain injuries resulting from intimate partner violence and using these data could help officials further target education campaigns to providers on the potential injuries associated with intimate partner violence.

Officials from HHS agencies acknowledge that the lack of prevalence data on brain injuries resulting from intimate partner violence is a challenge in addressing the intersection of these issues. However, HHS and its agencies do not have a plan for how they would collect better prevalence data, including a plan that specifies the extent to which HHS agencies should collaborate on data collection efforts. Although HHS agencies have some efforts underway, these efforts are limited or do not examine the connection between the issues. For example, CDC is working to add a question to NISVS to improve what is known about the prevalence of TBIs among victims of intimate partner violence; however, this effort overlooks brain injuries resulting from strangulation—which HRSA reports is often also experienced by these victims—because CDC’s priorities are to focus on TBIs specifically. Further, the newly funded NIH study is not intended to estimate the overall prevalence of brain injuries resulting from intimate partner violence.

Having complete data on the prevalence of brain injuries resulting from intimate partner violence could strengthen HHS’s efforts to address this public health issue. HHS and its agencies acknowledge that enhancing the health and well-being of Americans is critical to their public health mission and intimate partner violence and TBIs are both prominent injury and violence issues. As part of this mission, CDC uses its Public Health Approach to guide its public health related efforts. The first step of this approach is to define the problem, which includes collecting prevalence data to understand the magnitude of the problem, where the problem exists, and whom it affects. According to CDC, such data are critical to ensuring that resources are focused on the individuals most in need.

Collecting data on the prevalence of brain injuries resulting from intimate partner violence is a critical first step. With better data comes a better understanding of the overall prevalence of brain injuries resulting from intimate partner violence. This would give HHS and its agencies the information necessary to inform their efforts and allocate resources, including grant funding, to address victims of brain injuries resulting from intimate partner violence.

Conclusions

Intimate partner violence affects over 30 percent of women and men in the United States, and research has raised concerns about brain injuries sustained by these domestic violence victims. Officials from HHS agencies acknowledge the lack of overall prevalence data on brain injuries resulting from intimate partner violence and the adverse effect this lack of data has on understanding the intersection of these two issues. While HHS agencies have some efforts underway to address brain injuries and intimate partner violence, they are limited and address these issues separately. Therefore, HHS and its agencies have missed an opportunity to improve their public health efforts to address this issue, particularly the prevalence of the problem, where the problem exists, and whom it affects. By working together, HHS and its agencies can identify ways that each agency’s efforts could result in better prevalence data and a better overall understanding of brain injuries resulting from intimate partner violence. Improved data, in turn, could also help ensure that federal resources are allocated to the appropriate areas and used as efficiently and effectively as possible to address this public health issue.

Recommendation

We are making the following recommendation to HHS: The Secretary of HHS should develop and implement a plan to improve data collected on the prevalence of brain injuries resulting from intimate partner violence and use these data to inform HHS’s allocation of resources to address the issue. (Recommendation 1)

Agency Comment

We provided a draft of this report to HHS and DOJ for review and comment. In its written comments (reproduced in app. III), HHS concurred with our recommendation and noted that it is coordinating a plan amongst its relevant agencies to augment data collection on the prevalence of brain injuries resulting from intimate partner violence. HHS noted that these data will continue to inform the needs of this vulnerable population. HHS and DOJ also provided technical comments, which we incorporated as appropriate.

We are sending copies of this report to the appropriate congressional committees, Secretary of Health and Human Services, Attorney General, and other interested parties. In addition, the report is available at no charge on the GAO website at http://www.gao.gov.

If you or your staff members have any questions about this report, please contact me at (202) 512-7114 or yocomc@gao.gov. Contact points for our Office of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made key contributions to this report are listed in appendix IV.

Appendix I: Description of Literature Review and Bibliography

We identified articles for our literature review through a search of bibliographic databases, including Harvard Library Think Tank Search, MEDLINE, and Scopus, using terms such as “intimate partner violence,” “domestic violence,” “traumatic brain injury,” and “strangulation.” We determined there were 57 relevant articles from 2009 through August 2019 discussing brain injuries resulting from intimate partner violence. We reviewed the 57 articles to examine brain injuries resulting from intimate partner violence, including background information on the concerns of brain injuries resulting from intimate partner violence and challenges that researchers may have identified in conducting this work.

Of the 57 articles, we identified 28 that had conducted their own data analyses. We analyzed these 28 articles to examine data on prevalence rates, as well as research on health effects, treatment, and screening tools for identifying brain injuries resulting from intimate partner violence. The following articles are based on an original analysis of data.

Brown, Joshua, Dessie Clark, and Apryl E. Pooley. “Exploring the Use of Neurofeedback Therapy in Mitigating Symptoms of Traumatic Brain Injury in Survivors of Intimate Partner Violence.” Journal of Aggression, Maltreatment & Trauma, vol. 28, no. 6 (2019): 764-783.

Campbell, Andrew M., Ralph A. Hicks, Shannon L. Thompson, and Sarah E. Wiehe. “Characteristics of Intimate Partner Violence Incidents and the Environments in Which They Occur: Victim Reports to Responding Law Enforcement Officers.” Journal of Interpersonal Violence (2017): 1-24.

Campbell, Jacquelyn C., Jocelyn C. Anderson, Akosoa McFadgion, Jessica Gill, Elizabeth Zink, Michelle Patch, Gloria Callwood, and Doris Campbell. “The Effects of Intimate Partner Violence and Probable Traumatic Brain Injury on Central Nervous System Symptoms.” Journal of Women’s Health, vol. 27, no. 6 (2018): 761-767.

Cimono, Andrea, N., Grace Yi, Michelle Patch, Yasmin Alter, Jacquelyn C. Campbell, Kristin K. Gunderson, Judy T. Tang, Kiyomi Tsuyuki, and Jamila K. Stockman. “The Effect of Intimate Partner Violence and Probable Traumatic Brain Injury on Mental Health Outcomes for Black Women.” Journal of Aggression, Maltreatment & Trauma, vol. 28, no. 6 (2019): 714-731.

Crowe, Allison, Christine E. Murray, Patrick R. Mullen, Kristine Lundgren, Gwen Hunnicutt, and Loreen Olson. “Help-Seeking Behaviors and Intimate Partner Violence-Related Traumatic Brain Injury.” Violence and Gender, vol. 6, no. 1 (2019): 64-71.

Gagnon, Kelly L., and Anne P. DePrince. “Head Injury Screening and Intimate Partner Violence: A Brief Report.” Journal of Trauma & Dissociation, vol. 18, no. 4 (2017): 635-644.

Higbee, Mark, Jon Eliason, Hilary Weinberg, Jonathan Lifshitz, and Hirsch Handmaker. “Involving Police Departments in Early Awareness of Concussion Symptoms during Domestic Violence Calls.” Journal of Aggression, Maltreatment & Trauma, vol. 28, no. 7 (2019): 826-837.

Hunnicutt, Gwen, Christine Murray, Kristine Lundgren, Allison Crowe, and Loreen Olson. “Exploring Correlates of Probable Traumatic Brain Injury among Intimate Partner Violence Survivors.” Journal of Aggression, Maltreatment & Trauma, vol. 28, no. 6 (2019): 677-694.

Hux, Karen, Trish Schneider, and Keri Bennett. “Screening for traumatic brain injury.” Brain Injury, vol. 23, no. 1 (2009): 8-14.

Joshi, Manisha, Kristie A. Thomas, and Susan B. Sorenson. “‘I Didn’t Know I Could Turn Colors’: Health Problems and Health Care Experiences of Women Strangled by an Intimate Partner.” Social Work in Health Care, vol. 51, no. 9 (2012): 798-814.

Linton, Kristen Faye. “Interpersonal violence and traumatic brain injuries among Native Americans and women.” Brain Injury, vol. 29, no. 5 (2015): 639-643.

Messing, Jill T., Kristie A. Thomas, Allison L. Ward-Lasher, and Nathan Q. Brewer. “A Comparison of Intimate Partner Violence Strangulation Between Same-Sex and Different-Sex Couples.” Journal of Interpersonal Violence, vol. 00, no. 0 (2018): 1-19.

Messing, Jill T., Michelle Patch, Janet S. Wilson, Gabor D. Kelen, Jacquelyn Campbell. “Differentiating among Attempted, Completed, and Multiple Nonfatal Strangulation in Women Experiencing Intimate Partner Violence.” Women’s Health Issues, vol. 28, no. 1 (2018): 104-111.

Mittal, Mona, Kathryn Resch, Corey Nichols-Hadeed, Jennifer Thompson Stone, Kelly Thevenet-Morrison, Catherine Faurot, and Catherine Cerulli. “Examining Associations between Strangulation and Depressive Symptoms in Women with Intimate Partner Violence Histories.” Violence and Victims, vol. 33, no. 6 (2019): 1072-1087.

Nemeth, Julianna M., Cecilia Mengo, Emily Kulow, Alexandra Brown, and Rachel Ramirez. “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, vol. 28, no. 6 (2019): 744-763.

Pritchard, Adam J., Amy Reckdenwald, Chelsea Nordham, and Jessie Holton. “Improving Identification of Strangulation Injuries in Domestic Violence: Pilot Data From a Researcher-Practitioner Collaboration.” Feminist Criminology, vol. 12, no. 2 (2018): 160-181.

Ralston, Bridget., Jill Rable, Todd Larson, Hirsch Handmaker, and Jonathan Lifshitz. “Forensic Nursing Examination to Screen for Traumatic Brain Injury following Intimate Partner Violence.” Journal of Aggression, Maltreatment & Trauma, vol. 28, no. 6 (2019): 732-743.

Reckdenwald, Amy, Ketty Fernandez, and Chelsea L. Mandes. “Improving law enforcement’s response to non-fatal strangulation.” Policing: An International Journal (2019): 1-15.

Reckdenwald, Amy, Chelsea Nordham, Adam Pritchard, and Brielle Francis. “Identification of Nonfatal Strangulation by 911 Dispatchers: Suggestions for Advances Toward Evidence-Based Prosecution.” Violence and Victims, vol. 32, no. 3 (2017): 506-520.

Shields, Lisa B.E., Tracey S. Corey, Barbara Weakley-Jones, and Donna Stewart. “Living Victims of Strangulation.” American Journal of Forensic Medicine and Pathology, vol. 31, no. 4 (2010): 320-325.

St. Ivany, Amanda, Linda Bullock, Donna Schminkey, Kristen Wells, Phyllis Sharps, and Susan Kools. “Living in Fear and Prioritizing Safety: Exploring Women’s Lives After Traumatic Brain Injury From Intimate Partner Violence.” Qualitative Health Research, vol. 28, no. 11 (2018): 1708-1718.

St. Ivany, Amanda, Susan Kools, Phyllis Sharps, and Linda Bullock. “Extreme Control and Instability: Insight Into Head Injury From Intimate Partner Violence.” International Association of Forensic Nursing, vol. 14, no. 4 (2018): 198-205.

St. Ivany, Amanda, and Donna Schminkey. “Rethinking Traumatic Brain Injury from Intimate Partner Violence: A Theoretical Model of the Cycle of Transmission.” Journal of Aggression, Maltreatment & Trauma, vol. 28, no. 7 (2019): 1-23.

Sullivan, Karen A, and Christina Wade. “Assault-Related Mild Traumatic Brain Injury, Expectations of Injury Outcome, and the Effects of Different Perpetrators: A Vignette Study.” Applied Neuropsychology: Adult, vol. 26, no. 1 (2019): 58-64.

Sullivan, Karen A, and Christina Wade. “Does the Cause of the Mild Traumatic Brain Injury Affect the Expectation of Persistent Postconcussion Symptoms and Psychological Trauma?” Journal of Clinical and Experimental Neuropsychology, vol. 39, no. 4 (2017): 408- 418.

Valera, Eve M., Aihua Cao, Ofer Pasternak, Martha E. Shenton, Marek Kubicki, , Nikos Makris, and Noor Adra. “White Matter Correlates of Mild Traumatic Brain Injuries in Women Subjected to Intimate-Partner Violence: A Preliminary Study.” Journal of Neurotrauma, vol. 36 (2019): 661-668.

Valera, Eve, and Aaron Kucyi. “Brain Injury in Women Experiencing Intimate Partner-Violence: Neural Mechanistic Evidence of an “Invisible” Trauma.” Brain Imaging and Behavior, vol. 11 (2017): 1664-1677.

Zieman, Glynnis, Ashley Bridwell, and Javier F. Cardenas. “Traumatic Brain Injury in Domestic Violence Victims: A Retrospective Study at the Barrow Neurological Institute.” Journal of Neurotrauma, vol. 33, (2016): 1- 5.

Appendix II: Nonfederal Initiatives Focused on Intimate Partner Violence and Brain Injury

The following table provides a brief overview of each of the 12 initiatives we identified based on information provided by the Department of Health and Human Services, the Department of Justice, and other stakeholders. These initiatives engage in various efforts to address intimate partner violence and brain injuries, including traumatic brain injury and anoxic injuries resulting from strangulation. Our list includes those efforts identified during the course of our review and may not be exhaustive. The descriptions of initiatives are based on our review of documentation and information obtained from interviews with officials.

Appendix III: Comments from the Department of Health and Human Services

Appendix IV: Staff Acknowledgements and GAO Contact

GAO Contact

Staff Acknowledgments

In addition to the contact named above, Shannon Slawter Legeer (Assistant Director), Danielle Bernstein (Analyst-in-Charge), and Ashley Dixon made key contributions to this report. Also contributing were Leia Dickerson, Kaitlin Farquharson, Drew Long, and Ethiene Salgado- Rodriguez.