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Dealing with TBI. An Overview of Behavioral Symptoms and Interventions. Facts About Mild Traumatic Brain Injury (MTBI). Approximately 80% of all brain injuries are mild Males outnumber females 2:1 5.3 million people are estimated to have ongoing problems related to MTBI

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Dealing with TBI

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Dealing with tbi

Dealing with TBI

An Overview of Behavioral Symptoms and Interventions

Facts about mild traumatic brain injury mtbi

Facts About Mild Traumatic Brain Injury (MTBI)

  • Approximately 80% of all brain injuries are mild

  • Males outnumber females 2:1

  • 5.3 million people are estimated to have ongoing problems related to MTBI

  • Direct care costs are estimated at 5.3 billion annually, with indirect care estimated at 37.8 billion dollars annually

Diagnostic criteria for mtbi

Diagnostic Criteria for MTBI

  • Traumatically induced physiological disruption of the brain (an injury occurs)

  • Any period of loss of consciousness not to exceed 30 minutes

  • Loss of memory for events immediately before of after the accident

  • Any alteration in mental state at the time of the accident

Dealing with tbi


  • Focal neurological deficits that may or may not be transient

  • Post-traumatic amnesia does not exceed 24 hours

  • Glasgow Coma Scale of 13-15 after 30 minutes

    • Eyes open spontaneously

    • Oriented to place/time (Verbal output)

    • Obeys Commands (Motor output)

Assessment questions

Assessment Questions

  • Have you ever been told you have suffered a brain injury or concussion?

  • Have you ever hit your head hard enough that you saw stars or had a headache that lasted the rest of the day?

  • Have you ever been knocked unconscious? If so, for how long?

  • Did you seek medical treatment?

Assessment questions1

Assessment Questions

  • When you hit your head, did you feel nauseated or dizzy afterwards?

  • Did you have any speech or coordination problems?

  • Is there any part of the incident you cannot remember?

  • Did you have any visual problems?

Assessment questions2

Assessment Questions

  • Currently-

    • Do you have any memory problems?

    • Do you have problems keeping up with conversations or what people are saying?

    • Do you have problems concentrating or staying on task?

    • Are you sensitive to light? Does it cause you to have headaches?

    • Do you have problems pulling up words (are they on the tip of your tongue?)

Assessment questions3

Assessment Questions

  • Are you more irritable than before the incident?

  • Do people often say you act before you think?

  • Do you have problems multi-tasking?

  • Are you having any current balance or coordination issues?

  • Are you having any sensory problems (hearing, smell, taste, etc.) ?

  • Are there any changes you have noticed since the incident that I did not ask you about?

Frontal lobe injury

Frontal Lobe Injury

  • Higher cognitive functioning or “executive functioning”

  • Focusing attention

  • Generating and following through on decisions

  • Poor judgment

  • Self-awareness of deficits self-monitoring

  • Planning and carrying out activities (maintaining a job, grocery shopping, completing household duties, repairs, etc.)

Frontal lobe tbi

Frontal Lobe TBI

  • Concrete thinking

  • Trouble staying on task

  • Possible disinhibition and immaturity

  • Possible decreased energy, motivation and spontaneity

  • Possible speech and motor problems

Temporal lobe tbi

Temporal Lobe TBI

  • Storing NEW memories

    • Right: Visual memory

    • Left: Verbal memory

  • Behavioral problems

    • Irritability

    • Aggression

    • Modulating behavior

  • Word-finding and naming

Parietal lobe tbi

Parietal Lobe TBI

  • Processing sensory information

    • Right: Visual-spatial information

    • Left: Comprehension of spoken/written words

  • Get lost in familiar surroundings

  • Confused by multi-step instructions

Occipital lobe tbi

Occipital Lobe TBI

  • Processing of visual information

  • Visual deficits

    • Field cuts

    • Blindness

    • Inability to know objects

Cerebellum tbi

Cerebellum TBI

  • Coordination of movement

    • Walking and control of upper extremities for day-to-day tasks

    • Possible tremors associated with injury

Course of recovery of mtbi

In the majority of individuals symptoms of MTBI resolve in 6 months or less after injury

In some cases, symptoms can persist longer (12 – 18 months) and even life-long

The majority of people with moderate to severe TBI do not return to their full pre-injury status and will have ongoing cognitive and behavioral issues

Course of Recovery of MTBI

Overview of diffuse symptoms of mtbi

Overview of Diffuse Symptoms of MTBI

  • Cognitive

    • Memory, Attention, Processing Speed & Intelligence

  • Psychological

    • Depression, Anxiety, Irritability, and Sleep & Personality change

  • Physical

    • Light/sound sensitivity, dizziness & fatigue

Dealing with impaired attention concentration

Dealing with Impaired Attention/Concentration

  • Work slowly

  • Break your work down into small, manageable increments

  • Double check your work

  • Prepare all materials for tasks prior to starting

  • Take regular breaks to minimize fatigue

Attention and concentration con t

Attention and Concentration Con’t.

  • When reading and studying, read small passages, take a break, and then read them again

  • Clear away any materials not needed for tasks/work

  • Maintain a quiet environment with minimal distractions when focus is needed

Learning and memory difficulties

Learning and Memory Difficulties

  • Daily organizer/calendar to record appointments and important tasks

  • Multiple modalities to learn new material

    • Read it aloud (hearing)

    • Picture it (visual)

  • Set realistic goals

    • It will take longer to learn new things

    • Break material down into smaller portions

    • Allow breaks between studying to allow material to consolidate into memory

    • Be patient with yourself!

Dealing with executive control dysfunction

Dealing with Executive Control Dysfunction

  • Work on one task at a time

  • Work slowly and carefully

  • Check your work for errors

  • Use a pocket organizer, smart phone or palm pilot

  • Make a “to do” list and post it in a designated place

  • Be willing to allow family members/friends provide reminders without being upset

How to detect brain injury

How to detect brain injury

  • There are often no outward physical signs of Injury – Invisible Wounds

  • We need to focus on observable behavioral Indicators of TBI

Dealing with tbi1

Dealing with TBI

  • Signs to look for:

    • Distractibility

    • Difficulties focusing on what is being said

    • Answering slowly or answering questions that are not asked (poor comprehension issues or low comprehension)

    • Long pauses in speech (word retrieval issues)

What to look for

What to Look For

  • Client’s with TBI are often very anxious, look for:

    • Restlessness

    • Face flushed

    • Sweatiness

    • Shakiness

    • Increased breathing rates

What to look for cont

What to Look For cont.

  • Talking very loud/yelling

    • Self-awareness and self-monitoring

  • Staring

    • Inattentiveness

  • Shakiness

    • Can be neurologically based

  • Difficulty following orders

    • Delayed processing or comprehension problems

What to look for cont1

What to Look For cont.

  • Have significant short-term memory issues

    • They seem to understand instructions, then minutes later cannot remember what you told them

  • May become agitated/irritable very quickly and appear disinhibited due to frontal lobe injury

  • May have significant coordination issues and involuntary movements that are neurologically based

    • Fail field test, NOT due to substance use/intoxication

  • May have visual field cuts

What to look for cont2

What to Look For cont.

  • Flat affect and seem apathetic

  • Poor initiation of conversations

  • Provide short & concrete answers to complex questions

  • Suspect’s body language and poor verbal output (yes/no responses) suggests disinterest in what you are saying (flat affect)

    • Remember this is neurologically based



  • Tell individual one thing at a time; no multistep directions

  • Be willing to repeat instructions slowly and clearly

    • Memory, Processing speed, and Comprehension

  • Keep questions as simple as possible

  • Make sure you have eye-contact with individual

    • Attention



  • Have them reflect what you have told them

    • “Can you tell me what I ask you to do?”

  • Loud speech does not always imply anger or opposition

    • More likely confused or anxious; Inability to self-monitor

Interventions cont

Interventions cont.

  • Individuals with TBI often get overwhelmed with environments that are over-stimulating (too much noise, lights, movement around them), so:

    • When trying to talk to them or directing them, try to get them in quieter areas away from crowds, noise, lights, etc.



Write down any follow-up and

encourage them to put in


-Memory vs. non-compliance

For anxious or agitated

individuals, encourage breathing

and grounding skills

-Stress ball

-Sensory loaded modalities

Allow a time-out if necessary

Therapy interventions tbi

Therapy Interventions- TBI

  • Structure/routine

    • Pill reminder

  • Marker board

  • Symptom journal

    • Disorganization

    • Questions they want answered

  • Take notes in session

  • Involve family

    • Educational aspects

    • ADD-like aspects

  • They often won’t admit deficits

Tbi and ptsd overlapping and differentiating symptoms

TBI and PTSD: Overlapping and Differentiating symptoms

  • TBI:

    • Concentration

    • Memory

      • Commonly STM

    • Irritability

    • Fatigue

      • Constant detours

    • Headaches

      • Light sensitivity

    • Apathy

      • Flat affect

    • Sexual inhibition or impulsivity

  • PTSD

    • Concentration

    • Memory

      • Dissociative or amnestic

    • Irritability

      • triggers

    • Headaches

      • SNS arousal

    • Apathy

      • Secondary depression

    • Sexual aggression, heightened interest, or inhibition

Tbi and ptsd overlapping and differentiating symptoms1

TBI and PTSD: Overlapping and Differentiating Symptoms


  • Sleep problems

    • REM cycle disruption

  • Problems processing

    • Slowed

    • Word retrieval

    • Problems shifting focus

  • Emotional lability

    • Without external triggers

    • Overly emotional to small events

  • Personality changes

    • Flat

    • Lack of initiation

    • Loss of self-awareness/self-monitoring

  • Lack of spontaneity


  • Problems sleeping

    • Nightmares

    • Hyperarousal

    • hypervigilance

  • Problems processing

    • Scattered

    • Preoccupied

  • Emotional Lability

    • Anxious, irritable, numbing, laughing

  • Personality Changes

    • Self-esteem

    • Sense of damage

  • Everything pre-planned

  • Severe numbing



Brain Injury Association of Indiana

PO Box 24167

Indianapolis, Indiana 46224

P: (317) 356-7722 F: (317)

Brain Injury Association of America Inc.

1608 Spring Hill Rd

Suite 110

Vienna, VA 22182



Family Caregiver Alliance/National Center of Caregiving

180 Montgomery Street

Suite 1100

San Francisco, CA 94104

Defense and Veterans

Brain Injury Center

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