Characterization of Cognitive-Motor Function in Women Who Have Experienced Intimate Partner Violence-Related Brain Injury

Abstract

Intimate partner violence (IPV) affects at least one in three women worldwide, and up to 92% report symptoms consistent with brain injury (BI). Although a handful of studies have examined different aspects of brain structure and function in this population, none has characterized potential deficits in cognitive-motor function. This knowledge gap was addressed in the current study by having participants who had experienced IPV complete the bimanual Object Hit & Avoid (OHA) task in a Kinesiological Instrument for Normal and Altered Reaching Movement (KINARM) End-Point Laboratory. BI load, post-traumatic stress disorder (PTSD), anxiety, depression, substance use, and history of abuse were also assessed. A stepwise multiple regression was undertaken to explore the relationship between BI load and task performance while accounting for comorbid psychopathologies. Results demonstrated that BI load accounted for a significant amount of variability in the number of targets hit and the average hand speed. PTSD, anxiety, and depression also contributed significantly to the variability in these measures as well as to the number and proportion of distractor hits, and the object processing rate. Taken together, these findings suggest that IPV-related BI, as well as comorbid PTSD, anxiety, and depression, disrupt the processing required to quickly and accurately hit targets while avoiding distractors. This pattern of results reflects the complex interaction between the physical injuries induced by the episodes of IPV and the resulting impacts that these experiences have on mental health.

Introduction

It is estimated that one in three women will experience intimate partner violence (IPV) in their lifetimes.¹ IPV is defined as any physical, sexual, and/or emotional abuse, as well as controlling behaviors from an intimate partner.¹ It leads to a multitude of physical, psychological, neurological, cognitive, and emotional consequences, most notably, anxiety, depression, and post-traumatic stress disorder (PTSD).^2

–5 However, it is increasingly recognized that brain injury (BI) resulting from violent blows to the head, face, and neck, and/or strangulation, is also a common part of this experience.^6,7 Although some survivors may experience neuropsychological impairment without BI,⁸ a recent review⁹ reported that up to 92% of women reported symptoms consistent with BI following an IPV incident.^4,10 Therefore, it is clear that IPV may result in a multitude of physical, psychological, and social consequences; however, the extent to which BI plays a role in such dysfunction is still poorly understood.

Valera and Berenbaum have shown that in women who have experienced IPV-related BI, BI severity is related to decreases in (1) memory, learning, and cognitive flexibility;¹¹ (2) functional connectivity in the default mode network similar to that observed in individuals with BI from other causes;³ and (3) white matter tract integrity in the posterior and superior corona radiate.⁵ Importantly, these relationships were present even when taking psychopathological comorbidities (e.g., PTSD, anxiety, depression) into account. Although these studies have provided much needed foundational evidence for IPV-related BI, there remains a need to investigate other aspects of brain function.

Cognitive-motor function is defined as the cognitive processes underlying complex motor output, and it involves the engagement of the executive function to plan, prepare, and produce rule-based skilled performance.¹² Previous research has demonstrated that BIs and repetitive subconcussive head impacts in other populations (e.g., contact sport athletes, military personnel, people experiencing homelessness) are often associated with alterations in cognitive-motor performance.^12

–16 Given the chronic and repetitive nature of IPV, it is likely that alterations in cognitive-motor function may also be present in survivors of IPV-related BI. Therefore, the purpose of this study was to characterize cognitive-motor function in women who have experienced IPV and to examine the extent to which it was related to clinical measures of executive function. We hypothesized that women who reported more exposure to IPV-related BI would display more pronounced cognitive-motor deficits than those with less exposure.

Methods

Participants

Women who had experienced IPV were recruited from a local women's shelter and other women-serving organizations. Individuals were eligible if they identified as women, were between 18 and 50 years of age, and had experienced IPV. Exclusion criteria included being pregnant, or having been diagnosed with a neurological or neuropsychiatric disorder other than BI that could affect cerebrovascular, neurocognitive, and/or sensorimotor function (e.g. stroke, Parkinson's, Alzheimer's, migraine, seizures, schizophrenia) or an orthopaedic, musculoskeletal, or degenerative disorder that could affect balance control (e.g. osteoarthritis, recent lower limb joint surgery). Participants provided written informed consent and the study was approved by the local Clinical Research Ethics Board.

Procedures

Participants completed two sessions prior to which they were asked to refrain from consuming alcohol or using drugs for 24 h. During the first session lasting ∼2 h, participant demographics (including age, years of education, ethnicity, indigeneity, access to housing, and time since last injury), Clinician-Administered PTSD Scale for DSM-IV (CAPS-IV), Beck depression and anxiety inventories, Women's Experiences with Battering (WEB) scale,¹⁷ and initial substance use scale¹⁸ were collected. In addition, the Brain Injury Severity Assessment (BISA),¹¹ a semi-structured interview used to characterize BI load resulting from impacts targeting the head, face, and neck, and strangulation that resulted in alterations of consciousness during episodes of IPV, was also completed. The BISA yields an overall score of 0–8 composed of recency, frequency, and severity subcomponents. Further details on the BISA can be found in the original publication by Valera and Berenbaum¹¹ and in subsequent articles in which it has been used.^3,5,10,19

During the second visit, participants completed a series of physiological, neurocognitive, and sensorimotor assessments over the course of 90–120 min. The assessments were always done in the same order; therefore, although we did not directly test for fatigue, its potential impact on test results would be consistent across participants. This study reports the results for the Object Hit and Avoid (OHA) task performed on the Kinesiological Instrument for Normal and Altered Reaching Movement (KINARM) End-Point Lab (BKIN Technologies, Kingston, Ontario, Canada). The KINARM consists of two moveable robotic arms, one for each hand, and is equipped with a display screen that provides feedback during a variety of sensorimotor tasks. The reliability, sensitivity, and objectivity of the KINARM technology to detect deficits in motor, spatial and temporal, and global performance in brain-injured participants have been previously described.^20
–22 In the OHA task, participants were asked to hit two pre-determined target shapes while avoiding all other distractor shapes. Over the course of the 2-min task, the shapes descended from the top of the screen with increasing speed, starting at ∼10 cm/sec and ending at ∼50 cm/sec. Performance on the task was assessed via the parameters outlined in Table 1.^23
–25 Finally, to determine if IPV-related BI alterations in OHA task performance were related to clinical measures of executive function, participants also completed the Trail-Making A and B Tasks (TMT) and the Behavior Rating Inventory of Executive Function – Adult (BRIEF-A).

Table 1.

Task Parameters for the Object Hit Avoid Task and Associated Behavioral Attributes

Parameter	Description	Behavioral attribute
Total object hits (n)	Total number of objects hit (target and distractors)	Global performance
Total target hits (n)	Total number of targets hit off screen in opposite direction as original path	Global performance
Total distractor hits (n)	Total number of distractor hits	Global performance
Distractor proportion (%)	Proportion of distractors hit compared with total number of distractors	Global performance
Hand speed – L/R (m/sec)	Mean speed of right and left hand, respectively, throughout task	Motor performance
Hand movement area – L/R (cm²)	Area of space occupied by right and left hand, respectively	Motor performance
Median error (%)	Point in task (% complete) when participants made half of their errors	Spatial and temporal performance
Miss bias (m)	Value between -1 and 1 that describes the bias in number of balls missed in the dominant and non-dominant sides of the work space	Spatial and temporal performance
Hand bias hits (n/n)	Value between -1 and 1 that describes the bias in number of balls hit by the dominant and non-dominant hands	Motor performance
Hand transition (m)	Represents where preference for right or left hand switches in the work space.	Spatial and temporal performance
Hand selection overlap (%)	Captures use of both hands and how often their use overlaps within work space (i.e., balls hit with both hands in same area of work space).	Motor performance
Hand speed bias (m/sec)	Value between -1 and 1 that describes the bias in mean hand speed between the dominant and non-dominant hands	Motor performance
Movement area bias R/L (m²)	A value from -1 to 1 that describes the bias in movement area between the dominant and non-dominant hands	Motor performance
Object processing rate	Number of objects correctly processed per second at the time when 80% of the objects in the task have entered the screen	Global performance

Statistical analysis

Stepwise multiple regression analyses were completed in R (Version 3.6.3) to evaluate the relationship between BI load and task performance while accounting for potential confounders (i.e., age, PTSD, depression, anxiety, history of abuse, substance use, previous history of non-IPV-BI). Q-Q plots and residual plots were used to initially visualize the data and assess assumptions. Model fits were assessed using Akaike Information Criterion (AIC) with individual participants stratified based on their BISA score. Significance was set a priori at p < 0.05. To allow the reader to better visualize the model outputs, we plotted a subset of the significant results of the effect of IPV-related BI on task performance. These data were further broken down by BISA subcomponent score (i.e., recency, frequency, severity) and post-hoc t tests were used to examine potential differences. Finally, to better understand whether OHA performance measures predicted by the BISA scores were related to clinical measures of executive function (TMT, BRIEF-A), we calculated the correlations between these variables.

Results

Demographics

Our community partner organizations serve several hundred women each year. Over a 3-year period (2017–2020) each client was made aware of the study and asked if she would be interested in participating. Of those, 63 agreed to take part, 40 of whom participated in the experiment described in this article. The remaining 23 completed the first session, but were unable to complete the second session for a variety of reasons mainly related to their lives being in transition. Table 2 outlines the demographic and clinical characteristics of our sample. The median BISA total score was 4 ± 2.12. Only two participants scored 0 on the BISA scale, indicating that 95% (n = 38) of our sample experienced an IPV-related BI. As expected, 95% of participants fulfilled the criteria for battering according to the WEB scale (defined as scores >20). Moreover, elevated levels of PTSD (95% of participants), depression (62% of participants), and anxiety (58% of participants) were observed, consistent with previous research on women experiencing IPV.²⁶ Within the group, 22.5% of the participants were Indigenous women. This is an overrepresentation of the general population of the area (6% of the population in the region is Indigenous)²⁷ and is consistent with previous work examining the incidence of IPV in Indigenous populations in Canada.^28
–30 Lastly, 75% of participants also reported a non-IPV-BI.

Table 2.

Participant Characteristics; Median ± Standard Deviation (SD) Unless Otherwise Specified

Demographics
n	40
Age, years	37.4 ± 7.97
Education, years	14 ± 2.19
Visible minority, %(n)	12.5 (5)
Indigenous, %(n)	22.5 (9)
No access to housing, %(n)	20.0 (8)
Non-partner related BI %(n)	75.0 (30)
Time since last injury, months	21 ± 65
Assessment scores
WEB	52.5 ± 13.4
Battered, %(n)	95 (38)
BAI	22.5 ± 13.28
BDI	23.5 ± 13.1
CAPS-4 Severity	179.5 ± 70.22
Substance use, max years	14 ± 9.88
Substance used, %(n)
Tobacco	44.2. (19)
Alcohol	23.3 (10)
Marijuana	20.9 (9)
Other	13.9 (6)

BI, brain injury; WEB, Women's Experience with Battering scale; BAI, Beck Anxiety Inventory; BDI, Beck Depression Inventory; CAPS-4, Clinician-Administered PTSD Scale for DSM-4.

Stepwise multiple linear regression

The outputs of the stepwise multiple regression analysis are shown in Table 3. Model fits as assessed with AIC indicated that total targets hit, total objects hit, and right and left hand speed were predicted by the BISA total score along with different combinations of PTSD, anxiety, and depression. Moreover, total distractors hit, distractor proportion, and object processing rate were significantly associated with PTSD and depression, but not with the BISA total score. In other words, a higher BISA score was associated with a decrease in OHA performance accuracy and slower hand speed, when accounting for PTSD, anxiety, and depression. Age, abuse history, substance use, and previous history of non-IPV-BI did not significantly contribute to the model and the remaining OHA performance variables (Table 1) were not significantly accounted for by any of the predictors.

Table 3.

Results of Stepwise Regression Analysis

Predictors	Target hits	Distractor hits	Objects hit	R hand speed	L hand speed	Distractor proportion	Object processing rate
BISA	-2.83^**		-3.1^**	-0.01^**	-0.01^**
CAPS-IV	0.17^**	-0.059^**	0.13^**			-0.03^**	0.003^**
BAI			-0.36^*		0.0018^**
BDI	-0.54^**	0.37^**		0.002^**		0.21^**	-0.012^**
Years of substance use				0.002		0.11	-0.007
Non-IPV-BI				-0.03
Multiple R²	0.28	0.19	0.224	0.18	0.23	0.23	0.28
F statistic	4.59	4.36	3.75	4.05	5.49	3.63	3.55
p value	0.008	0.02	0.02	0.026	0.008	0.02	0.02

Each cell represents the unstandardized model estimates for each predictor for each dependent variable.

Significant at p < 0.05; ^*Entered into the model at p < 0.10. All others predictors were not significant. Assumptions of normality, linearity, and homoscedasticity were all met and there were no influential cases.

BISA, Brain Injury Severity Assessment; CAPS-IV, Clinician-Administered PTSD Scale; BAI, Beck Anxiety Inventory; BDI, Beck Depression Inventory; Non-IPV-BI, Non-Intimate Partner Violence-Related Brain Injury.

To better visualize these results, we plotted simple linear regressions for a subset of dependent variables that had significant model fits. As an example, Figure 1A shows that women with higher BISA scores tended to hit fewer targets than those who had lower BISA scores. We further examined the extent to which this relationship was driven by specific subcomponents of the BISA (e.g., frequency, recency, or severity) and found that women who experienced >10 BIs (BISA frequency score: 3,4) hit fewer targets than women who experienced ≤10 or fewer BIs (BISA frequency score: 1,2) (t test = 1.78, p = 0.04) (Figure 1B). Similarly, women who reported loss of consciousness and/or a period of post-traumatic amnesia following an episode of IPV (BISA severity score hit fewer targets than women who did not (BISA severity score: 0) (t test = 1.89, p = 0.03) (Figure 1C). As a second example, women with higher BISA scores tended to move more slowly than those with lower BISA scores (Fig. 2A) and that this was because women who had experienced an IPV-related BI in the past year (BISA recency score: 1,2,3) moved more slowly than women who experienced their most recent IPV-related BI >1 year ago (BISA recency score: 0) (t test = 2.11, p = 0.02) (Fig. 2B). Finally, despite the significant model fit for the Total Objects Hit score, none of the BISA subcomponents were found to contribute, suggesting that only the total BISA score (plus PTSD and anxiety levels) accounted for the variability in this measure.

FIG. 1.

Total target hits plotted as a function of Brain Injury Severity Assessment (BISA) score (A). Total target hits for participants who had experienced ≤10 brain injuries (BIs) (frequency scores: 1,2) versus those who had experienced ≥11 BIs (frequency scores: 3,4) (B). Total target hits for those who had not lost consciousness and/or had a period of post-traumatic amnesia (severity score: 0) versus those who had (severity score: 1) (C).

FIG. 2.

Hand speed (averaged across left and right hands) plotted as a function of Brain Injury Severity Assessment (BISA) score (A). Average hand speed for participants who had experienced their most recent episode >1 year ago (recency score: 0) versus those who had experienced their most recent episode within the last year (recency scores: 1,2,3) (B).

Executive function measures

To better understand how deficits in the OHA task associated with IPV-related BI were related to clinical measures of executive function, we performed Pearson's correlations. We found significant negative relationships between total target hits and total object hits and Trail-Making A time (r = -0.39, p = 0.012; r = -0.37, p = 0.017) and Trail-Making B time (r = -0.42, p = 0.008 for both). No significant correlations were found between these performance measures and BRIEF-A scores or for the hand speed measures.

Discussion

This exploratory study provides a first investigation of cognitive-motor function in women who have experienced IPV. We found that BI load, as assessed by the BISA score, accounted for a significant amount of variability in the number of targets hit, the number of objects hit, and hand speed. These findings suggest that IPV-BI at least partially accounts for the decrements observed in global and motor performance. Our analysis also revealed that PTSD, anxiety, and depression contributed to these deficits as well. Moreover, the number and proportion of distractors hit and the object processing rate were driven by PTSD and depression. The fact that comorbidities such as PTSD, anxiety, and depression also contribute to these deficits in global performance reflects the complex interaction between the physical injuries induced by the episodes of IPV and the resulting impacts that these experiences have on mental health. Thus, whereas BI significantly contributes to certain aspects of global and motor performance in this task, the results are also consistent with the fact that the psychopathological comorbidities that are part of the experience of IPV also partially drive the results observed.

Our findings add to the small but growing body of literature highlighting the chronic and deleterious effects of BI in this population. In particular, the results of this study suggest that women who have experienced IPV exhibit cognitive-motor deficits that are at least partially attributed to BI. The fact that these deficits were correlated with measures of attention and executive function (i.e., Trail-Making Task performance) suggest that they also offer clinically meaningful information. Moreover, the current results are consistent with studies of repetitive head impacts in collision sport athletes showing impairments in cognitive-motor function that have been linked to an increased risk for long-term impairment.³¹ This is relevant given that survivors of IPV may experience violent episodes at regular intervals over a period of months or years.^32,33 Crucially, the median time since the last IPV-related BI in our sample was just <2 years, with a substantial range of times across participants. It remains unknown whether chronic and repetitive exposure to IPV, and, by extension, potential BI, puts women at risk for long-term cognitive impairment or neurodegeneration. However , it has been demonstrated that spousal abuse increases the odds of an Alzheimer's diagnosis in women,³⁴ and there are at least two case reports of women who had experienced IPV demonstrating progressive dementia and morphological brain changes consistent with chronic traumatic encephelopathy (CTE).^35,36 In light of the growing body of evidence suggesting that high exposure to both concussive and subconcussive impacts may increase the risk of progressive neurodegeneration,³⁷ there is an urgent need to investigate the risk of long-term functional impairments and neurodegeneration in the context of IPV.

Measures of global and motor performance, assessed using the KINARM, were also associated with PTSD and depression. These results are consistent with the literature, reporting neurocognitive deficits in both IPV and associated psychopathologies.^8,38,39 These findings also support the idea that deficits in cognitive-motor function may be attributed to the complex interaction among the trauma – whether emotional, psychological, or physical – induced by episodes of IPV, resulting psychopathologies, and BIs, rather than to a singular factor. Although disentangling these factors remains a challenge, their overall impact on women's lives and well-being remains significant. As an example, we speculate that IPV-related BI and the impact of associated comorbidities may contribute to the challenges for survivors in making appropriate and timely decisions around safety planning and accessing supports and, thereby, may contribute to difficulties in successfully transitioning to a life free from abuse. Therefore, supports, resources, and training created for this population should consider the added burden of BIs on women experiencing IPV. Whereas anti-racist and anti-discriminatory trauma- and violence-informed care should be at the heart of all healthcare practices, further knowledge and awareness of IPV-related BI and its effect on brain function may help explain some of the behaviors historically attributed to faults in character.⁴⁰

Despite the novel findings of this research, it should be viewed as a pilot study with a number of limitations. First, because of the small sample size, we may lack sufficient power to detect subtle but meaningful deficits. In addition, the cohort tested was a convenience sample of women recruited from local anti-violence organizations, therefore limiting the generalizability of our findings. It is well documented that IPV can affect all women, irrespective of age, race, ethnicity, and religion; therefore, it is essential that future studies include a more diverse sample. In addition, by recruiting primarily from a shelter that asked residents to remain clean during their stay and asking participants to refrain from consuming alcohol or using drugs for 24 h prior to testing, we may have excluded women with more severe episodes of IPV and thereby failed to encompass a wide spectrum of experiences. Further, the overrepresentation of Indigenous women among our participants is consistent with the literature³⁶ and highlights the urgent need for more collaborative engagement, education, services, and research in these communities. Haag and colleagues⁴¹ recently described IPV knowledge and service gaps in several Inuit and First Nations communities, further supporting a call to action and emphasizing the need for a strength-based and collaborative approach in studying IPV with Indigenous communities. It remains critical to study and quantify IPV-related BI in these populations to better understand the systemic barriers to care and safety that they face. Given the cross-sectional design of this study, one should also be cautious about drawing causal links between IPV-related BI and cognitive-motor function. Factors, such as childhood abuse and BIs from other incidents (e.g., car accidents, falls, sports concussion) may also partly account for the alterations in cognitive-motor function that we observed. Although participants sometimes referred to such experiences in our assessments, we did not systematically characterize them. Lastly, we did not include a control group, therefore limiting our ability to infer the independent effect of IPV-related BI on cognitive-motor function. Indeed, identifying an appropriate control group for IPV-related BI survivors presents a significant methodological challenge. Whereas the ideal control group would consist of women who have experienced IPV but not a BI, our data indicate that this is an uncommon occurrence, as evidenced by the fact just 2 of the 40 women (5%) included in the current investigation reported a BISA score of 0 (the score expected from someone who has experienced IPV but not sustained an IPV-related BI). This further highlights the prevalence of IPV-related BIs and underscores the urgency for continued research efforts.

Despite these limitations, this study provides a first exploration of cognitive-motor function related to IPV and adds to the growing body of literature demonstrating evidence of chronic effects of BI in this population. Future studies should aim to further characterize IPV-related BI in a larger, more heterogeneous sample. In addition, given the association between cognitive impairment and history of BI, there is a need for longitudinal studies documenting neurocognitive and sensorimotor function in women who have experienced IPV, to better understand the long-term consequences of IPV-related BIs, including the risk for cognitive impairment and neurodegeneration. Ultimately, investigating the physiological basis of IPV-related BI will improve our understanding of the various dimensions of this experience, and support efforts to improve access to resources designed for this population.

Conclusion

Overall, the findings from the current study suggest that IPV-related BI, in combination with the comorbid PTSD, anxiety, and depression, disrupts global and motor performance during a complex cognitive-motor task. We suggest that these results reflect the complex interaction among the emotional, psychological, and physical trauma associated with IPV and support the call for more trauma-informed BI supports and resources for this underserved population.

Footnotes

Acknowledgments

The authors thank the clients and staff at Kelowna Women's Shelter and the Central Okanagan Elizabeth Fry Society.

Authors' Contributions

Dr. van Donkelaar was responsible for the conceptualization of the study and obtaining institutional review board (IRB) approval. Drs. Maldonado-Rodriguez, Crocker, Jones, Rothlander, Smirl, and Wallace were responsible for data collection, and Drs. Maldonado-Rodriguez, Crocker, Smirl, and Wallace completed the data analysis. All authors contributed to data interpretation, editing of the manuscript, and approval of the final version.

Data Sharing

Anonymized data collected for this study have been deposited in the Dataverse repository and can be viewed here: https://doi.org/10.5683/SP2/6MJNOD

Funding Information

Dr. Maldonado-Rodriguez was supported by a Canada Graduate Scholarship – Master's award. This work was supported by grants from the Department of Women and Gender Equality (GV18315-01), Canadian Institutes of Health Research (013902), Canadian Foundation for Innovation, and an anonymous donor (012153).

Author Disclosure Statement

No competing financial interests exist.

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