BEHAVIORAL

MANAGEMENT STRATEGIES
IN THE TRAUMATIC BRAIN
INJURY (TBI) SETTING
Summer Demeuse
 Behavioral/Emotional Changes
Behavior Problem Concerns:
• Affects clients’ abilities to participate in therapy
sessions
• Frustration
• May slow down clients’ progress in therapy
• Impulsivity
• Safety for clients’ and staff members Behavior • Social skills
• Impaired self-
• Source of stress for clients’, family members, awareness
caregivers, staff, etc.

• Depression
Aggressive behavior is present in • Anxiety
Emotional • Mood swings
about 25% of adults with TBI at
6-, 24-, and 60-months post-
injury1
 Cause of Emotional/Behavior Problems?
Brain Tissue Involved Cognitive  Emotional Changes Major Life Changes

◦ Cognitive problems can result in

changes in emotional reactions or
control over emotions
◦ Major life changes can elicit strong
emotions or contribute to changes in
behavior.
Behavioral/Emotional Consequences
Personality Changes

◦ Less outgoing2
◦ Irritability2
◦ Loss of interest in previously enjoyed
activities2
Behavioral/Emotional Consequences
Anger/Frustration

◦ Quick to become angry/frustrated2,3

◦ “short tempered”

◦ Less patient2
◦ Low tolerance for change2
◦ Particularly with new situations or when client is
stressed/tired
◦ Anger outbursts2,3
◦ More likely to become verbally/physically
aggressive
Behavioral/Emotional Consequences
Emotional Distress

These may directly result from changes to the

brain or problems adjusting to cognitive,
physical, behavioral difficulties from the injury.
2

◦ Nervousness, restlessness, panic attacks2

◦ Increased fear/anxiety in situations related to
the TBI2,3
◦ Adapting to change in sense of self, self-
identity2,3
Behavioral/Emotional Consequences
Social Relationships/Effective Interpersonal
Communication

◦ Reciprocal interactions2
◦ Appropriate eye contact2
◦ Awareness and respect to interpersonal space2
◦ Awareness and appropriate use of non-verbal
communication skills2
◦ Less sensitive to social norms and others’
feelings2
Behavioral/Emotional Consequences
Executive Functioning

◦ Reduced self-control2
◦ Issues inhibiting automatic responses (inappropriateness)
◦ Non-tactful statements

◦ Increased impulsivity2
◦ Risk-taking behaviors
◦ Decision-making

◦ Impaired judgement and reasoning2

◦ Poor decision making
◦ Led or influenced by others

◦ Decreased motivation/interest (apathy) 2

Strategies for Behavioral Issues
◦ Planned listening
◦ Planned ignoring
◦ Direct instruction
◦ Specific praise
◦ Short responses/commands
Planned Listening
• PT related?
- Hear what was said, receive • Utilize distractions
General
information Complaining • Encourage or suggest break

- Understand the message

• Identify source, within scope?
- Evaluate the message • Problem-solving
Distress
(specific)
- Respond appropriately

• Acknowledge
Distress • Honest/supportive feedback
(general)
Planned Ignoring
Inattention to target behaviors
- Begin ignoring immediately4
- Ensure client clearly knows
which behavior is being ignored4
• Aggressive complaining
• General complaining
• Inappropriate joking
• Shock comments/behaviors
Behaviors (degrading/belittling humor)
• No eye contact
• Relaxed facial expression
• Relaxed body posture
Planned • No verbals/para-verbals
Ignoring
Direct Instruction
Straightforward message for what
you want or expect the client to
do/not do4
- Instruct to/not to engage in
specific behavior4
- Do not deliver in form of
question to deliver choice4
• Inappropriate touch/romantic pursue
• General complaining
• “I don’t want to exercise today”
Behaviors
• “Keep your hands to yourself”
• “Please do not touch/hug me”
• “Will you please stop touching me?”
Direct • “Today we will be working on your balance”
Instruction
Specific Praise
Encourage remark + describe
specific behavior4 • “You did a great job focusing on
your cane placement today”
- Not general praise • “You did a great job participating in
- Address specific positive “Good job!” session today.”
behavior due to clients’ poor
memory and language/attention
issues4

- Sincere
Short Responses/Commands • Romantic pursuit questions
• Problem questions (defined by
- Least amount of information
as designated by each client's clients’ individual behavior
Behaviors plan)
behavior plan4

• New learning = challenge

• Explanation is key!
Short • Focus and concentration
Commands
Documentation of Behaviors
◦ Definitions/ Behaviors (aggressive
complaining, inappropriate touch/joking, etc.)
◦ Correct Implementation (therapist response,
outcome)
◦ Communication to team
General Behavior Rules/Guidelines
◦ Focus on the positive more and negative less4
◦ Positive behaviors will occur more, negative behaviors will occur less

◦ Communicate and document everything4

◦ To prevent problem situations and/or target behaviors
◦ So the client’s treatment team can make rehabilitation decisions

◦ Do not use the term inappropriate to describe a target behavior4

◦ Too vague  may produce target behaviors
General Behavior Rules/Guidelines
◦ Altercation between clients4
◦ Request assistance from any staff member through loud verbal requests
◦ Remove any other clients in the vicinity to a safe area

◦ Elopement4
◦ Clients at risk will be identified as well as methods used for individual client
◦ In general, if a client refuses to participate in scheduled therapy session,
◦ Follow specific behavior management plan
◦ Monitor client’s whereabouts/activities for the session
◦ Notify internal treatment team/next scheduled therapist of client’s actions

◦ Don’t take things personally

◦ Your reaction to the target behavior may create additional problems
References
1. Baguley IJ, Cooper J, Felmingham K. Aggressive behavior following traumatic brain injury: how common is
common?. Journal of Head Trauma Rehabilitation 2006; 21: 45–56
2. Behaviorial and Emotional Impacts of TBI - Brain Injury, braininjuryeducation.org/tbi-basics/behaviorial-and-emotional-
impacts-of-tbi.html#consequences.
3. “Managing Behavior Problems During Brain Injury Rehabilitation.” BrainLine, 30 Apr. 2019,
www.brainline.org/article/managing-behavior-problems-during-brain-injury-rehabilitation.
4. Student Orientation Packet, Willowbrook Rehabilitation Services.