Brain Injury and Behavior

10 Things You Should Know About Behavior and Brain Injury
from the Brain Injury Association of Virginia (BIAV)

1. Behavior has a neuro-anatomical basis:
   • Damage to the frontal and temporal lobes is common with TBI.
   • Damage to the frontal lobe may cause disinhibition, impulsivity, problem stopping an ongoing pattern of behavior, perseveration, loss or lack of motivation, and emotional dyscontrol
   • Temporal lobe injury may result in lower frustration tolerance and altered mood states, usually depression



2. Behavioral characteristics of persons with brain injury may include:
   • Lack of insight and ability to self monitor may leave the person unable to see the effects of their behavior on others or to make judgments as to the appropriateness of their behavior
   • Inability to modulate their behavior or responses to situations well
   • Appearance of being uncaring, lazy and unmotivated when not directed by others
   • Irritating or explosive social behaviors that those of us who are neurologically intact manage to inhibit when stressed or otherwise provoked
   • Failure to change their behavior patterns in response to the types of consequences and potential outcomes that may be effective in managing the behavior of others



3. Thinking difficulties can lead to behavioral issues when someone:
   • Cannot initiate activity, or stop once they’ve started
   • Is impulsive, and cannot inhibit their behavior
   • Is egocentric and unable to see another’s perspective
   • Can’t do what you want or need them to do, so they engage in other behavior
   • Cannot understand what is expected of them, or cannot remember long enough to carry out what is expected
   • Cannot attend to what’s important in their environment



4. Some things are often mislabeled as inappropriate behavior:
   • Confusion about expectations
   • Inaccurate interpretation of instruction
   • Language and non-verbal communication deficits
   • Planning and organization deficits
   • Poor insight into deficits
   • Inability to generalize learning from one situation to another
   • Memory problems - Diminished cognitive flexibility - getting stuck on one way of responding



5. Behavior is communication; what is the person trying to communicate?
   • Territory: Needs for comfortable space (freedom from crowding) or privacy, or freedom from unwanted physical intrusion
   • Communication: Need to be able to talk to another person and be heard and understood
   • Self-Esteem: Need for respect from others; freedom from insults, shaming by others, stigma, or humiliation
   • Safety and security: Need to protect self from physical/psychological harm
   • Autonomy/control: Need to make own decisions, have control over life
   • Time: Need to move at one’s own pace, and not to be hurried or rushed by others
   • Comfort: Need to be free from physical or emotional pain, loneliness, hunger, thirst, excessive heat or cold
   • Personal Identify: Need to retain personal items and identifying materials
   • Cognitive understanding: Need to be aware of surroundings, free from confusion about what is happening and to be aware of self



6. Types of communication difficulties persons with brain injury may have include:
   • Recognizing and repairing breakdowns in communication (i.e.) asking for clarification or
     responding to a request for clarification
   • Coming across as argumentative, stubborn or belligerent
   • Interpreting body language and social cues; may not recognize jokes, teasing and verbal/non verbal emotional responses
   • Poor listening skills; may not seem to care what you have to say, and lack of eye contact gives you the feeling they aren't listening
   • Passive, monotone, and slurred speech, trouble finding the word they want, difficulty using correct volume for the situation
   • Judging personal space; may stand too close or too far away; may not differentiate private body parts; may stare at the person speaking and; invade your space
   • Getting stuck on an aspect of conversation, in the form of repeated questions, arguments or ramblings
   • Seeing things from a different point of view; may have difficulty predicting other person's reaction to them
   • Lack of tactfulness
   • Poor recognition of dangerous situations. May approach and talk to strangers. May possess weak help seeking skills and not know where/how to get help for problems
   • May be unable to distinguish between minor and serious problems, and have trouble understanding/giving important information or answering questions



7. Common pitfalls when communicating with someone who has a brain injury are:
   • Communicating in an environment that is too distracting
   • Speaking too fast
   • Speaking too slowly, speaking for/finishing the person’s sentences
   • Failure to use non verbal cues to improve comprehension
   • Giving too little or too much verbal information
   • Personalizing inappropriate or aggressive language
   • Demonstrating or verbalizing frustration when the person wanders off, forgets something, or fails to comply with an instruction
   • Not deciphering underlying cause of unusual or aggressive behavior



8. Actions that can be taken to help the situation include:
   • Talking in direct, short phrases
   • Allowing for delayed responses to questions or directions or commands
   • Providing clear and direct feedback regarding behavior
   • Responding to undesirable behaviors with a clear and specific statement of the behaviors you do and do not want; you cannot count on a person with a brain injury to understand what’s implied—it must be explicit
   • Avoiding sarcasm, innuendo, literal expressions and random comments; because of concrete thinking, they may take your comments literally or miss the meaning of your statement or request
   • Repeating your questions or instructions in exactly the same way to allow for slowed processing; if problems complying with direction appear to be related to comprehension, phrase it another way
   • Remembering that talking louder will not help understanding, and repeating is not the
     same as understanding
   • Modeling calm body language, move and breathe slowly, keep hands down, and use low
     vocal pitch and congruent facial expression. The behavior of the messenger can affect the behavior of others; rapid movement and increased voice tone convey an escalation of emotion
   • Looking and waiting for response and/or eye contact; when comfortable ask to "look at me", don't interpret limited or lack of eye contact as deceit or disrespect
   • Recognizing and being aware of a person's protective responses to even usual lights, sound, odors, touch, orders, and animals
   • Following performance of a requested/desired behavior with reinforcement immediately
   • Reinforcing successive approximations and avoid back-handed compliments (e.g., “It’s about time you…..”)
   • Remembering that positive feedback changes behavior; punishment only stops behavior, and only temporarily eliminating or reducing the things that may trigger an outburst
   • Making sure that when demands are made, the person is in a state where he or she is able to comprehend them
   • Providing environmental compensations to reduce stress and minimize the effects of learning differences; take into account the “why” of behaviors
   • Designating one person for interactions
   • Redirecting rather than confront perseverative and organically based behaviors



9. De-escalation strategies:
   • Utilize people who know the person well, who have worked with them before, and know what their behavior may result from and how to handle it
   • “Mirroring” can be an effective strategy to reflect back another person’s feelings and statements, it can be used when negative emotions are verbalized or when someone makes confused and/or disoriented declarations.

     It is done without agreement or disagreement,
     without frustration or emotional reaction,
     without insinuation of judgment,
     and without attempt at logic or correction.

     The approach utilizes a slow, respectful, non judgmental and patient look at the other person’s statements and feelings. It can prevent escalation of emotions, aid in de escalation, and allows you to control your emotions by underreacting and staying cool enough to try other approaches. It prevents engagement in a power struggle and allows the person to hear and evaluate what they are saying or feeling without the need to be defensive and argumentative.

   Some examples might be:
   

   • I guess you’re really are mad about this…
   • So, you really think I do not understand…
   • Sounds like you think this is a problem…



10. Some things to remember
    • Don’t take inappropriate behavior personally; remember that it’s not about you
    • At any given time, a person is doing the best they are capable of given their unique skills, personality, environment, and circumstances
    • The very nature of brain injury creates disordered thinking
    • Almost anyone would prefer to be viewed as BAD rather than DUMB
    • There are two main functions of behavior: to obtain or escape something
    • There is no single treatment or approach for intervention relative to the behavioral problems commonly associated with brain injury
    • To manage behavior effectively, one must first seek to understand the motivation of the person and then design a specific, individualized, comprehensive approach

This article is provided courtesy of the Brain Injury Association of Virginia (BIAV) for informational and educational purposes only. The information is not intended as a substitute for professional medical or psychological advice, diagnosis or treatment, and you should not use the information in place of the advice of your physician or other healthcare provider. For more information about brain injury or services and resources in Virginia, please contact BIAV at 800-444-6443, by email (info@biav.net), or through our website (www.biav.net)

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