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Traumatic Brain Injury: Challenging Behavior


Traumatic Brain Injury: Challenging Behavior Anastasia Edmonston MS CRC TBI Projects Director Maryland Traumatic Brain Injury Project MD Mental Hygiene Administration – PowerPoint PPT presentation

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Title: Traumatic Brain Injury: Challenging Behavior

Traumatic Brain Injury Challenging Behavior
  • Anastasia Edmonston MS CRC
  • TBI Projects Director
  • Maryland Traumatic Brain Injury Project
  • MD Mental Hygiene Administration

What We will Cover Today
  • Brain Anatomy-form and function
  • Brain Injury-how many who is affected
  • Types of Brain Injury

What We will Cover Today
  • The Physical, Cognitive and Emotional/Behavioral
    Aftermath of Brain Injury
  • TBI Screening Tool
  • Brain Injury and Co-occurring disorders

What We will Cover Today
  • Strategies for Supporting Individuals with Brain
  • Resources Available Statewide, Regionally and

Skull Anatomy
The base of the skull is rough, with many bony
protuberances. These ridges can result in injury
to the temporal and frontal lobes of the brain
during rapid acceleration.
The skull is a rounded layer of bone designed to
protect the brain from penetrating injuries.
Bony ridges
Skull Anatomy
Injury to frontal lobe from contact with the skull
Lobes of the Cerebrum
Frontal lobe
Parietal lobe
Limbic Lobe
Occipital lobe
Temporal Lobe
The Frontal Lobe
  • The frontal lobe is the area of the brain
    responsible for our executive skills - higher
    cognitive functions.
  • These include
  • Problem solving
  • Spontaneity
  • Memory
  • Language
  • Motivation
  • Judgment
  • Impulse control
  • Social and sexual behavior.

Frontal Lobe Injury
The frontal lobe of the brain can be injured from
direct impact on the front of the head. During
impact, the brain tissue is accelerated forward
into the bony skull. This can cause bruising of
the brain tissue and tearing of blood
vessels. Frontal lobe injuries can cause changes
in personality, as well as many different kinds
of disturbances in cognition and memory.
Prefrontal Cortex
The prefrontal cortex is involved with intellect,
complex learning, and personality. Injuries to
the frontal lobe can cause mental and personality
The Developing Brain
  • Childrens brains do not reach their adult weight
    of 3 pounds until they are 12 years old
  • The brain, and most importantly, the brains
    frontal lobe region does not reach its full
    cognitive maturity till individuals reach their
    mid twenties

The Developing Brain
  • The Frontal Lobe houses our executive skills,
    these include judgement, problem solving, mental
    flexibility, etc.
  • The Frontal Lobe is very vulnerable to injury
  • Damage to the Frontal Lobe any where along the
    developmental continuum can impact executive
    skill functioning

Temporal Lobe
The temporal lobe plays a role in emotions, and
is also responsible for smelling, tasting,
perception, memory, understanding music,
aggressiveness, and sexual behavior. The temporal
lobe also contains the language area of the brain.
Temporal Lobe Injury
The temporal lobe of the brain is vulnerable to
injury from impacts of the front of the head. The
temporal lobe lies upon the bony ridges of the
inside of the skull, and rapid acceleration can
cause the brain tissue to smash into the bone,
causing tissue damage or bleeding.
Parietal Lobe
The parietal lobe plays a role in our sensations
of touch, smell, and taste. It also processes
sensory and spatial awareness, and is a key
component in eye-hand co-ordination and arm
movement. The parietal lobe also contains a
specialized area called Wernickes area that is
responsible for matching written words with the
sound of spoken speech.
Side Impact Injuries May Impact the Parietal Lobe
Injuries to the right or left side of the brain
can occur from injuries to the side of the
head. Injuries to this part of the brain can
result in language or speech difficulties, and
sensory or motor problems.
Occipital Lobe
The occipital lobe is at the rear of the brain
and controls vision and recognition.
Occipital Lobe Damage
Occipital lobe injuries occur from blows to the
back of the head. This can cause bruising of the
brain tissue and tearing of blood vessels. These
injuries can result in vision problems or even
The Limbic System
The limbic system is the area of the brain that
regulates emotion and memory. It directly
connects the lower and higher brain functions.
Coup-Contra Coup Injury
A French phrase that describes bruises that occur
at two sites in the brain. When the head is
struck, the impact causes the brain to bump the
opposite side of the skull. Damage occurs at the
area of impact and on the opposite side of the
Diffuse Axonal Injury
Brain injury does not require a direct head
impact. During rapid acceleration of the head,
some parts of the brain can move separately from
other parts. This type of motion creates shear
forces that can destroy axons necessary for brain
functioning. These shear forces can stretch the
nerve bundles of the brain.
Diffuse Axon Injury is a very serious injury, as
it directly impacts the major pathways of the
The Neuron
Dendrites Collects information from other neurons
Cell Body
Axon Transmits information to other neurons.
  • Traumatic Brain Injury is an insult to the brain
    caused by an external physical force
  • Diffuse Axonal Injury the tearing and shearing of
    microscopic brain cells
  • Acquired Brain Injury is an insult to the brain
    that has occurred after birth, for example TBI,
    stroke, near suffocation, infections in the
    brain, anoxia

Incidence of TBI CDC 2004
  • In the United States, at least
  • 1.4 million sustain a TBI each year
  • (That we know about)

What are the Costs of TBI? CDC 2006
  • Direct medical costs and indirect costs such as
    lost productivity of TBI totaled an estimated 60
    billion in the United States in 2000. (That is
    equal to the cost of building the international
    space center or 60 times the net worth of Oprah
    Winfrey )Jean Langlois of the CDC

About 3.17 Million American civilians (more than
1.1 of population, live with the consequences of
traumatic brain injury CDC in Journal of Head
Trauma Rehabilitation 2008 (Vol. 23, No. 6, pp
What Might it Feel Like
  • Handwriting
  • Processing Exercise

Incidence of TBI CDC 2004Of those 1.4 million..
  • 51,000 die
  • 290,000 are hospitalized and
  • 1,224,000 million are treated an released from an
    emergency department

Reframed, the numbers nauseate. In America
alone, so many people become permanently disabled
from a brain injury that each decade they could
fill a city the size of Detroit...
.Seven of these cities are filled already. A
third of their citizens are under fourteen years
of age. From Head Cases, Stories of Brain
Injury and its Aftermath Michael Paul Mason 2008
published by Farrar, Straus and Giroux
Brain Injury and Children
  • According to the BIAA, Brain Injury is the
    leading cause of death and disability among
  • Approximately 470,000 TBIs occur among children
    0-14 years old a year
  • Brain injuries account for over 90 of emergency
    department visits in children 0-14 years old CDC
    Report Traumatic Brain injury in the United
    States January 2006

Brain Injury and Concussion in Children
  • In sports alone, 300,000 concussions are
    estimated to occur annually
  • For every 1 concussion in the NFL, there are
    5,650 youth injuries
  • Sports associated with concussion soccer,
    football, lacrosse, hockey, horseback riding,
    cheerleading.. Gerard Gioia, Ph.D., Childrens
    National Medical Center in remarks at the BIAMD
    conference 2005

Other potential Neurotoxins that may impact the
  • Exposure to lead paint
  • Regarding exposure to alcohol in utero, according
    to Dr. Jacobson of Wayne State University We
    found more serious cognitive impairment in
    relation to alcohol than cocaine or other drugs,
    including marijuana and smoking From Fetal
    Brains Suffer Badly From Effects of Alcohol NYT

To Underscore The Developing Brain
  • Childrens brains do not reach their adult weight
    of 3 pounds until they are 12 years old
  • The brain, and most importantly, the brains
    frontal lobe region does not reach its full
    cognitive maturity till individuals reach their
    mid twenties

This is important to keep in mind because..
  • The Adult Consumer you are serving in your
    program may have suffered a brain injury as a

Causes of TBI CDC 2006
Who is at the Highest Risk of TBI? 2005
  • Males 1.5 times as likely as females to sustain a
  • Two age groups most at risk are 0-4 year olds and
    15-19 year olds
  • The elderly, 75 and older from falls
  • African Americans have the highest death rate
    from TBI

What about those with unidentified TBI? Adapted
from MCHB webcast, Wayne Gordan, Ph.D 5.21.08
  • 425,000 people treated by MDs in office visits
    Langlois 2004
  • 90,000 treated in other types of outpatient
    settings Langlois, 2004
  • Uncounted injuries on the playground, on the
    playing fields, from falls in the home, assaults,
    domestic violence, returning veterans, etc. etc.

The Scope of the Problem
  • Distribution of Severity
  • Mild injuries 80 (LOC lt 30 min, PTA ,1 hour)
  • Moderate 10 - 13 (LOC 30 min-24 hours, PTA
    1-24 hours)
  • Severe 7 - 10 (LOC gt24 hours, PTA gt24 hours)

The Importance of Post Traumatic Amnesia
  • PTA is the period of time after injury when a
    person is unable to lay down new memoriesfor

That first morning, wow, I didnt want to move,
I was thankful that nothings broken, but my
brain was all scrambled Ryan Church, NYT 3/10/08
  • All he remembers from the collision with
    Anderson is the aftermath, being helped off the
    field by two people, although he said he did not
    know who they were until he saw a photograph
    later Ben Shpigel NYT reporter

The Faces of Brain Injury A short video by the
Brain Injury Association of Florida
Possible Changes-Physical
  • Motor skills/Balance
  • Hearing
  • Vision
  • Spasticity/Tremors
  • Speech
  • Fatigue/Weakness
  • Seizures
  • Taste/Smell

Possible Changes-Thinking
  • Memory
  • Attention
  • Concentration
  • Processing
  • Aphasia/receptive and expressive language
  • Executive skills
  • Problem solving
  • Organization
  • Self-Perception
  • Perception
  • Inflexibility
  • Persistence

Possible Changes-Personality and Behavioral
  • Depression
  • Social skills problems
  • Mood swings
  • Problems with emotional control
  • Inappropriate behavior
  • Inability to inhibit remarks
  • Inability to recognize social cues

Personality and Behavioral cont..
  • Problems with initiation
  • Reduced self-esteem
  • Difficulty relating to others
  • Difficulty maintaining relationships
  • Difficulty forming new relationships
  • Stress/anxiety/frustration and reduced
    frustration tolerance

A memory deficit might look like trouble
remembering or it might look like (Capuco
  • She frequently misses appointments-avoidance,
    irresponsibility (for example...)
  • He says hell do something but doesnt get around
    to it (for example...)
  • She talks about the same thing or asks the same
    question over and over-annoying perservation
  • He invents plausible sounding answers so you
    wont know he doesnt remember (for example)

An attention deficit might look like trouble
paying attention or it might look like (Capuco
  • He keeps changing the subject
  • She doesnt complete tasks
  • He has a million things going on and none of them
    ever gets completed (for example)
  • When she tries to do two things at once she gets
    confused and upset

A deficit in executive skills might look like the
inability to plan and organize or it might look
like... (Capuco Freeman-Woolpert)
  • Uncooperativeness, stubbornness
  • Lack of follow through
  • Laziness
  • Irresponsibility

Unawareness might look like (Capuco
  • Insensitivity, rudeness
  • Overconfidence
  • Seems unconcerned about the extent of her
  • Doesnt think she needs supports
  • Covering up problems (everythings fine)
  • Big difference in what he thinks and what
    everyone else thinks about his behavior
  • Blaming others for problems, making excuses

Lack of Awareness
  • A common and difficult to remediate hallmark of a
    brain injury

Levels of Awareness Crossen (1989) J Head
Trauma Rehabilitation
  • Intellectual Awareness-individual is able to
    understand at some level, that a particular
    function or functions is impaired. A greater
    level of intellectual awareness is required to
    recognize some common thread in the activities in
    which they have difficulty
  • Emergent Awareness-individual is able to
    recognize a problem when it is actually
    happening. To do so, they must recognize a
    problem exists (intellectual awareness), and
    realize when it occurs
  • Anticipatory Awareness-individual is able to
    anticipate a problem will occur and plan for the
    use of a particular strategy or compensation that
    will reduce the chances that a problem will
    occur, e.g. keep and refer to a calendar to
    support memory for daily schedule

The Relationship Between Brain Injury and Mental
  • Depression is the most common Axis I psychiatric
    disorder after TBI followed by alcohol abuse,
    panic disorder, specific phobia and psychotic
    disorders (Gordon et. al 2004)
  • A 50 yr.. Follow-up of 1,198 WWII vets found that
    520 had incurred a TBI. 18.5 of vets with brain
    injuries had a life time prevalence of major
    depression verses 13.4 rate of depression among
    on brain injured vets (Holsinger 2002)

The Post -Concussive Syndrome and PTSD Dr. Paul
  • Increased startle response especially to loud
  • Irritability
  • Avoidance of many social events
  • Intolerance of new situations

Organic Personality Disorder Anti-Social or
Hysterical Personality Traits Dr. Paul McClelland
  • Decreased impulse control
  • Labile and superficial affect
  • Impaired insight and self awareness
  • Decreased empathy and social awareness
  • Impaired initiative (Depression?)

Partial Seizures Panic Attacks or Dissociative
States Dr. Paul McClelland
  • Most common type of post-traumatic epilepsy
  • Temporal lobe damage and complex partial seizures
  • Spells starting suddenly lasting a few
  • Olfactory (smell) or gustatory (taste)
  • Déjà vu or jamais vu
  • Micropsia, macropsia and other symptoms

Obsessive-Compulsive Traits after TBI
Pre-Existing Conditions or Adaptation to
Cognitive Deficits Other Changes? Dr. Paul
  • Compulsive behaviors as adaptations for memory
  • Temper tantrums and other adaptations
  • Non-pharmacological management of brain-injured

Other Mental Health Disorders Related to TBI
  • PTSD is noted in some individuals following TBI
    even if there is no memory of the incidence
    (Klein, Caspi 2003)
  • Rapid cycling bipolar is rare but noted in the
    literature for individuals with temporal lobe
    damage (Murai, Fujimoto 2003)
  • Psychotic syndromes occur more frequently in
    individuals who have had a TBI then in the
    general population (McAllister, Ferrell 2002)

TBI Suicide
  • The risk of attempted or completed suicide in
    neurological illness is strongly related to
    depression, feelings of hopelessness or
    helplessness, and social isolation (Arciniegas
    Anderson, 2002)
  • Simpson and Tate (2002) screened 172 individuals
    for suicidal ideation and hopelessness. Findings
    using the Beck Suicide Ideation and Hopelessness
    Scales found 35felt hopeless and 23expressed
    suicide ideation. 18 had attempted suicide post

Individuals with or without a history of brain
injury often share identical risk factors for
suicide Teasdale Engberg 2001
  • Young Adults
  • Males
  • Substance Abuse
  • Other psychosocial disadvantages

Teasdale Engbergs population study of 145,440
Danes post TBI
  • Followed individuals with concussion, skull
    fractures and cerebral contusions or traumatic
    intracranial hemorrhages (lesions) for 15 years
  • Incidence of suicide among all three groups
    higher compared to general population
  • Presence of a co-occurring substance abuse
    diagnosis increased suicide rates among all three
  • Significantly greater risk for suicide found
    among those with lesions than those with
    concussion or fracture
  • Rate of suicide was 1 over a 15 year period

Subsequent Studies.. Simpson Tate
  • A 2003 study found of 172 individuals post TBI,
    17attempted suicide over a period of 5 years
  • A 2005 study of 172 individuals with a hx of
    brain injury found that those with comorbid post
    injury history of psychiatric/emotional
    disturbance and substance abuse were 21 times
    more likely to attempt suicide post injury

Why Screen?
  • What other TBI Screening efforts have found

2000 Epidemiological Study of Mild TBI J. Silver
of NYU, cited in WSJ by Thomas Burton 1.29.08
  • 5,000 interviewed
  • 7.2 recalled a blow to the head
    w/unconsciousness or period of confusion
  • Follow up testing found 2x rate of depression,
    drug and alcohol abuse
  • Elevated rates of panic and and
    obsessive-compulsive DO

Brain Injury in the Correctional
Setting-Nationally CDC website 2008
  • According to jail and prison studies,25-87 of
    inmates report having experienced a TBI-this
    compared with 8.5 of the general population
  • Prisoners with a history of TBI may also
    experience mental health disorders (including
    severe depression, anxiety, substance abuse)

Brain Injury in the Correctional
Setting-Nationally CDC website 2008
  • Woman inmates who are convicted of a violent
    crime are more likely to have sustained a
    pre-crime TBI or some other form of physical
  • Women with substance abuse disorders have an
    increased risk for TBI compared with women in the
    general population

In Maryland- Screening Results from the MD TBI
Post Demo II Project-2005
  • Summary of TBI Incidence Among all Screened at 7
    public mental health agencies in Frederick and
    Anne Arundel counties
  • N190
  • 39 no reported history of TBI (78)
  • 58.94 of individuals with a history of TBI
  • 35.78 of individuals with a history of a single
    incidence of TBI (68)
  • 23 of individuals with a history of 2 or more
    TBIs (44)

Details-County Detention Center 2005
  • N41
  • Single TBI 16
  • 2 or more incidents of TBI 14
  • No history of TBI 11
  • 73 screened reported a history of TBI

County Detention Center 2008
  • N25 (16 male, 9 female)
  • 22 reported possible TBI(s)
  • Single TBI10
  • 2 or more incidents of TBI 12
  • No History of TBI 3
  • 88 screened reported a history of TBI

TBI in a County Jail Population Slaughter et. al
Brain Injury 2003
  • 69 randomly selected inmates
  • 60 (87) reported TBI over their lifetime
  • 25 (36) reported TBI in the prior year
  • Later group had worse anger and aggression
    scores, trend towards poorer cognitive test
    results and higher prevalence of psychiatric DO
    then those w/out TBI in prior year

Brain Injury in the Correctional
Setting-Nationally CDC website 2008
  • According to jail and prison studies,25-87 of
    inmates report having experienced a TBI-this
    compared with 8.5 of the general population
  • Prisoners with a history of TBI may also
    experience mental health disorders (including
    severe depression, anxiety, substance abuse)

Brain Injury in the Correctional
Setting-Nationally CDC website 2008
  • Woman inmates who are convicted of a violent
    crime are more likely to have sustained a
    pre-crime TBI or some other form of physical
  • Women with substance abuse disorders have an
    increased risk for TBI compared with women in the
    general population

Brain Injury Violence Domestic Violence
  • Greater than 90 of all injuries secondary to
    domestic violence occur to the head, neck or face
    region (Monahan OLeary 1999) Adapted from The
    Alabama Department of Rehabilitation Services DV
  • Corrigan, (2003) found that of 167
    individuals treated for domestic violence related
    health issues, 30 experienced a loss of
    consciousness on at least one occasion, 67
    reported residual problems that were potentially
    TBI related
  • Valera and Berenbaum, (2003) assessed 99 battered
    women. Of these, 57 had brain injured related

Homelessness Brain Injury A little studied
population, however..
  • A University of Miami study found that 80 of 60
    homeless individuals had high incidence of
    neuropsychological impairment
  • Researchers in Milwaukee found possible cognitive
    impairment in 80 of 90 homeless men evaluated.
  • Dr. LaVecchia of the MA Statewide Head Injury
    Program reported in 2006 that of 140 homeless
    individuals evaluated, 83.6 of males and 16.4
    of females had an acquired brain injury
  • Other studies in the UK and Australia show
    similar rates of brain injury among homeless

Correlation between TBI Homelessness Hwang 10.7.08 Canadian Medical Journal
  • 904 homeless individuals surveyed
  • Lifetime Prevalence of TBI-53, more common among
    men than women surveyed
  • Rates 5 or more times greater than the 8.5
    lifetime prevalence in general population and
    consistent w/ prison studies

TBI Homelessness For Veterans, A Weekend Pass
From Homelessness from the New York Times
7.26.09, Erick Eckholm
Human service professionals will be seeing
increasing numbers of returning service members
in need of services over the next few years
.The ranks include young men like Kenneth
Kunce, 26, who suffered a traumatic brain injury
when his Humvee was hit by a roadside bomb in
Iraq. The injury left him disorientated, jumpy
and temperamental. When he came home he started
using Ecstasy and alcohol, he said he lost his
wife and more than one job. He said he was
grateful to the Veterans Affairs hospital for
providing speech and physical therapy, but added
that he still had trouble coping with noises and
anger. Mr. Kunce, who sometimes lost his train of
thought as he spoke to this reporter, is living
out of his car.
The HELPS Brain Injury Screening Tool (see
handout) The original HELPS tool developed by M.
Picard, D. Scarisbrick, R. Paluck, 9.1991 Updated
by the Michigan Department of Community Health
  • Have you ever Hit your Head or been Hit on the
  • Prompt individual to think about TBI at any age,
    MVAs. Assaults, Sports injuries, Service related
    injuries, Shaken baby and/or adult

  • Were you ever seen in the Emergency room,
    hospital, or by a doctor because of an injury to
    your head?
  • Explore the possibility of unidentified
    traumatic brain injury many do not present in
    medical settings

  • Did you ever Lose consciousness or experience a
    period of being dazed and confused because of an
    injury to your head?
  • Remember, a LOC isnt required for someone to
    develop symptoms subsequent to a blow to the
    head. alteration of consciousness AKA post
    traumatic amnesia (PTA). At this point, the
    interviewer may consider asking the individual if
    they have had multiple mild TBI

  • Do you experience any of these Problems in your
    daily life since you hit your head?
  • You want to know when any problems began (or
    began to be noticed) Remember, lack of awareness
    is a hallmark of brain injury, you might ask if
    anyone close to the individual has made any
    observations regarding changes in function.

  • Difficulty reading, writing, calculating
  • Poor problem solving
  • Difficulty performing your job/school work
  • poor judgement (being fired from job, arrests,
    fights, relationships affected)
  • Headaches
  • Dizziness
  • Anxiety
  • Depression
  • Difficulty concentrating
  • Difficulty remembering

  • Any significant Sickness?
  • Acquired Brain Injury (ABI) can result in many of
    the same functional impairments as traumatic
    brain injury (TBI). For example, brain tumor,
    meningitis, West Nile virus, stroke, seizures,
    toxic shock syndrome, aneurysm, AV malformation,
    any history of anoxic injury, e.g. heart attack,
    near drowning, carbon monoxide poisoning can all
    result in multiple deficits

Scoring the HELPS Positive for a possible Brain
Injury when the following three are identified
  • An event the could have caused a brain injury
    (YES to H, E, or S), and
  • A period of loss of consciousness or altered
    consciousness after the injury or another
    indication that the injury was severe (YES to L
    or E), and
  • the presence of 2 or more chronic problems listed
    under P that were not present before the injury.

Scoring the HELPS
  • A positive screening is not sufficient to
    diagnose TBI as the reason for current symptoms
    and difficulties-other possible possible reasons
    need to be ruled out
  • Some individuals could present exceptions to the
    screening results, such as people who do have
    TBI-related problems but answered no to some
  • Consider positive responses within the context of
    the persons self-report and documentation of
    altered behavioral and/or cognitive functioning

Additional comments and observations of the
  • Any visible scars?
  • Walks with a limp?
  • Uses a cane or walker?
  • Has a foot brace?
  • Limited use of one hand?
  • Appears to have difficulty focusing vision?
  • Difficulty answering questions?
  • Answers are unorganized and/or rambling
  • Becomes easily distracted, agitated or is
    emotionally labile

What you are looking for..And Why
  • Any reported or suspected functional difficulties
    that are interfering with home, work or community
  • With the identification a history of brain
    injury, professionals can better support the
    individuals served and make informed referrals to
    brain injury specialists when appropriate

Remember, for most, Brain Injury is
  • -A loss of Self
  • -A loss of future
  • -loss of possibilities

I had a job, I had a girl, I had something going
mister in this world
  • A 10 year survivor of a TBI quoting a Bruce
    Springsteen song when describing what he had lost
    because of his injury

A compromised brain can lead to compromised
behavior, further adding to social isolation and
social failure The following slides 3 are adapted
from Webcast sponsored by the Health Resources
and Services Administrations Federal TBI Program
Web cast July 27, 2006
  • Harvey E. Jacobs, Ph.D., Licensed Clinical
    Psychologist/Behavioral Anaylist
  • Marty McMorrow, Director of National Business
    Dev., The MENTOR Network
  • Jane Hudson, JD., senior Staff Attorney, National
    Disability Rights Network

Behavioral Statistics
  • Approximately 90 of all people who experience
    severe disability following brain injury
    experience some emotional or psychiatric distress
  • 40 continue to demonstrate behavioral difficulty
    five years post injury

Behavioral Statistics
  • 25 experience behavior dysfunction that
    interferes with other activities of daily life
  • 3-10 experience severe behavioral dysfunction
    that may require intensive professional and
    residential intervention (3,000-9,000 new people
    per year)

Research findings regarding Behavior Problems
after TBI
  • Aggressive behavior is associated with presence
    of major depression, frontal lobe lesions, poor
    premorbid social functioning and a history of
    alcohol and substance abuse Tateno J of
    Neuropsychiatry Clin. Neuroscience 2003

Research findings regarding Behavior Problems
after TBI
  • Research conducted by Wood and Liossi in 2006
    reports it is tentatively suggested that
    significant impairment in verbal memory and
    visuospatial abilities against a background of
    diminished executive-attention functioning is
    associated with the development of aggression
    after brain injury,especially when other risk
    factor such as low premorbid IQ, low
    socioeconomic status, and male gender are
    present J of Neuropsychiatry Clin. Neuroscience

Research findings regarding Behavior Problems
after TBI
  • Impairments in recognizing the emotional state
    of others may underlie some of the problems in
    social relationships that these patients
    experienceTBI patients were found to be
    impaired on emotional recognition compared to the
    control patients both early after injury and one
    year later Ietswaart et. al. Neuropsychologia,

According to McMorrow, Jacobs and Hudson HRSA
Webcast July 27, 2006 Almost all people who
experience disability following brain injury are
not inherently aggressive or assaultive. However,
for some people, when challenges are not properly
addressed this can result in
-Lack of responsiveness to requests -Property
destruction -Verbal or physical
aggression -Violation of personal or sexual
boundaries -Wandering or flight -Self harm/self
Neurobehavioral Challenges According to
McMorrow, Jacobs and Hudson are caused by
  • Pre-injury history
  • Post-Injury learning and experiences
  • Inability to negotiate difficult situations
  • Others not recognizing the basic challenges to
    an individual with TBI, and
  • Not providing proper treatment

With the Proper Supports
  • -A renewed sense of self
  • -A future can be imagined
  • -New possibilities can be created

Attention is the ability to stay focused on a
specific topic or task. It is critical to
successful participation in purposeful activity.
The next 10 slides are from the Rhode Island BIA
presentation Brain Injury A Practical Training
for Caregivers
  • Gain and encourage eye contact when appropriate.
  • Use an opening statement such as Are you ready
    to get started to gain the consumers attention
    before explaining an activity or giving
  • Be specific and clear. Avoid lengthy or vague
  • Slow down when you speak. It is very difficult to
    listen carefully to someone who is talking at a
    fast pace.
  • Limit interruptions when possible.

  • Minimize environmental distractions (competitive
    background noise, cluttered work areas and
    cluttered walls).
  • Present information in an organized fashion.
  • Pause to allow the consumer to process or to
    finish taking notes before moving to the next
    direction or to a new piece of information.

  • Encourage a steady work pace. Rushing can result
    in an increase in mistakes or in skipping an
    important step in an activity.
  • Breakdown assignments into smaller more
    manageable portions.
  • Provide a task breakdown or assist the consumer
    in developing a task breakdown for specific

  • Avoid overwhelming the consumer. Dont plan on
    covering large amounts of information in a single
  • When assigning tasks that the consumer will be
    expected to complete independently, begin with
    simple activities. Progress to more difficult or
    complicated tasks if the consumer is successful
    with the simple activities.

  • If you notice that the consumer is beginning to
    lose focus, give a cue to redirect to task, or
    ask if they need a short break.
  • Provide positive feedback when the individual is
    performing well or requesting to use appropriate
    modifications or strategies during a session.
  • When finishing an instructional session, help the
    consumer to review the material that was covered.
    Place emphasis on any follow up activities the
    consumer is supposed to complete independently.

  • To pay attention, we must be awake and alert,
    this is referred to as arousal level. Under
    normal circumstances our central nervous system
    automatically keeps the arousal level regulated.
    As a result of brain injury clients may
    experience lethargy or sluggishness referred to
    as a state of under arousal. Or they may appear
    to be hyper or over stimulated known as a state
    of over arousal. In some cases the use of sensory
    stimulation, relaxation or focusing techniques
    can be helpful. Responses to sensory input can
    vary from person to person.

  • Use an appropriate volume and tone of voice for
    the individual consumer. A softer voice may be
    more tolerable to someone who is over stimulated.
    A louder voice with extra emphasis on key words
    may be helpful to someone who is under aroused.
  • Determine if the use of white noise or
    environmental sound machines is helpful.
  • Use high intensity white light or bright natural
    light for individuals who are under aroused,
    dimmed lighting for those who are over aroused.

  • Play background music that the individual finds
    helpful when paying attention to a particular
    activity, or for relaxation (soft soothing music,
    upbeat or rhythmic music).
  • Include breaks into the daily schedule to listen
    to short guided meditation or relaxation tapes.
  • Pause between activities or during lengthy
    activities to take a few deep breaths.

  • Movement such as gentle use of a rocking chair,
    or brisk movement can help to regulate arousal.
  • Joint and muscle stimulation experienced during
    weight bearing or resistive exercises can also
    assist with regulation of arousal.
  • Encourage participation in a regular exercise
    program or activity such as Yoga or Tai Chi when

The Benefits of Exercise Post Injury TBI
Consumer Report 2 TBI Central MT. Sinai Model
  • Those who exercise had fewer physical, emotional
    and cognitive complaints. E.g. sleep problems,
    irritability, forgetting and being disorganized
  • Non-exercisers complained of more cognitive
    problems or symptoms than those who exercise
  • Exercisers with TBI were less depressed
  • Exercisers viewed themselves as healthier
  • Exercisers were often engaged in school, work,
    and got around the community more freely
  • Exercisers had more severe brain injuries than
    the non-exercisers, suggesting that a severe
    injury does not prevent engaging in exercise

Memory functions are complicated and sensitive.
Memory is frequently the first function to be
notably impaired and one of the last functions to
be regained in the recovery process.
  • The next 32 slides are adapted from the Rhode
    Island BIA presentation Brain Injury A
    Practical Training for Caregivers

  • Memory Systems can significantly improve client
    follow through and independence when used on a
    regular basis. When a new system is introduced a
    repetitive training and cueing period is
    recommended to reinforce consistent use. Systems
    can be updated to accommodate for improvements in
    memory, or for changing needs.

  • When designing a memory system
  • Define the goals or exact needs the system will
    be meeting.
  • Designate separate sections based on specific
  • Use a format and style that the individual
  • Encourage use of one system that is taken
    everywhere. (technology!) See Tony Gentry, Ph.D.
    OTR/Ls website

  • Timers, wrist watch alarms or talking watches can
    provide prompts.
  • Use check off sheets (this allows the individual
    to self-monitor and reference back).
  • Post simple reminder signs for prompts to turn
    off appliances, lights, etc.
  • Label drawers and cupboard fronts indicating
    their contents.

  • Post step by step directions for appliances such
    as the coffee maker, microwave etc.
  • Post-it notes for extra reminders, for example
    place a post it note on the memory book as a
    reminder to check the to do list if there is a
    critical item on the schedule the next day.
  • Provide written or picture based instructions in
    addition to verbal instructions.

  • Color code folders, storage containers, or
    calendar entries to help with recall and
  • Use tape recorders to record meetings or
  • Provide repetitive training or instruction when
    reintroducing functional activities into the
    daily schedule, and with all activities that
    require new learning.
  • Encourage note taking at meetings, appointments,

  • Pocket Voice it recorders can be used to record
    reminders throughout the day.
  • Use the home answering machine to leave
    reminders to self.
  • Have a back up plan. For instance, in addition to
    strategies for remembering keys, have a
    contingency plan with extra keys available at
    accessible locations (neighbors, friends, etc.)

Problem Solving
  • Problem solving is used for completion of a wide
    range of activities throughout the day. Many
    activities are sequenced performed by using a
    step by step approach. Cues can support consumer
    participation in activities Written or picture
    task breakdowns can be used during early training
    or as a prop for independent task completion as
    the consumer progresses.
  • Strategies and approaches can also be developed
    to help consumers with higher level or abstract
    problem solving skills.

Problem Solving/Sequencing example
  • Squat Pivot Transfer
  • 1)Park- at an angle along the mat, left front of
    the wheelchair touching the mat.
  • 2)Lock both wheels
  • 3)Check your locks
  • 4)Flip up left arm rest
  • 4)Scoot your bottom forward
  • 5)Feet flat on the floor 8 -10 inches apart,
    left foot forward
  • 6)Hands- Left hand on the mat, Right hand on the
    chair arm
  • 7)Push on arms, lift up bottom, pivot onto the mat

Problem Solving
  • State Problem_________________________
  • List 3 solutions 1)_____________________
  • 2)__________________
  • 3)__________________
  • Solution 1 Solution 2
    Solution 3
  • Pros Cons Pros Cons
    Pros Cons
  • Describe the most logical and effective solution
    based on the above_______________________________
    _ _____________________________________

  • Impulsivity is often a consequence of injury to
    the frontal lobes.
  • Impulsivity can have a negative impact on
    independent living, particularly when life
    changing decisions are made without carefully
    thinking things through.

  • Change Plan
  • What change do I want to make?____________________
  • Why do I want to make the change?_________________
  • Change
    Not Changing
  • Pros Cons
    Pros Cons
  • List step for change1)________________2)_________
  • 3)________________4)________________5)____________
  • Who could help me?________________________________
  • What might interfere with my change?______________
  • How would I evaluate success? ____________________

  • Poor initiation, a decreased ability to initiate
    or begin activities, can be a consequence of
    brain injury. Initiation deficits are often
    misinterpreted, caregivers may assume the
    consumer doesnt care or that they arent
    motivated. Damage to any one of several different
    areas of the anterior part of the brain can
    result in deficits in this area.

  • Many individuals respond well to structure and
    consistent routines.
  • When preparing daily and weekly schedules be
    specific. Designate specific times for activities
    to be performed. In addition to using a general
    concept such as clean-up the kitchen, indicate
    specific tasks for example put dishes in the
    dishwasher, wipe off the table, wash the counter.
  • Begin with lighter demands that promote success.
    The difficulty of demands can be increased when
    the consumer demonstrates consistent follow
    through with the easier activities.

  • Encourage consumer participation when developing
  • Provide training and cues when introducing a new
    or updated schedule.
  • Accept close approximations of the desired
    behavior when changes are initially instituted.
  • Use positive reinforcement for all successful
    follow through.
  • Engage the consumer in a problem solving approach
    when addressing areas of difficulty.

  • Communication is very complex and involves
    processing of both verbal and nonverbal
    information. Individuals may have receptive
    deficits, difficulty understanding specific words
    or with the way in which words are presented.
    They may have expressive deficits, difficulty
    remembering a word, or with pronouncing words
    correctly when speaking

  • Receptive Deficits
  • Slow your rate of speech
  • Simplify sentence structure, be clear and concise
  • Pause between sentences or topics to allow for
  • Repeat key words or concepts
  • Rephrase as needed
  • Summarize information frequently

  • Expressive Deficits
  • Do not expect an immediate response to a question
    or statement. Pause to allow the individual time
    to prepare their response.
  • Accept gestures and pantomime in addition to
    verbal speech.
  • Ask yes/no questions, avoid questions that
    require lengthy or detailed answers.
  • Provide extra time for consumers who are using
    augmentative communication devices.
  • Accept written answers or drawings.

Hearing/Central Auditory Processing
  • When there is trauma to the temporal lobe area,
    individuals may experience a change in the
    ability to hear sound or in the ability to
    process auditory (sound) input. Once sound is
    detected by the ear, the brain processes what was
    heard on multiple levels. Individuals with
    central auditory processing deficits may have
    difficulty with
  • Filtering out competitive background noise
  • Noticing the differences between similar sounds
    or words
  • Maintaining attention on a speaker who is giving
    a presentation on complicated information or when
    listening to a long presentation.
  • Remembering information as it is processed.

Hearing/Central Auditory Processing
  • Reduce or eliminate background noise.
  • Instruct the client to directly face the speaker
    to maximize on visual speech cues.
  • Increase the volume of the speakers voice in
    relation to the surrounding background noise at
    presentations or meetings. Provide a speaker
    microphone or assisted listening device.
  • Speakers should avoid covering their mouth,
    shouting or over-enunciating words.
  • Consider referring for an audiological evaluation
    to determine if hearing aides or specialized
    alerting devices would be beneficial.

  • Vision is an extremely important source of
    sensory information. The eyes send many messages
    to the brain, the brain must interpret all of the
    incoming messages. There can be problems with
    coordinated movements of the eyes and/or with the
    brains ability to process and interpret
    information accurately. Deficits can range from
    mild to severe. Even subtle deficits can affect
    the individuals ability to work on visual tasks
    and should be addressed.

  • Use enlarged print.
  • Print on yellow instead of white paper or use a
    yellow acetate overlay on documents to increase
  • A book mark or ruler can be used to help with
    staying on the line when reading or scanning for
  • Change florescent lights to high intensity white
    lights, or increase natural light.
  • Simplify forms determine if extra spacing, grid
    lines, bold print or bold lines are helpful.

  • Use a cut out guide to isolate sentences or
  • When consumers are working on near vision tasks
    for long periods, have them take short breaks to
    shift their gaze to distant objects to decrease
    eye fatigue.
  • Refer to a vision care professional trained in
    working with acquired brain injury for thorough
    assessment of vision related complaints.
  • Refer for adaptive technology assessment for
    computer modification or low vision technology
    when appropriate.

Activity Tolerance
  • Fatigue is a common complaint after brain injury.
    It is more difficult for individuals with brain
    injury to compensate for their deficits when they
    are over tired.
  • Consumers may need more sleep than they did
    before they were injured. They may not be able
    to tolerate a very busy schedule. It is important
    to consider energy conservation and work
    simplification when preparing daily and weekly
  • In some cases they may have sleep disturbances
    the physician should be consulted if a consumer
    is unable to get to sleep or stay asleep during
    the appropriate hours.

Activity Tolerance
  • When developing a plan to manage fatigue
  • Carefully review the current schedule with the
  • Make a list of the most important activities,
    those that must be done on a daily or weekly
    basis, and plug them into the new schedule (Some
    activities may need to be eliminated when
    revising a schedule).
  • Schedule activities that are more difficult or
    demanding throughout the week. Dont schedule all
    heavy or difficult activities on a single day.

Activity Tolerance
  • Alternate between light or low demand activities
    and high demand more difficult activities on the
    daily schedule.
  • Determine if there are certain times during the
    day that the consumer is at his or her best try
    to schedule important or priority activities at
    those times.
  • Determine what times of the day the consumer is
    usually more fatigued, schedule only light
    activities or rest periods during these times.

Activity Tolerance
  • Encourage consumers to increase their use of
    accommodations and strategies or provide extra
    supports during the times of day that they are
    usually more fatigued.
  • Avoid rushing, schedule enough time for each
    activity to be performed at a steady and
    reasonable pace.
  • Remember that cognitive activities can be very
    tiring for some consumers. You will need to
    observe how each individual responds to different

Considerations for Plan Development
  • Each plan must be developed on a case by case
    basis to meet the individuals needs.
  • Always include the client in development of the
    plan when possible.
  • Each consumer may present with a wide variety of
    strengths and challenges.
  • Individuals may have deficits in multiple areas.
  • Because a consumer does do well in some areas
    does not mean they should automatically be
    expected to do well in all areas.

Considerations for Plan Development
  • Limitations in each deficit area may require
    specific accommodations.
  • Some deficits may not be obvious when your first
    meet the consumer.
  • Recovery can vary greatly from individual to
    individual. Consumers may need extra support to
    realize they cant compare their recovery with
    that of other brain injury survivors.
  • Because recovery can continue for some time the
    plan may need to be changed and updated on a
    regular basis to meet the consumers changing

Additional Considerations
  • It is important that consumer is motivated to
    work on the goals that have been developed.
  • Always consider the consumers input when
    developing goals.
  • If the team has developed goals that are
    different from the consumers, be sure to explain
    what the purpose and potential value of working
    on those goals might be. Discuss how the goals
    developed by the team may compliment or support
    the consumers personal short and long term
  • Keep the discussion focused on identifying goals
    and activities that offer the opportunity for

Potential Disruptive Behaviors
  • Not all brain injury survivors will experience
    difficulty with social behavior. However, TBI
    survivors who have had severe frontal lobe injury
    or who have been more recently injured may
    exhibit disruptive behaviors. You may observe
  • Social judgment errors
  • Threatening comments
  • Inappropriate sexual comments or
  • advances

Potential Disruptive Behaviors
  • In most cases these behaviors are not intentional
    but rather the result of poor inhibition and
    judgment. These behaviors, although upsetting are
    not usually meant to be harmful, and can be
    addressed by using a consistent team approach.

The next 10 slides are adapted from the New
Hampshire Project Response presentation Changes
After Brain Injury
Environmental Triggers for Behavioral Problems
  • Too much stimulation
  • Rapid pacing
  • Lack of predictability and clear structure
  • Overwhelming physical and cognitive demands
  • Negative social input

Note if you manage the environment, you can
prevent many problems
Guidelines For Behavior Management
  • Increase rest time. Fatigue is a common problem.
  • People have limited coping skills. Reduce stress.

Guidelines For Behavior Management
  • Keep the environment simple. People with brain
    injuries are easily overstimulated
  • Decrease interruptions and distractions
  • Be consistent
  • Decrease surprises

Guidelines For Behavior Management
  • Keep instructions simple, concrete.
  • If the person has problems processing language,
    try gesturing or cueing.
  • Write things down.

Guidelines For Behavior Management
  • Give feedback and set goals
  • Feedback should be direct, caring, nonjudgmental,
    but not subtle
  • Avoid criticism
  • Give supportive encouragement
  • Have a positive attitude
  • Use the feedback sandwich

Guidelines For Behavior Management
  • Be calm, cool, and friendly during an incident
  • This can reduce agitation
  • Avoids reinforcing misbehavior
  • Redirection works. When the person is upset,
    agitated, aggressive, focus attention on some
    other topic, task, person.
  • Provide choices

Guidelines For Behavior Management
  • Decrease chance of failure
  • Keep success rate above 80
  • Watch for frustration
  • Behavioral momentum
  • Expect the unexpected. People with brain injuries
    can have great variability from day to day. Mood
    swings are common. People with TBI are sensitive
    to changes, disruptions in routine, lack of
    sleep, alcohol, minor illnesses, fatigue, other

  • Progress can be inconsistent and unpredictable
  • What works today may not work tomorrow, but may
    work the following day
  • Reduced stamina and fatigue may persist
  • Impairment of memory may hinder new learning
  • Transitions may be especially difficult

Prevention, Prevention, Prevention
  • Communicate expectations
  • Recognize internal and environmental triggers,
    plan strategies
  • Provide clear structure and predictable routines
  • Maintain realistic expectations
  • Help peers learn to alter interactions to avoid

Additional Strategies
  • From the MD TBI Project

Most Strategies address more than one cognitive
and or behavioral deficit
  • Spontaneous restoration of functioning occurs
    most rapidly and dramatically in the first year
    following a brain injury. Generally speaking, the
    greater the time from the injury the more
    rehabilitation efforts will focus on compensation

Environmental Internal Aides Creative
cognitive strategies will employ both kinds of
aids depending on individual need
Environmental, AKA Prosthetic external memory
strategies and devices
  • Changing or modifying the environment to support
    and/or compensate for a injury imposed deficit
  • For Example labeling kitchen cabinets

  • The strategy is in your head
  • For Example
  • I have to work the memory muscle by counting
    everything, like how many times I pedal when I am
    on a bike
  • Actor George Clooney discussing the use of
    internal memory strategies in The London Sunday
    Times10. 23.05

Oftentimes a strategy can transition with
practice from the external to the internal
  • For Example
  • Preparing remarks on paper with pauses written
    in to slow down impulsive speech can eventually
    segue into a internal strategy, At the end of
    every 2-3 sentences, I will take a breath and
    check in with my listener

Strategies can help individuals compensate for
the physical barriers imposed by a brain injury
  • For Example
  • Prism glasses may be prescribed to address double
    vision after injury just as bifocals are
    prescribed for many after age 40

  • Use of a template for routine tasks, on the job,
    at home
  • Use of a high lighter (RED)
  • Use of ear plugs to increase attention, screen
    out distractions (Parente Herman 1996)
  • Partitions/cubicles, at work, quiet space at home
  • Model tasks e.g. turning on a computer and
    accessing email

  • Use of pictures, for faces/names, basic
    information, for step-by-step procedures, e.g.
    making coffee
  • Use of a timer, to track breaks at work, the time
    minimum technique, allocated time to puzzle over
    a problem or vent a frustration
  • Books on tape, movies, keep the subtitles (for
    processing content in the case of memory and
    comprehension problems and increase awareness of
    nonverbal cues/communication)

  • Car Finder-low tech, install a longer radio
    antenna with a day-glow flag, high tech, Design
    Tech International by DAK Corp.
  • Electronic pill boxes/blister packs with day of
    the week labels
  • Review schedule each day
  • Post signs on the wall etc. (use pictures/symbols
    for low literacy skills)
  • Try to routinize the day as much as possible

Teach a variety of strategies for individuals to
incorporate into their daily routines Michelle
Rabinowitz OTR/L
  • Safety checklist (e.g. for use of
    stove)reinforces attention
  • Checklists- things to do before leaving the
    house (turn off all the appliances?, lock all
    the doors?, did I take my morning medications?
    turn down the heat/turn off the air conditioner?,
    do I have money or keys?, where am I going?, how
    will I get there? What time should I leave?
    Etc.) Very good for routine tasks, reinforces
  • Place visual cues in the environment (cupboard
    labels, written directions, calendars, list of
    emergency phone numbers) reinforces memory

Memory Strategies Adapted from Parente Herman
in Retraining Cognition 1996 Aspen Publishers
SOLVE Mnemonic
  • S (S)pecify the problem
  • O (O)options-what are they?
  • L (L)isten to advice from others
  • V (V)ary the solution
  • E (E)valuate the effect of the solution, did it
    solve the problem?