by Marilyn Lash, MSW and Ron Savage, EdD
Introduction
Changes in behavior and personality are among the most disturbing and unsettling consequences of brain injury. When these changes occur among children, it can be troubling—especially for parents—since their child's personality is evolving still. Suddenly, familiar traits change and behavior and emotions become unpredictable. With adolescents, the "normal" storminess can be accentuated even more, adding to the stress among all family members. Below are many of the commonly asked questions of parents when a child's behavior changes after a brain injury.
Why does our daughter act much younger than her peers since her injury?
Social immaturity is one of the common consequences of brain injury. Some children and adolescents seem "stuck" at an earlier developmental stage. This can make it difficult for peers and friends to relate and may even lead to ridicule or social isolation for the child with a brain injury. Altered social skills can be very difficult for adolescents with brain injury when peer pressures for dating, appearance and "fitting in" increase.
After a brain injury, a child may not be able to remember events and information as well as before. This child will need to be taught strategies to increase their memory. The same holds true for social skills. A child with a brain injury may need to be taught particular social skills that—prior to the injury—would have been learned naturally. Teaching a child how to greet new people, recognize nonverbal communication, appear well groomed and clean and/or act in public are all skills that may need to be taught and practiced with a child with a brain injury.
Why has our child's behavior become so difficult to manage since the brain injury? He was never like this before the injury.
Certain areas of the brain, such as the frontal and temporal lobes, monitor and direct behaviors. When these areas are damaged, a child may have difficulty controlling temper, actions and feelings. Even the child's personality may seem different. Common changes in behaviors after brain injury include restlessness, hitting, swearing, impulsiveness and difficulty following directions. Many children and adolescents remember how they were before their brain injury. This also can result in emotional reactions that contribute to changes in behaviors as youths struggle to gain a new sense of self.
How do I know what is "normal" adolescent behavior and what is related to the brain injury?
One of the most frequently asked questions by parents, this also is one of the most difficult to answer. Adolescence is known for its “storminess,” with many rapid physical and hormonal changes occurring simultaneously with increased social and academic pressures. The brain continues to develop right up through adolescence so new difficulties may emerge, especially if the frontal lobes which affect impulse control and emotions have been damaged. The impulsiveness and mood swings that we expect from adolescents may be compounded and aggravated by a brain injury that affects these control centers. An evaluation by a neuropsychologist can help identify behaviors that are directly related to the brain injury.
What is a neuropsychologist and how can this person help?
A neuropsychologist is a psychologist with additional special training in the relationship between the brain and behavior. A neuropsychologist can evaluate how a brain injury affects a child or adolescent's learning, communication, planning, organizational skills and relationships with others. Once the causes of the behavior are understood, the neuropsychologist can recommend compensatory strategies and help parents and educators respond to behaviors.
Will traditional behavior management techniques work for a student with a brain injury?
The traditional approach to managing behavior is based on the model of antecedent, behavior and consequence. The antecedent is what happens before the behavior; the behavior is the action and the consequence is what happens as a result of the behavior. For example, if a child is asked to turn off the television (antecedent), refuses and throws a tantrum (behavior), the child may be sent to bed or given a time-out (consequence). This approach emphasizes the consequence of the behavior. Most children learn to change their behavior to avoid negative consequences or punishment.
This consequential management often does not work for children with brain injury. The child may not remember the rules. Changes in insight and self-awareness may make it difficult for this child to learn from the consequences of behaviors. Think of the old saying, "The horse is already out of the barn." Punishing children after the behavior has occurred may not help them learn how to self-monitor or recognize when they are overwhelmed or confused.
A more successful approach for youths with brain injury emphasizes managing what is going on before the behavior occurs. Once the antecedents are identified, they can be changed to prevent the behavior from happening. For example, a student may not be following instructions or paying attention in class because of distractions from other students or hallway activity. This distractibility and difficulty focusing can be the direct result of a brain injury and one that detention and reprimands will not change. By moving this student's desk to the front row the student may be less distracted and better able to pay attention to the teacher.
Will medications help?
Many children with brain injury have short attention spans, are easily distracted and have difficulty following instructions and directions. Some become fidgety, impulsive and hyperactive. Because these symptoms are similar to those in children with attention deficit disorders, many parents and educators ask if medication will help. This requires careful evaluation by a physician.
When a child has a brain injury it can cause physical injury to the neurons (brain cells) and brain tissue. At the same time, it also can cause chemical changes in the brain. Some medications are designed to help children learn and pay attention better; others are used to control seizures or help manage challenging behaviors. However, some medications have side effects that can affect alertness, memory, moods, sleep or appetite. Any consideration of medication requires a physician experienced in brain injury and careful monitoring.