Coping With Behavior Problems After Brain Injury

This article has been reprinted with permission from the Family Caregiver Alliance

By Claude Munday, Ph.D., William Lynch, Ph.D., and John Haller, Traumatic Brain and Spinal Cord Injury Project; and Carol Welsh, MPA, CBIS, Services For Brain Injury, San Jose, CA.

Identifying Behavior Problems

People with brain injuries may experience a range of neuro­psychological problems following a traumatic brain injury. Depending on the part of the brain affected and the severity of the injury, the result for any one individual can vary greatly. Just as no two brains are alike, no two injuries are the same. Your loved one’s deficits following brain injury are completely unique, which makes a specific prognosis for recovery challenging.

Personality changes, memory and judgement deficits, lack of impulse control, and poor concentration are all common issues. Behavioral changes can be stressful for families and caregivers who must learn to adapt their communication techniques, reestablished relationships, and change expectations of what the impaired person can or cannot do.

In some cases, extended cognitive and behavioral rehabilitation in a residential or outpatient setting will be necessary to regain certain skills. A neuropsychologist also may be helpful in assessing cognitive deficits and behavioral issues. However, over the long term both the person with a brain injury and any involved family members will need to explore what combination of strategies work best for them to improve the functional and behavioral skills of the individual with a brain injury.

Personality Changes

Even a person who makes a “good” recovery may go through some personality changes. Family members must be careful to avoid always comparing the impaired person with the way s/he “used to be.” Personality changes are often an exaggeration of the person’s pre-injury self, in which traits become intensified. Some changes can be quite striking. It may be, for example, that the person with a brain injury used to be easygoing, energetic, and thoughtful and now seems easily angered, self-absorbed, and unable to show enthusiasm for anything. Nonetheless, try not to criticize or make fun of the person’s deficits. This is sure to make the person feel frustrated, angry, or embarrassed. Always try keep in mind that the behavior of the person with a brain injury – although seemingly willful or intentional − is not fully in their control due to damaged brain cells.

Memory Problems

People with brain injuries may experience short-term memory problems and/or amnesia related to certain periods of time. In general, pre-injury knowledge is more easily retained. In contrast, new learning presents the greatest challenge to memory or remembering. Consistent repetition of new information, or repeated engagement in an activity, is most helpful to enable the person to retain the learning. Real-time learning (or learning about something when you need it) − with an actual problem and consequences − is much more meaningful than discussion about a problem or situation.

The ability to focus and concentrate are keys to addressing some short-term memory problems.

Keep distractions (e.g., music, noise) to a minimum. Focus on only one task at a time. Give one command at a time.

if memory impairment is severe, without condescending, have the individual repeat the name of a person or object after you.

Whenever possible, have the person write down key information (e.g., appointments, phone messages, list of chores).

Keep to routines. Keep household objects in the same place. Use the same route to walk to the mailbox or bus stop. Changes in environment or routines are much more disruptive to the person with a brain injury as they work to accommodate new information.

If getting lost is a problem, you can label or color-code doors or hang arrows to indicate directions. When going out, the person should be accompanied initially to ensure the route is understood and can be repeated. A simple map can be sketched from the bus stop to the house. And make sure that the person always carries his/her address and emergency phone numbers.

Establishing Structure

A structured environment is essential in helping a person with a brain injury relearn basic skills. A written, routine schedule of activities and repetition make it easier to remember what’s expected and what to do next. The schedule may need to be as specific as the time for dressing in the morning, getting ready for bed at night, and when to eat and take medications.

Lack of Emotion

After a brain injury, a person may lack emotional responses such as smiling, laughing, crying, anger, or enthusiasm, or their responses may be inappropriate. This may be especially present during the earlier stages of recovery.

Try not to take it personally if the person does not show an appropriate response. Above all, always remember this is not willful or consciously directed at you, even though it may seem that way. It is a consequence of the injury to the brain and its functional ability.

Encourage the person to recognize your smile at a humorous situation (or tears if you are sad), and to take note of the proper response.

Emotional Lability

In some cases, neurological damage after a brain injury may cause emotional volatility (intense mood swings or extreme reactions to everyday situations.) Such overreactions can be sudden tears, angry outbursts, or laughter. It is important to understand that the person has lost some control over emotional responses. The key to handling emotional lability is recognizing that the behavior is unintentional.

Caregivers should model calm behavior and try not to provoke further stress by responding in-kind, being overly critical, arguing or demanding. Be in the person’s world first. Then work to gently bridge the gap to help him/her recognize what is currently happening in the moment. The key is to help the person relearn behavior (or modifications to that behavior). It’s important to remember that relearning behavior or behavior with modifications is not actually “relearning”, since these behaviors are now new. Work to support/reinforce the techniques that produce emotional responses which are under the person’s control, while respecting their current feelings. Seek out the help of a neuropsychologist if emotional behaviors become too stressful, problematic, aggressive or violent.

Aggressive Behaviors

Provided a situation does not present a physical threat, there are various approaches to diffuse hostile behavior.

Remain as calm as you can; ignore the behavior.

Try to change the person’s mood by agreeing with the person (if appropriate) and thus avoiding an argument. Show extra affection and support to address underlying frustrations.

Validate the emotion by identifying the feelings and letting the person know these feelings are legitimate. Frustration over the loss of functional and/or cognitive abilities can reasonably provoke anger.

Do not challenge or confront the person. Rather, negotiate − e.g., if you don’t like what’s planned for dinner tonight, how about choosing Friday’s menu?

Offer alternative ways to express anger − e.g., a punching bag, a “gripe” list.

Try to understand the source of the anger. Is there a way to address the person’s need/frustration? Perhaps it can be redirected by making a phone call or choosing an alternative activity.

Help the person regain a sense of control by asking if there is anything that would help him/her feel better.

If necessary, isolate a disruptive person. Consider your own safety and his/hers. Treat each incident as a single occurrence, as the person with a brain injury may not remember having acted this way before or may need to be gently prompted to remember the previous behavior. Try to establish consistent, non-confrontational responses from all family members. For example, children may need to learn some “dos” and “don’ts” in reacting to the person with a brain injury.

Seek support for yourself as a caregiver. Consult a neuropsychologist, attend a support group, and/or seek personal counseling. If necessary, protective services or law enforcement may need to be contacted.

Self-Centered Attitude

The person who has survived a brain injury may lack empathy. That is, some people with brain injuries have difficulty seeing things through someone else’s eyes. The result can be thoughtless or hurtful remarks or unreasonable demanding requests. This behavior stems from a lack of abstract thinking.

Help cue the person to recognize thoughtlessness. Remind him/her to practice polite behavior. Realize that awareness of other people’s feelings – and even basic, social behavior we take for granted − may have to be relearned by the person with a brain injury. Again, even if hurtful personally, understand this behavior is not willful but a result of injury to the brain.

Poor Concentration

“Cueing” or reminders can be helpful in improving concentration and attention. Check to see if the person is tired, anxious or upset which greatly effects cognitive performance. Ask simple questions and repeat if necessary. Don’t provide too much information at once. Get in the habit of always breaking thoughts or information down into easily comprehensible pieces.

People with brain injuries should be encouraged to develop self-checks by asking themselves questions such as “Did I understand everything, did I write it down, and is this what I’m supposed to be doing?” “I made a mistake,” or “I’m not sure,” should lead to the conclusion, “Let me slow down and concentrate so I can adjust my actions or behavior.” Correct actions should be consciously praised, “I did a good job.” Consistent repetition of self-checking will help to modify behavior more permanently.

Lack of Awareness of Deficits

It is relatively common for a person with a brain injury to be unaware of his/her deficits. Remember that this is a part of the neurological damage and not just obstinacy. Be aware, however, that denial can also be a coping mechanism to conceal the fear of lost functioning in the brain or that s/he cannot do a particular task. The person may insist that the activity cannot be done or is perhaps “stupid.”

Build self-esteem by encouraging the person to try a (non-dangerous) activity that s/he feels confident doing.

Give the person visual and verbal reminders or “hints” − e.g., a smile or the words “good job”− to improve confidence in carrying out basic activities more independently. Be careful not to condescend. If you feel the person can handle confrontation, challenge him/her to try the activity.

Inappropriate Sexual Behavior

After a brain injury, a person may experience either increased or decreased interest in sex. The causes could be a result of brain regulation of hormonal activity or an emotional response to the injury, or both.

Sexual disinterest from a spouse with a brain injury should not be taken personally. Avoiding sexual contact could stem from fear or embarrassment about potential performance. Do not pressure the person to resume sexual activity before s/he is ready. Helping the person dress nicely and practice good hygiene may help increase his/her confidence in feeling attractive.

Increased sexual interest can be particularly stressful and embarrassing to families and caregivers. Without good impulse control, the person with a brain injury may make crude remarks out in public, make a pass at a married friend, try to touch someone in an inappropriate setting, or demand sexual attention from a spouse or significant other.

It is very important to be consistent in reminding the person that certain behaviors are not acceptable. Consistent, positive reinforcement is key to reestablishing boundaries.

A spouse should not feel pressured into submitting to sexual demands that are unwanted.

A sexually aggressive person may need to be isolated from others when inappropriate behavior is not controlled. Consultation with a neuropsychologist may be necessary, or a caregiver (spouse, or other family member) may need to call for help if physical threats are made. Consult with a physician if this is an ongoing problem as there may be medication that can help.

Support groups may be useful in helping the person realize the consequences of inappropriate sexual behaviors.

Learning to Cope/Getting Support

Coping with behavior problems after a brain injury requires identification and acknowledgment of the deficits of the individual with a brain injury. A comprehensive neuropsychological assessment is recommended. This will help both the person with a brain injury and the family to better understand neurological and cognitive deficits and behavioral issues. The neuropsychological evaluation provides trained rehabilitation professionals − neuropsychologists, psychologists, speech and occupational therapists – with a “map” of where compensatory strategies and behavior modification should be directed. Oftentimes families or caregivers can recognize personality changes and cognitive deficits but find it difficult to resolve the issues. A treatment plan developed from a neuropsychological evaluation can more efficiently uncover deficits and enable professionals to help the person and their caregivers resolve them.

Finally, it is critical that family members seek and receive support from other family members, friends, support group, and/or counselor as they deal with their own emotional responses to caring for a person with a brain injury.

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This article originally appeared in Volume 17, Issue 1 of THE Challenge! published in 2023.