Sociologically, “structure” is defined as the pattern or organization of elements in a society or culture and/or a number of parts that make up the whole. As a result of brain injury, individuals often experience a loss of wholeness due to disruption of connections within the brain. Structure for an individual with brain injury is often the lifeline that enables one to organize life in a meaningful way that contributes to his/her overall well-being and successful interaction within the community.

The frontal lobes of the brain are the most vulnerable to injury, particularly in acceleration/deceleration car crashes in which the brain bounces within the skull. Individuals sustaining injury to the frontal lobes of the brain usually experience a loss of higher level executive functioning. Such losses cause difficulties in managing many facets of life that heretofore were taken for granted. With age and sophistication, individuals develop a repertoire of skills used to establish pre-injury goals and strategies to achieve those goals. After injury, establishing even the most basic short-term goals may be impossible, as are managing simple tasks, initiating activities and organizing items without written and/or auditory cues.

After brain injury, it is mandatory to understand an individual’s preserved strengths and identify areas of weakness utilizing a comprehensive neuropsychological assessment and evaluations by various therapies (i.e., occupational, physical and speech therapy). In a rehabilitation setting and following this evaluation, a treatment plan is designed to remediate, retrain and/or develop strategies to compensate for the identified deficits. While in rehabilitation, clients have a very structured environment with meals at designated hours and a set schedule of therapy appointments, and little need to plan their time independently. Most clients are encouraged to use journals, day minders, lists, memory devices and other external cues to enhance functional capabilities as they regain some control over their lives. Good discharge planning should prepare families to assume—at least for a short time—responsibility for guiding the individual and reinforcing the goals of the discharge plan.

Unfortunately, families and care providers are not always provided with adequate information about the importance of maintaining structure once in the home setting. Few individuals with brain injury, if any, return home and pick up right where they left off, although most will resume many of their old over learned routines. To ensure that skills acquired in rehabilitation generalize back into a community setting, the most successful transitions from rehabilitation to home are those where the family/caregivers structure the environment and consistently reinforce the recommendations included in the discharge plan. Gradually, as the individual readjusts, the structured environment becomes an accepted way of life and—with flexibility to account for unexpected events—it can create a harmonious household.

In the absence of rehabilitation and discharge planning, families have to be very creative in designing their own “programs” to occupy the day with productive activities. Most families are puzzled by cognitive changes after brain injury and find the inconsistent performance of their family member very frustrating. Just as everyone has good and bad days, the individual with brain injury may find the successes of Monday are failures on Tuesday and self-esteem can decline gradually. Other factors such as fatigue, distractibility and reduction in level of performance when doing repetitious tasks, can be major barriers to employment.

Damage in the frontal lobes of the brain play havoc with judgment, reasoning, impulsivity, problem solving and organizational skills. Once the family/care provider has a working knowledge of the deficits, simple logic and common sense usually can provide better ways for managing the individual with brain injury. An impulsive individual prone to say things without thinking of the effect on others may need some cues about more appropriate conversation. Social skills can be rehearsed prior to social occasions where one might be embarrassed by telling an off-color joke in the wrong setting. Memory deficits are managed better by providing the individual with memory devices such as those used in rehabilitation settings (i.e. journals, memo masters, written lists). In the home, it may be necessary to use labels or post-it notes to identify items in drawers and cabinets or organize the steps required to perform necessary chores. Helping an individual organize personal possessions in an accessible place can prevent lost items. When things are structured so that everything is kept consistently in one place, it prevents the frustration of never knowing where to find lost items.

When cognitive deficits are severe, it is vitally important to ensure the safety of the individual. For example:

• It may be safer for the individual with brain injury to cook in a microwave rather than risk starting a fire on a stove.
  
  
• An egg timer with a bell may be all that is required to enable an individual to resume laundry chores without leaving clothes in the washing machine or dryer.
  
  
• Dry erase bulletin boards are very helpful in listing a schedule of activities. Individuals having difficulties managing finances can be assisted in setting up a budget. Having a family member act as banker when purchases are planned and money is needed also can be useful.
  
  

Changing the environment is easier than trying to change the person. Planning and structuring the environment offsets many behavioral outbursts borne of confusion and lack of organizational skills. In the beginning, it can be very labor-intensive and time consuming to get that structure in place but it pays dividends once it is established. Having a schedule of activities as well as a place for everything and everything in its place reduces frustration, not only for the individual with brain injury but also for those with whom that person lives. Structure, structure, structure. Try it. It works, but it may take some getting used to.

Carolyn Rocchio is the parent of a son with a brain injury sustained in a 1982 automobile crash. She is the founder of the Brain Injury Association of Florida and a former member of the Board of Directors of the Brain Injury Association.