Traumatic Brain Injury A to Z - Behavioral Effects

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Managing Cognitive Effects of TBI

Click to play Managing Cognitive Effects of TBI
Listen as the group members discuss changes in the way the brain works after a TBI. Some of the most common cognitive effects are confusion, slower thinking, and problems with paying attention.
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Managing Cognitive Effects

Tracy
Hi everybody. Welcome back. I hope you each had a wonderful week. So how are you all doing?

Good. That’s good. Now remember, last week we talked about the physical effects of TBI. Today we’re going to talk about some of the other effects that can result from a brain injury. Let’s start with the cognitive effects you might have noticed in your loved one.

Travis
Tracy, what do you mean by cognitive effects?

Tracy
Travis, cognitive effects are the changes in the way the brain thinks. After a TBI, thinking may be different. It may be harder than it used to be. Now in most cases, cognitive problems will improve over time through rehabilitation, and of course the natural healing of the brain itself. But… but keep in mind that cognitive recovery often takes longer than physical recovery, so… so you really do have to try to be patient.

The neuropsychologist, the OT, the speech pathologist they’re all the team members who specialize in treating those cognitive problems. The neuropsychologist will do some testing to see how well your loved one’s brain is working and if there are any cognitive challenges.

Megan
So what kind of cognitive problems are there?

Tracy
You know some of the most common cognitive effects are things like confusion, slower thinking, problems with paying attention. Many TBI patients have memory issues, challenges with planning, organization, decision-making, problem solving, you know things like that.
 
Travis
So, we have to just sit around and wait for Dad’s brain to heal?

Tracy
Well you know to some extent. It will heal on it’s own but you know, Travis, there are things that you and your family can do to help.

Julie
That’s right, Travis. When Sam first woke up he had a hard time understanding what we were saying, and he was confused about what had happened to him. So the doctors told me and Carl to speak slowly and to frequently remind Sam about the things that happened.

Carl
They also said that we should break down complex tasks and activities into smaller steps. We learned to give Sam extra time to respond to questions and to comprehend and learn new information.  Another thing they told us was to avoid situations that are too stimulating for Sam, because his brain couldn’t handle the sensory overload.

Tracy
Yeah. Those are good suggestions. Along that same line, now if your Dad has problems with memory, you can help him use memory aids on a regular basis. You can encourage him to write down tasks on a calendar for instance or a notebook, and then check those tasks when they’re done. And in some cases, you may have to write down things for him.

Julie
Another thing that really helps Sam with his memory, especially his short-term memory, is his PDA. It’s set to remind him about his appointments, any plans he makes, and even when to take his medicine.

Michelle
That sounds like a good way to stay organized.

Julie
Exactly. Sam has had to relearn all of his organizational skills, and the PDA really seems to help.

Michelle
I’ll ask Tom’s OT about getting one tomorrow. She’s been great about giving Travis, Emily and me tips on helping Tom get organized…things like using notes and cue cards as reminders, and keeping Tom’s things in the same place so he can find them.

Travis
Well that’s pretty easy in the hospital room, but it’ll be harder when he comes home.

Tracy
That’s a good point, Travis. It may also be harder to get rid of the distractions, things like… well the TV, the stereo, when your Dad gets home, but you know it’s important to help him concentrate on specific tasks. That will make a difference.

Michelle
One thing that I’ve noticed is that Tom is having trouble right now making decisions - - even small ones like what to eat for dinner.

Tracy
Yeah, that’s pretty common, Michelle. Making decisions, problem solving they can be very challenging after a TBI. But you can help Tom by giving him plenty of time to make a decision. And it will be helpful if you talk him through all those possible options. When it’s possible, you can limit the number of choices... maybe keeping them to 2 or 3 at best. Too many choices can just obviously be overwhelming.

So those are just a few of the cognitive problems that your loved one may have as they get better. You’ll find information on more cognitive challenges and what you can do to help in your Guide for Caregivers.

Michelle
I also noticed some great tips in the Guide about how to help Tom with his communication problems. That’s been really helpful.

Megan
What kind of communication problems is Tom having?

Michelle
Well, even though he’s speaking more, he seems to have a problem finding the words he needs to express himself.

Tracy
That’s not unusual Michelle. And, sometimes people with TBI have a hard time actually forming the words or speaking clearly. They also may have a hard time hearing and understanding when people talk to them.

Megan
So what things have you tried to help Tom with his communication?

Michelle
I think the biggest thing is letting him know when we can’t understand him. I ask him to say things again, and to talk slower sometimes.

Travis
And the speech therapist told me to do this to let Dad know that I don’t know understand him sometimes.

Tracy
What you’re doing is you’re giving your Dad a visual cue that you don’t understand him. And those… Those are really good suggestions. So Julie and Carl, have you run into any communication problems with Sam?

Carl
Well, he’s definitely gotten better, but he still has a hard time starting or following a conversation. We’ve learned to be encouraging, and to help direct him by asking sort of open-ended questions.  That helps him.

Julie
He’s also having some problems understanding things that he reads. So to help him with that, we’ve been reading with him, and using something called the 5W strategy, so that helps him comprehend what he’s read. The 5W’s are who, what, where…

Carl
When and why.

Julie
I knew that.

Tracy
Well that’s great, you guys. You know there’s information on how to use the 5W’s and lots of other tips on how to help with communication, and reading and writing in the Guide for Caregivers.

Okay, before we move on there’s another area that I’d like to touch on, and that’s how TBI can affect your loved one’s emotions, their behavior. You may notice changes in the way your family member acts. They may be angry, might be aggressive behavior, impulsive actions, things like that.

Travis
My Dad’s like… frustrated a lot of the time. He seems really moody. And just some of the things he says seem weird.

Julie
I understand, Travis. Sam is like that too. Sometimes he seems really anxious and depressed. We’ve been trying to help him with that.

Tracy
It’s important that you offer a lot of emotional support, a lot of encouragement. Anxiety and depression are very common in people with TBI. You have to remember being depressed isn’t a sign of weakness. It’s not anyone’s fault. Just remember that help is available so don’t wait to call someone. If you think your family member needs help, get on it right away. There’s… there’s more information about how to help you loved one and the behavioral and emotional effects in your Guide for Caregivers.

Okay so let’s take a short break and when we get back we’ll talk more about your job as a caregiver. So help yourselves to some coffee if you’d like.

Behavioral and Emotional Effects Overview

You may notice changes in the way your family member acts. People with a TBI may have many emotional and behavioral effects.

That’s because our brain controls the way we act and feel. An injury to the brain—usually an injury to the frontal lobe—causes changes in emotion and behavior. The life changes that happen after a TBI also affect how people act and feel.

Changes in behavior may include: 

  • frustration, increased anger/aggressiveness 
  • impulsivity or difficulties in self-control 
  • faulty or poor judgment
  • decreased ability to initiate conversation or activity 
  • repetitive behaviors (perseveration) 
  • less effective social skills 
  • changes in sexual behaviors 
  • impaired self-awareness about how TBI impacts him/herself and others

Emotional effects may include:

  • depression 
  • increased anxiety 
  • mood swings (emotional lability) 
  • changes in self-esteem

Pay attention to changes in how your family member acts and feels. Ask the health care team for advice. They can help your family member manage these changes through counseling, medication, and healthy coping behaviors.
 

Frustration, Anger/Aggressiveness

After a TBI, many people become frustrated more easily than before. Your family member may not be able to do things as easily as he or she once did. Sometimes, he or she may not know what others expect. This can be frustrating.

You may notice a quicker temper or a tendency to fly off the handle more easily.

Loss of independence, fatigue, overstimulation, or cognitive problems can also lead to feelings of frustration and anger.

What you might see:

  • Strong reaction to minor annoyances or sources of frustration 
  • General lack of patience (e.g., when others don’t understand the changes resulting from the injury)
  • Low tolerance for change
  • Unexpected outbursts of anger
  • Increased irritability
  • Verbal or physical demonstrations of anger
  • Increased tendency towards anger when tired, in new situations, and during high levels of stress

How you can help:

  • Develop a plan to manage frustration or anger. This might mean taking a walk or going to another room and turning on the television. This can be a good signal to others in the family that your family member needs to be alone for a while.
  • Remain calm. Encourage your family member to recognize when he or she is becoming angry or frustrated. Help him or her learn to ask for a break or some space to calm down.
  • Reinforce all efforts to use effective anger management strategies. 
  • Prepare your service member/veteran for challenging situations when possible.
  • Simplify tasks and provide a consistent, structured environment.
  • Try to avoid surprises. People with TBI do better when they are prepared and can anticipate a change in plans.
  • Try to consistently react to certain behaviors in a certain way. Often, a consistent approach helps to  manage difficult behaviors.
  • Rehearse and role play specific situations to boost confidence in managing life outside the home.
  • Approach challenges calmly and allow yourself to take a break when necessary.
  • If your family member is often angry, ask the health care team to develop a plan to manage this behavior. The rehabilitation psychologist or neuropsychologist is the team member who will work on this plan.

Tell the health care team if anger increases or your family member is violent. You do not have to tolerate verbal or physical attacks.

Your family member is no more comfortable with this behavior than you are. Get help. There are effective medications and behavior management approaches to help manage angry outbursts.
 

Impulsivity/Self-Control

Many individuals with TBI react before thinking. “Stop and think” is a good way to help a person make up for various cognitive problems. It allows the person to stop, slow down, pause, and take the needed time to think about something before doing it. This allows time to develop a reasonable plan or response.

What you might see:

  • Saying whatever comes to mind without thinking about how it might affect the person, him/herself or someone else
  • Acting without thinking about potential consequences (e.g., crossing the street without checking traffic)
  • Inappropriate comments to or about others

How you can help:

  • Use redirection (e.g., suggest a different activity or topic of conversation).
  • Develop a special “stop and think” signal that you can use to alert your family member when he/she is doing or saying something inappropriate (e.g., raising your finger, saying a special word).
  • Suggest that your family member stop and think, slow down, and consider options.
  • Praise and reward desired behaviors; discuss consequences in private, after the fact.
  • Avoid comparing past and present behaviors.

Lack of Initiation

Your family member may seem to have lost interest in activities he or she used to enjoy. You may find yourself offering frequent reminders to do simple tasks, like brushing teeth or taking a bath.

Your service member/veteran may not begin activities on his or her own. This is not laziness. Injury to the brain is the reason.

What you might see:

  • Remaining in bed until encouraged to get up 
  • Spending much of the day sitting around, not actively engaged in activities 
  • Not speaking unless spoken to
  • Problems completing tasks without a lot of supervision
  • Agreeing to do something, but then not following through

How you can help:

  • Set up a regular schedule for your service member/veteran to follow. The goal is to learn a routine so well that it becomes automatic.
  • Post the schedule. Make sure it is in the person’s calendar or memory notebook.
  • Work with your service member/veteran to develop a list of goals or tasks to be completed. Help your family member check off completed tasks so he or she can see progress.
  • Encourage your service member/veteran to become involved. Having purpose along with structure can help.

Poor Judgment

Sometimes it’s hard for a person with TBI to analyze a situation and understand what could happen.

What you might see:

  • Inappropriate decisions; potentially harmful decisions 
  • Difficulty reasoning 
  • Ineffective problem solving

How you can help:

  • Help your service member to use effective problem-solving skills: 
    • Identify the problem. If the problem has many parts, break it down into one problem at a time.
    • Brainstorm possible solutions together. Think of as many possibilities as you can.
    • Evaluate the alternatives. Consider the pros and cons of each possibility.
    • Choose a solution, the one that seems to fit best.
    • Role play with your service member/veteran to prepare him or her for various situations.
    • Have him or her try the solution out.
    • Evaluate the solution. If it didn’t work, try another solution until he or she finds the one that works.

Repetitive Behaviors

Perseveration means getting stuck on one idea or one behavior and repeating it again and again. Injury to the frontal lobe of the brain is the cause.

What you might see:

  • Writing the same letters or words or repeating the same word or phrase over and over
  • Repeating physical movements or tasks 
  • Getting “stuck” on one topic or theme (e.g., “when can I drive?”, “when can I go home?”, “I need a cigarette.”)

How you can help:

  • Use redirection (i.e., try to change the topic or focus of interest to something else).
  • Try engaging the person in a physical task if he or she is verbally “stuck” on a topic.
  • Try engaging the person in a conversation or thinking task if he or she is physically “stuck” on a task.

Self Awareness

Your family member may not be aware of how the TBI has affected him or her. He or she may also not understand how it affects others.

Self-awareness means understanding our own strengths and weaknesses. Our sense of self-awareness is housed in the frontal lobe of the brain.

A reduced sense of self-awareness is a hallmark effect of TBI. Your family member may say very little has changed. He or she is not deliberately denying there is a problem. People with TBI simply do not understand that they are having problems.

Self-awareness usually improves with time and feedback from others. People with TBI learn from their successes and failures, just as we all do.

What you might see:

  • Underestimating the problem areas related to TBI
  • Not understanding why rehabilitation therapies are needed
  • Not following the recommendations of the health care team (i.e., driving restrictions, no alcohol)
  • Unrealistic expectations about future plans or abilities
  • Inaccurate self-perception or self-image

How you can help:

  • Learn how to use safe, “supported risk taking” techniques from the health care team. This method allows the person to try to do something that he thinks he can do but that may be beyond his capabilities. The goal is to raise the person’s awareness through real trial and error situations.
  • Work with your service member/veteran to use effective problem- solving techniques.
  • Give realistic and supportive feedback. 
  • Help to set realistic goals. Develop plans to take steps towards larger goals. 
  • Use a memory notebook to track progress and setbacks.

Sexual Behavior

Many people with TBI change how they act during intimate moments.

Those with moderate to severe TBI may sometimes act in sexually inappropriate ways. These behaviors can often be managed over time. It takes patience, feedback, and a consistent approach.

What you might see:

  • Hypersexuality (thinking about or wanting frequent sexual activity, e.g., masturbation)
  • Hyposexuality, or a lack of interest in sex 
  • Discomfort with intimacy 
  • Trying to kiss or touch strangers 
  • Making suggestive or flirtatious comments to or about others 
  • Disrobing or engaging in masturbation in front of others

How you can help:

  • Develop a “stop and think” signal to let your family member know that he/she is saying something inappropriate.
  • Use redirection (i.e., try to change the topic or focus of interest to something else).
  • Talk to your family member about what are and are not acceptable ways to act in public.
  • Tell your family member that having sexual feelings is normal. Sexual behavior, however, is a private matter.
  • Find a way for your family member to express his or her sexual needs (i.e., in the privacy of his or her room).
  • Emotional changes and physical symptoms can affect desire for intimacy and sex. Ask your family member to discuss concerns with the doctor or counselor.

Social Skills

Social skills are all of the things we do and say in order to fit in, get along with others, and read and understand the people and situations around us.

Social skills form the foundation for relationships with others. They include: 

  • Thinking of topics for a conversation
  • Listening to the other person without interruption
  • Keeping the conversation going
  • Reading the facial and verbal cues that the other person sends and responding to them
  • Knowing when and how to end a conversation

What you might see:

  • Lack of awareness of personal space and boundaries (e.g., talking about private family matters, asking questions that are too personal, flirting with a married person)
  • Reduced sensitivity for the feelings of others 
  • Possible disregard for acceptable standards of conduct at home or out in public 
  • Use of vulgar language or behavior

How you can help:

  • React calmly.
  • Role play or rehearse responses to social situations.
  • Use an agreed-upon signal to let your service member/veteran know that he/she may be saying something inappropriate.
  • Use redirection (i.e., try to change the topic or focus of interest to something else).
  • Praise and reinforce appropriate behavior.
Related Information:
Cognitive Effects
Neuropsychological Evaluation
Common Cognitive Effects
Memory Compensation
Communication Effects
Behavioral Effects
Emotional Effects
Glossary
Frequently Asked Questions
"He really won’t tell me the whole story because I think he doesn’t want to scare me. But, he brought me a piece of metal back home that was embedded in the wall right behind him. He said it missed his head by a few inches. He said that he thanks God every day that he’s still alive, and that’s why he brought the piece of metal home, to show me that that’s how close he had come to dying." -  Lynn C-S.

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