Mark
It has been a while since I last contacted you. I just wanted to let you know that I___’s results of the QEEG have shown significant frontal cortex impairment which would affect his behaviour. I attach a copy of the letter the Clinical Neuro psychologist sent to the school requesting for additional time for his exams.
The neuro-psychologist says that it is not a license for his bad behaviour though. But she does point out that he cannot control his anger and does not always know what he is doing until it is too late. Also she says he should not be provoked or argued with as his brain cannot deal with it. It seems that he does go into a mad fit when he is angry.
In the meantime, we have had 4 sessions of Brain biofeedback treatment after the QEEG test (weekly sessions, he requires at least 18) for which I have to pay.
His behaviour, however, has become somewhat erratic. He has been caught in school while he was excluded from it for rude behaviour to a teacher) for drinking from a can of beer in the playground with a friend of his. This is the friend called Lloyd who is getting him in a lot of trouble (drinking, truanting bad behaviour, who has been expelled from a previous school). I___ seems to have joined forces with this trouble maker and together they are causing double trouble.
Question: You told me last time, to wait until I get the results of I___’s QEEG test which I have and which confirm frontal cortex damage. He is receiving treatment. In the meantime, while he is receiving these weekly sessions to repair his brain (he can only have 1/ week) as the brain cannot cope with any more. What do I do about his rude behaviour and drinking alcohol with friends, staying out late at night at the weekend with the same (bad) friends? His swearing at me and his dad if we reprimand him of any of his behaviour. He is breaking furniture in his bedroom and being rude and fighting with his brother. He can be quiet and good for about 7 – 10 days and then something will spark him off, normally when he does not get his own way or I ask him to have a time out. Whereas I feel that when I first started with your programme, I was very slowly getting some success but now with the diagnosis, I don’t know which way to turn. Should he be allowed to get away with everything as I cannot confront him.
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This situation does put you in a "double bind". On the one hand, the psychologist is saying "that it is not a license for his bad behavior" ...but on the other hand, you have been advised that "he should not be provoked or argued with."
But...
If you follow the program as outlined, you will not be doing any "provoking" or "arguing." I know you may want to view your situation as extremely unique -- and you may always run the risk of "feeling sorry" for your son. However, your situation is not that much different from any other parent who is working this program -- and you should NOT fall into the "feeling sorry" trap.
Continue to work the program with no modifications. After all, this program is designed for kids who have issues such as mood disorders, impulse control problems, anger management difficulties, and so on.
Here are some pointers:
Head injury survivors may experience a range of neuropsychological problems following a traumatic brain injury. Depending on the part of the brain affected and the severity of the injury, the result on any one child can vary greatly. Personality changes, memory and judgment deficits, lack of impulse control, and poor concentration are all common. Behavioral changes can be stressful for families and caregivers who must learn to adapt their communication techniques, established relationships, and expectations of what the impaired child can or cannot do.
In some cases extended cognitive and behavioral rehabilitation in a residential or outpatient setting will be necessary to regain certain skills. A neuropsychologist also may be helpful in assessing cognitive deficits. However, over the long term both the survivor and any involved family members will need to explore what combination of strategies work best to improve the functional and behavioral skills of the impaired child.
Even a child who makes a “good” recovery may go through some personality changes. Family members must be careful to avoid always comparing the impaired child with the way he/she “used to be.” Personality changes are often an exaggeration of the child's pre-injury personality in which personality traits become intensified. Some changes can be quite striking. It may be, for example, the head injury survivor used to be easy going, energetic, and thoughtful and now seems easily angered, self-absorbed, and unable to show enthusiasm for anything. Nonetheless, try not to criticize or make fun of the impaired child’s deficits. This is sure to make the child feel frustrated, angry, or embarrassed.
Head injury survivors may experience short-term problems and/or amnesia related to certain periods of time. Generally, new learning presents the greatest challenge to memory or remembering. In contrast, pre-injury knowledge is more easily retained. The ability to focus and concentrate are keys to addressing some short-term memory problems.
· Have the child repeat the name of a person or object, after you, if memory impairment is severe.
· Keep distractions (e.g., music, noise) to a minimum and focus on one task at a time.
· Keep to routines. Keep household objects in the same place. Use the same route to walk to the mail box or bus stop.
· Whenever possible, have the child write down key information (e.g., appointments, phone messages, list of chores).
If getting lost is a problem, you can label doors or color code doors inside the house or hang arrows to indicate directions. When going out, the child should be accompanied initially to ensure the route is understood. A simple map can be sketched from the bus stop to the house. And make sure that the child always carries his/her address and emergency phone numbers.
A structured environment can be essential in helping a head injury survivor relearn basic skills. A written routine schedule of activities and repetition make it easier to remember what’s expected and what to do next.
After a head injury a child may lack emotional responses such as smiling, laughing, crying, anger, or enthusiasm or their responses may be inappropriate. This may be especially present during the earlier stages of recovery. Recognize that this is part of the injury. Try not to take it personally if the child does not show an appropriate response.
Encourage the child to recognize your smile at a humorous situation (or tears if you are sad) and to take note of the proper response.
In some cases, neurological damage after a head injury may cause emotional volatility (intense mood swings or extreme reactions to everyday situations). Such overreactions could be sudden tears, angry outbursts, or laughter. It is important to understand that the child has lost some degree of control over emotional responses. The key to handling lability is recognizing that the behavior is unintentional. Caregivers should model calm behavior and try not to provoke further stress by being overly critical. Help the child recognize when his/her emotional responses are under control and support/reinforce techniques that work.
Provided a situation does not present a physical threat, various approaches may be used to diffuse hostile behavior:
· Do not challenge or confront the child when he is already angry about something Rather, negotiate (e.g., if you don’t like what’s planned for dinner tonight, how about choosing Friday’s menu?). Try to understand the source of the anger. Is there a way to address the child’s need/frustration? (e.g., make a phone call, choose an alternative activity).
· Help the child regain a sense of control by asking if there is anything that would help him/her feel better.
· Ignore the small problems.
· Isolate the disruptive impaired child. Consider you own safety and his/hers. Treat each incident as an isolated occurrence as the survivor may not remember having acted this way before or may need to be prompted to remember. Try to establish consistent, non-confrontational responses from all family members (children may need to learn some “dos” and “don’ts” in reacting to the survivor).
· Offer alternative ways to express anger (e.g., a punching bag, a gripe list).
· Remain as calm as you can.
· Seek support for yourself as a caregiver. Support groups, professional counselors, and, if necessary, protective services or law enforcement may be contacted.
· Show extra affection and support to address underlying frustrations.
· Try to change the child’s mood by agreeing with the child (if appropriate) and thus avoiding an argument.
· Validate the emotion by identifying the feelings and letting the child know these feelings are legitimate. Frustration over the loss of functional and/or cognitive abilities can reasonably provoke anger.
The child who has survived a head injury may lack empathy. That is, some head injury survivors have difficulty seeing things through someone else's eyes. The result can be thoughtless or hurtful remarks or unreasonable, demanding requests. This behavior stems from a lack of abstract thinking.
Help cue the child to recognize thoughtlessness. Remind him/her to practice polite behavior. Realize that awareness of other people's feelings may have to be relearned. “Cueing” or reminders can be helpful in improving concentration and attention. Repeat the question. Don’t give too much information at once, and check to see that the child is not tired.
Head injury survivors should be encouraged to develop self-checks by asking themselves questions such as:
· “Did I understand everything?”
· “Did I write it down?”
· “I made a mistake” or “I’m not sure” should lead to the conclusion, “let me slow down and concentrate so I can correct the error.”
· “Is this what I’m supposed to be doing?”
Correct actions should be consciously praised, “I did a good job”.
It is relatively common for a head injury survivor to be unaware of his/her deficits. Remember that this is a part of the neurological damage and not just rebelliousness. Be aware, however, that denial can also be a coping mechanism to conceal the fear that he/she cannot do a particular task. The child may insist that the activity cannot be done or is “stupid.”
· Build self-esteem by encouraging the child to try a (non-dangerous) activity that he/she feels confident doing.
· Give the child visual and verbal reminders or “hints” (e.g., a smile or the words "good job") to improve confidence in carrying out basic activities more independently.
· If you feel the child can handle confrontation, challenge him/her to try the activity. Demonstrate that you can do the task easily.
Coping with behavior problems after a head injury requires identification and acknowledgment of the impaired child’s deficits. A comprehensive neuropsychological assessment is recommended. This may help both the survivor and the family to better understand neurological and cognitive deficits.
In some cases, it may be easier for the family caregiver to recognize personality changes than to resolve the problem behavior. Targeted strategies may be used to deal with specific behavioral issues.
Finally, it is critical that family members seek and receive support (family, friends, support group, counselor) in dealing with their own emotional responses to caring for a head injured loved one.
Good Luck!
Mark Hutten, M.A.
Recommended Reading—
Awake Again, Martin Krieg (1994), WRS Publishing, available from the author: P.O. Box 3346, Santa Cruz, CA 95063. (408) 426-8830.
Head Injury and the Family: A Life and Living Perspective, Arthur Dell Orto and Paul Power (1994) GR Press, 6959 University Blvd., Winter Park, FL 32193. (800) 438-5911.
Head Injury Peer Support Group Training Manual, Family Caregiver Alliance (1993): San Francisco, CA.
Professional Series and Coping Series, HDI Publishers, PO Box 131401, Houston, TX 77219. (800) 321-7037.
Therapeutic Fun for Head Injured Persons and Their Families, Sally Kneipp (ed) 1988, Community Skills Program, c/o Counseling and Rehabilitation, Inc., 1616 Walnut St., #800, Philadelphia, PA 19103.
