Managing Problem Behaviors: Tips for Families and Caregivers

By April Groff, Ph.D., Program Direction, Learning Services

When a loved one experiences a brain injury, it impacts the entire family. Changes in behavior are common and can be particularly stressful for families and caregivers. Family members often have to adapt expectations and modify responses to behavior both at home and in the community. Below are some tips for responding to behavior once it has occurred along with suggestions for how to prevent problem episodes.

AGITATION

A person with a brain injury may feel overwhelmed, which can lead to agitation. He may become restless, causing the need to pace, fidget, or move around. He may feel upset more easily than before his injury or for reasons that aren’t readily clear. A person with a brain injury is more sensitive to anything that interferes with the natural ability to think and is more susceptible to cognitive overload. Cognitive overload often leads to agitation.

How to Respond:

• Reduce stimulation. Decrease noise and distractions or help the person move to a quieter place.
• Consider whether thirst, hunger, fatigue, pain, temperature, or toileting demands could be causing physical discomfort.
• Simplify the task at hand.
• Use calm, positive, and reassuring statements. Say things like “I will stay with you until you feel better” or “I’m sorry this is overwhelming.” Slow down your rate of speech.
• Avoid asking questions or placing additional demands on the person. If you have to ask questions, avoid open-ended questions and instead offer the choice of options. Instead of asking “Where do you want to go?,” try “We can go to the car or to the restroom.”
• Provide a distraction that involves physical or focused activity. Offer to go for a walk, or use art or music to divert attention away from what is overwhelming.

Strategies for Prevention:

• Keep the environment calm. Avoid noisy places, having the television on, or being in the same room where others are having conversations. If home is loud or busy, identify a quiet area where the person can go. Plan outings for days of the week or times of day that are likely to be less crowded and less noisy.
• Support the physical comfort of the individual. Make sure the room is at a comfortable temperature and the person is not hungry or in pain or does not need a restroom.
• Support opportunities for the person to get regular physical exercise as part of his routine.
• Support your loved one in reducing or eliminating caffeine or other stimulating substances.
• Identify a list of soothing rituals that are effective in calming the person when agitation does occur. Having a plan for what to do in case of agitation will reduce anxiety for both you and your loved one.

ANGRY OUTBURSTS

Angry outbursts can occur when issues related to confusion and cognitive overload escalate, or they can occur suddenly and unexpectedly. Outbursts can be either verbal or physical and tend to be triggered by environmental factors, internal factors like pain or discomfort, or an inability to communicate effectively. Provided that the situation does not present a physical threat, various approaches may be used to diffuse or prevent outbursts.

How to Respond:

• Step back and stand away from the person. Direct others in the immediate environment to do the same.
• Avoid physical contact, guidance, holding, or restraint.
• Remain as calm as you can. Try not to get upset or take the behavior personally. Speak slowly and in a soft tone.
• Don’t challenge, confront, or criticize. Be positive and reassuring. It can help to consider the feelings that are underlying the behavior.
• Consider whether pain or physical discomfort is a factor and address.
• Shift focus to another activity. The immediate situation or activity may have unintentionally caused the outburst. Try something different.
• Think about what happened right before the reaction that may have triggered the behavior. Try to understand the source of the anger and address the unmet need if possible.
• Validate the emotion by identifying the feelings and letting the person know these feelings are legitimate. “It makes sense that you are angry” can be an effective response.
• Treat each incident as an isolated occurrence.

Strategies for Prevention:

• Identify and talk about acceptable ways of expressing anger in the household. It’s important to acknowledge that anger will happen, and it can be helpful to have a family goal about how it can be safely expressed.
• Try to establish consistent, non-confrontational responses from all family members. Roleplay and practice these responses to gain comfort.
• Manage the environment to minimize triggers.
• Be sure that pain management strategies are in place and situations that are physically uncomfortable or minimized.

REPETITION

A person with brain injury may also do or say something over and over, such as repeating a word, question, or activity. In most cases, repetitive behavior isn’t harmful, but it can be difficult for family members and requires patience and understanding.

How to Respond:

• If the person is asking a question repetitively, provide an answer. Repeat yourself. It’s easy to get frustrated or to feel like the person isn’t listening to you, but don’t take it personally. Remember that it is the brain injury causing the behavior, not the person.
• Stay calm and be patient. Offer reassurance with a calm voice. Don’t argue or try to use logic to convince the person to behave differently.
• Focus on the emotion, not the behavior. Rather than reacting to repetition, try to think about how the person is feeling and respond to the feeling.
• Use memory aids. Refer to calendars, notebooks, smart phones, visual reminders, or other memory aids that are familiar to the person.
• Engage the person in a pleasant or fun activity.
• If the behavior isn’t harmful, try not to worry about it. Find ways to accept and work with it rather than trying to stop it or change it.

Strategies for Prevention:

A structured environment and daily routine are essential in reducing behavioral problems related to memory issues. Having a written daily schedule that is similar from day to day can make it easier for your loved one to remember what is expected and what to do next.

• Keep household objects in the same designated places.
• Use the same route to walk to a specific location.
• Keep distractions to a minimum and focus on one task at a time.
• Use a memory aid system specific to the person’s needs. This may entail recording key information on a calendar, in a memory notebook, or in a smart phone. It may involve the use of visual reminders, alarms, or labels.
• Have the person wear an identification bracelet with brain injury status, address, and emergency phone numbers.

April Groff, Ph.D., is a licensed Clinical Psychologist specializing in Neuropsychology. She currently is the Program Director at Learning Services in North Carolina, where she oversees post-acute residential rehabilitation and supported living program for individuals with acquired brain injury. Her previous roles include Director of the Polytrauma Transitional Rehabilitation Program and Staff Psychologist within the Polytrauma Rehabilitation Center at the VA Palo Alto Healthcare System. She has extensive experience working with active duty service members, veterans, and civilians with brain injury and their family members.

This article originally appeared in Volume 9, Issue 4 of THE Challenge! published in 2015.