Brain Injury and Deficits in Initiation

By Taylor Sustarsic, M.S., CCC-SLP, CBIS, Prisma Health-Roger C. Peace Rehabilitation Hospital

Individuals with brain injury may experience a number of challenges that can impact daily efficiency. More noticeable deficits – such as visual impairments, memory and balance issues, difficulty with problem solving, etc. – frequently receive greater attention during the recovery process. Initiation, on the other hand, can be less obvious and as a result, often goes unidentified and unaddressed. Decreased initiation can be present in a person’s physical, social, cognitive, and/or emotional abilities. Failure to identify and treat initiation deficits can negatively impact a person’s independence and quality of life. 

Damage to the frontal lobe of the brain may result in myriad deficits. An injury to this area is frequently associated with changes to one’s executive skills, which involve the planning, coordination, and execution of daily tasks. Initiation is part of this skill set, and it normally involves your “internal monitoring system” identifying the need to act and then letting you know when it’s time to get started. Tasks can range from simple to complex and can include things like starting a new project, quickly going from sitting to standing up if the doorbell rings, taking a turn in conversation, or even calling 9-1-1 in the event of an emergency. When a brain injury occurs, this system can be interrupted. While one may understand and be able to state what needs to happen next, it may be difficult to actually do what needs to be done. An example of this might be hearing the doorbell ring, verbalizing or acknowledging the doorbell rang, but not physically getting up from the couch to go answer the door. Problems with initiation can have a negative impact on a person’s ability to live alone, complete activities of daily living, and engage socially with friends.

In order to understand what initiation is, it is also important to understand what it is not. Decreased initiation is not an unwillingness to do something or defiance against the person making the request. Although it might appear this way on the surface, initiation deficits are not due to a lack of understanding of what needs to be done or how to do something. The lack of initiation often gets labeled as a person being “unmotivated,” but this incorrectly implies that a person is actively and independently making a decision about whether or not to complete a task. Initiation is an organic deficit that is a direct result of a traumatic brain injury.

What can you do if you or a family member is struggling with decreased initiation? Here are a few strategies that may help:

• Creating routines. Establish repeatable routines and schedules and make as little deviation from them as possible. Having a morning routine or a bedtime routine can help increase independence with initiating the next step. For example, each night before bed, build a routine such as changing into pajamas, brushing teeth, taking medications, and then laying down. Keeping the routine the same allows for someone to initiate the next activity without having to decide what should come next.
• Setting alarms. Use a timer or a cell phone to set alarms to help trigger the individual to start or switch a task. These can serve as useful reminders that prompt initiation.
• Using visual reminders. Use signs, pictures, to-do lists, or written schedules that can help identify the next steps involved in tasks throughout the day.
• Being patient. Provide increased wait time for the person to complete a task or to respond in a conversation. This will allow their brain time to process the next step or the question they were asked.
• Trying self-monitoring techniques. Questions to ask oneself to prompt initiation might include “What am I doing now?” and “What needs to be done next?”

While these are helpful strategies, additional resources might include participation in rehabilitation. Working with an interdisciplinary team of brain injury specialists including a physical therapist, occupational therapist, and speech language pathologist can help identify and treat specific deficits in initiation. Importantly, an interdisciplinary team would be able to develop strategies unique to the person and the goal as well as train and educate caregivers for increased carry-over of these strategies.

Through increased awareness of initiation issues, one can learn and apply strategies to regain a sense of independence and continue to live a fulfilling life. Additional resources for life after brain injury, including family and caregiver support, can be found through national and state Brain Injury Associations. 

It is also important to identify other factors that can impact initiation, such as significant depression. If you notice problems with initiation, consider screening for and possible treatment of depression or other conditions.

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This article originally appeared in Volume 15, Issue 1 of THE Challenge! published in 2021.