You are still the expert on your child. You will always have the special knowledge and memories of your child before the brain injury. No one will know him as well as you, and no one will work harder to take care of him than you will. Nevertheless, your child may seem like a new and different person in some ways now. The more that your family and friends understand how the brain injury has affected your child, the better prepared they will be to help and support your child. As a child's physical recovery progresses, it is often the less visible changes in behavior, thinking, and memory that are harder for others to recognize.
A traumatic brain injury often affects the part of the brain that directs executive functions. These help your child understand his strengths and weaknesses and help him plan and carry out activities. Executive functions include planning, goal setting, self-monitoring, self-control, self-initiating, self-evaluating, and flexible problem solving. Distractibility, poor organization, the inability to control emotions, and many other changes in behaviors are all signs of changes with the brain's ability to perform executive functions.
The following information describes behaviors that can change when executive functions have been affected by a brain injury. These descriptions include examples of how to help children with these behaviors. This list is long because the brain is very complex. Each brain injury is different and so are the changes in behavior for each child. Your child may show only a few of these behaviors; they will probably change over time. Use this list to guide you in discussions with members of your family, doctors, educators, counselors, and rehabilitation specialists. For a list of books with more information, see Reading Resources for Families/Educators.
Behaviors often seen in children after a traumatic brain injury include:
Tiredness and fatigue
Many children tire easily after a brain injury, even after the physical injuries heal. Fatigue is more than just being sleepy. It can affect other functions. For example, a child with weakness on one side of his body may be more likely to stumble or trip when tired. A child with speech difficulties may be harder to understand when tired.
When Bill first went back to second grade, he went for half-days for one month and then returned full time. He had plenty of energy in the morning, but was dozing off in the afternoon. By dinner, he was so irritable that he argued constantly with his brothers. The only relief came when he fell asleep right after dinner. His parents were constantly shushing his brothers and arguing to keep the TV volume down to avoid waking him. Life at home alternated between walking on eggshells and being in a war zone.
The school day was shortened so Bill could go home after lunch for a nap. Then a tutor came to the house for two hours in the afternoon. After three months of this schedule, he no longer needed afternoon naps and went back to school full time. The school nurse arranged a place for him to rest when he was tired. Progress was slow, but Bill gradually worked up to a full school day. After-school activities were reduced during the first year after his injury. Two years later, he can handle a full schedule in and after school. His parents notice that he still tires more easily than his brothers, and he needs extra sleep at night.
Some changes in memory may be temporary; others may last longer. Forgetfulness, or memory loss, may be more noticeable with certain types of information. For example, your child may find it hard to remember names, places, or dates. Memory of recent events is often more affected than long-term memory.
Excited but somewhat nervous about starting middle school, Karen was quickly gathering detention reports. She often had to stay after school because she forgot to bring in her homework. She also had trouble getting to classes on time because she kept losing her schedule and couldn't remember where she was supposed to be. Three trips to the principal's office for chronic tardiness during the first month had produced no results.
The occupational therapist showed Karen how to put together a daily organizer that she could update each week. They developed a plan in which Karen met with her educational assistant at the start of each day to review her schedule. Her organizer included a check-off list for her to review at the end of the school day. There was a special folder in the organizer to hold her completed homework. A note on the kitchen door reminded her to bring her organizer to school. Reports of missing homework and tardiness dropped after Karen's first week of using her organizer.
Noises and activities may easily interrupt your child's attention or concentration. As a result, your child often does not finish a task or activity.
Getting out of bed, eating breakfast, and getting dressed for day care seemed to take Susan forever. Susan would listen to her favorite songs on the radio, watch cartoons on TV, or play with her cat. Her mom was constantly telling her, "Hurry up! You'll be late." The day care teacher was finding Susan more difficult to supervise because she was wandering off during group activities. Since her injury, Susan didn't play well by herself. Because she worked, Susan's mom was worried about what she would do if she lost her day care arrangement.
By setting rules that no radio or television were allowed before school, those distractions were avoided. By putting the cat outside before waking Susan, that distraction was avoided. More one-to-one and small group activities at day care helped Susan pay attention and follow directions.
Many activities require making an action plan. Most of us do this so easily that we do it without thinking. But the child who has had a brain injury often finds it hard to identify all the steps and put them all together in the proper order. Making a plan with reminders or cues can help.
Tom got a part-time job as shelf stocker at the local supermarket. It was taking him so long to sort out where things went that he worked much slower than the others. His boss was sympathetic, but was having second thoughts about keeping Tom.
Tom's boss worked out a plan so that Tom was responsible for stocking only the produce section. The work was broken down into steps: inventorying the fresh produce section, noting on paper what items were low or no longer fresh, removing old produce, finding the new inventory in the stock room, loading the stocking cart, and replacing the produce out front. Once Tom had learned how to do this efficiently, he was able to take on stocking other sections over the next couple of months.
Irritability and Anger
Changes in your child's ability to control emotions may result in sudden temper flare-ups, yelling or swearing outbursts, and even hitting or punching others. These changes can cause your child to frighten others, lose friends, and be seen as a "problem" in school. Noise, pressure, frustration, fatigue, and other stressors may trigger your child's temper.
Sorting out how much of this behavior is due to changes in your child's brain functioning and how much is an emotional response is difficult. Too often, the target of an outburst takes it personally and holds a grudge against the child or avoids further contact. You can help others understand that these actions are a consequence of the injury rather than intentional insults or accusations. While they may feel like personal attacks, they are caused by changes in the child's ability to control emotions. Very often, the outburst will fade away as quickly as it appeared. Your child may be puzzled by why others are so upset, and he may need your help to understand the reactions of strangers and friends. By understanding the consequences of his irritability and anger, your child can work on preventing outbursts.
Professionals can help you develop a plan to help your child better control his impulses and to help others respond effectively. This plan may include identifying what triggers emotional outbursts, changing the environment, modeling calm behaviors, providing distractions, and talking it out.
One of Michael's favorite hobbies was producing music using a high tech sound system in his room. By mixing several audio tracks, he could make new tapes. This required a lot of mental concentration, keen listening , and technical skills with electronic equipment. His mother was initially pleased to see him get back to this hobby after he came home from the hospital, but she became frightened when he punched two holes in the wall after she interrupted him. Still easily distracted, Michael blamed his mother for ruining his taping session.
Michael and his mother agreed to share the responsibility for changing the environment so that Michael could concentrate better. Michael was responsible for minimizing distractions by telling his mother when he was mixing, turning off the phone in his room, not allowing friends to watch, and letting his mother know when he was done. His mother agreed not to interrupt him, by taking messages and keeping the house quiet.
Acting without thinking is typical of a young child who has not developed the awareness of risks and consequences. A brain injury can result in impulsive actions that can make behavior seem puzzling to others, but it can also pose risks for your child. Moving too quickly can risk another injury; interrupting can disrupt conversations and become annoying. A child who speaks or acts impulsively may need more supervision and guidance to recognize and respect the rules of what is safe and what is acceptable.
What scared me most about Sam was the possibility that he could get hurt again. He moved so quickly, and he just didn't think about what he was doing. Before he was hurt, he walked to school and I never worried about him. But now, I don't dare let him go by himself because he just doesn't look for traffic. I have seen him run across the road without even looking, and my heart just about stops. He hates having me drive him to school because all his friends walk. He says it makes him feel like a baby, but I can't risk him getting hurt again.
We worked out a plan for Sam's dad to drop him off at school on his way to work. We told him he could choose one friend a week to ride with him to school. I arranged the schedule with four of his friends after talking with their parents. That way he had a buddy to go with and didn't feel so singled out. His friends thought it was a treat to get a ride one week a month, so there was something in it for everyone. The only one who was inconvenienced was my husband. He got to work a little later, but they have flex time at his business. I picked the boys up at the end of the school day.
Your child's skills for getting along with others, acting his age, making comments that fit the situation, and interpreting the reactions and body language of others are generally described as social skills. Sometimes a brain injury affects these abilities so that a child acts younger than her age, constantly interrupts others, makes rude remarks, and generally has trouble "fitting in" and "getting the picture". These changes can be embarrassing for family and friends, but your child may be unaware of the reactions of others and simply miss the social cues or messages that most of us read easily. Repeating the same joke over and over again, or talking constantly and monopolizing the conversation can make others feel like they are "listening to a broken record". When friends and family do not understand the cause of these behaviors, your child may be avoided or teased. You can help your child relearn these social skills and teach others how to react helpfully instead of critically.
While shopping with her Mom, Rebecca said hello to everyone, whether she knew them or not. Most simply smiled or nodded. She asked the cashier at the check-out counter why he wore an earring in one ear. He gave her a puzzled look and looked relieved when her mother spoke to her quietly and asked her to wait by the door.
Whenever Rebecca started conversations in settings or with persons where it was not appropriate, her parents took her aside and talked about her behavior. This happened often at first, including interrupting others at the dinner table, talking aloud in church, commenting about people, and talking with strangers. They practiced situations that might happen and rehearsed how she would respond. They were firm but direct and let her know what was appropriate and what needed to change. Gradually, they needed to remind her less and she seemed to "fit in better" with people and situations outside her family.
The ability to be sympathetic to others and to understand how one's actions affect others is part of developing maturity. By contrast, a brain injury may result in a child focusing more on himself, with remarkable unawareness of how others feel. This can cause resentment by others who view such behavior as selfish and self-centered, resulting in avoidance by friends.
Alan never asked about his best friend who was also in the car crash. Alan didn't seem to make any emotional connection. He never talked about being sorry. He only talked about how his life had changed and what he wanted to do. He seemed unaware that I felt like I was hanging on by only a thread. It seemed like it was always, "Me, me, me."
I learned to speak up by telling Alan when I needed time by myself or time to go places and do things. Rather than seeing him as selfish, I learned to help him think about others by asking direct questions. I tried not to make him feel guilty but to be more aware that others had been affected by his injury and that he was not the only one who had changed. It helped to suggest specific activities to involve him with other people, such as sending a card to his friend and making a list of chores to help me around the house.
It is more often the child who is quiet and "good" rather than a troublemaker, who slips through the cracks or whose difficulties go unnoticed. If your child finds it hard to get started or seems to daydream a lot, you may hear others describe her as "lazy" or "unmotivated". Passive behavior may be caused by your child's inability to use areas of the brain that initiate and plan behavior.
The sitter reported that all Suzy did after school was watch TV. Any attempts to get her to do homework before supper seemed to fail. As a result, evenings were spent struggling to get homework done, arguing about TV, and worrying over why she never played outside. Although progress reports from school were encouraging, everything fell apart when she came home. Suzy's parents thought she might be depressed because she didn't seem to care about doing anything after school.
Every hour of the school day was planned for Suzy. She got lots of special help from an educational assistant. A written schedule helped her know what she was supposed to do every hour at school. By contrast, her time at home was totally unplanned. Suzy ignored the sitter's suggestions that she do her homework or go out to play. Suzy's parents shared their frustration with school staff. Suzy found it hard to get started on tasks, as this required planning and organizing. They put together an after-school plan using the same strategies that were successful at school. Once the sitter understood that Suzy needed specific action steps, she helped review Suzy's assignments, find the assigned pages in her books, and begin homework exercises. Once Suzy started, she only needed occasional guidance, often when she moved to a new subject or assignment. She had a limit of one hour of TV which was contingent upon completion of assignments.
Feelings of sadness and loss are normal reactions to brain injury and are a recognition of changes in your child's abilities. However, depression is more serious and may require professional help or medications. Warning signs to watch for include a lack of interest in life, changes in sleeping and eating patterns, withdrawal from friends and activities, and expressions of hopelessness and feelings that life is not worth living. Any references to suicide must be given serious attention and evaluation by professionals.
After a brain injury, depression can be difficult to evaluate. It can be the result of physical changes in the brain, but it can also be an emotional reaction to the injury. Very often, a person's flat or dull tone of voice and slowed speech cause others to assume that the person is depressed. Passive behavior caused by difficulties with initiation and planning can easily be misinterpreted because depressed people often are less active and less interested.
There are medications that can help depression, but a professional evaluation is essential. Because medications can affect the brain differently after an injury, it is helpful for the doctor or psychiatrist to have experience with children or adolescents with brain injury.
When Linda lost interest in everything she had ever cared about, her parents were very concerned. They had thought that the worst was behind them after she came home from the hospital. She was back in school and had physically recovered almost 100% from her injuries. Most people meeting her for the first time didn't even know that she had had a brain injury. But Linda was increasingly lonely and felt that she wasn't the same person anymore, despite her parents' optimism and reassurances. She felt cut off from her friends, lost confidence in herself, and spent most of her free time alone.
Through counseling, Linda was able to talk about how her life had changed. No longer required to put on a brave front for her parents and friends, she could talk about her anger, express her doubts, and share her fears. Medication helped her feel less moody, and she slept less. Counseling also helped her sort out the subtle changes that were related to the brain injury and those which were part of learning how to cope with growing up and thinking about her future.
The brain controls hormonal activity, and it also controls the ability to control our sexual thoughts and actions. When the ability to control or inhibit these urges and thoughts is damaged, your child may make sexual comments or gestures, or use behaviors that are embarrassing and inappropriate. As the hormones of adolescence kick in, controlling these impulses may be even more difficult. You can help your child control sexual behavior by understanding its cause and teaching your child what is appropriate and where it is acceptable.
When Allison returned to school following her injury, her friends were surprised at how she had changed around boys. The shy girl who didn't date much in the past was now asking boys for rides home, asking them out on dates, and making very suggestive jokes and remarks. Her close friends were embarrassed and afraid she might get into "trouble" if she continued.
After talking with Allison's mother and guidance counselor, her friends set up a buddy system. They gently spread the word that Allison was still recovering from her injuries, and that her comments were not to be laughed at or encouraged. Allison's counselor met with her regularly to talk about dating and the possible consequences of her behaviors. At home, her parents set strict rules for activities and enforced a curfew when she went out with friends.