With the winter weather upon us, we may be seeing more falls outside. Some individuals may even sustain a head injury that results in a Traumatic Brain Injury (TBI). A TBI occurs when an individual sustains an insult, force or blow to the head that causes changes in brain functioning. These types of injuries can occur after a fall, a hit to the head during sports or a motor vehicle collision.
TBI Range of Severity
TBIs can range in severity from Mild (minimal to no loss of consciousness and no long-term symptoms) to Severe (long period of loss of consciousness and amnesia and long-term symptoms). Typically, mild TBIs cause a temporary change in cognitive and physical functioning and do not lead to long-term difficulties; whereas, a moderate or severe injury may lead to longer recovery and challenges.
Possible Changes in Cognition, Mood and Behavior
Children present differently after a TBI. Depending on the severity and location of the injury, children may show changes in their thinking skills (cognition), mood and behaviors. Injuries to specific areas of the brain, such as the frontal lobe, may lead some children to be more impulsive or struggle with filtering their thoughts, words and actions. They may also become frustrated and tantrum more easily. All children may present with these challenges at times.
The following tips may be helpful for managing new behaviors seen after TBI but can also be used for managing behavior challenges for any child:
How to Manage Challenging Behaviors
Be aware of your body language, tone of voice and facial expression.
We want to model the behaviors we are expecting from our children. It is important to exhibit calm behaviors (voice, face) even if we are feeling frustrated, though that can certainly be easier said than done. Try to speak with your child at eye level in a calm and firm voice. If you need time to cool down, use the opportunity to model for your child how you release stress.
Describe the behavior you want to see rather than tell your child what behaviors to avoid.
Try to limit No’s and Don’ts when possible. For example, it is more helpful to say, “Use an inside voice” or “Show me calm hands and mouth,” rather than “Stop fidgeting and touching others. Don’t yell.” It is also important to collaborate with your child and try to explore problem-solving solutions together as a team rather than solely giving instructions. This helps build their critical thinking and problem solving skills and gives you the opportunity to help guide this process.
Provide alternative behaviors.
For example, if your child has difficulty keeping their hands to themselves, then you can provide a fidget or encourage them to keep their hands in their pockets. If your child bites, then you can provide a chew fidget or piece of “chewelry” (jewelry you can chew). You can make a list of alternative behaviors for your child when they feel upset, such as punching a pillow, ripping or crumpling paper or squeezing stress balls. After a TBI, children may experience increased stress and frustration when activities feel more challenging than before their injury. Alternative behaviors can also include relaxation strategies. You and your child can make a “cool down” box that contains relaxation items, such as stress balls, fidgets, kinetic sand, or pinwheels/bubbles for deep breathing. Encourage your child to add to it when they find an activity that is relaxing or that helps them to soothe.
Provide “if/then” statements or a visual schedule.
After a TBI, a child may experience new difficulties understanding cause and effect relationships. This is also a skill that young children in general are starting to learn and master. By using “if/then” statements, we can help them connect an action with a consequence. These statements can be used to describe both positive and negative outcomes. It is important to make statements specific and concrete when possible. For example, rather than saying, “if you work hard, you can have a break,” it is more helpful to say, “if you finish five math problems, then you can take a five-minute break.” Children can also benefit from a visual schedule and a consistent routine each day to help set up expectations and follow-through. A visual timer can be helpful to track how long a child needs to perform an activity or how long they can receive a break.
Above all, look for the positive behaviors no matter how small and provide descriptive praise.
For example, rather than saying, “Good job!” you can say “I like the way you listened and followed directions!” Your child may benefit from a reward chart/system where they can earn tokens or stickers for good behaviors. These tokens can earn a bigger prize, such as receiving extra screen time, choosing the game on game night, or choosing dinner from a limited number of options. Address one goal/behavior at a time and clearly state how your child can earn tokens. If your child is experiencing difficulty earning tokens or reaching a goal, then break the goal down into a smaller, more achievable goal and gradually progress to more challenging goals over time.
WakeMed Services to Support Children After TBI or Head Injury
It can be challenging to manage behavior problems in the best of times. New cognitive, mood, and behavior changes can make it particularly challenging for both children and family. There is not a “one size fits all” approach to navigating behaviors.
At WakeMed, a team of providers assists patients and family members in learning more about a child’s needs and identifying strategies and resources for meeting these needs. If you are experiencing difficulty managing behaviors, it can be especially helpful to work with a neuropsychologist, clinical psychologist, or counselor to create an individualized treatment plan.
For mild head injuries or concussion, learn more about our Concussion Program.
For a more complicated mild TBI or a more serious brain injury, learn more about services through WakeMed neuropsychology outpatient clinic.
Additional Resources
About Dr. Maria Butler
Dr. Butler joined WakeMed Neuropsychology in 2021. She received her doctorate in clinical psychology from the American School of Professional Psychology Washington D.C. She completed her post-doctoral fellowship in neuropsychology at Mt. Washington Pediatric Hospital affiliated with Johns Hopkins Medical System and the University of Maryland Medical System. Dr. Butler provides neuropsychological assessments to pediatric and young adult patients with a variety of developmental and neurological diagnoses.
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