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Strategies to Cope With Behavior Changes After Acquired Brain Injury

      Behavior changes are common after acquired brain injury (ABI) because the brain processes information differently after the injury. About 62% of people with ABI experience behavior changes.
      • Stefan A.
      • Mathe J.F.
      SOFMER Group
      What are the disruptive symptoms of behavioral disorders after traumatic brain injury? A systematic review leading to recommendations for good practices.
      For some people with ABI, the changes in behavior have a major effect on their daily lives, while for others they may be relatively small. These changes can make daily tasks and social interactions difficult. People with ABI may be more sensitive to stress and fatigue, which can make the behaviors described in this article worse. It is important to understand why people with ABI might act differently and how to deal with them. This article provides strategies to help people with ABI and their care partners cope with changes in behavior.

      What are noticeable behavior changes after ABI?

      Agitation

      What you notice: Individuals may become verbally or physically aggressive toward themselves or others. Agitation may include irritability or overreacting to a situation by yelling, throwing objects, or hitting. Individuals with ABI may become agitated when they have difficulty communicating (due to language problems like aphasia), or when they feel frustrated, confused, or overwhelmed. These behaviors are often intensified if the person is overstimulated, such as when in a loud or busy area.
      Strategies to cope: Remain calm and do not take the agitation personally. Ensure the safety of everyone in the situation. Speak in a calm, quiet, even tone. Let the person know his or her behavior is inappropriate using a combination of verbal (words) and nonverbal (gestures and body language) communication. Listen to their concern but do not feel the need to give in to demands, especially if they are unreasonable or unsafe. Offer specific choices to resolve the issue. Change the topic if possible. If your presence or approach is contributing to the agitation, leave and/or ask another person to step in. Offer the person with agitation the opportunity to rest in a quiet environment. It may be helpful to discuss the situation later, after the person has calmed down and had time to reflect. Try to identify triggers (situations/emotions) that lead to agitation and avoid them in the future.

      Self-centered attitude

      What you notice: Individuals may lack empathy and awareness of others’ feelings and perspectives. They may come across as demanding, unreasonable, or thoughtless. Such individuals may become angry when people do not meet their demands. Social etiquette may be unintentionally forgotten; for example, a person with ABI may intrude on personal space during a conversation with a stranger or talk over someone telling a story.
      Strategies to cope: Cue the individual to recognize when his or her behaviors are inconsiderate or impolite. This can increase awareness of the effects they have on others, but must be done with sensitivity so the person does not get defensive. Talk through social scenarios to help the individual see how his or her actions affect others.

      Changes in emotional expression

      What you notice: Individuals with ABI may express emotions differently than before the injury. This can range from having a flat affect to exaggerated emotions. A flat affect is a decrease in emotional responses and facial expressions (eg, not smiling or frowning) in social situations. They may also have monotone speech and appear apathetic. He or she may not make eye contact or initiate social interactions with others.
      They may also have heightened emotions that rapidly change within a short amount of time, including excitement, agitation, and tearfulness. This is called emotional lability. These mood swings do not always match the way the individual feels (eg, crying without actually feeling sad or laughing at a sad story).
      Strategies to cope: For a flat affect, discuss the emotions and how they are coming across. Ask the person how he or she is feeling; do not rely solely on facial expressions. If exaggerated emotions are present, respond in a supportive manner, offering the individual time to share his or her feelings and to regain control. Change the subject if strong emotions persist.
      Encourage eye contact in social situations and provide feedback regarding performance in social situations. Set up opportunities for positive social interactions.

      Sexually inappropriate behavior

      What you notice: Individuals with ABI may display sexually inappropriate behavior, such as making sexual comments, making physical advances to inappropriate people or at inappropriate times, or dressing more suggestively than normal. This behavior can be very alarming to family members and can interfere with participation in daily activities at home and in the community.
      Strategies to cope: Give feedback on the specific behavior and why it is not appropriate. Educate others who will be interacting with the person with ABI on how to redirect him or her and set limits when necessary. Plan ahead and provide guidance throughout situations that may elicit this behavior such as a swimming pool or during personal care activities, like dressing or bathing. Provide opportunities for sexual expression in appropriate private settings.

      Difficulty concentrating and paying attention

      What you notice: Individuals with ABI may become easily distracted, have difficulty focusing on one thing at a time, or have trouble multitasking. They may lose train of thought easily, impairing the ability to complete both simple and complex tasks. For example, while cooking they may get distracted by the television, burn their food, and set off the fire alarm. Depending on the nature of the task, there may be safety concerns for both the person with ABI and for other people.
      Strategies to cope: Break down tasks into simple parts and focus on one step at a time. For example, ask the person to sweep the kitchen floor rather than clean the entire kitchen. For important tasks, development of checklists can help the person with ABI ensure that they complete all necessary parts of the activity. Using a day planner, notebook, or organizational apps can help organizational skills. Structure the environment to reduce clutter and distractions. For example, turn off the television or radio and place electronic devices out of sight.

      Difficulty recognizing their limits and monitoring their behaviors

      Executive functioning is a person’s ability to gather, use, and respond to information; this is central to a person’s ability to monitor and adjust their actions to achieve a goal. These skills are essential for success in home management and community tasks such as driving and working. Executive functioning deficits are common after ABI, even among people with mild ABI who experience a strong recovery.
      What you notice: People with executive function difficulties may have trouble managing competing priorities, planning multistep tasks, and managing their time and schedules.
      Individuals with ABI may not recognize their physical or cognitive limitations, which can lead to impulsive behaviors, such as standing from a wheelchair before locking the brakes or grabbing a hot pan without a potholder.
      Difficulty with executive function limits a person’s ability to change their behaviors in response to social and environmental factors, for example walking more slowly across a wet floor, speaking more formally when talking with a stranger versus a close friend, or being able to understand another individual’s opposing viewpoint.
      Strategies to cope: Open communication between individuals with ABI and their care partners can help identify problems and develop solutions. Create opportunities for coaching on performance in real time. For example, help the individual with ABI make a plan for a shopping trip. Coach them to follow it while also making appropriate changes as needed while at the store.
      To build awareness of limitations, ask the individual with ABI to predict how he or she will do prior to a task, then once the task is completed reflect on the actual task performance. Use objective measurements, such as the time to complete the task, to gauge success.
      Structure activities in a way to discourage impulsive behaviors. Anticipate needs and meet them proactively. Use environmental cues, such as putting a bedside commode next to the bed to reduce fall risks from walking to the bathroom at night without their mobility aids (eg, cane, walker, or wheelchair).

      Can I modify the environment to help behavior?

      The physical and social environment can have an effect on behavior, for better and for worse. Work with the person with ABI to create an environment that supports positive behaviors and minimizes challenging ones.
      • Reduce triggers for agitation such as loud noise, bright lighting, and sensitive conversation topics.
        • Limit number of guests at the home. Begin with 1 guest at a time.
        • Designate a quiet room/space in the home where the individual can be calm and relax.
        • Avoid overstimulation by limiting television, loud music, and tablet use.
      • Set up a daily schedule and follow it consistently. Prepare for any changes in the routine in advance. Plan time for down time when the person can rest and/or nap to reduce headaches, fatigue, and stress.
      • Identify activities or items that calm the individual with ABI and have these readily available. These activities could include: listening to music, looking at a photo album, having a snack, or participating in a hobby.

      Who can help manage behaviors?

      • A rehabilitation doctor who specializes in brain injury can help develop an interdisciplinary plan for the individual with ABI. This is typically a neurologist or physiatrist. They can also prescribe medication to help with behaviors if needed.
      • A neuropsychologist works with an individual with ABI to evaluate cognitive and behavioral needs and develop a treatment plan.
      • A psychiatrist can evaluate the effect of psychosocial factors to suggest pharmacological and nonpharmacological interventions.
      • A psychotherapist works with an individual and a family therapist works with the whole family to adjust to behavioral changes after ABI.
      • Social workers can provide supportive counseling or help with identifying community programs and resources.
      • Occupational therapists and speech-language pathologists are both trained in cognitive rehabilitation (to help thinking skills).
      • Support groups are available for both individuals with brain injury and their caregivers. Many people find it helpful to talk with others who have had similar experiences.
      • The Brain Injury Association of America is a national brain injury association with many state chapters offering support and resources. Learn more at www.biausa.org.
      • The Model Systems Knowledge Translation Center has information and consumer factsheets on topics related to brain injury. Learn more at http://www.msktc.org/.
      • Brainline has info on both brain injury and posttraumatic stress disorder with behavioral information. Learn more at https://www.brainline.org/.

      Authorship

      This page was developed by Amanda Behe, MOT, OTR/L, CBIS, Nikkie Dorsey, MS, OTR/L, Cecilia Mahle, MS, OTR/L, CBIS, and Sara Kate Frye, MS, OTR/L, ATP (e-mail address: [email protected] ).

      Disclaimer

      This information is not meant to replace the advice from a medical professional and should not be interpreted as a clinical practice guideline. You should consult your health care provider regarding specific medical concerns or treatment. This Information/Education Page may be reproduced for noncommercial use for health care professionals and other service providers to share with patients or clients and their caregivers. Any other reproduction is subject to approval by the publisher.

      Reference

        • Stefan A.
        • Mathe J.F.
        • SOFMER Group
        What are the disruptive symptoms of behavioral disorders after traumatic brain injury? A systematic review leading to recommendations for good practices.
        Ann Phys Rehabil Med. 2016; 59: 5-17