NAVIGATING THE CURVES: BEHAVIOR CHANGES AND BRAIN INJURY
A Companion Guide To The Road To Rehabilitation Series
Problem behaviors are those that interfere with rehabilitation or a person's ability to be independent. The most common forms of behavior problems in people who have sustained brain injury involve social skills and the ways people interact with each other. Other less frequent, but more dangerous behavior problems include aggression, self-injury, property destruction, verbal abusiveness, tantrums and noncompliance.
All behaviors are the product of two factors: the brain and the environment. The brain plays a critical role in how people behave. When the brain has been injured, vision, hearing, communication, sensory perception and stamina can all be affected. These changes can lead people to behave in different ways that are not always acceptable or safe. The environmental factor consists of two parts. One is events that happen in the presence of people. After brain injury, people sometimes respond to certain events with unacceptable behavior. For example, responding to a request to turn off the TV by cursing and threatening violence. The second factor is other people's reaction to us. When others react positively, a person's behavior is strengthened and more likely to occur again. It is important to note that behavior problems are not the fault of the person. Behavioral problems should be attributed to the injury to the brain, and the different environments that have accidentally strengthened inappropriate behaviors.
When a person does not understand a cue or instruction to do something, he or she might express this as aggression or yelling. Or a person might not react in a normal way to customary cues because they are not capable of processing the information. Examples of positive reactions and events are attention from others and access to desired objects or activities. When these events follow behaviors such as aggression or tantrums, these inappropriate behaviors can be strengthened. Another way that behavior is strengthened is the removal of an unpleasant situation. If an individual does not like therapy or resents being told to get dressed or do a chore, any behavior that removes the unpleasant demand is strengthened. This is often what happens when inappropriate behavior occurs in therapy during the difficult rehabilitation process. Unfortunately, it is sometimes rehabilitation itself that accidentally strengthens behavior problems. Staff can present cues that are unclear or confusing. Staff can unknowingly provide attention following behavior problems, or allow a person to escape from unpleasant therapies. In these cases, it is easy to see that the individual with behavior problems is not to blame.
No. However, many people have agitated behavior in the early stages of recovery from brain injury. In most cases, behavior problems improve and eventually go away completely. Unfortunately, in some cases, a tendency to engage in problem behaviors can be a lifelong condition, particularly if effective treatment is not provided in the early stages of recovery.
Yes. Everyone with behavior problems has many more appropriate behaviors than inappropriate acts. And once again, the behavior is not the fault of the individual. One of the, more harmful aspects of problem behaviors is that they take the place of appropriate behaviors. For example, if you get angry with someone, and scream, yell and throw things, these behaviors prevent you from having appropriate interactions. Thus, the opportunity to develop more effective social techniques is missed.
In some cases, behavior problems may improve if the individual is in a positive, supportive environment where many appropriate responses are rewarded. However, with many people, even being in a supportive environment is not enough to reduce behavior problems.
In most cases, you can expect the behavior problems to get worse either in severity or frequency. This can be a problem particularly with children. Although manageable when still small, children can become too large to be handled safely during a behavioral outburst.
Yes. Minor behavior problems are those that can be safely managed in the home, school, workplace or community setting. If the behavior is minor (e.g., a mild tantrum or yelling) or if it occurs infrequently, it may be manageable by others in the person's environment. Behavior problems become major when they are so severe that they are dangerous no matter how infrequently they occur (severe aggression or self-injury). Also, less serious behavior problems can become major when they occur so frequently that they disrupt others (e.g., tantrums or yelling that happens dozens of times a day).
Several types of professionals can be helpful in treating behavior problems: analysts, neurologists, neuropsychologists, pediatricians and psychiatrists. Behavior analysts have been the most effective in using positive programs to treat behavior problems. Neuropsychologists can also be very helpful in identifying neurological factors that are critical in the design of effective behavioral treatment programs. Unfortunately, some individuals with brain injury are placed in psychiatric facilities because of their behavior problems. Because staff in psychiatric facilities are not trained to treat individuals with behavior problems, individuals do not receive effective treatment.
There are number of methods for treating minor behavior problems. The treatment of choice would depend on the behavior, how often it occurs and in what situations. In general, any effective program must be positive, designed to teach adaptive skills in addition to decreasing inappropriate behaviors. The program should be structured, consistently implemented and be evaluated on the basis of reliable data collected to monitor progress. Also, it is critical that the person with behavior problems be included in the design of the program.
Unfortunately, major behavior problems are not likely to be effectively treated in most home, school or community settings. The design, implementation and evaluation of the necessary program must be done in highly structured settings, where staff are well-trained in specific treatment techniques.
They can help by being positive in their interactions. Another very important factor is keeping interactions consistent. When a person is treated differently from one occasion to the next, or different family members respond differently, mixed messages are sent. This can be very confusing to the person who is trying to behave more appropriately.
Terry J. Page, PhD, Vice President of Rehabilitation and Brain Trauma Services at Bancroft, Inc., is currently responsible for overseeing rehabilitation and brain injury programs at Bancroft, Inc. Dr. Page received a doctoral degree in psychology from Western Michigan University. He served as a faculty member in psychiatry at the Johns Hopkins University School of Medicine for nine years, where he directed an impatient treatment unit for severe behavior problems. He has an adjunct faculty appointment at Temple University, where he currently teaches behavior analysis courses.