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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

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
  • 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