Cognitive Problems After Traumatic Brain Injury Dawn Neumann, PhD and Anthony Lequerica, PhD, Model Systems of Knowledge Translation Center Page 2 of 2

• They may have trouble with tasks that require multiple steps done in a particular order, such as laundry or cooking.

What can be done to improve planning and organization?

• Make a list of things that need to be done and when. List them in order of what should be done first.
• Break down activities into smaller steps.
• When figuring out what steps you need to do first to complete an activity, think of the end goal and work backwards.

Problems with reasoning, problem-solving and judgment

• Individuals with TBI may have difficulty recognizing when there is a problem, which is the first step in problem-solving.
• They may have trouble analyzing information or changing the way they are thinking (being flexible).
• When solving problems, they may have difficulty deciding the best solution, or get stuck on one solution and not consider other, better options.
• They may make quick decisions without thinking about the consequences, or not use the best judgment.

What can be done to improve reasoning and problem-solving?

• A speech therapist or psychologist experienced in cognitive rehabilitation can teach an organized approach for daily problem-solving.
• Work through a step-by-step problem-solving strategy in writing: define the problem; brain¬storm possible solutions; list the pros and cons of each solution; pick a solution to try; evalu¬ate the success of the solution; and try another solution if the first one doesn’t work.

Inappropriate, embarrassing or impulsive behavior

Individuals with brain injuries may lack self-control and self-awareness, and as a result they may behave inappropriately or impulsively (without thinking it through) in social situations.

• They may deny they have cognitive problems, even if these are obvious to others.
• They may say hurtful or insensitive things, act out of place, or behave in inconsiderate ways.
• They may lack awareness of social boundaries and others’ feelings, such as being too personal with people they don’t know well or not realizing when they have made someone uncomfortable.

What causes it?

• Impulsive and socially inappropriate behavior results from decreased reasoning abilities and lack of control. The injured person may not reason that “If I say or do this, something bad is going to happen.”
• Self-awareness requires complex thinking skills that are often weakened after brain injury.

What can be done about it?

Things family members can do:

• Think ahead about situations that might bring about poor judgment.
• Give realistic, supportive feedback as you observe inappropriate behavior.
• Provide clear expectations for desirable behavior before events.
• Plan and rehearse social interactions so they will be predictable and consistent.
• Establish verbal and non-verbal cues to signal the person to “stop and think.” For example, you could hold up your hand to signal “stop,” shake your head “no,” or say a special word you have both agreed on. Practice this ahead of time.
• If undesired behavior occurs, stop whatever activity you are doing. For example, if you are at the mall, return home immediately.

Cognitive outcome/recovery and rehabilitation

Cognition is usually evaluated by a neuropsychologist. Since there are many factors that can affect how someone will improve cognitively, it is very difficult to predict how much someone will recover. With practice, cognitive problems usually improve to some degree.

Cognitive rehabilitation is therapy to improve cognitive skills and has two main approaches, remediation and compensation:

• Remediation focuses on improving skills that have been lost or impaired.
• Compensation helps you learn to use different ways to achieve a goal.

Discuss your concerns with your physician or treatment provider.

You should discuss any questions or concerns you have with a physiatrist (rehabilitation specialist) or the rehabilitation team. It is important to mention new problems as they develop. New problems could be the result of medication or require further evaluation.

Recommended reading

• Managing Cognitive Issues, in Making Life Work after Head Injury, South Carolina Department of Disabilities and Special Needs. www.state.sc.us/ddsn/pubs/head/issues.htm
• Guideposts to Recognition: Cognition, Memory and Brain Injury, in The Road to Rehabilitation, Brain Injury Association of America. www.biausa.org/publications/roadToRehab3.pdf
• Cognitive and Communication Disorders, in TBI Resource Guide, Centre for Neuro Skills. www.neuroskills.com/cogcomm.shtml
• Cognitive Rehabilitation, Brain Injury Resource Center. www.headinjury.com/rehabcognitive.html

Cognitive Problems after TBI was developed by Dawn Neumann, PhD and Anthony Lequerica, PhD, in collaboration with the Model Systems Knowledge Translation Center. Portions of this document were adapted from materials developed by the Rocky Mountain Regional Brain Injury System, the UAB TBI Model System, the Mayo Clinic TBI Model System, the New York TBI Model System, and from Picking up the Pieces after TBI: A Guide for Family Members, by Angelle M. Sander, PhD, Baylor College of Medicine (2002). Copyright © 2010 by University of Washington/MSKTC. 

Please check the MSKTC site for any recent updates on this article.

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