Management of Behavioral Problems During Acute Rehabilitation of Individuals with TBI Tom Novack, PhD, University of Alabama at Birmingham Department of Physical Medicine and Rehabilitation and the Department of Psychology Page 1 of 5

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• Adolescents with Traumatic Brain Injuries

Introduction

Behavioral problems during acute rehabilitation following traumatic brain injury (TBI) present tremendous challenges to rehabilitation staff. In the presence of behavioral problems, it is difficult for the individual with TBI to participate in therapies and, as a result, their progress may be slowed. There is also appropriate concern for the safety of patients and staff. These problems also create a great deal of concern among family members, which may heighten their anxiety. Dealing with behavioral problems in an efficient and effective manner represents an important rehabilitation goal following TBI.

Types of behavioral problems exhibited by individuals with TBI vary. Some may have difficulty with temper outbursts, while others are socially inappropriate or noncompliant. Some individuals seem to experience no behavioral problems, whereas others exhibit a wide range of such problems. The time of onset of these problems, as well as the duration, are also unpredictable. Restlessness and agitation have been described as phases of recovery. It has yet to be determined if these problems occur at a set time after injury and if there are any variables, which might predict the duration of restlessness and agitation.

All of these problems have one thing in common, however. All are caused by the neurological disruption associated with TBI. It is important to recognize that when people exhibit behavioral problems during acute rehabilitation they are not themselves. It is not the situation or the people around them that generate the temper, noncompliance, or socially inappropriate behavior. Knowledge of cognitive deficits associated with brain injury, such as confusion, poor memory, and limited reasoning, is important in understanding these behavioral problems.

How can staff members handle behavioral problems?

The first basic rule for staff to understand is that managing behavior does not mean controlling another person’s life. You cannot force someone to do something. Each of us is responsible only for ourselves and cannot take responsibility for another person’s behaviors or thoughts. Thus, the management goal of the rehabilitation staff in this sense is to manage one’s own behavior and not that of other people. Staff can create an environment where individuals with TBI will be better able to manage their behavior by managing their own actions and responses.

Another basic rule involves our goals in dealing with individuals who have behavioral problems. If our aim is to totally do away with negative behaviors exhibited by individuals with TBI, then we will likely be very frustrated. A more appropriate goal is to minimize the behavioral problems without the expectation of doing away with them altogether. Thus, doing something that minimizes the inappropriate behavior is a success, even if there are periodic problems.

This paper discusses ways to manage our own behavior, particularly in relation to specific behavioral problems that might be exhibited by individuals with TBI. In any situation in which there is a behavioral problem, it is important that staff members keep their options open as to how they respond. The best way to accomplish this is to remain calm and not take the behavioral outbursts personally. The individual with TBI may behave in a very offensive manner and direct their comments or actions towards another person. However, it is important that staff distance themselves emotionally from this and recognize that it is a neurological problem and not a personal issue. When such situations occur, staff must use judgment in how to approach the situation. Appropriate judgment is more likely to occur when one is calm and not reacting emotionally to what is occurring.

Approaching and Interacting with the Individual with TBI

Your initial encounter with an individual with TBI can determine the success of your efforts. Therefore, you need to pay attention as to how you present yourself. Keep in mind that these individuals may be confused and reactive; you want to avoid increasing any restlessness or agitation that already exists.

Your contact with a patient with TBI should involve a social greeting, such as “Hi (name), how are you?” A handshake may accompany the greeting. The handshake and greeting are cues to relax. It is important to introduce yourself each time since, due to memory problems, the person may not remember you.

When you talk with patients, speak slowly so that the slowed cognitive processing often exhibited by TBI patients will not hinder your encounter. You also need to speak briefly and clearly. Be very direct in what you want to communicate. For instance, it is better to say, “I need to take your blood pressure” than, “You wouldn’t mind if I took your blood pressure, would you?” For those of us in the South, this requires some discipline since Southern speech patterns are often quite verbal and somewhat flowery.

Many individuals with TBI are confused; it is tempting to correct their confusion by directly disagreeing with what is said. However, this can be detrimental and generate increased agitation. Rather than disagreeing, it is better to direct attention to some other topic or make comments that do not state either agreement or disagreement. For instance, if a patient believes that he has lost an item it is not necessary to tell him it has not been lost. You can assure him that the lost item will turn up shortly.

It is important to always explain your intentions before beginning an activity with patients. If there is some procedure that must be done with the patient, explain in very brief terms what is going to happen. This can prevent a startle reaction that could lead to agitation.

Also, avoid touching or grabbing the patient suddenly. If touching is to take place, there should be a greeting and some conversation first. Then only use gentle hand pressure on the shoulder or arm. Grabbing and holding firmly should be reserved for situations in which there is obvious danger to the patient and other interventions are not sufficient.

Redirecting the patient’s attention to less distressing topics, and even using humor, may be appropriate. It is important that we laugh at ourselves to show that we are not too rigid or formal. The only instance in which humor would not be used is if the patient feels that others are laughing at him. In this case, any attempts at humor should be discontinued.

From the University of Alabama at Birmingham Traumatic Brain Injury Model System. Reprinted with permission. http://main.uab.edu/tbi/show.asp?durki=9505.

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