Understanding the Relationship between Family Violence and Brain Injury by Brain Injury Association of Tasmania

UNDERSTANDING THE RELATIONSHIP BETWEEN FAMILY VIOLENCE AND BRAIN INJURY

THE BRAIN INJURY ASSOCIATION OF TASMANIA

AUGUST 2016

ACKNOWLEDGEMENTS This research was undertaken by Rosemary Mooney BA Hons, PhD, and the report written by her and Brain Injury Association of Tasmania (BIAT) Executive Officer, Deborah Byrne. It was funded by BIAT, from their Department of Health and Human Services (Disability Services) grant. The research findings and recommendations presented in this report are those of the Brain Injury Association of Tasmania and should not be attributed to research funders or contributors. Any errors are the responsibility of the authors.

ABOUT THE BRAIN INJURY ASSOCIATION OF TASMANIA The Brain Injury Association of Tasmania (BIAT) is the peak body formed to monitor and support the long term needs of people living with or affected by brain injury in Tasmania. The Association has three key strategic objectives: raise community awareness of acquired brain injury (ABI) and its impacts; drive changes to improve the lives of people living with or affected by ABI; and build strategic partnerships and undertake collaborative work to provide a strong voice for people affected by ABI. BIAT advocates for Tasmanian Government policies, programs and services that reflect the needs and priorities of people living with or affected by brain injury. It provides input into policy, legislation and program development through active contact with Tasmanian Government ministers, parliamentary representatives, Tasmanian Government departments and agencies, and other disability and community organisations. BIAT has a key role in activities that contribute to a community that is more informed about acquired brain injury (ABI). Through the provision of training, education and resources, BIAT works to promote awareness and understanding of the impact of ABI to families, communities, and service providers.  BIAT is also focused on ensuring that the Australian Government’s proposed National Disability Insurance Scheme (NDIS) and National Injury Insurance Scheme (NIIS) truly reflect the lived experience of ABI, in all its disparateness and diversity. © Brain Injury Association of Tasmania Inc, August 2016. This work is copyright. Apart from any personal use permitted under the Copyright Act 1968 no part may be reproduced without permission of Brain Injury Association of Tasmania Inc.

TABLE OF CONTENTS TABLE OF CONTENTS ....................................................................................................................................i EXECUTIVE SUMMARY ............................................................................................................................... 1 RECOMMENDATIONS................................................................................................................................. 3 DEFINITIONS ................................................................................................................................................... 6 Acquired Brain Injury (ABI) ....................................................................................................................... 6 Head Injury ...................................................................................................................................................... 6 Sequelae............................................................................................................................................................ 6 Family Violence .............................................................................................................................................. 6 Victim ................................................................................................................................................................. 6 THE GENDERED NATURE OF FAMILY VIOLENCE ............................................................................ 7 SCREENING FOR BRAIN INJURY ............................................................................................................. 7 1.

INTRODUCTION .................................................................................................................................. 8 BRAIN INJURY ASSOCIATION OF TASMANIA RECOMMENDATION 1 ........................... 9

BRAIN INJURY AS A CONTRIBUTING FACTOR TO FAMILY VIOLENCE ..................... 10 2.1. The prevalence of brain injury among perpetrators of family violence .................... 10 2.2. ‘Injury-related’ violence ............................................................................................................... 10 2.3. The association between brain injury and aggression ..................................................... 11 2.4. A targeted and integrated approach to rehabilitation ..................................................... 11

BRAIN INJURY AS A CONSEQUENCE AND RISK FACTOR OF FAMILY VIOLENCE. 13 3.1. The prevalence of brain injury among victims of family violence ................................ 13 3.2. The prevalence of brain injury among victims of family violence in Australia and Tasmania: a projection .................................................................................................................. 14 3.3. The association between brain injury and vulnerability ................................................. 14 BRAIN INJURY ASSOCIATION OF TASMANIA RECOMMENDATIONS 2 - 4 ............... 16

COMPOUNDING FACTORS IN RECOGNISING THE RELATIONSHIP BETWEEN BRAIN INJURY AND FAMILY VIOLENCE ................................................................................. 17 4.1. Why is the relationship between brain injury and family violence poorly understood?....................................................................................................................................... 17 i

4.1.1. Brain injury in Australia: prevalence and economic costs ................................ 17 4.1.2. The characteristics of brain injury related disability: unique and complex 18 4.1.3. An ‘invisible’ phenomenon: under reported, under diagnosed, under rehabilitated, under researched .................................................................................. 19 4.2. The need for a collaborative and targeted approach ....................................................... 20 4.3. A question of agency...................................................................................................................... 21 4.4. Additional interlinked concerns................................................................................................ 21 4.4.1 The National Disability Insurance Scheme .............................................................. 21 4.4.2 Child Protection ................................................................................................................. 22 BRAIN INJURY ASSOCIATION OF TASMANIA RECOMMENDATIONS 5 - 7 ............... 22 5.

THE WAY FORWARD: WHERE TO FROM HERE? ................................................................. 23 5.1. Recommendations for action: Promoting a preventative and supportive approach ............................................................................................................................................. 23 5.1.1 The National and State response to family violence and brain injury........... 23 5.1.2 Victorian Royal Commission into Family Violence............................................... 24 5.2. Primary prevention of family violence in the context of brain injury ........................ 25 5.2.1. BIAT primary prevention services ............................................................................. 26 BRAIN INJURY ASSOCIATION OF TASMANIA RECOMMENDATIONS 8 - 11 ............. 27 5.3. Strengthening support for people affected by family violence in the context of brain injury ................................................................................................................... 28 5.4. Strengthening perpetrator management and rehabilitation in the context of brain injury ................................................................................................................... 29 5.5. Strengthening legal response to family violence in the context of brain injury..... 30 BRAIN INJURY ASSOCIATION OF TASMANIA RECOMMENDATION 12 ..................... 31 5.6. Building the evidence base: Future research....................................................................... 31 BRAIN INJURY ASSOCIATION OF TASMANIA RECOMMENDATIONS 13-14 ............ 33

BRAIN INJURY ASSOCATION OF TASMANIA POSITION STATEMENT: BRAIN INJURY AND FAMILY VIOLENCE ................................................................................. 34

REFERENCES ................................................................................................................................................. 35 ANNEXURE 1. Acquired Brain Injury (ABI) Factsheet ......................................................................... 38

EXECUTIVE SUMMARY Research findings position brain injury as both a contributing factor to, and consequence of, family violence, and suggest urgent attention is needed to ensure the sequelae of living with a brain injury are accommodated within current family violence intervention and prevention strategies. This report presents a summary of the key issues surrounding the complex relationship between brain injury and family violence in Australia, and outlines the Brain Injury Association of Tasmania’s (BIAT) position statement on family violence and brain injury. Findings from the literature are presented and, in the context of brain injury, the priorities of the National Plan to Reduce Violence against Women and their Children 2010-2022 (COAG, 2011), the Safe Homes, Safe Families: Tasmania’s Family Violence Action Plan 2015-2020 (DPAC, 2015b), and the Victorian Royal Commission into Family Violence (State of Victoria, 2014-16) are discussed. While it is estimated that half of the people who perpetrate family violence have an existing brain injury (Crane & Easton, 2015; Farrer, Frost, & Hedges, 2012; Marsh & Martinovich, 2006), it is important to recognise that not all people living with brain injury perpetrate family violence. International and Australian research however demonstrates the association between brain injury and increased aggressive behaviour (Alderman, Knight, & Brooks, 2013; Baguley, Cooper, & Felmingham, 2006) with Rosenbaum et al. stating that: “A history of significant head injury increased the chances of marital aggression almost sixfold” (1994: 1191). The types of abuse that victims of family violence often report experiencing, including being hit in the face, head and neck, being shaken and being choked, are all risk factors for brain injury (Valera & Berenbaum, 2003). Research has found that at least a third of women who had experienced family violence sustained a brain injury (Monahan & O'Leary, 1999), yet the needs of women (and children) experiencing traumatic brain injury as a result of family violence are not being addressed. Victims of family violence are seldom screened for brain injury which means that the phenomenon of brain injury as a consequence of family violence is under reported (Banks, 2007; State of Victoria, 2014-16: 4); the same is true for perpetrators of family violence. Prevalence rates are therefore difficult to estimate due to under reporting, under diagnosis, and under researching of brain injury, making it an ‘invisible’ problem. The Victorian Royal Commission into Family Violence (State of Victoria, 2014-16) established that there was enough evidence of the intersection between family violence and brain injury to make a direct recommendation [171] to fund research examining the prevalence of acquired brain injury among family violence victims and perpetrators. The report describes the issue as “neglected” and “undiagnosed” to date in Australia. The economic consequences of family violence on the Australian and Tasmanian economies are significant. The routine identification of brain injury among perpetrators and victims of family violence, and implementation of targeted and integrated rehabilitation would significantly reduce the (re)occurrence of family violence and thus lessen the economic burden. 1

Primary prevention of family violence is the number one action of both the Australian National Plan (COAG, 2011) and the Tasmanian Safe Homes, Safe Families (DPAC, 2015b). BIAT supports the goal of primary prevention of family violence, and advocates the provision of effective targeted rehabilitation and support of people living with a brain injury from as soon as the brain injury event occurs. Focus should be placed on brain injury related characteristics that could become contributing factors to family violence perpetration or victimisation. The correlation between acquired brain injury and a propensity for domestic violence has important implications for therapy interventions. The identification of ABI in men who commit family violence would allow behaviour and cognitive strategies to be taught and thereby assist with inhibiting aggressive behaviours. Educating victims and perpetrators of family violence who are living with a brain injury about the way their brain works, how they can be instrumental in their own rehabilitation, and what options are available to them, has the potential, through self-awareness and knowledge, to assist recovery and behavioural change, and reduce further incidence of family violence. The complexity and individuality of brain injury as a health concern does not respond to a one-size fits all solution. In response to the evidence that victims and perpetrators of family violence living with a brain injury are multiple service users, the literature and government reports recommend a collaborative, integrated approach to support, rehabilitation and intervention. Communication between services is crucial for an effective response to family violence. Mapping of service and referral pathways for people living with brain injury who have experienced or perpetrated family violence is needed. Identifying gaps in the support, rehabilitation services, and referral pathways in Tasmania can assist with the prevention of family violence through the establishment of targeted supports and interventions, and a subsequent reduction in the cycle of victimisation and reoffending. The relationship between brain injury and family violence evidenced in this report points to an urgent need for education and training across all intersecting areas in relation to implementing brain injury screening and the provision of targeted services that are appropriate and effective for people living with a brain injury. The Brain Injury Association of Tasmania has the knowledge and expertise to take the lead in the development and delivery of a state wide program of education and training in brain injury across all intersecting service areas including, but not limited to, family violence, mental health, sexual assault, police, child protection, courts, and disability. Fourteen recommendations have been made in this report by the Brain Injury Association of Tasmania for moving forward. In the context of the relationship between family violence and brain injury these recommendations aim to improve knowledge, prevention, identification, rehabilitation, and the evidence base. We all have a responsibility to act. The relationship between family violence and brain injury cannot be ignored and must be addressed by the community, with a coordinated approach across all departments and sectors. 2

RECOMMENDATIONS In preparing this paper, a number of key issues relating to the relationship between brain injury and family violence were identified. In response, BIAT makes the following recommendations: 1.

The Tasmanian Government lead and facilitate interagency, cross sectoral collaboration and co-ordination in the development of a state wide framework of initiatives that respond to current family violence intervention and prevention strategies in the context of brain injury. Research findings position brain injury as both a contributing factor to, and consequence of, family violence, and suggest urgent attention is needed to ensure the sequelae of living with a brain injury are accommodated within current family violence intervention and prevention strategies.

Mandated brain injury screening for both perpetrators and victims of family violence. For all perpetrators of family violence, screening should be applied across the service sectors, particularly the criminal justice system given the prevalence of brain injury in the prison system (P. W. Schofield et al., 2006). Identification of brain injury would flag individuals for appropriate targeted rehabilitation and intervention, assisting behavioural change and reducing the likelihood of a reoccurrence of family violence. Routine screening for brain injury at first point of contact for all victims of family violence is recommended. Screening should be applied across the service sectors, including womenâ&#x20AC;&#x2122;s shelters, legal services, and counselling services. Identification of a brain injury would flag individuals for appropriate targeted support and rehabilitation, reducing the likelihood of a reoccurrence of family violence and preventing a cycle of victimisation and abuse.

Targeted and integrated intervention and rehabilitation programs for, and which incorporate the specialist and diverse needs of, both family violence perpetrators and victims living with a brain injury. Targeted support would assist perpetrators to make behavioural changes and reduce the likelihood of reoffending. To be effective programs need to include perpetrators already within the criminal justice system. For victims living with a brain injury, targeted support would assist individuals to escape and report family violence, take legal action against the perpetrator, and rebuild their lives.

The provision of timely and relevant information will better equip family violence program staff to recognise, understand and respond more effectively to the specific needs of people living with brain injury as a result of family violence. Increasing the ability of providers to identify family violence victims living with brain injury will help to increase victim’s chances of enhancing their lives. 5.

A whole-of-government response and strategy to address the needs of all Tasmanians living with or affected by brain injury in Tasmania An effective system response that crosses all government departments will do much to alleviate the current ad-hoc and inequitable system that fails many Tasmanians with ABI.

The identification and resolution of any inadequacies in the NDIS process for individuals living with brain injury. An examination of the referral pathways to support and the availability of services would highlight any potential gaps for victims and perpetrators of family violence who are living with brain injury.

The Tasmanian Government examine the implications for Child Protection services of the relationship between brain injury and family violence. BIAT urge the Tasmanian Government to undertake research to discover the impact for children living in families affected by brain injury and family violence, to take appropriate action in response to the research findings, and to provide targeted services.

Targeted education and rehabilitation for people newly diagnosed with brain injury and their families. Primary prevention of family violence starts with identification of brain injury in the population and subsequent targeted rehabilitation programs implemented soon after the brain injury is first diagnosed. Supporting individuals living with brain injury, and their families, to learn how to manage any changed cognitive and psychosocial functions they may experience, especially those relating to aggressive behaviour, can reduce the likelihood of family violence.

Education and training of all services who come into contact with people newly diagnosed with brain injury. The Brain Injury Secondary Consultation Information and Training (BISCIT) Project, (Headway Victoria and the Brain Foundation Victoria, 2000) found: •

Information tools as well as training and secondary consultation are almost nonexistent among service providers and this contributes to a widespread naiveté about acquired brain injury;

•

Of those service providers who were providing services to people with acquired brain injury, 89% reported a need for some form of information, training, or secondary consultation. This demonstrates a huge unmet need for assistance in working with people with acquired brain injury; 4

The Tasmanian Department of Health and Human Services Review of Funded Services for People with Acquired Brain Injury Final Report (1999) clearly states “Education was seen as one of the major gaps in the current service delivery system. Throughout the consultations, education was continually raised as a priority area. If this service is provided correctly it may impact on the level of pressure that is placed on other service types by this client group.” 10.

The BIAT Heads up to Brain Injury (HU2BI) and Custody for Lifeä (CFL) Programs be resourced to continue. Funding for these programs would enable the state-wide implementation of HU2BI and CFL, providing primary prevention of family violence through the goal of raising awareness of, and reducing the incidence of, brain injury.

11.

The Tasmanian Government resource continuation of the BIAT/Royal Hobart Hospital Acquired Brain Disorder Community Liaison Officer (CLO) position. The support provided by the CLO for people newly affected by brain injury and their families acts as a preventative tool against further negative life events through the provision of education, referral and guidance at the point of diagnosis and through the rehabilitation process.

12.

Education and resources for people experiencing and people perpetrating family violence. Providing knowledge about brain injury and family violence to people experiencing these life events and their families has the potential to increase self-awareness and empowerment, and reduce future vulnerability. Providing knowledge about brain injury and family violence to perpetrators living with brain injury, and their families, has the potential to increase self-awareness and understanding, and reduce future perpetration. BIAT has the knowledge and expertise to facilitate this process through the establishment of an education and resource program as part of the service sectors’ response to positive brain injury screening.

13.

Research be undertaken into the relationship between brain injury and family violence. This research would initiate data collection on victims and perpetrators of family violence who screened positively for brain injury, and enable the prevalence to be calculated for Tasmania.

14.

Research be undertaken into the mapping of services and referral pathways for people living with brain injury who have experienced or perpetrated family violence. This research would identify gaps in service provision and access, facilitate referral to appropriate services, provide recommendations to national guidelines for referral, and move Tasmania towards best practice care in the brain injury and family violence sectors.

DEFINITIONS Acquired Brain Injury (ABI) Acquired brain injury is an injury to the brain that occurs after birth. ABI is defined nationally as “…injury to the brain which results in deterioration of cognitive, physical, emotional or independent functions. It can occur as a result of trauma, hypoxia, infection, substance abuse, degenerative neurological disease or stroke. These impairments to cognitive abilities, sensory or physical function can be either temporary or permanent and cause partial or total disability or psychosocial maladjustment” (Department of Human Services and Health, 1994). Head Injury Head injury is a general term indicating damage to any part of the head, including the skin covering the skull, face or jaw, or the brain. When indicating damage to brain cells, causing temporary or permanent damage the term Brain Injury is used. Sequelae Sequelae is defined as an after effect or secondary result of a disease, condition, or injury. Family Violence In the Tasmanian Family Violence Act 2004 family violence is defined as:- family violence means – (a) any of the following types of conduct committed by a person, directly or indirectly, against that person's spouse or partner: (i)

assault, including sexual assault;

(ii)

threats, coercion, intimidation or verbal abuse;

(iii)

abduction;

(iv)

stalking within the meaning of section 192 of the Criminal Code;

(v)

attempting or threatening to in subparagraph (i), (ii), (iii) or (iv); or

commit

conduct

referred

(b) any of the following: (i) economic abuse; (ii) emotional abuse or intimidation; (iii) contravening an external family violence order, an interim FVO, an FVO or a PFVO. Victim Consistent with the National Plan to Reduce Violence against Women and their Children 20102022 (COAG, 2011), and Safe Homes, Safe Families: Tasmania’s Family Violence Action Plan 20152020 (DPAC, 2015b), BIAT has used the term ‘victim’ throughout this report rather than ‘survivor’. 6

THE GENDERED NATURE OF FAMILY VIOLENCE While this report recognises family violence can be perpetrated by both men and women, against both men and women, research has shown that family violence is most often violence committed by men against women. In Tasmania, over a ten year period from 2005 to 2015, 82.2% of family violence offenders were male and 87.8% of victims were female (DPAC, 2016: 2).

SCREENING FOR BRAIN INJURY “A face-to-face interview conducted by an informed professional is indeed the gold standard for determining lifetime history of TBI [traumatic brain injury]” (Corrigan & Bogner, 2007: 316). A screening tool for brain injury usually involves a self-report interview and acts as an initial indicator for the presence of brain injury. Screening for brain injury does not diagnose brain injury but acts as a prompt for further exploration and consideration of relevant pathways for support and rehabilitation (Hux, Schneider, & Bennett, 2009). The screening tool is designed to be administered by non-brain injury professionals across sectors and organisations. Victims of brain injury are screened using tools such as HELPS (Picard, Scarisbrick, & Paluck, 1991), which asks individuals about: previous blows to the head; medical treatment as a result of the head injury; loss of consciousness; and medical issues involving cognitive functioning of the brain, including headaches, depression and difficulty concentrating (Hux et al., 2009). The HELPS screening tool was designed to be used by professionals whose primary field of practice is other than brain injury. This makes the process of screening and identifying brain injury among victims of family violence straight-forward for first-response service providers, such as women’s shelters, family violence counselling services, police, and court officials. The brain injury screening tools for perpetrators of family violence needs to have a broader scope of enquiry due to the more varied ways in which perpetrators may have acquired their brain injury. In addition to screening for traumatic brain injury, the screening tool needs to incorporate: alcohol and/or drug related acquired brain injury, hypoxia, stroke, toxin-induced acquired brain injury, infection-related (meningitis, encephalitis) acquired brain injury, tumour, and neurological illness. Self-report has been found to be the gold standard in screening for brain injury (Corrigan & Bogner, 2007; Hux et al., 2009) and, when compared with medical records, to provide accurate data (P. Schofield, Butler, Hollis, & D’Este, 2011). A self-report screening process for brain injury, rather than purely a review of medical records, is necessary given the probability that no medical records exist due to the high proportion of head injuries, including those resulting in loss of consciousness, that receive no medical help: estimated at between 25-60% (Corrigan & Bogner, 2007). Even when medical attention is provided, the brain injury may not be visible or identifiable, as there is no biomarker that identifies all brain injury, meaning that mild and older brain injuries would be unlikely to be identified (Corrigan & Bogner, 2007; Valera & Berenbaum, 2003). 7

1. INTRODUCTION

This report presents a summary of the key issues surrounding the complex relationship between brain injury and family violence in Australia. The report identifies the Brain Injury Association of Tasmaniaâ&#x20AC;&#x2122;s position on ways to prevent and respond to family violence in the context of brain injury; outlines the issues, initiatives, and research; and points to a way forward in regard to prevention, support and rehabilitation. Research has demonstrated a relationship between brain injury and family violence. It is estimated that half of people perpetrating family violence have an existing brain injury (Crane & Easton, 2015; Farrer et al., 2012; Marsh & Martinovich, 2006). It is also estimated that between one to two-thirds of family violence victims sustain a brain injury as a result of the physical abuse they experience (Corrigan, Wolfe, Mysiw, Jackson, & Bogner, 2003; Hux et al., 2009; Kwako et al., 2011; Monahan & O'Leary, 1999; St. Ivany & Schminkey, 2016; Valera & Berenbaum, 2003). Both family violence and brain injury are under reported and under diagnosed. It is necessary to look behind the known statistics to find the individuals who do not seek family violence or medical help when they require it and therefore remain invisible. The issue of invisibility suffered by both family violence and brain injury make discussion of prevalence rates difficult. Prevalence rates for brain injury among perpetrators and victims of family violence within Australia are unknown and can only be extrapolated. With victims of domestic violence exposed to significant and ongoing risk for severe brain injury, healthcare professionals need to increase their awareness of family violence as a cause of traumatic brain injury, and to understand the cumulative and total effects of violence on the person. Australian research on the relationship between brain injury and family violence is limited. A direct recommendation from the Victorian Royal Commission into Family Violence (State of Victoria, 2014-16) states the need for research into the prevalence of acquired brain injury among family violence victims and perpetrators in the next two years. The literature supports this submission and points overwhelmingly to a need for brain injury screening to be mandated for victims and perpetrators of family violence, to document prevalence and build the evidence base (Corrigan & Bogner, 2007; Corrigan et al., 2003; Crane & Easton, 2015; Davis, 2014; Jackson, Philp, Nuttall, & Diller, 2002; Kwako et al., 2011; New York State Coalition Against Domestic Violence; New York State Office for the Prevention of Domestic Violence, 2009). Importantly, identification of brain injury among victims and perpetrators of family violence would enable effective and targeted support and rehabilitation that recognises the diversity of need among people living with a brain injury (Jackson et al., 2002; Kwako et al., 2011; State of Victoria, 2014-16).

The education and training of first response service providers to implement the screening of brain injury among victims and perpetrators of family violence is specifically recommended. “TBI [traumatic brain injury] professionals can play an important role in educating domestic violence workers, health care providers, and other professionals, including those in law enforcement, about ways to better identify and assist persons who experience violence” (Langlois, 2008). These recommendations support the objectives of the National Plan to Reduce Violence Against Women and Children (COAG, 2011) and Safe Homes, Safe Families: Tasmania’s Family Violence Action Plan (DPAC, 2015b). These Action Plans highlight the need for: •

primary prevention;

•

the provision of needs based service delivery that supports and accommodates all family violence victims, with particular mention of those living with a disability (including brain injury);

•

an effective justice response, recognising differing access needs, again with a focus on disability;

•

effective management and rehabilitation of family violence perpetrators, with an emphasis on behavioural change and the accommodation of perpetrators with complex needs who are at risk of committing violence.

Each directive focuses on the need for inclusive integrated services that ensure family violence intervention and prevention strategies are effective through recognition of diversity of need. The National Plan (COAG, 2011) also echoes the Victorian Royal Commission (State of Victoria, 2014-16) recommendation of building the evidence base on family violence.

BRAIN INJURY ASSOCIATION OF TASMANIA RECOMMENDATION 1.

The Tasmanian Government lead and facilitate inter agency, cross sectoral collaboration and co-ordination in the development of a state wide framework of initiatives that respond to current family violence intervention and prevention strategies in the context of brain injury. Research findings position brain injury as both a contributing factor to, and consequence of, family violence, and suggest urgent attention is needed to ensure the sequelae of living with a brain injury are accommodated within current family violence intervention and prevention strategies.

2. BRAIN INJURY AS A CONTRIBUTING FACTOR TO FAMILY VIOLENCE 2.1.

THE PREVALENCE OF BRAIN INJURY AMONG PERPETRATORS OF FAMILY VIOLENCE “Head injury is one of those risk factors that we think… may disinhibit risk among those who may already be at higher risk [of perpetrating violence]” (Dr Casey Taft a clinical research psychologist talking to Ginger Gorman, 2015).

Research has found that the prevalence of brain injury among perpetrators of family violence is significantly higher than the prevalence of brain injury in the general population (Farrer et al., 2012). Results varied; however, evidence suggests the prevalence of brain injury among perpetrators of family violence to be over 50%, as opposed to 10-38% in the general population (Farrer et al., 2012; Marsh & Martinovich, 2006). These statistics are largely based on international research as there is limited Australian research on brain injury as a contributing factor to family violence (State of Victoria, 2014-16). The evidence suggests that, while the prevalence of brain injury among family violence perpetrators is significant, brain injury is often one of several risk factors that combine in a complex interaction to result in family violence. A study of men with alcohol use disorders, a risk factor for the perpetration of family violence, found that family violence was significantly associated with having a brain injury (Crane & Easton, 2015). Similarly, the presence of both a brain injury and low verbal intelligence among a group of family violence perpetrators was discovered to increase the severity of the perpetrators aggression (Walling, Meehan, Marshall, Holtzworth-Munroe, & Taft, 2012).

2.2.

‘INJURY-RELATED’ VIOLENCE

The association between frontal lobe deficits and violence is one neuropsychological area of particular importance. In general, frontal lobe deficits refer to compromised abilities to inhibit impulsivity or aggression or to redirect attention from repetitive behaviour (Westby & Ferraro, 1999), and to exhibit lack of emotion regulation (Shorey, Brasfield, Febres, & Stuart, 2011). Individuals may not be able to stop, or have considerable difficulty stopping, themselves from using violence when they become angry if they have frontal lobe deficits that affect their ability to inhibit impulses. This violence can be described as ‘injury-related’ violence, in recognition of the contribution made by the brain injury. Whilst brain injury can lead to long term problems with aggression and impulse control, it does not lead to an intentional pattern of coercive control and family violence (Office for the Prevention of Domestic Violence). A family violence perpetrator who is living with brain injury may exhibit sudden violent reactions, due to changes in their cognitive and psychosocial functioning; they do not however, purposely switch between being violent and calm, behaviour sometimes demonstrated by perpetrators without a brain injury. They often do not understand why they react the way they do, and may not attribute their behaviour to their brain injury (Byrne, 2015). 10

The concept of holding perpetrators to account for their family violence, a theme emphasised across the National (COAG, 2011: 2) and Tasmanian (DPAC, 2015b) family violence action plans, becomes complicated in the context of brain injury. However, it is argued that despite the presence of brain injury, perpetrators are still responsible for their actions (Gorman, 2015), pointing to an urgent need for targeted education and rehabilitation to assist this population prevent recidivism.

2.3.

THE ASSOCIATION BETWEEN BRAIN INJURY AND AGGRESSION “There is good evidence that aggressive behaviour disorders are a serious legacy of ABI [acquired brain injury] for some people, so intervention is essential” (Alderman et al., 2013: 16).

International and Australian research demonstrates the association between brain injury and increased aggressive behaviour (Alderman et al., 2013; Baguley et al., 2006). However, aggression is one of a broad sequelae of symptoms associated with brain injury, some of which can also act as disinhibiting factors to violence through the cognitive changes the individual has experienced. Other connected sequelae include: increased irritability, frustration and reduced impulse control. Due to the heterogeneous nature of brain injury, reports on the prevalence of aggressive behaviour among people living with a brain injury varied from 6%, while still in hospital, to over 90%, later in their lives, with the suggestion that the prevalence of aggressive behaviour increased over time (Alderman et al., 2013). An Australian study found that those living with a severe brain injury were three times more likely to perpetrate physical violence than those without a brain injury, and suggested that brain injury related aggression is linked to depression (Baguley et al., 2006). Where increased aggression does occur as a result of a brain injury there is a high chance of that aggression impacting on close relationships. Rosenbaum et al. state that: “A history of significant head injury increased the chances of marital aggression almost sixfold” (1994: 1191). Exhibiting aggressive behaviour can preclude those living with a brain injury from accessing rehabilitation and can result in them gravitating to services that do not meet the needs of someone with a brain injury, such as the criminal justice system (Alderman et al., 2013: 5). This potential barrier to rehabilitation creates a self-perpetuating problem in regard to family violence.

2.4.

A TARGETED AND INTEGRATED APPROACH TO REHABILITATION

The correlation between acquired brain injury and a propensity for family violence has important implications for therapeutic interventions. The National Outcome Standards for Perpetrator Interventions (COAG, 2015), produced as part of the Australian National Plan on family violence (COAG, 2011), recognised that:

â&#x20AC;&#x153;We must provide opportunities that enable perpetrators to take responsibility for their violence, change their violent attitudes and behaviours and address any factors that may be amplifying their risk of violenceâ&#x20AC;? (COAG, 2015). The report, along with research that has found a causal link between brain injury and family violence, recommends a targeted approach to perpetrator interventions that recognise diverse needs in order for rehabilitation to be effective (COAG, 2015; Marsh & Martinovich, 2006; Persampiere, Poole, & Murphy, 2014). Determining what constitutes a successful family violence perpetrators program, therefore, requires an understanding from service providers of the contributing factors to violence and an ability to address those factors and produce lasting behavioural change. Rehabilitation programs should include, for example, behavioural and cognitive strategies taught to assist with inhibiting aggressive behaviours. An integrated approach to rehabilitation management of perpetrators of family violence who are living with a brain injury was advocated, recognising the number of services the individual was likely to be involved with, including the criminal justice system (Crane & Easton, 2015).

3. BRAIN INJURY AS A CONSEQUENCE AND RISK FACTOR OF FAMILY VIOLENCE 3.1.

THE PREVALENCE OF BRAIN INJURY AMONG VICTIMS OF FAMILY VIOLENCE â&#x20AC;&#x153;There is growing recognition of the potential for TBI [traumatic brain injury] among victims and survivors of IPV [intimate partner violence]. However, to date, there has been little attention paid to how to address TBI in the multidisciplinary, community-based interventions, and treatments for this populationâ&#x20AC;? (Murray, Lundgren, Olson, & Hunnicutt, 2016: 304)

Brain injury is a likely consequence of family violence (Corrigan et al., 2003; Davis, 2014; Valera & Berenbaum, 2003). The types of abuse that victims of family violence often report experiencing, including being hit in the face, head and neck, being shaken and being choked, are all risk factors for brain injury (Valera & Berenbaum, 2003). A review of the literature found that over 80% of family violence victims who sought medical assistance had facial injuries (Banks, 2007; Kwako et al., 2011; see also Wu, Huff, & Bhandari, 2010). One study of 53 women from three family violence shelters in the USA found that 92% of the women had been hit in the face or head by their partners, most more than once, 83% had been both hit in the head and severely shaken, and 40% had lost consciousness (Jackson et al., 2002). Victims of family violence are seldom screened for brain injury which means that the phenomenon of brain injury as a consequence of family violence is under-reported (Banks, 2007; State of Victoria, 2014-16: 4). Research has found that at least a third of women who had experienced family violence sustained a brain injury (Monahan & O'Leary, 1999). Other studies placed the prevalence of brain injury as a consequence of family violence at over two-thirds (Kwako et al., 2011; St. Ivany & Schminkey, 2016). In one investigation, 74% of the 99 women interviewed had received a brain injury as a result of family violence, with half the women suffering multiple brain injuries (Valera & Berenbaum, 2003). A research study that used the HELPS brain injury screening tool (Picard et al., 1991) to screen 42 women who attended a family violence facility, found over half (52%) screened positively for a brain injury and a further third reported at least one possible brain injury incident despite screening negative for brain injury (Hux et al., 2009). Women report multiple and repeated injuries as a consequence of family violence (Murray et al., 2016; State of Victoria, 2014-16). This magnifies the risk and severity of brain injury due to a cumulative effect (Corrigan et al., 2003). Of the 99 women Jackson et al. (2002) interviewed 8% of them had been hit in the head over twenty times in the past year; the more times individuals had been hit in the head the more frequent and severe their brain injury related symptoms were.

These statistics are based on international research as there is limited Australian research on the consequence of brain injury among victims of family violence (State of Victoria, 2014-16). The implications of living with a brain injury are considerable and ongoing; it is known that women with traumatic brain injury often exhibit reduced capacity to make informed, consistent choices and their ability to plan and to respond appropriately to safety, health, child care, and parenting issues may be significantly compromised (Monahan & O'Leary, 1999).

3.2.

THE PREVALENCE OF BRAIN INJURY AMONG VICTIMS OF FAMILY VIOLENCE IN AUSTRALIA AND TASMANIA: A PROJECTION

The statistics are sobering when you consider the number of women who are victims of domestic violence in Australia, and in Tasmania, each year. In 2012, in Australia, an estimated 132,500 women aged 18 years and over experienced violence at the hands of their partner, compared with an estimated 51,800 men. In Tasmania 2,300 women experienced the same fate (ABS, 2013). Using the Tasmanian statistics we can project from findings in the literature that around 80% of these women will have received injuries to their face, neck or head (Banks, 2007; Kwako et al., 2011). It is reasonable to predict, therefore, that in one year 1,840 women in Tasmania were at risk of experiencing a brain injury as a consequence of family violence. Estimates that between one and two-thirds of victims of family violence will have experienced a brain injury (Kwako et al., 2011; Monahan & O'Leary, 1999), point to a projected toll of 766-1533 women having acquired a brain injury as a result of family violence in Tasmania in 2012. A similar projection for Australia suggests there is the potential for more than 44,000 women to suffer a brain injury as a result of family violence each year in Australia. Until screening for brain injury is mandated for victims of family violence we will not know the true extent of the problem.

3.3.

THE ASSOCIATION BETWEEN BRAIN INJURY AND VULNERABILITY â&#x20AC;&#x153;Health care practitioners have the means to respond to violence by assisting women who are victims of violence and preventing the downward spiralling situations where they are further abused, become more hopeless, and are vulnerable to more acts of violence. Intervention and treatment can only be accomplished by increasing domestic violence surveillance, recognizing MTBI [mild traumatic brain injury] patterns of injury, and developing screening tools that delineate the triad of PCS [post-concussion syndrome], depression, and PTSD [post-traumatic stress disorder] associated with MTBIâ&#x20AC;? (Davis, 2014: 307).

Women with a disability are at a higher risk of experiencing violence than women without a disability (ABS, 2013; COAG, 2011; DPAC, 2015b). A large representative Canadian study found that women with a disability were 40% more likely to experience family violence than women without a disability (Brownridge, 2006). These statistics place women living with a disability at greater risk of experiencing a brain injury and include women already living with a brain injury. This association is supported by a qualitative Australian study which found that women living with a brain injury were particularly vulnerable to family violence (Alston, Jones, & Curtin, 2012). 14

Consequently, brain injury related symptoms among victims of family violence make these individuals more vulnerable to further victimisation, including future family violence (Davis, 2014; Jackson et al., 2002). Brain injury related symptoms that increase vulnerability include: headache, dizziness, poor concentration, memory problems, anxiety, lack of insight and anger management (Hux et al., 2009). Post-concussion syndrome, depression, and post-traumatic stress disorder are recognised as related symptoms of brain injury (Davis, 2014: 307). These characteristics impact decision-making and the ability to make appropriate choices. For a victim of family violence living with a brain injury they may make it harder to: accurately assess danger; make safety plans; remember appointments, including medical appointments and court dates; hold a job; leave an abusive partner; live independently; access services; live in a shelter; navigate the legal justice system; care for children (Monahan & O'Leary, 1999; New York State Office for the Prevention of Domestic Violence, 2009). For example, the combined effect of the characteristics of brain injury and the impact of family violence on an individualâ&#x20AC;&#x2122;s physical and mental health can make navigation of the justice and service systems and regaining financial and social independence unattainable for many (State of Victoria, 2014-16: 65). There is also a correlation between sustaining a brain injury as a consequence of family violence, either as a child or an adult, and becoming a perpetrator of family violence. A New Zealand pilot study found that mothers who were at high risk of child abuse were three times more likely to have a brain injury than the general population (McKinlay, van Vliet-Ruissen, & Taylor, 2014). The sequelae associated with brain injury can therefore make daily life a struggle, especially if the brain injury is undiagnosed, and/or no supports are put in place to assist the individual. This situation creates the potential for a cycle of service dependence among people who sustain a brain injury as a consequence of family violence.

BRAIN INJURY ASSOCIATION OF TASMANIA RECOMMENDATIONS 2.

Mandated brain injury screening for both perpetrators and victims of family violence. For all perpetrators of family violence screening should be applied across the service sectors, particularly the criminal justice system given the prevalence of brain injury in the prison system (P. W. Schofield et al., 2006). Identification of a brain injury would flag individuals for appropriate targeted rehabilitation and intervention, assisting behavioural change and reducing the likelihood of a reoccurrence of family violence. Routine screening for brain injury at first point of contact for all victims of family violence is recommended. Screening should be applied across the service sectors, including womenâ&#x20AC;&#x2122;s shelters, legal services, and counsellors. Identification of a brain injury would flag individuals for appropriate targeted support and rehabilitation, reducing the likelihood of a reoccurrence of family violence and preventing a cycle of victimisation and abuse.

Targeted and integrated intervention and rehabilitation programs for, and which incorporate the specialist and diverse needs of, both family violence perpetrators and victims living with a brain injury. Targeted support would assist perpetrators to make behavioural changes and reduce the likelihood of reoffending. To be effective programs need to include perpetrators already within the criminal justice system. For victims living with a brain injury, targeted support would assist individuals to escape, and report family violence, take legal action against the perpetrator, and rebuild their lives.

Education and training on the intersection between brain injury and family violence for all services who come into contact with perpetrators of family violence and victims of family violence. Understanding the complex nature of brain injury in the context of family violence is essential in order to provide effective services and valuable resources. Education and training will increase awareness of the issues, and build the knowledge and skill of all services interacting with both perpetrators and victims of family violence. The provision of timely and relevant information will better equip family violence program staff to recognise, understand and respond more effectively to the specific needs of people living with brain injury as a result of family violence. Increasing the ability of providers to identify family violence victims living with brain injury will help to increase victimâ&#x20AC;&#x2122;s chances of enhancing their lives.

4. COMPOUNDING FACTORS IN RECOGNISING THE RELATIONSHIP BETWEEN BRAIN INJURY AND FAMILY VIOLENCE 4.1.

WHY IS THE RELATIONSHIP BETWEEN BRAIN INJURY AND FAMILY VIOLENCE POORLY UNDERSTOOD?

Achieving recognition for the true magnitude of the relationship between brain injury and family violence is compounded by the very nature of brain injury, a significant life event that results in pervasive, unique, complex and ongoing health concerns. Brain injury, similarly to family violence (COAG, 2011), is known as an ‘invisible’ problem (Alston et al., 2012), which is under-reported, under-diagnosed, under-supported and under-researched. The lack of mandated screening processes for brain injury, results in a lack of statistics on which to base decisions about services and government spending, which in turn results in a lack of support and rehabilitation targeted at people living with a brain injury. This lack of understanding and recognition is despite brain injury being a major burden on Australia’s health, resulting in high service use and high economic costs. 4.1.1. Brain injury in Australia: prevalence and economic costs An acquired brain injury (ABI) is a life event. ABI refers to damage to the brain that has occurred after birth. Common causes of brain injury include accidents, such as motor vehicle accidents, falls, sporting; assault; stroke; lack of oxygen; toxicity; and degenerative neurological diseases (Corrigan et al., 2003). Research indicates that 1 in 45 Australians have an acquired brain injury that has resulted in limitations to their capacity to lead independent lives. The prevalence rates for ABI are higher for men than women and increase with age. Two-thirds of the ABI population sustained their injury under the age of 25 years old (O’Rance & Fortune, 2007). In Tasmania it is estimated that 2,500 people acquire a brain injury, across all severities, each year (Tasmanian Coalition of ABI Service Providers, 2007). Like family violence, brain injury is a major public health problem in Australia. The economic consequences of family violence on the Australian and Tasmanian economies are significant. In 2009 the cost of family violence to the Australian economy was estimated at $13.6 billion for one year, calculated to rise to $15.6 billion by 2021 (KPMG, 2009). In Tasmania the direct cost of family violence in 1994 was estimated at $17.6 million (KPMG, 2009). The routine identification of brain injury among perpetrators and victims of family violence, and implementation of targeted and integrated rehabilitation has the potential to significantly reduce the (re)occurrence of family violence and thus lessen the economic burden.

It is hard to estimate the economic costs of brain injury in Australia; due to lack of data and under diagnosis prevalence rates for brain injury are hard to calculate, the emotional and social costs, impossible. Furthermore, cost estimates that do exist often exclude mild brain injuries, whose prevalence and relevance to family violence are significant, as this report indicates. In 2009 the cost of traumatic brain injury to the Australian economy was estimated at $8.6 billion. This is a conservative estimate of moderate and severe brain injuries based on extrapolating prevalence rates for brain injury incidence in Victoria (Access Economics, 2009). It was estimated by the Tasmanian Government that the cost of an 18 year old male with acquired brain injury as a result of road crash will be $12 million in care, support and medical fees over the person’s lifetime (Department of Infrastructure Energy and Resources, 2007). This figure does not recognise the emotional and social costs for people with brain injury who are also more likely to experience breakdown in relationships (family, friends, and partners), drug and alcohol abuse, homelessness and criminal justice issues. Prevention through education and rehabilitation of people living with brain injury is the best means of reducing ongoing economic costs. Effective and targeted intervention and rehabilitation programs work to prevent the occurrence or reoccurrence of family violence: Slowing the cycle of violence and therefore reducing service load. Supporting an individual from the moment their brain injury is recognised increases the potential for primary prevention of family violence. 4.1.2. The characteristics of brain injury related disability: unique and complex Acquired brain injury related disability can affect a person’s physical, cognitive, and psychosocial functioning. The outcomes and effects of ABI are as unique as each person who sustains one, and often depend on the cause, nature and severity of the injury. “If you have met one person with a brain injury, you have met one person with a brain injury” is a quote that resonates for many individuals. Brain injury can occur at anytime, anywhere, and to anyone; it is not confined to any one age, ethnicity, gender or geographical location. The severity of the brain injury is described as mild, moderate or severe. The sequelae of brain injury related disability are wide-ranging, and, as discussed above, include, increased aggression and irritability, reduced impulse control, depression, post-concussive syndrome; post-traumatic stress disorder, poor concentration, memory, and judgement, and problems with decision-making (Alderman et al., 2013; Baguley et al., 2006; Davis, 2014; Hux et al., 2009; Monahan & O'Leary, 1999; Rosenbaum et al., 1994). The person may tire easily, lack motivation, become self-centered and have a reduced tolerance to stress (O’Rance & Fortune, 2007; Synapse: The Brain Injury Association of Queensland, 2013). Some effects of brain injury are only experienced in the short term, but many permanently impact on the person’s ability to lead an independent life. A review of the literature found that 40-80% of people with mild brain injuries, and nearly all people with moderate and severe brain injuries, experienced a combination of symptoms as a consequence of their brain injury (Bazarian et al., 2005; Corrigan et al., 2003; Hux et al., 2009).

One study found that 60% of the women who experienced a family violence related brain injury continued to exhibit related symptoms three months after the injury (Monahan & O'Leary, 1999). While other research found that, of those who experienced a mild brain injury, 15% continued to experience related symptoms a year later (Hux et al., 2009). The complexity and individuality of brain injury as a health concern does not therefore respond to a one-size fits all solution. This can create difficulties for family violence service providers to accommodate victims and perpetrators living with a brain injury. 4.1.3. An â&#x20AC;&#x2DC;invisibleâ&#x20AC;&#x2122; phenomenon: under reported, under diagnosed, under rehabilitated, under researched Brain injury as a contributing factor to, and consequence of, family violence is largely unrecognised in Australia (State of Victoria, 2014-16), as evidenced by the paucity of research and statistics. It is suggested in the literature that brain injuries suffered as a consequence of family violence are more likely to be mild to moderate (Valera & Berenbaum, 2003). Research shows that mild and moderate brain injuries are often undiagnosed (Corrigan et al., 2003; Hux et al., 2009; Setnik & Bazarian, 2007). One reason for their lack of detection is that many individuals do not seek medical assistance in response to a mild or moderate brain injury event (Setnik & Bazarian, 2007). Research found that even when the brain injury victim had experienced a loss of consciousness, 20% did not attend a medical facility (Corrigan et al., 2003). Moreover, acquiring a brain injury in the home, where the vast majority of family violence takes place, has been found to reduce the likelihood of the victims seeking medical help (Setnik & Bazarian, 2007). These findings are further compounded for victims of family violence who are less likely to report injuries due to issues of safety and stigma (Monahan & O'Leary, 1999). A study of 99 victims of family violence found that only 25% of the 74% who suffered brain injuries had sought medical attention (Valera & Berenbaum, 2003). When people do seek medical assistance after a brain injury event, if the symptoms are mild, they may receive no screening, diagnosis or treatment (Corrigan & Bogner, 2007). A Tasmanian study found that only around a quarter of people who were diagnosed with a brain injury were hospitalised. In addition, acquiring a brain injury as a result of assault, the very definition of physical abuse in family violence, was shown to further reduce the likelihood of the victim being hospitalised (Ta'eed, Skilbeck, & Slatyer, 2013). The lack of identification of a brain injury results in a lack of support and rehabilitation for the person living with the brain injury. Even when a brain injury is diagnosed it is possible that no support or rehabilitation will be offered. The Tasmanian study also investigated pathways to rehabilitation following a brain injury, and highlighted the limitations of the current system, with those people not admitted to hospital (75%) seldom having any rehabilitation for, or education about, their brain injury. While these individuals, who were not hospitalised, likely suffered mild brain injuries, the same study found that 16% of those who were not referred for rehabilitation had suffered moderate or severe brain injuries (Ta'eed et al., 2013).

Brain injury among perpetrators of family violence was similarly under-diagnosed; this lack of recognition likely contributes to the high number of people living with a brain injury who are incarcerated (Moore, Indig, & Haysom, 2014), and poses questions for the criminal justice system in terms of the provision of targeted intervention for perpetrators with diverse needs. However, discussion of recommendations to screen perpetrators of family violence for brain injury was largely absent from the literature (Crane & Easton, 2015). Brain injury research often focuses on those who have been hospitalised. Consequently a large percent of people living with a brain injury are overlooked in the research (Ta'eed et al., 2013), especially those whose brain injury is a contributing factor to or consequence of family violence. This reduces the knowledge base on brain injury, and the intersection with family violence, and inhibits development of targeted support and rehabilitation programs. Central to the hidden nature of brain injury as a contributing factor to and consequence of family violence is the lack of routine screening by service providers. The literature points overwhelmingly to the need for mandated brain injury screening among victims and perpetrators of family violence (Banks, 2007; Corrigan & Bogner, 2007; Corrigan et al., 2003; Crane & Easton, 2015; Davis, 2014; Jackson et al., 2002; Murray et al., 2016). Screening for brain injury at first point of contact with family violence victims and perpetrators is essential for the provision of effective and appropriate rehabilitation. It has also been argued that early identification is more responsive to rehabilitation (Banks, 2007; Corrigan & Bogner, 2007).

4.2.

THE NEED FOR A COLLABORATIVE AND TARGETED APPROACH

The complexity of the impact of family violence and brain injury result in individualâ&#x20AC;&#x2122;s who experience both of these events having contact with multiple service providers, including: homeless shelters, vocational rehabilitation and employment agencies, mental health facilities, criminal justice system, child protection, developmental disability facilities, family violence facilities, and womenâ&#x20AC;&#x2122;s shelters (Hux et al., 2009). There is a need therefore, for a collaborative, integrated approach to support and rehabilitation for both victims and perpetrators of family violence who are living with brain injury (Kwako et al., 2011). Communication between services is crucial for an effective response to family violence. The Victorian Royal Commission into Family Violence (State of Victoria, 2014-16) provides an example of the current difficulties in referral pathways, whereby a family violence perpetrator living with a disability was excluded from a live-in facility due to a personal safety intervention order, and then returned to the family home, where he was suspected of family violence, as he had nowhere else to go. In order to respond effectively to the requirements of those affected by family violence, service providers must be aware of and trained to deal with the consequences of the association between brain injury and family violence (Hux et al., 2009; Monahan & O'Leary, 1999; Wong, Fong, Lai, & Tiwari, 2014).

“Failure to associate observable, functional impairments with the occurrence of traumatic brain injury can lead survivors, as well as the professionals who work with them, to select ineffective or even inappropriate coping, intervention and remediation strategies” (Hux et al., 2009: 13). The Victorian Royal Commission into Family Violence (State of Victoria, 2014-16) highlights the barriers to support for victims of family violence living with a disability, and the lack of rehabilitation programs for perpetrators of family violence living with disability. These groups include people living with a brain injury, and highlight their unmet needs. A lack of targeted services for people living with a brain injury who are victims or perpetrators of family violence emphasises the limitations in the current system in Australia. If there are no relevant services, or no referral pathways to relevant services, for victims and perpetrators of family violence who are living with a brain injury, the likely trajectory for these individuals involves unemployment, homelessness, and economic stress, along with continued family violence victimisation and perpetration, and a cycle of service use that escalates the economic costs involved.

4.3.

A QUESTION OF AGENCY

Barriers for Tasmanians living with or affected by brain injury have unwittingly been created by a narrow portfolio focus on ‘disability’. Current research has identified strong linkages between the impact of brain injury and a range of variables in a person’s life including education, employment, housing, mental health issues, abuse of alcohol and other substances, an increased risk of suicide, greater risk of entering the criminal justice system, family breakdown and social difficulties (see Baguley et al., 2006; Byrne, 2015; Mackelprang et al., 2014; Moore et al., 2014; Rushworth, 2009; P. W. Schofield et al., 2006; van Velzen, van Bennekom, Edelaar, Sluiter, & Frings-Dresen, 2009). Government has recognised that a whole-of-government response to family violence is needed to drive change (COAG, 2011; DPAC, 2015b). Achieving improved outcomes for people living with brain injury, their families and their carers, is also contingent upon the effective co-ordination of efforts across all government departments. Planning needs to be multi-pronged and include key portfolio areas such as of health, mental health, children’s services, transport, education and justice.

4.4.

ADDITIONAL INTERLINKED CONCERNS

The pervasive nature of the relationship between brain injury and family violence means that it is outside the scope of this preliminary report to document every interlinked concern. Two significant issues not covered in this report are the new National Disability Insurance Scheme (NDIS), and Child Protection. 4.4.1 The National Disability Insurance Scheme The National Disability Insurance Scheme (NDIS) is a once-in-a-lifetime opportunity. It has the potential to meet the support needs of many Australians who have an acquired brain injury (ABI). Unfortunately, history tells us that the needs of people with an ABI are often overlooked and misunderstood by disability services, health professionals and governments. 21

The implications of changes to service provision after the implementation of the NDIS must be closely monitored to ensure the provision of relevant rehabilitation and support services for individuals living with brain injury who are also victims or perpetrators of family violence. 4.4.2 Child Protection Child Protection is associated with brain injury and family violence on a number of levels. Stigma surrounds the parenting capability of a person living with brain injury, especially if family violence is involved, even when they are not the perpetrator. This encourages people not to seek help for fear their children will be taken away from them. Abuse and neglect of a child can be a consequence of family violence and brain injury, either in combination or separately. Brain injury as a contributing factor to family violence has the potential to impact children (Butera-Prinzi & Perlesz, 2004). While acquired brain injury among children as a consequence of family violence is another â&#x20AC;&#x2DC;invisibleâ&#x20AC;&#x2122; statistic (Bedi & Goddard, 2007). Research has also suggested the potential for a cycle of violence where a parent sustains a brain injury as a consequence of family violence and then becomes a perpetrator of family violence themselves towards their children (McKinlay et al., 2014). These issues warrant further examination if the relationship between brain injury and family violence is to become fully transparent, appropriately resourced and, ultimately, prevented.

BRAIN INJURY ASSOCIATION OF TASMANIA RECOMMENDATIONS 5.

The identification and resolution of any inadequacies in the NDIS process for individuals living with brain injury. An examination of the referral pathways to care and the availability of services would highlight any potential gaps for victims and perpetrators of family violence who are living with brain injury.

Recommendation 2 - Mandated brain injury screening for both perpetrators and victims of family violence; Recommendation 3 - Targeted and integrated intervention and rehabilitation programs for, and which incorporate the specialist and diverse needs of, both family violence perpetrators and victims living with a brain injury; and Recommendation 4 - Education and training on the intersection between brain injury and family violence for all services who come into contact with perpetrators of family violence and victims of family violence, are also relevant to this section.

5. THE WAY FORWARD: WHERE TO FROM HERE? 5.1.

RECOMMENDATIONS FOR ACTION: PROMOTING A PREVENTATIVE AND SUPPORTIVE APPROACH

The statistics found in this report are particularly stark when we consider that violence against women is an under-reported crime (DPAC, 2015a) and brain injury is an under-diagnosed event (Corrigan et al., 2003; Hux et al., 2009; Setnik & Bazarian, 2007). 5.1.1 The National and State response to family violence and brain injury Family violence in Australia has been recognised as a pervasive national issue in need of urgent action. In 2011 the Council of Australian Governments released the National Plan to Reduce Violence against Women and their Children 2010-2022 (COAG, 2011). The plan is being implemented in four stages: First Action Plan (2010-2013) Building a Strong Foundation; Second Action Plan (2013-2016) Moving Ahead; Third Action Plan (2016-2019) Promising results; Fourth Action Plan (2019-2022) Turning the Corner. The National Plan to Reduce Violence against Women and their Children has five national priority areas including: prevention, understanding diverse experiences of violence, supporting innovative services and integrated systems, improving perpetrator interventions, and building the evidence base. The National Plan recognises that family violence intersects with numerous services and recommends the need for a coordinated all-inclusive approach, an approach that accommodates diverse needs in the service, support and rehabilitation response (COAG, 2011). The States and Territories of Australia have each produced their own government response to family violence that aligns to the priorities of the National Plan: ACT

ACT Prevention of Violence Against Women and Children Strategy 20112017 (ACT Government, 2011)

New South Wales

Stop the Violence, End the Silence: NSW Domestic and Family Action Plan (NSW Department of Premier and Cabinet, 2010)

Northern Territory Domestic and Family Violence Reduction Strategy 2014-17: Safety is Everyone’s Right (Northern Territory Government, 2014) Queensland

Queensland says: Not Now, Not Ever. First Action Plan of the Domestic and Family Violence Prevention Strategy 2015–2016 (Queensland Government, 2015)

South Australia

Taking a Stand: Responding to Domestic Violence (South Australia Department of Premier and Cabinet, 2014)

Tasmania

Safe Homes, Safe Families: Tasmania’s Family Violence Action Plan 20152020 (DPAC, 2015b)

Victoria

Victoria's Action Plan to Address Violence Against Women and Children 2012-2015: Everyone has a Responsibility to Act (Victorian Government, 2012)

Western Australia

Western Australia’s Family and Domestic Violence Prevention Strategy to 2022: Creating Safer Communities (Government of Western Australia)

The National, State and Territory government responses to family violence each incorporate recommendations relevant to the intersecting relationship family violence has with brain injury, including the need for inclusive services that meet diverse needs and a coordinated approach that recognises multiple service use. The National Plan (COAG, 2011) and Tasmanian Safe Homes, Safe Families report (DPAC, 2015b) are discussed in sections 5.2-5.6 of this report in the context of how their objectives relate to brain injury as a contributing factor to and consequence of family violence. 5.1.2 Victorian Royal Commission into Family Violence The Victorian Royal Commission into Family Violence (State of Victoria, 2014-16) established that there was enough evidence of the intersection between family violence and brain injury to make a direct recommendation [171] to fund research examining the prevalence of acquired brain injury among family violence victims and perpetrators. The report describes the issue as “neglected” and “undiagnosed” to date in Australia. Ten recommendations on family violence and people with disabilities were made in total, including: growing an evidence base through data collection [170] and targeted research [171]; education and training on family violence in the disability sector [172, 173]; and education and training on disability for police and the justice sector (State of Victoria, 2014-16: 91-92). These recommendations reflect the recommendations and standpoint of BIAT in this report. In addition to the screening for, and appropriate referral of individuals with, brain injury among victims and perpetrators of family violence, BIAT’s recommendations extend to the education and training on disability, specifically to refer to brain injury, across the service sectors and particularly within family violence support services and the criminal justice sector. Victorian Royal Commission Recommendation 170 The Victorian Government adopt a consistent and comprehensive approach to the collection of data on people with disabilities who experience or perpetrate family violence. This should include collecting data from relevant services—for example, incident reports made to the Department of Health and Human Services by disability services when family violence has occurred [within two years]. Victorian Royal Commission Recommendation 171 The Victorian Government fund research into the prevalence of acquired brain injury among family violence victims and perpetrators [within two years].

Victorian Royal Commission Recommendation 172 The Victorian Government fund training and education programs for disability workers— including residential workers, home and community care workers, interpreters and communication assistants and attendant carers—to encourage identification and reporting of family violence among people with disabilities [within two years]. Victorian Royal Commission Recommendation 173 The Victorian Government, through the Council of Australian Governments Disability Reform Council, encourage the Commonwealth Government and the National Disability Insurance Agency to ensure that all disability services workers involved in assessing needs and delivering services have successfully completed certified training in identifying family violence and responding to it. This could include further developing and mandating the units on family violence and responding to suspected abuse in the Community Service Training Package [within five years]. Victorian Royal Commission Recommendation 174 Victoria Police, in the redesign of the police referral (L17) form, ensure that disability data is collected, including on the type of disability and the support required. Training should be provided to help police members identify how and when to make adjustments for people with disabilities [within 12 months]. Victorian Royal Commission Recommendation 175 The Judicial College of Victoria provide training to judicial officers in order to raise awareness and encourage consistent application of section 31 of the Evidence Act 2008 (Vic), which allows courts to make adjustments to the way people with disabilities may be questioned and give evidence [within 12 months] (State of Victoria, 2014-16: 91-92).

5.2.

PRIMARY PREVENTION OF FAMILY VIOLENCE IN THE CONTEXT OF BRAIN INJURY

Primary prevention of family violence is the number one action of both the Australian National Plan (COAG, 2011) and the Tasmanian Safe Homes, Safe Families (DPAC, 2015b). They advocate for improved access to resources and systems of support across the community and service sectors, with regular monitoring and evaluation of efficacy. “Through primary prevention we can engage with individuals and all communities to reshape the beliefs, attitudes and behaviours that allow violence against women and children to continue” (DPAC, 2015a).

The Brain Injury Association of Tasmania supports the goal of primary prevention of family violence and advocates the inclusion of community education on brain injury, and the provision of effective targeted rehabilitation for, and support of, people living with brain injury from as soon as the brain injury event occurs. Targeted rehabilitation must recognise the individuality of brain injury and assist individuals to manage the specific way their brain injury affects them. Focus should be placed on brain injury related characteristics that could become contributing factors to family violence perpetration or victimisation. These include possible cognitive and psychosocial changes such as increased aggression, irritability, frustration and impulsiveness in regard to family violence perpetration, and increased vulnerability through reduced insight and poor decision-making in regard to family violence victimisation. BIAT advocate that people living with brain injury need to be supported to live a full life that includes basic human needs such as housing, social and economic wellbeing and options for employment. 5.2.1. BIAT primary prevention services A major role of BIAT is to promote community awareness and understanding of acquired brain injury, in terms of both prevention and the impact of acquired brain injury on the lives of individuals, families and the broader community. BIAT has instigated three services in the Hobart region in regard to primary prevention and brain injury, and recommends their continuation and broader application across Tasmania. Heads up to Brain Injury (HU2BI) Program: Primary prevention of brain injury The Heads up to Brain Injury (HU2BI) Program is facilitated and run by BIAT and offers an interactive learning experience for students with the goal of influencing their behaviour and attitudes to reduce their chances of sustaining a brain injury. The HU2BI Program strengthens the Tasmanian Government’s Respectful Relationships program through changing the attitudes and behaviours that lead to family violence. Custody for Lifeä Program BIAT is especially concerned about educating those most at risk of brain injury - young people aged between 15-24 years make up over 40% of people who sustain an ABI each year. In response to this, BIAT developed the innovative community education program Custody for Life™ (CFL). Through a partnership with Tasmania Police and Community Youth Justice, the CFL Program has the capacity to reduce the incidence of young people committing or re-committing vehicle and/or assault offences. Acquired Brain Disorder Community Liaison Officer Program: Primary prevention of family violence Through the Acquired Brain Disorder Community Liaison Officer Program BIAT provided support at hospital level to people newly diagnosed with an acquired brain injury, connecting the patient and their family to relevant services. During the year-long funded period 2015-2016, BIAT supported 80 individuals and their families with positive results. 26

This guided pathway to rehabilitation and support services for people living with brain injury offers the potential of primary prevention of family violence through the connection of individuals to supportive services that reduce the potential for a negative trajectory of life events that can follow a brain injury, such as marital problems and homelessness. Patients and their families were referred to targeted rehabilitation, as required, to assist in the management of possible cognitive and psychosocial changes associated with being contributing factors of family violence perpetration and victimisation.

BRAIN INJURY ASSOCIATION OF TASMANIA RECOMMENDATIONS 8.

Information tools as well as training and secondary consultation are almost nonexistent among service providers and this contributes to a widespread naiveté about acquired brain injury;

•

11.

5.3.

STRENGTHENING SUPPORT FOR PEOPLE AFFECTED BY FAMILY VIOLENCE IN THE CONTEXT OF BRAIN INJURY

The need to strengthen support for, and ensure services meet, the needs of people affected by family violence is a key priority of the National Plan (COAG, 2011), Safe Homes, Safe Families (DPAC, 2015b), and recommendations 172 and 173 in the Victorian Royal Commission into Family Violence (State of Victoria, 2014-16). This includes the need to support mainstream services to identify and respond to the needs of victims of family violence, for example an internal performance review of Safe at Home, the Tasmanian Governmentâ&#x20AC;&#x2122;s integrated criminal justice response to family violence, recommended the inclusion of specialist family violence training for members of the police department. In the context of brain injury BIAT recommends the provision of education and training in both family violence and brain injury across the service sector. BIAT aims to ensure services working with or coming into contact with people living with or affected by brain injury have access to the information and training they require to work effectively. As part of any education and training program, BIAT advocates for brain injury screening to be mandated for all victims of family violence, with individuals being screened across all service sectors, ideally at first point of contact. Identification of a potential brain injury would result in targeted integrated support that meets the specialist needs of individuals living with a brain injury who are affected by family violence. A coordinated approach is required to accommodate the multiple service providers individuals come in contact with. Effective support will help to reduce the potential of increased service dependence, prevent continued victimisation, and reduce the possibility of a person living with brain injury becoming a perpetrator of family violence themselves, situations that can occur if people affected by family violence and brain injury are left unsupported. BIAT also recommends the provision of education and resources about acquired brain injury to individuals who have experienced family violence and who are living with brain injury. This acts as a process of self-support through the empowerment of gaining knowledge about the way their brain works, how they can be instrumental in their own rehabilitation and what options are available to them, and has the ability to reduce vulnerability (see for example Jorm, 2012). The families of those living with a brain injury also profit from this approach, in the context of learning how they can be supportive to, and facilitate recovery for, the victim of both family violence and brain injury. The benefit of this self-awareness and family understanding and support will work best if applied in conjunction with targeted rehabilitation from service providers. 28

The Acquired Brain Disorder Liaison Officer Program, facilitated by BIAT, performed a similar role whereby information and support accessing services were provided to the families of people who had recently suffered a brain injury. Carers were also supported with practical knowledge on how to be carers, how to maintain their own well-being and information on where to seek ongoing support as new issues arise. This type of support increases life opportunities for the patient as their recovery potential is maximised.

5.4.

STRENGTHENING PERPETRATOR MANAGEMENT AND REHABILITATION IN THE CONTEXT OF BRAIN INJURY

Strengthening the management and rehabilitation of perpetrators of family violence and holding the perpetrators to account forms a third pillar of action for the National Plan (COAG, 2011) and Safe Homes, Safe Families (DPAC, 2015b). The plans recognise that if the risk of recidivism is to be reduced rehabilitation must aim to change the offending behaviour, and accommodate people with complex needs who are at risk of committing violence. “This outcome is supported by research that shows the likelihood of recidivism may be reduced by addressing the underlining causes of offending behaviour. Focussing just on punishing perpetrators will not bring about behaviour change. Perpetrators need assistance to end their violence” (COAG, 2011: 29). Research indicates that a high number of incarcerated people are living with brain injury. Submissions to the Victorian Royal Commission into Family Violence suggest that the lack of provision of rehabilitation targeted to perpetrators of family violence who are living with a brain injury is one contributing factor to the high number of incarcerated individuals with a brain injury. The Commission found that “people with intellectual disabilities or acquired brain injuries, which restrict their capacity to learn in a group setting, are currently screened out of behaviour change programs” (State of Victoria, 2014-16: 280). From an economic perspective rehabilitation is cheaper than incarceration: it is argued that “the costs of running a men’s behaviour change program for 100 men in an urban setting for a year is less than the annual cost of incarcerating three offenders” (State of Victoria, 2014-16: 209). A successful family violence perpetrators program was viewed as accommodating diversity through a targeted approach, with the goal of producing lasting behavioural change (COAG, 2015; Marsh & Martinovich, 2006; Persampiere et al., 2014). BIAT also recommends the provision of education and resources about acquired brain injury to individuals who have perpetrated family violence and are living with a brain injury. This acts as a process of self-awareness through gaining knowledge about the way their brain works, how they can be instrumental in their own rehabilitation, and what options are available to them, and has the ability to assist behavioural change and reduce further perpetration (see for example Jorm, 2012). The families of those living with a brain injury also profit from this approach, in the context of learning how they can support behavioural change, and facilitate rehabilitation. The benefit of this self-awareness and family support will work best if applied in conjunction with targeted rehabilitation from service providers.

5.5.

STRENGTHENING LEGAL RESPONSE TO FAMILY VIOLENCE IN THE CONTEXT OF BRAIN INJURY

Effective justice responses to family violence are a fourth shared goal of the National Plan (COAG, 2011) and Safe Homes, Safe Families (DPAC, 2015b). This includes improving access to justice for all people, by recognising different access needs, such as those people living with a disability. Training is recommended for police, lawyers, judicial officers, counsellors and other professionals working in the family law system (COAG, 2011). The Victorian Royal Commission supports these intentions, contributing two recommendations: [174] ensure that disability data is collected on the police referral form including the type of disability and the support required, ensure training on this is provided to police; [175] provide training to judicial officers to encourage the use of the Evidence Act 2008 which allows adjustments to the way people with disabilities may be questioned and give evidence. “Consider other challenges that domestic violence survivors face, for example, child custody proceeding or criminal court testimony. Successful utilization of the justice system often requires the ability to communicate incidences of abuse from memory using detailed, sequential, rapid, clear communication. These functions may be compromised by the brain injury. These challenges may diminish the survivor’s credibility in the courtroom, and have dire outcomes to the survivor’s life” (New York State Coalition Against Domestic Violence). In the context of brain injury BIAT recommends a legal process that screens for, and recognises, brain injury in both victims and perpetrators of family violence, and offers effective pathways through the legal system appropriate for people living with a brain injury. This process requires the criminal justice system to receive education and training, in both family violence and brain injury; for screening of brain injury to be mandated in the court system; and for targeted services to be provided to individuals living with a brain injury. A therapeutic justice approach utilises disability information to guide dealings in the criminal justice system for both victims and perpetrators of family violence, improving support, accessibility and effectiveness (State of Victoria, 2014-16). This preventative approach looks at the contributing factors to perpetration with the aim of stopping reoffending. “Courts in the United States, Canada and to some extent Australia, have moved towards providing greater support to witnesses in criminal cases who have suffered traumatic experiences… and to some categories of defendants in criminal cases, including those who have complex needs who may repeatedly re-offend unless these needs are addressed (for example, people with an intellectual disability or acquired brain injury). These changes are examples of a ‘therapeutic justice’ approach, which emphasises the importance of solving the problems that bring people before court” (State of Victoria, 2014-16: 157). In regard to the prevention of family violence, the importance of a therapeutic justice approach is highlighted by findings from Victorian Legal Aid who found that clients receiving legal aid for multiple breaches of family violence intervention orders (FVIO) were more likely to be males aged 25-44 years and were twice as likely to report having an acquired brain injury (Victoria Legal Aid, 2015). These data suggest that the systems in place to enact and enforce FVIOs need to be adapted to ensure their adherence by perpetrators living with a brain injury. 30

Court Integrated Services Program is a case management program operating in three magistrates courts across Victoria, including Latrobe, Melbourne and Sunshine. The accused can self-refer, or be referred by police, legal representatives, magistrates, court staff, support services, family, or friends. Services can include assessing and referring an accused for treatment, including acquired brain injury-related needs (State of Victoria, 2014-16: 269). This program is specifically designed to reduce re-offending among complex offenders, such as those with a brain injury.

BRAIN INJURY ASSOCIATION OF TASMANIA RECOMMENDATIONS 12.

5.6.

BUILDING THE EVIDENCE BASE: FUTURE RESEARCH “The Commission also notes the limited Australian research into acquired brain injuries and family violence. The Victorian Government and other funders should consider supporting research into acquired brain injuries among both survivors and perpetrators of family violence. Subject to this research, there is scope for policy and practice development, including to ensure identification of acquired brain injuries by family violence services, crisis accommodation services and health services” (State of Victoria, 2014-16: 193).

While the research documented in this report clearly demonstrates an intersecting relationship between family violence and brain injury, the evidence base in Australia is small and fragmented. Research studies to date usually involve small numbers of participants, from specific groups within the family violence or brain injury populations, such as only those living in family violence shelters or only those who access medical help or are hospitalised, or only those with a severe brain injury, and often do not involve a comparative sample. 31

Consequently a large number of people living with a brain injury are overlooked in the research (Ta'eed et al., 2013). This reduces the knowledge base on brain injury and family violence, and inhibits development of targeted support and rehabilitation programs. The limitations these factors present in generalizing findings, as highlighted in the research papers themselves, point to a need for large scale, integrated research, with input across academic disciplines, the service sector, and public health discourses. â&#x20AC;&#x153;Additional research is needed to better quantify the extent of the problem and to ensure that screening methods for identifying a history of TBI [traumatic brain injury] are valid and reliableâ&#x20AC;? (Langlois, 2008). The need for an evidence base on disability and family violence was recognised in the National Plan (COAG, 2011) and the Victorian Royal Commission into Family Violence (State of Victoria, 2014-16). The latter made two recommendations, [170] a comprehensive approach to data collection on people with disabilities who experience or perpetrate family violence, and [171] research specific to the prevalence of acquired brain injury among family violence victims and perpetrators. BIAT propose a suite of research initiatives in a research proposal designed to examine the relationship between brain injury and family violence and enhance the current family violence intervention and prevention strategies. These include the re-funding and reinstatement of the BIAT Acquired Brain Disorder Liaison Officer Program as a service that contributes to the primary prevention of family violence. An education and training project to be implemented by BIAT across the family violence service sector in Tasmania, educating professionals on the diverse support and rehabilitation needs of an individual living with a brain injury, and training them to implement a brain injury screening tool for all victims and perpetrators of family violence. This project would build the evidence base, enable prevalence rates to be calculated, and improve the relevancy and efficacy of support and rehabilitation offered. Finally, a support and rehabilitation mapping project is proposed which aims to map both the brain injury and family violence service sectors, and the referral pathways through these services. The project is proposed in response to recommendations from the literature, the National Plan (COAG, 2011), Safe Homes, Safe Families (DPAC, 2015b), the Victorian Royal Commission on Family Violence (State of Victoria, 2014-16), and National Outcome Standards on Perpetrator Interventions (COAG, 2015), who all identify a need for targeted support and rehabilitation for family violence victims and perpetrators who are living with a brain injury. Mapping existing support and rehabilitation services will highlight whether that need is being met and identify gaps in the provision of services to these populations. A similar mapping exercise was recently conducted on the ACT Domestic Violence Service System (Community Services Directorate, 2016), suggesting the process is an important part of the progression towards best practice. The discovery by a Tasmanian research study of a lack of clear pathways to rehabilitation after a brain injury for non-hospitalised individuals (Ta'eed et al., 2013) suggests further research is needed in this area. Identifying best practice in referral pathways for brain injury rehabilitation can be utilised to inform the production of national guidelines. 32

Identifying gaps in the support, rehabilitation services, and referral pathways, for victims and perpetrators of family violence living with a brain injury in Tasmania, and providing recommendations on best practice, can assist with the prevention of family violence through the establishment of targeted supports and interventions, and a subsequent reduction in the cycle of victimisation and reoffending.

BRAIN INJURY ASSOCIATION OF TASMANIA RECOMMENDATIONS 13.

14.

6. BRAIN INJURY ASSOCATION OF TASMANIA POSITION STATEMENT: FAMILY VIOLENCE AND BRAIN INJURY The Brain Injury Association of Tasmania’s position is that: •

Living with a brain injury is a contributing factor for perpetrating family violence.

•

Living with a brain injury is a contributing factor to becoming a victim of family violence.

•

Brain injury is a likely consequence of family violence. People who have experienced family violence must be screened for brain injury and provided with appropriate support.

•

Violence is preventable. There is an urgent need for perpetrators of family violence to be screened for brain injury. Only then can effective interventions be offered to support and rehabilitate, and prevent further family violence.

•

The relationship between family violence and brain injury must be understood. Education and training of all services who come into contact with people experiencing these life events is critical to providing best practice care for identification, support and rehabilitation.

•

Education about the possible characteristics related to brain injury must form part of the rehabilitation process if people living with a brain injury are to be fully supported and family violence is to be prevented.

•

The intersection between family violence and brain injury must be addressed with a coordinated approach across all Government departments and community sectors.

•

Research investigating the prevalence of acquired brain injury among family violence victims and perpetrators is needed.

•

The economic consequences of family violence on the Australian and Tasmanian economies are significant.

•

There are significant potential cost savings and other economic and social benefits to be gained from primary prevention strategies.

•

We all have a responsibility to act.

The Brain Injury Association of Tasmania is committed to monitoring this issue, raising awareness about the circumstances of this cohort and to working collaboratively with Government and other key stakeholders to ensure a positive and planned strategy that will provide increased opportunities and effect positive change in the lives of these individuals. With our peak role and focus on acquired brain injury (ABI), we seek a society where people affected by ABI feel understood, respected, and included; laws and systems are just and fair, and people with ABI access them without discrimination; health and community services for people with ABI are respectful, responsive, and meet demand; people with ABI participate fully in community life; and the incidence of ABI is much reduced. 34

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Persampiere, J., Poole, G., & Murphy, C. M. (2014). Neuropsychological Correlates of Anger, Hostility, and Relationship-Relevant Distortions in Thinking among Partner Violent Men. Journal of Family Violence, 29(6), 625-641. Picard, M., Scarisbrick, D., & Paluck, R. (1991). HELPS TBI Screening Tool. International Center for the Disabled, TBI-NET, Department of Education, Rehabilitation Services Administration, USA. Queensland Government. (2015). Queensland says: Not Now, Not Ever. First Action Plan of the Domestic and Family Violence Prevention Strategy 2015â&#x20AC;&#x201C;2016 Brisbane: Queensland Government. Rosenbaum, A., Hoge, S. K., Adelman, S. A., Warnken, W. J., Fletcher, K. E., & Kane, R. L. (1994). Head Injury in Partner-Abusive Men. Journal of Consulting and Clinical Psychology, 62(6), 1187-1193. Rushworth, N. (2009). Understanding the Complexity of Causality: The View from Here. Parity, 22(1), 50-51. Schofield, P., Butler, T., Hollis, S., & Dâ&#x20AC;&#x2122;Este, C. (2011). Are Prisoners Reliable Survey Respondents? A Validation of Self-Reported Traumatic Brain Injury (TBI) Against Hospital Medical Records. Brain Injury, 25(1), 74-82. Schofield, P. W., Butler, T. G., Hollis, S. J., Smith, N. E., Lee, S. J., & Kelso, W. M. (2006). Traumatic Brain Injury Among Australian Prisoners: Rates, Recurrence and Sequelae. Brain Injury, 20(5), 499-506. Setnik, L., & Bazarian, J. J. (2007). The Characteristics of Patients Who Do Not Seek Medical Treatment for Traumatic Brain Injury. Brain Injury, 21(1), 1-9. Shorey, R. C., Brasfield, H., Febres, J., & Stuart, G. L. (2011). An Examination of the Association between Difficulties with Emotion Regulation and Dating Violence Perpetration. Journal of Aggression Maltreatment & Trauma, 20(8), 870-885. South Australia Department of Premier and Cabinet. (2014). Taking a Stand: Responding to Domestic Violence. Adelaide: Government of South Australia. St. Ivany, A., & Schminkey, D. (2016). Intimate Partner Violence and Traumatic Brain Injury: State of the Science and Next Steps. Family & Community Health, 39(2), 129-137. State of Victoria. (2014-16). Royal Commission into Family Violence (Parl Paper No 132). Synapse: The Brain Injury Association of Queensland. (2013). Acquired Brain Injury - The Facts: The Practical Guide to Understanding and Responding to Acquired Brain Injury and Challenging Behaviours. The Brain Injury Association of Queensland. Ta'eed, G., Skilbeck, C. E., & Slatyer, M. (2013). Which Factors Determine Who is Referred for Community Rehabilitation Following Traumatic Brain Injury? Brain Impairment, 14(2), 222-234. Tasmanian Coalition of ABI Service Providers. (2007). Acquired Brain Injury "Neglected, not forgotten". Hobart: Tasmanian Coalition of ABI Service Providers. Tasmanian Department of Health and Human Services. (1999). Review of Funded Services for People with Acquired Brain Injury: Final Report. Hobart: Department of Health and Human Services, Tasmanian Government. Valera, E. M., & Berenbaum, H. (2003). Brain Injury in Battered Women. Journal of Consulting and Clinical Psychology, 71(4), 797-804. van Velzen, J. M., van Bennekom, C. A. M., Edelaar, M. J. A., Sluiter, J. K., & Frings-Dresen, M. H. W. (2009). How Many People Return to Work After Acquired Brain Injury?: A Systematic Review. Brain Injury, 23(6), 473-488. Victoria Legal Aid. (2015). Characteristics of Respondents Charged with Breach of Family Violence Intervention Orders: Research Brief. Melbourne: Victoria Legal Aid. Victorian Government. (2012). Victoria's Action Plan to Address Violence Against Women and Children 2012-2015: Everyone has a Responsibility to Act. Melbourne: State of Victoria. Walling, S. M., Meehan, J. C., Marshall, A. D., Holtzworth-Munroe, A., & Taft, C. T. (2012). The Relationship of Intimate Partner Aggression to Head Injury, Executive Functioning, and Intelligence. Journal of Marital and Family Therapy, 38(3), 471-485. Westby, M. D., & Ferraro, F. R. (1999). Frontal Lobe Deficits in Domestic Violence Offenders. Genetic, Social, and General Psychology Monographs, 125(1), 71-102. Wong, J. Y.-H., Fong, D. Y.-T., Lai, V., & Tiwari, A. (2014). Bridging Intimate Partner Violence and the Human Brain: A Literature Review. Trauma, Violence, & Abuse, 15(1), 22-33. Wu, V., Huff, H., & Bhandari, M. (2010). Pattern of Physical Injury Associated with Intimate Partner Violence in Women Presenting to the Emergency Department: A Systematic Review and Meta-Analysis. Trauma, Violence, & Abuse, 11(2), 71-82. 37

ANNEXURE 1. ACQUIRED BRAIN INJURY (ABI) FACTSHEET • Acquired brain injury is a complex and individual condition that describes any injury to the brain that occurs after birth. • There are multiple causes of ABI, which can be grouped into two categories – traumatic brain injury and non-traumatic brain injury. -

A traumatic brain injury (TBI) is an insult to the brain caused by an external physical force that can produce a diminished or altered state of consciousness (such as a coma). It is often (but not always) accompanied by loss of consciousness. A TBI does not include degenerative (brain disease) or congenital (hereditary) injuries. Causes of TBIs include motor vehicle crashes, assaults, falls, sports injuries, bicycle and pedestrian accidents, shaking babies, blasts and being close to an explosion.

ABI can also occur as the result of a non-traumatic event, such as disease, aneurysm, tumour, lack of oxygen, alcohol or drugs causing damage to the brain. The leading cause of non-traumatic ABI is a stroke, where the brain’s blood supply is stopped by a clot or bleeding.

• A mild brain injury, or concussion, may occur even if there is no loss of consciousness or noticeable physical injury. Even mild brain injuries can cause temporary or permanent changes in the way a person thinks, feels, act and interacts with others. • ABI related disability can affect a person’s cognitive, physical, emotional and independent functioning. People with ABI often experience a combination of difficulties with communication, thinking, physical functioning and control of their emotions and/or behaviour. They may also experience changes to their memory function, ability to concentrate, plan and solve problems. The person may tire easily, lack motivation, become self-centred and have a reduced tolerance to stress. • The outcomes and effects of ABI are different for each person and often depend on the cause, nature and severity of the injury. Some effects of brain injury are only experienced in the short term, but many permanently impact on the person’s ability to lead an independent life. • ABI is often termed ‘the invisible disability’ because the nature and impact of brain injury are not widely understood or acknowledged. • ABI is not to be confused with intellectual disability. Though people with a brain injury may experience speech, memory and/or communication difficulties, they generally retain their intellectual abilities.

•

Consequences of brain injury may include, but are not limited to: Cognitive Symptoms

Physical Symptoms

Emotional and Behavioural Symptoms

• Short or long-term memory loss • Slowed ability to process information • Trouble concentrating or paying attention for periods of time • Difficulty with conversation and other communication difficulties such as trouble finding the correct words • Reading and writing challenges not present prior to injury • Difficulty in judging distance and space, (called spatial disorganization) • Organizational problems • Impaired judgment • Inability to do more than one thing at a time • Unusual sensitivity to light and/or noise

• Seizures • Fatigue, increased need for rest • Sleep difficulties • Vision impairments — double or low vision, even blindness • Sensory loss — smell, touch, taste • Loss of hearing or ringing in the ears • Slow or slurred speech • Headaches or migraines • Lack of balance • Difficulty speaking or understanding language • Decreased motor skills • Sexual dysfunction • Increased or decreased muscle control • Partial or total paralysis

• Depression, grief, or chemical changes caused by the injury • Anxiety, restlessness, agitation • Lower stress tolerance • Behaviour changes • Inappropriate behaviours such as sexually acting out • Irritability, frustration, impatience • Mood swings such as excess laughing and crying • Impulsiveness and a lack of judgment • Emotional flatness and acting passive • Anger that is uncontrolled • Impaired self-perception, such as not seeing themselves as disabled • Impaired insight about the effects of the brain injury on their behaviour

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This injury has a direct impact on the Australian suicide rate, petty and major crime rates, drug addiction, alcoholism, violence in the family home, employment and discrimination within the social welfare state along with impacting on the social and political economy.

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The significant changes in personality and behaviour of a person with a brain injury can be difficult for families to cope with. This has been described as the ‘ripple’ or ‘domino’ effect on family after the injury where other family members experience their own adjustment difficulties.

The Brain Injury Association of Tasmania exists to assist people with brain injury, their families, carers and service providers within the community to understand and manage the impact of brain injury. You can contact them on FREE CALL 1300 242 827 or visit www.biat.org.au.