Managing Challenging Behavior after Brain Injury

Handling Behavior after Brain Injury

By Carolyn Rocchio

There are many misconceptions concerning the word “behavior.”  The American Heritage Dictionary defines behavior as “the actions or reactions of a person (or animal) in response to external or internal stimuli.”  The reality is that no two people react similarly to the same stimuli.  Occasions considered to be happy by most may be too over stimulating or interpreted differently by a person with an acquired brain injury (ABI) leading to their acting out inappropriately.  Both parties are reacting to the same external stimuli (the event) but internalizing it differently. Everything we do constitutes behavior.

Brain injury can create major challenges to the way an individual thinks and acts in many of the following functions:

  • attention
  • concentration
  • awareness
  • memory
  • initiation
  • organization
  • abstraction
  • sequencing
  • stamina
  • vision
  • smell
  • touch
  • other factors unique to the individual.

These cognitive impairments coupled with physical residual, i.e., mobility issues, pain and premorbid conditions can contribute to unexpected or unreasonable responses to a situation.

Behavioral challenges change over time

Behavior is always changing and it is important for the observer to be aware of what occurred before the behavior changed. Identifying the antecedent is an important step toward determining how to redirect or manage the resulting behavior.  As a result of ABI, the individual may undergo many changes in daily routines, diminished skills, altered relationships, loss of income, lowered self awareness and many other factors over which they have may have little control.  The result is that the person is not necessarily acting badly but acting differently in relation to a diversity of internal and external factors.

Premorbid issues can have a profound effect on behavior.  Science and medicine can do very little to “fix” neurologic impairments.  It may be some time after the conclusion of medical and rehabilitative treatment before the behavioral challenges are addressed.  Ideally, a proactive approach might offset a crisis by identifying the challenges, defining the factors that promote these behaviors and developing strategies that promote functional competency.  This approach could potentially prevent the behavior from escalating to a crisis stage.

  • Recognize the problem.
  • Assess the factors that contribute to it.
  • Understand the goals and abilities of the individual.
  • Develop the supports needed to promote increased function.

“The concept of ‘behavior’ is not just relegated to ‘bad things’ people do, but represents the sum of everything that we do” (Jacobs, 2008).

Specialized behavioral modification programming

Behavioral modification, specific to ABI, was slow to develop as most disruptive or difficult patients were channeled into the mental health systems.  The origin of behavioral modification has its roots in Northampton, England over thirty years ago.  One of the pioneers, neuropsychiatrist Dr. Peter Eames, was experienced in managing behavioral programs for disturbed adolescents and believed the same principles could be applied in the treatment of persons with brain injury.  Their first program was a classic token economy with the emphasis on positive reinforcement for acceptable behavior.  In order that the tokens distributed were meaningful, the staff was required to make all interactions with the clients positive and enjoyable.

To work effectively, token economies have to have consequences when performance does not measure up to the expected level.  When that occurred, clients were unceremoniously removed to a quiet room for short periods of “time out” until the unwanted behavior ceased. Realizing that the clients had injured and under functioning brains, in addition to the positive reinforcement some clients were placed on medications to replace lost functioning.  Those medications that control abnormal behaviors that interfere with daily functioning were found to be efficacious.  Clients with Episodic Dyscontrol (sudden outburst of short duration, with sudden onset and offset, followed by remorse) usually benefited from certain seizure medications.  Anti-depressives were used for those with depressive illness and antipsychotics for those with clearly defined psychiatric disorders.

The programs developed by Dr. Eames, et. al, later abandoned the token system for an internally recorded point system relying purely on the power of social reinforcement combined with use of time out interventions for positive reinforcement.  With this change, staff became more engaged in the program goals.  They even quit locking the time out room which seemed to make no difference to staff or clients or the effectiveness of the intervention.

Although behavioral modification programs are universally used with both inpatients and outpatients, Dr. Eames believes the results are less stable and lasting when limited to short term time frames.  He further states, “There have really been no new initiatives or methods of behavioral modification in recent years.  That may be simply because the basic nature of this form of treatment has long been well established” (Eames, 2008).

Crisis hospitalization

Quality programs exist to manage all phases of recovery following brain injury; however, when it comes to crisis hospitalizations there is scarcity of care available in most communities.  Mental health professionals are often poorly equipped to manage patients with ABI.  When behavioral decompensation occurs, traditional treatments and protocols are frequently ineffective.

“Other then brief screenings of limited value, mental health units do not routinely conduct neuropsychological evaluations on all individuals with ABI.  The lack of such data can undermine treatment since behavioral dyscontrol leading to hospitalization often has its roots in cognitive dysfunction” (Karol, Sevenich, 2008).

The key variables that ABI presents for effective treatment in mental health systems include:

  • Consideration of cognitive deficits and strengths.
  • Unique adjustments following brain injury.
  • The response of the patient to psychotropic medications.
  • The need for supradisciplinary teams.
  • Specialized discharge planning.

Traditional mental health counseling and psychotherapy, in order to be effective, must be adapted to compensate for the cognitive and communication challenges of this population. Mental health professionals can be unlikely to address the way ABI behavior can be so different from other mental health issues in ways, such as:

  • Catastrophic condition or the failure to perform as expected.
  • Manifestation of grief which is different from depression.
  • Psychological denial (anosognosia) or unawareness of the truth.

Medications are an important component to managing behavior. But medications in mental health programs may produce a very different response with ABI. Community supports must be carefully managed and in place before discharge to prevent relapse. Crisis hospitalization for ABI should be managed in dedicated brain injury neurobehavioral units with experts in brain injury and behavioral management working in a supradisciniplinary team.


Eames, P. (2008). Neurobehavioral Beginnings: the kelmsley unit. Brain Injury/Professional 5:4(12-14).

Jacobs, H. (2008). Ain’t Misbehaving! Brain Injury/Professional 5:2(8-10).

Karol, R & Sevenich, R. Neurobehavioral Crisis Hospitalization: on the need to provide specialized hospital brain injury crisis programming. Brain Injury/Professional 5:4(16-21).

Recommended reading

This Fact Sheet is based on a special issue on Behavior of the Brain Injury/Professional (vol. 5, issue 4, 2008). Brain Injury/Professional is the largest professional circulation publication on the subject of brain injury and is the official publication of the North American Brain Injury Society (NABIS).  Brain Injury Professional is published jointly by NABIS and HDI Publishers. Members of NABIS receive a subscription as a benefit of NABIS. Visit to order the entire issue or become a member.

For more information, see:

Myths & Facts about Behavior after Brain Injury

By Harvey E. Jacobs, Ph.D.

Brain injury behavior problems are reinforced by myths with inaccurate information about changes in behavior after head trauma. Helps families and caregivers understand causes and reasons for behaviors and learn how to respond positively.


Behavior at Home

By Carolyn Rocchio and Harvey E. Jacobs, Ph.D.

Information and tips for families and caregivers on managing behaviors after brain injury at home. Identifies behavior problems and shows families how to develop successful strategies for change and positive support.


Behavior Programs and Behavior Problems

By Harvey E. Jacobs, Ph.D.

Information on changes in behavior after traumatic brain injury and challenges for behavior programs are described. Helps caregivers, staff and families identify effective treatment strategies and develop positive behavior supports.



One response to “Managing Challenging Behavior after Brain Injury”

  1. Ellyn Galvin says:

    Appreciate it for this marvelous post, I am glad I found this web site on yahoo.

Leave a Reply

Your email address will not be published. Required fields are marked *


This site uses Akismet to reduce spam. Learn how your comment data is processed.