Lifelong Adjustment and Behavioral Changes with TBI/ABI

By Leif E. Leaf, Ph.D.

Life after a brain injury is different, but worth living! The changes that happen after a brain injury often result in lifelong consequences and challenges. As the physical recovery becomes more stable, the cognitive and behavioral challenges remain. The progress and gains made in physical therapy, occupational therapy, speech therapy, and adaptive functioning can help with a person’s recovery. The cognitive and behavioral challenges, however, continue to impact one’s success in reentering community and evolving into the new “person.”

The impact of changes to behavior after brain injury

The neurobehavioral consequences of a brain injury can have a long-term impact on adjustment, relationships, social interaction, vocational reentry, and life satisfaction. Like it or not we live in a social oriented society and culture. As social beings, we need interaction, support, feedback, and positive regard from those we care about.

When we think of behavior, we need to recognize how complicated it is to manage all the changes in life. One way to understand the challenges of behavior issues after a brain injury is to break behavior down into three separate parts.

The first part to remember is that behavior is controlled by the command center, that three-pound universe called the brain. A major influence on behavior will be the type of injury, severity, and integrity of the brain. Damage to the frontal and temporal lobes is common in traumatic brain injuries and often involved with acquired brain injury, and behavioral issues can arise due to the injury to the brain’s communication. Control issues with the primary areas of self-management can arise as well. Our frontal-temporal areas have been shown to be critical for integrating and assessing cognitive, emotional, and social events in one’s world. Damage to these areas can result in disinhibition, emotional discontrol, and reduced ability to manage everyday life. It is important to remember that a lack of insight, confusion, or inability to recognize the effects of their actions along with poor motivation may have an organic basis that is misattributed to intentional behavioral incidents. The person is not intentionally being disagreeable.

Secondly, the person injured has a history and a personality, and nothing happens outside the realm of who they are and what they were like at the time of the injury. The person’s social style, personality style, and their sense of self are critical in assessing and intervening with behaviors. A family member who has lived with the person has insight into their values and how they managed anger and frustration before the injury. Generally, after an injury the person will be like their old self only at times exaggerated.

Finally, the environment where a behavior occurs can be telling. From a management perspective, the environment is generally the easiest factor to control. You may see certain behaviors in some settings but not in others, be aware of these. The person may have sensitivities to how differing settings impact them. Knowing this can go a long way to reducing behavioral incidents. After a brain injury, a person may easily be overstimulated by an environment that is too active. If so, they can be removed or redirected. This is where knowing the person’s preferences can be helpful.

When dealing with behavior, be aware that what may be labeled inappropriate behavior may in fact be the residual deficits from the injury. Understanding the changes in the brain and awareness of the cognitive, personality and social history of the person can help in managing the behavior and creating a safe environment.

Addressing behaviors

In looking at some specific situations in which behavior may be an issue there are some important fundamentals to review. The first is not to take behaviors personally. The situation, the person’s injury, and how you respond all need to be considered. The person’s pre-injury personality will generally be exaggerated from their preinjury personality style. They may feel anxious, agitated, and angry that they are different without appreciating the severity of their injuries.

Always try to remain calm and in charge of your emotional responses. When dealing with the person, try and maintain the 3 C’s: stay cool, calm, and in control (of yourself). In the hospital or rehabilitation center, the person with a brain injury was in a controlled environment with staff that are trained to assist and manage behavioral issues. In the community that responsibility falls on the person and the family or significant others.

After a brain injury, new learning may be difficult due to memory changes, poor attending, concentration skills, lack of awareness of deficits and limited insight. The inability to see the other person’s point of view or to recognize one’s own responsibility is common with frontal-lobe injuries. Taking it slowly and intentionally is critical to helping the person learn new and effective strategies for self-control.

When addressing behaviors, try not to make it a control issue. You want the person to participate willingly to achieve the desired outcome. Talk to the person, discuss the situation if able. Starting here allows you to move on by working together to find a solution. Always listen and treat them with respect.

One way to encourage participation is to offer choices. This gives a sense of control and not being forced to do something. As with most brain injuries, cognitive skills can be a challenge. Try to avoid arguing and reasoning when emotions are high, they can’t process what you are saying. Take a timeout and redirect the person, come back to it after things have cooled.

Remember, we all like to feel good and needed, and it is critical that you reinforce the good and whenever possible ignore the bad. When you can catch them doing it right, it will go a long way to building positive self-management.

The key to behavior management is to understand the injury, the person and control the environment. Treat a person according to their potential, not their disability.

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This article originally appeared in Volume 16, Issue 4 of THE Challenge! published in 2022.