Brain Injury and Behavior
Wendy Adams Ed.S., NCSP
Dr. Karen McAvoy
Behavior can be defined simply as:
the interaction of a person with their
environment, or daily situation
Why Are Behavioral Issues
Important For Many Students
With TBI?
Studies show up to 50% or more of
students with TBI have some behavioral
challenges
 Most often have externalizing behavior
problems (e.g. hitting, yelling, making
rude comments)
 Sometimes have internalizing problems
(social withdrawal, inactivity)

Why Are Behavioral Issues
Important For Many Students
With TBI?
Directly related to injury itself (e.g.
aggression related to frontal lobe injury
causing inhibition impairment
 Some responses are related to the
restrictions in life after the injury or are
consequence of distress or disability

What is a Behavior Problem?
A problem behavior is a behavior that
someone (the person or others) find to
be a problem!!
 The absence of a behavior can count as
a behavior.
 “Behavior” is not a synonym for “bad
behavior”.

There is Always a Reason For Our
Behavior
Behavior is a barometer or gauge of
how a person is doing.
 The way a person acts can be a good
measure of what is going on within or
around him.

 Is the person angry or aggressive?
 Is the person not paying attention?
 Is the person refusing to do what they have
been asked?
Understanding the Behavior
and its Function
Description versus Interpretation of
Behavior
 Function of Behavior

 Behavior related to antecedents and
consequences

Observe
 A=antecedent
 B=behavior
 C=consequence
LEARNet
Antecedents
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Physical environment
Visual cues
Schedules and mini-schedules
Physical prompts
Modeling of skills and positive behavior
Language used
Instructions and directions
Learning materials
Child’s physical and emotional state
Behavior

Behavior refers to something specific,
observable, and measurable, an event
or action that can be seen and
measured.
Consequences for Students with
TBI
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Difficulty Learning from Consequences
Emphasis on Positive Consequences: Reinforcement
Strengthening Positive Behaviors
Teaching Alternative Behaviors
Procedures Not Recommended for Students with
TBI’s
 Natural versus Artificial Rewards
 Systematically Reducing Negative Behavior
 Time Out Procedures
 Punishment Procedures
 Response-Cost Procedures
Modifying Behavior

Behavior management/behavior modification
used to increase or decrease the likelihood of a
specific behavior (antecedent management).
 Procedures used before student engages in a
specific behavior with goal of increasing or
decreasing frequency of that behavior.
○ Increasing: teacher shows student an organizer with
goal to increase the chance student will stay with task
○ Decreasing: teacher does first 2-3 math problems with
goal of preventing negative reaction to math
assignment
LEARNet
Behavioral Impairments with
Traumatic Brain Injuries
Irritability/Agitation (overstimulation)
 Frustration
 Aggressive Behavior

 Anger Outbursts
 Short Temper
Apathy
 Withdrawal

Behavioral Impairments with
Traumatic Brain Injuries
Emotional Lability
 Impulsivity
 Hyperactivity
 Social Disinhibition/Inappropriate
Behavior
 Lack of Awareness of Deficits

SOS Model:
Structure,
Organization and
Strategies
NASP, 2004
Structure
 Augment
behavioral consistency: Brief
and clear rules that are understandable,
reasonable, and obtainable, with
consequences enforced across the
educational experience.
 Consider endurance and stamina:
Modify assignments or length of school
day and/or increased rest time.
Structure (continued)
 Control
environmental stimulation:
Avoid distractions and disruptions.
 Utilize a life skills curriculum: Activities
relevant to everyday living.
 Support and validate feelings: Need
to be encouraged
 Forge a home-school partnership:
Strong link to home
Organization
Utilize tactics of effective instruction:
Students must use planning skills and
strategies; “learn how to learn”.
 Organize assignments

Strategies
Consider method and process: Single
learning or multi-modal learning style may
be required.
 Utilize compensatory methods: i.e.
calculator
 Offer remediation when appropriate:
Direct instruction in content areas.
 Teach Social Skills: Social skills training to
address loss of friends.

NASP, 2004
“Oregon Model”
‘07-’08 TBI Team Manual
Characteristic: Memory Impairment

Strategy: Errorless learning and high
rates of success in interactions
 Acquisition and retention of new information
tends to increase with high rates of success
(and error frequency increases with frequent
errors and error correction).
Characteristic: Unpredictable Recovery,
Unusual Profiles, and Inconsistency in
Behavior

Strategy: Ongoing assessment and
flexibility in curricular modification.
 Adjustment of interaction based on ongoing
assessment of the individual’s progress
facilitates learning and allows for curricular
modifications “on the fly”.
Characteristic: Unpredictable
Recovery, Unusual Profiles, and
Inconsistency in Behavior

Strategy: Strategy-based intervention
 Organized intervention designed to facilitate
a strategic approach to difficult tasks,
including organizational strategies.
Characteristic: Decreased SelfAwareness/ Denial of Deficits

Strategy: Self-awareness/attribution
training
 Facilitation of individual’s understanding of
his/her role in learning.
Characteristic: Behavioral Difficulties

Strategy: Positive behavior supports
 Using an approach to behavior intervention
that focuses primarily on the antecedents of
behavior in the broadest sense (including
setting events and establishing operations),
environmental management, and role
improvement.
cokidswithbraininjury.com
BrainSTARS Manual
www.cokidswithbraininjury.com

Traumatic Brain Injury Matrix (3 areas commonly
affected)
 Memory
○ The mental ability to store and retrieve words, facts,
procedures, skills, concepts, and experiences.
 Visual-spatial
○ The ability to generate, retain, retrieve and transform
well- structured visual images.
 Organization
○ The ability to create and maintain orderliness in
thoughts, activities, materials and the physical
environment.
Memory
Traumatic Brain Injury Matrix

Behavioral Impacts
 Can’t remember more than one thing at a time
 Doesn’t remember recent events
 Disorganized
 Gets lost frequently and easily
 Looks spacey
 Appears to have attitude issues
 Appears manipulative
 Learned Helplessness
○ BrainSTARS Chapter 3 and Blue Tabbed sections: #9 Memory
Visual-Spatial
Traumatic Brain Injury Matrix

Behavioral Impacts
 Difficulty organizing materials
 Can experience behavior difficulties due to
frustration of not understanding visual
materials and expectations
Organization
Traumatic Brain Injury Matrix

Behavioral Impacts
 Difficulties with transisitions
 Follower
 Loses things easily
 Is disorganized
 Copies behaviors of others
 Spacey
 Easily frustrated
○ BrainSTARS Chapter 3 and Blue tabbed section: #14 and #15
Jeanne E. Dise-Lewis, Ph.D.
Margaret Lohr Calvery, Ph.D
Hal C. Lewis, Ph.D.
BrainSTARS Manual
Brain Injury: Strategies for Teams And
Re-education for Students
 Provides education about brain injury
and clarifies the many after-effects of
brain injury on development
 Teaches a systematic approach for
analyzing and changing behavior
problems

(At least one manual of BrainSTARS is in each school in
District 20)
Memory

Teach your child how to pay careful attention
and how to engage actively in thinking about
what he is learning.
 Use everyday activities
○ Establish regular location for essential
items. Key, wallet, shoes, backpack, etc.
should always be stored in the same
location. Practice a daily routine for putting
items away. Initially, provide supportive
supervision or post visual cues and
reminders.
BrainSTARS (Blue tab # 9)
Memory
○ To help your child remember recent events,
have her repeat out loud what just happened.
○ When you ask the student to recall
information, remind him of the situation in
which the information was first learned.
BrainSTARS (Blue tab # 9)
Memory
○ The following strategies may help your child
remember important information.
 Repeat out loud the main points.
 Make up rhymes, acronyms, or letter
associations.
 Relate the new information to something
familiar.
 Relate the information to a personal
experience.
BrainSTARS (Blue tab # 9)
Organization

She will probably be unable to organize her
workspaces, her learning process, and her
daily life independently. Teachers need to set
up and maintain organizational systems.
 Use everyday activities
○ Make a daily schedule for the child, using pictures or
words, ad tape it inside her notebook or folder. The
daily schedule helps the student to understand the
organization of her day and allows her to anticipate
special event and other changes in the routine.
BrainSTARS (Blue tab # 14)
Organization (continued)
○ Create routines and schedules for everyday events
(lunch, music, art) as much as possible, stick with
them. Prepare the child for a change in the routine,
and give her a visual reminder about the change.
○ Prepare the child in advance if there is something
you need to do. Remember to focus on the
positive: tell the child what to do and avoid telling
her what she should not do.
○ Provide visual reminder and teach their use. Break
down multistep activities and sequence them, using
pictures or phrases.
BrainSTARS (Blue tab # 14)
Strategies for Interventions
(For All Ages)
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Assign a paraprofessional or another adult
as a behavior coach.
Set up a time-out or cool down procedure
for acting-out behaviors.
Post classroom rules for appropriate
behavior.
Repeat classroom rules aloud.
Use a quiet voice when reinforcing
classroom rules.
Teach and encourage the use of relaxation
procedures.
Strategies for Interventions
(For All Ages)
Correct inappropriate behaviors by
providing verbal feedback to the student
regarding the behaviors exhibited and the
correct behaviors expected.
 Coach other students in the classroom
about how to the treat the student by using
problem solving techniques and scenarios.
 Develop and implement a behavior
intervention plan (BIP).
 Teach awareness of all disabilities
including TBI’s.

Strategies for Interventions
(For Younger Students)
Give clear and simple directions
 Avoid time outs (the student is not likely
to independently regroup or calm down
 Label the emotion and direct the student
to show the acceptable behavior

Strategies for Intervention
(For Older Students)
Teach strategies and how to use them
rather than offering assistance
 Discuss and practice age-appropriate
behaviors in real life situations
 Create structured social activities (e.g. a
school friendship group focused on the
student)
 Assume limited ability to generalize from
one setting to another
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School-based Intervention
Identify Strengths
 Identify several people who are willing
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 Natural helpers (prior relationship is best)
○ Peers
○ Counselors
○ Parents
○ Teachers
○ Mentors

Student Strengths + strength of natural
helpers + strategies in natural context
Further considerations
Expect impulsive and poorly regulated
behavior at times.
 Anticipate and prevent. For example, if
student arrives at school anxious or
angry as a result of events before
school, early in the day give them an
opportunity to do some job that defines
them as positive contributors to the
classroom.

Top 10 Things to Remember
When Working With Kids With
Challenging Behaviors
Tim Feeney
10. Best behavior intervention is prevention.
9. Successful behavior programs focus on
ANTECEDENTS.
8. Behavior problems and cognitive
problems are inseparable after brain
injury; successful behavior interventions
must include cognitive supports.
7. Always look like you feel like you know
what you’re doing.
6. Always make your expectations clear;
make sure the student knows where you’re
going to take them, how much work you
want done, etc.
5. Make a plan prior to beginning an activity.
Clearly identifying when the tasks begins
and ends.
4. All behaviors communicate something.
The key to successful intervention is
figuring out what the student’s behavior is
telling you, and then giving them another
more positive way to say it.
3. BE PATIENT – BE PATIENT – BE PATIENT.
2. Keep your sense of humor, sometimes that’s
all you’ve got.
1. Remember the cardinal rule in behavior
management…we may really want our kids to
succeed but we can’t make them do what we
want!!
Tim Feeney
References
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BrainSTARS, Brain Injury: Strategies for Teams and Re-education for
Students. Jeanne E. Dise-Lewis, Ph.D.; Margaret Lohr Calvery, Ph.D; Hal
C. Lewis, Ph.D.
Colorado Department of Education. Brain Injury: A Manual for Educators
Feeney, Tim, Ph.D., Project Director, New York State Neurobehavioral
Resource Project (Contributor to LEARNet)
Florida Department of Education, Bureau of Exceptional Education and
Student Services, 2005; Understanding and Teaching Students with
Traumatic Brain Injury: What Families and Teachers Need to Know
http://www.bianys.org/learnet
http://cokidswithbraininjury.com
National Association of School Psychologists (NASP) 2004. Traumatic Brain
Injury (TBI): Strategies for Educators.
Oregon ‘07-’08 TBI Team Manual