Practical Issues in Behavior Managentent for Fantily Mentbers of Individuals with Trauntatic Brain Injury Changes in behavior, both cognitive and emotional, are common following traumatic brain injury (TBI). Typically, these changes have a greater impact on family members than the physical limitations that often accompany brain injury. In this article, we present an overview ofthe behavioral techniques that have been used by family members of individuals with brain injury to deal with these problematic behavior dUlnges. Clinical vignettes are presented that describe the actual solutions that family members have used in the home to help deal with behavior changes. The importance of determining the source of the behavior changes is highlighted, and the need to apply behavior intervention programs with consistency is discussed. In addition, this article stresses the need for continued interaction between rehabilitation staffand family members beyond the period of inpatient rehabilitation.

The research presented in this article was made possible by financial assistance from the u.s. Department of Education, National Institute on Disability and Rehabilitation Research, grant # H133B80014. The authors also wish to thank the Head Injury associations of Nebraska, New Hampshire, New York, Ontario, South Carolina, and Texas for arranging for participation of subjects.

Barry S. Willer, PhD Richard T. Linn, PhD Department of Psychiatry, School of Medicine and Biomedical Sciences; and Rehabilitation Research and Training Center on Community Integration of Individuals with Traumatic Brain Injury State University of New York at Buffalo, Buffalo, NY Numerous research studies have documented the effects that behavior changes that accompany a traumatic brain injury (TBI) have upon the integrity of the family system. Several of these studies have shown that these behavior changes persist well beyond the period of inpatient rehabilitation. For example, it has been reported that as many as two thirds of the individuals who sustain a TBI demonstrate significant changes in personality at five-year follow-up. 1 A longitudinal study of individuals with severe brain injury evaluated at 10 to 15 years postinjury found that up to 50% of the subjects had persistent changes in personality. 2 Arguably, changes in personality and behavior that continue beyond the period of inpatient rehabilitation have their greatest impact on the injured individual's ability to return to the home and family setting. Unfortunately, most families of individuals with TBI are ill-prepared to understand and cope with these behavior changes. Family members often receive little information from rehabilitation professionals about behavioral sequelae specific to TBI and, even when they understand the source of the behavior changes, hunilies feel helpless in dealing with them. Although the effect that behavior changes have on the family's ultimate adaptation to TBI is still being researched, there is a growing literature that suggests that these behavior changes can have NeuroRehabil 1993; 3(2):40-49 Copyright © 1993 by Andover Medical.

Practical Issues for Family Members

a significant and lasting impact on family functioning. For example, it has been shown that by 6 years postinjury, a significant number of individuals who were married prior to their injury have divorced or separated. 3 Similarly, several studies have reported that the behavior changes that follow TBI contribute more to the family's sense of burden than do other injury-related changes such as the presence of physical disability. 1,4 In this article, we briefly discuss some of the common behavior changes confronted by family members and present the methods the families have used to deal with them. These brief vignettes underscore the ways in which family members have been successful in applying behavioral interventions in the home. This article, while written primarily for rehabilitation professionals, is aimed at bridging the gap between the behavioral intervention that occurs in the rehabilitation setting and that provided by family members during the later stages of recovery. Before addressing the behavior interventions employed by family members within the home, we wish to highlight several global issues. First, not all of the behavior changes that accompany TBI are considered to be "problems" by family members. For example, one family pointed out to us that an individual who had problems with impulsivity prior to a TBI was much less impulsive after the injury. Although such instances are rare, rehabilitation professionals must be careful to distinguish between behavior changes that contribute to family discord and those that do not. A second issue concerns the premorbid adjustment of the individual and his or her family. While a wide range of problematic behaviors can be addressed using behavioral techniques, the injured individual's pre-injury personality style may be a limiting factor. For example, an individual who had significant problems with anger control that predated his or her brain injury may be less responsive to behavioral intervention for anger control than someone without such premorbid tendencies. Similarly, a family system that was not in perfect psychological balance before an ir~ury should not be expected by rehabilitation professionals to be in perfect balance afterward. A third issue is that any discussion of the attempt to address the behavior problems associ-

41

ated with TBI runs the risk of oversimplification. Following TBI, each affected individual presents with a unique set of impairments, behavior changes, and family circumstances. An intervention that works in one situation may have little success in another. Development of successful behavioral interventions within the family setting depends largely on the application of creat.ive approaches that are matched to the individual and his or her specific circumstances. Finally, we believe that rehabilitation professionals have an important and necessary role in helping family members develop behavior intervention programs for use in the home environment. Many of the behavior problems that are of concern to family members have previously been identified by the staff on the inpatient rehabilitation unit, and often successful intervention strategies have already been developed. However, it is also true that previously treated behavior problems can reemerge after the individual with TBI has returned to the more naturalistic home environment. In addition, new behavior problems (i.e., those that were not present during the acute rehabilitation stay) may appear as the individual with TBI is faced with the challenges of community re-integration. It is our belief that the success of behavioral int~rvention programs implemented in the home depends on the continued interaction of family members with rehabilitation staff.

TYPES OF BEHAVIOR PROBLEMS IDENTIFIED BY FAMILY MEMBERS At the Research and Training Center on Brain Injury at the State University of New York at Buffalo, we have collected information on a group offamilies and individuals coping with TBI, with a f()eus on evaluating long-term adjustment to severe brain injury (Family Studies Prqject). Thus far, we have interviewed 60 married couples in which one member of the pair has sustained a TBI and 7 I families in which a son or daughter has been injured. The methods for contacting families and conducting interviews and group discussions are described in detail elsewhere. 5 ,6

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As part of the Family Studies Project, we asked family members (either parents or spouses) to rate the individual with TBI on a 40-item behavior rating scale. The results of this survey, expressed as the percentage of family members who endorsed a particular behavior change as present, are shown in Table 1. The most frequent concern cited by family members was the presence of fatigue: 83% of our sample reported that the individual with TBI had a tendency to tire easily. Other frequently reported changes included impulsivity, frustration leading to anger, a tendency to interrupt other's conversations, social isolation, and labile mood. Among the primarily cognitive changes identified were problems with decision making, memory impairment, and difficulty fi:)llowing directions. Some behavior changes, such as "occasionally takes things from others" or "rocking back and forth" were reported relatively infrequently. These findings, while generally consistent with other studies of family members reporting behavior changes following TBI, 4,7 must be interpreted with caution. The list of possible behavior changes presented to the family members was finite, and there was no guarantee that the problems on the list were those of greatest concern to the family. To address these potential shortcomings, we also asked family members to discuss their concerns about behavior changes in open-ended group meetings and instructed them to rank order their concerns. To summarize these findings, the spouses of individuals with TBI identified changes in personality, mood swings, lack of insight, general insecurity, and a tendency to remain homebound as primary concerns. Parents identified problems of anger and aggression, mood swings, and sleep disturbances as those of most concern. 5 ,6 It is interesting to note that changes in personality, emotionality, and social behavior appear to be among those of most concern to family members.

BEHAVIOR INTERVENTION IN THE HOME SETTING It has been our experience that family members are usually not equipped to deal with the changes

in behavior exhibited by the individual with TBI. Family members have little knowledge about the neurobehavioral syndromes that contribute to these changes and typically lack basic knowledge about the practice of behavior intervention techniques. It is our belief that the more family members know about the neurobehavioral sequelae of TBI and the behavioral techniques available to address behavior disturbances, the more likely it is that successful intervention strategies will be implemented. As has been stipulated elsewhere, 8 it is critical that family members be informed and educated about the behavioral disturbances common to TBI. Further, we strongly endorse the suggestion that family members receive formal training in the use and application of behavior management techniques and thus be trained as "therapists. "9 A number of authors have addressed the theory and clinical practice of behavioral intervention in TBI,8,10 so we will only touch on these issues briefly. As traditionally practiced, behavior therapy has three m~jor goals: (1) identification of the behavior to be modified, (2) elucidation of the antecedent and consequent stimulus events that either increase or decrease the likelihood that the behavior will occur, and (3) consistent manipulation of these environmental events so that the behavior is changed. The first goal of behavioral intervention, identification of the behavior to be modified, appears on the surface to be a simple task. It has been our experience, however, that this aspect of behavior modification can be particularly difficult for family members. At issue is the development of an operational definition of the behavior to be changed that is both precise and complete. In some instances, the identified behavior is too broad to realistically undergo intervention. An example of this is the complaint of family members that "We wish that John's personality was the same as it was before the injury." Another problem is that families identifY behaviors that they would like to change, which do not easily come under behavioral control. For example, behavioral intervention techniques will not be particularly useful in restoring an individual's memory for events that occurred on the previous day. Therefore, one of

Practical Issues for Family Members

Table 1.

Percentage of relatives reporting problems (n = 131 respondents). Problem

I. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40.

43

Percentage

Trouble following written directions Interrupts the conversation of others Gets tired easily Has trouble understanding oral directions Handles money wisely (False) Makes threatening gestures Is moody Gets lost easily outside the home When talking with others, has good eye contact (False) Personal habits embarrass others Can be relied on for the truth (False) Occasionally talks about sex at the wrong times Sometimes intimidates others Displays warmth as a person (False) Forgets the names of people he or she sees often Stands too close or too far away when talking with others Sometimes rocks back and forth while standing or sitting Uses swear words excessively Contact with members of the opposite sex must be supervised Sometimes lets frustration lead to anger Is suspicious of others Has difficulty remembering events that happened during the past 24 hours Talks too loudly when talking to others Does not display emotion Occasionally takes things from others Sometimes uses obscene gestures Exaggerates his or her difficulties Occasionally acts as if he or she is helpless Has problems remembering important things he or she must do Speech is clear (False) Often finds it difficult to make decisions Talks too much Tends to repeat a behavior for no reason Occasionally has verbal outbursts Sometimes has physical outbursts Is occasionally self-centered Is sometimes impulsive Is occasionally socially isolated Usually completes a planned activity (False) Ideas sometimes don't make sense

58.3 64.1 82.8 62.5 50.8 31.5 61.7 38.9 21.1

42.2 26.6 28.9 43.0 12.6 37.5 19.0 20.3 21.1

14.1 78.9 29.7 60.2 30.7 18.9 13.3 20.3 31.6 48.4 64.6 43.3 68.4 36.8 31.3 55.9 40.2 61.7 72.4 74.2 30.7 51.2

the more important services that rehabilitation

conditions or stimuli that evoke the behavior, and

staff can provide to families is assistance in defining and pinpointing the specific behavior to undergo modification. Emitted behaviors are thought to be under the control of external and/or internal stimuli. In order for a behavior to be modified, the antecedent

the consequent conditions that either increase or decrease the behavior, must first be identified. For example, suppose that an individual with TBI is found to have frequent anger outbursts. With a comprehensive evaluation of the pattern of these outbursts, it might be determined that the outbursts

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NEUROREHABILITATION / SPRING 1993

occur only in the late afternoon or evening, and only when the individual is in large group situations. It would therefore be surmised that the anger outbursts are more likely to occur when the individual is fatigued, and also in situations where he or she is overwhelmed by sensory input. In this instance, the behavioral intervention might consist primarily of changing the environment so that the individual is not exposed to sensory overload during the end of the day. However, one might also wish to reinforce behaviors that are incompatible with anger, as well as reducing the attention that is paid to the injured individual when he has the outbursts. A third focus important to the success of a behavior modification program is consistency in the use of feedback. Unfortunately, carefully thought out programs that were effective on the rehabilitation unit often fail in the home environment because family members are unwilling or unable to provide feedback in a consistent manner. For example, it is well documented that the withdrawal of a stimulus that reinforces a behavior will lead, initially, to an increase in the targeted behavior. When family members find that the targeted behavior has increased rather than decreased, they may feel that the intervention is not working and may abandon it. Even when families can be convinced to stick with the original intervention despite initial increases in the unwanted behavior, it is very difficult to get family members to apply intervention strategies uniformly. Of note, lack of consistency in the provision of feedback is also a major barrier to the effective use of behavioral strategies on the rehabilitation unit. II The issues raised in this section highlight some of the problems associated with implementing behavioral intervention programs within the family setting. In the sections to follow, we discuss some specific types of behavior problems and the practical ways in which family members have dealt with them.

COGNITIVE BEHAVIOR CHANGES Disturbances in cognitive functioning are among the most dramatic behavior changes to appear

following TBI. Since these changes are linked directly to pathologic dysfunction of the brain and, hence, are not learned behaviors, deficits in cognitive functioning do not typically respond to behavioral intervention. However, behaviors that occur in conjunction with cognitive deficits can come under behavioral control. Disturbances in memory functioning are extremely common among individuals with TBI and frequently lead to problems with adjustment within the home. Consider, for example, the case of a young woman with TBI whose family was upset because she was unable to take phone messages. She was frequently at home alone and because of this she answered the phone more often than other family members. Due to problems with memory and organizational skills, however, she often forgot to inform family members that anyone had called. Her family became very upset with her and began to restrict her participation in other household duties. The eventual solution in this instance was to have the woman tape record every incoming call. She was taught to replay the taped conversation and record the message in a book set aside specifically for that purpose. By listening to the recorded telephone conversations, she was able to provide family members with accurate messages. These recordings also provided her with feedback with respect to her telephone answering skills. Eventually, she learned to transcribe the messages directly into the book without the use of the tape recorder. Cognitive changes are sometimes incorrectly perceived by family members as reflecting reduced motivation or passive aggressive behavior. For example, one woman complained that her husband, who had sustained a severe brain injury, was "lazy and irresponsible." Upon further questioning, it turned out that the woman was upset because her husband could not put the dinner she had prepared the night before in the oven so that it would be ready when she returned home from work. The problem of failing to reheat dinner stemmed primarily from her husband's inability to remember what he was supposed to do, but his wife interpreted the behavior as intentional. This issue was resolved in a manner similar to that of the young woman who could not remember to

Practical Issues for Family Members

record telephone messages. Using a tape recorder connected to an alarm clock, the husband received taped instructions to put the food in the oven at the appropriate time and on using the correct temperature settings. Ironically, the use of the tape recorder allowed an expansion in the number and complexity of instructions associated with dinner preparation. The clinical application of the use of prosthetic memory and cognitive orthotic devices by individuals with TBI has been addressed in detail elsewhere. 12 In our interviews, we discovered that families were sometimes resistant to the use of aids, since they felt that such use would encourage laziness or dependency. Families were more receptive when it was pointed out that external aids could be used to reduce one type of behavior that was of concern to the family, which would allow families the opportunity to focus on other, perhaps more important, problems. External aids are relatively inexpensive and can produce quick results, which, in turn, may give family members the confidence to tackle other behavior problems.

AWARENESS OF DEFICIT Individuals with a history ofTBI who are unable to appreciate the degree to which cognitive and social behaviors are impaired are considered to have a lack of awareness oftheir deficits. 13.14 Lack of awareness can be extreme, as in the case of the individual with unilateral neglect of the lefthemiattentional field, 15 or can be relatively subtle, such as not realizing that one's style of social interaction is intrusive. Invariably, problems with awareness of deficit are a source of great concern to family members of individuals with TBI. For example, an individual who lacks the ability to appreciate his problems with visuospatial skills may press his family to allow him to drive and will become incensed when family members resort to hiding the car keys from him. Similarly, family members are much less likely to allow the individual with TBI to stay at home alone ifhe or she has lowered awareness of cognitive and/or social interaction problems.

45

A critical issue whenever a family is dealing with an individual with lack of awareness is the determination of the problem's severity and consequences. On the one hand, to attempt to change a person's behavior when he or she is not in agreement that the behavior is problematic is not only an ethical dilemma but may also be a violation of the individual's legal rights. On the other hand, if the problematic behavior greatly interferes with the normal functioning of the family or represents a threat to the safety of the individual or a family member, then the behavior must be confronted. The presence of problems with awareness can pose substantial obstacles to behavior change intervention. Prigatano 16 has suggested that the ability to learn new behavior patterns depends to some degree upon the capacity of the individual for self-awareness. According to Prigatano,16 behavior change requires the ability to profit from feedback, but this ability may be lost in individuals with diminished self-awareness. Brain-injured individuals who are unaware of their behavior problems cannot make realistic appraisals of their strengths and deficits, and therefore tend to be less motivated to participate in behavior intervention programs. Some family members have had success in dealing with issues of unawareness simply by changing the stimulus environment so that the antecedent stimulus to the unwanted behavior does not occur. For example, one wife reported that her husband's anger greatly increased whenever he went "out drinking with his friends." Her husband was unable to recognize that he became abusive and argumentative after these episodes. However, he eventually agreed to drink nonalcoholic beverages and this appears to have resolved the problem. In fact, because he is often called on to be the designated driver for his friends who do drink, he has an improved sense of self-esteem and self-worth. Some researchers have suggested that increases in a brain-injured individual's capacity for self-awareness may be associated with increases in the presence of affective symptoms. 17,18 Thus, as individuals with TBI become more aware oftheir limitations, they may develop symptoms of depression and anxiety. In any behavioral intervention

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NEUROREHABILITATION I SPRING 1993

program, it is important for those who have implemented the program to keep a careful watch on other aspects of the injured individual's behavior, and to be prepared to titrate the program in accordance with these other behavior changes.

EMOTIONAL CHANGES FOLLOWING TBI The decision to modify the emotional changes that often accompany TBI has many ethical pitfalls. For example, families often wish that the brain injured individual's personality would return to its pre-injury expression, so even relatively unimportant behavior changes, such as the tendency to be less talkative, may be seen as possible targets of intervention. As with any decision to implement a behavior modification program, families should first consider the following questions: (1) Is the emotional behavior life threatening, as in the case of severe depression? (2) Does it interfere with the individual's opportunities to participate in normal community activities? and (3) Does it disrupt family life to a significant degree? The answers to these questions should help to guide the family's decision to intervene. Depression and anxiety are among the most common emotional changes to appear following TBI.19 Depression that is present during the acute and post acute stages of recovery may be linked directly to disturbances in brain functioning. For example, it has been shown that in individuals who have suffered a stroke, those with lesions in the anterior frontal region of the left hemisphere have the greatest chance of demonstrating major depression when compared to individuals with strokes in other regions of the brain. 2o Affective symptoms that appear in the later stages of recovery from TBI, rather than representing a direct disturbance in brain function, may reflect the response of the brain-injured individual to various losses, including loss of cognitive functioning, loss of employment, loss of independence, and so on. 21

Given that there are at least two distinct sources for affective changes following TBI (i.e., pathophysiological versus reactive), families wishing to intervene must first make a determination of the proximate cause of the disturbance. Affective symptoms that are believed to be secondary to central nervous system (CNS) dysfunction are probably best treated through the use of pharmacologie intervention. 22 Affective changes that are reactive in nature may also require pharmacologic intervention. In addition, it has been proposed that psychotherapy can be effective in reducing affective symptoms following TBI. 2:~ From the families' perspective, however, there are also a number of interventions that can be attempted in the home environment. One behavioral theory of depression relevant to this discussion is that concerning "learned helplessness."24 Learned helplessness is thought to occur in situations where, initially, an organism is prevented from escaping from an unpleasant stimulus. After many failed attempts to escape, the organism "learns" that escape is impossible, so that even when the. barrier to escape is removed, the organism no longer attempts to leave the unpleasant environment. Individuals with TBI are constantly faced with unpleasant environmental conditions from which they cannot escape. Consider, for example, the case of the young brain injured man who, soon after his injury, attempted to return to college. Due to his many cognitive losses, he failed all of his courses and was forced to quit. As time passed, many of his cognitive abilities improved to the extent that he could now handle some college level classes. However, because of his initial failure, he became anxious, depressed, and withdrawn, and was unwilling to return to school. He became a burden on his family because he complained bitterly about his lack of academic ability and refused to participate in even minor household activities. In this case, the initial focus of intervention was to encourage his family to stop reinforcing his tendency to complain (through withdrawal of attention) and, instead, to increase their attention and praise for any activities that were performed independently by the individual, such as taking the initiative to prepare the evening meal or set

Practical Issues for Family Members

the table. Over time, his complaints decreased significantly and he became more willing to attempt activities around the house. As his selfconfidence increased, he was more open to the possibility of returning to college and as a first step enrolled in a remedial math course. With each new success, the number and severity of his depressive symptoms decreased, and pharmacological intervention was not required.

AGGRESSION AND SOCIAL DISINHIBITION Problems of aggression and social disinhibition present families with a great challenge. From our interviews with family members, socially inappropriate behaviors are the behavior changes most likely to lead to family disharmony and discord. The presence of socially inappropriate behaviors causes families to feel uncomfortable in taking the affected individual out into the community. The brain injured individual may also be shunned by friends and neighbors. In response, many families withdraw from participating in any social activities outside of the house. In addition, some family members, such as the sons and daughters of the brain injured individual, adapt by avoiding the situation and tend to spend inordinate amounts of time outside of the home. Socially inappropriate behavior can be reduced through the use of systematic behavioral intervention. For example, McCabe and Green 25 reported on three cases of brain injured adolescents in which aggression and/or socially inappropriate acting out behaviors were addressed using various behavioral techniques. Interestingly, in all three of these cases the parents of the brain injured individual had tremendous difficulty adjusting to the inappropriate behavior, and successful remediation of the behavior problems required extensive inpatient and outpatient treatment as well as longterm follow-up. The use of conditioning procedures to treat difficult behavior such as aggression has been reviewed in detail by Wood. 26 Wood 26 has identified several approaches used in the behavioral treatment of aggressive behaviors. These include de-

47

termination if the behavior is "electrically based," as in episodic dyscontrol, use of time-out procedures, employment of classical conditioning procedures, discriminant reinforcement of other behaviors, and the application of behavioral selfcontrol. Notably, Wood 26 points out that these procedures do not necessarily require inpatient hospitalization and, therefore, may be amenable to use in other settings. However, in our interviews we found that most family members preferred that aggressive behaviors be dealt with by rehabilitation professionals outside of the home setting.

FATIGUE Fatigue is very common following injury to the brain 27 and yet the underlying mechanisms responsible for fatigue are poorly understood. Although the fatigue present after a TBI has many possible sources, it is likely that a disturbance of the CNS arousal system, perhaps as a result of diffuse axonal injury, is involved. As a result, fatigue itself may not easily come under behavioral control. However, there are many environmental situations that either increase or decrease the likelihood that fatigue will occur, and these environmental stimuli can be modified through the application of behavior therapy. It has been our experience that many individuals who complain about fatigue also report problems with sleep. These individuals report a wide range of sleep disturbances, including problems with sleep onset, frequent awakening throughout the night, and early morning awakening. Therefore, the first things that a family should do when fatigue is an issue is to encourage the brain injured individual to keep a diary of his or her sleep patterns over the course of a month, noting the approximate time of sleep onset, the number of hours slept, and the general quality of sleep. During the same recording period, family members should keep an independent diary rating the degree of fatigue demonstrated by the injured individual. To our knowledge, there are no published fatigue rating scales developed specifically for use with TBI, but the fatigue scales used with other

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NEUROREHABILITATION / SPRING 1993

medical populations 28 may be helpful in documenting fatigue following TB1. At the end of the month, the two diaries can be compared and a determination made about the relationship between sleep and fatigue. If a specific pattern of sleep disturbance is identified, then the brain i~ured individual and his or her family can develop a plan to combat this disturbance. Sometimes, relatively simple interventions such as sticking to a strict pattern of turning the television and lights off at a regular time every night or taking a brisk walk several hours before going to bed can substantially improve the quality of the brain injured individual's sleep. However, if the sleep disturbance is more severe or does not respond to simple environmental changes the family should seek medical guidance. Regardless of whether a sleep disturbance is identified, there are several actions that families can take to reduce the impact of fatigue on the individual's daily functioning. First, a determination must be made of the environmental conditions that are most likely to produce the fatigue. Many individuals with TBI can function relatively well during the early part of the day, but lose steam in the late afternoon and early evening. It is usually best to encourage the individual to take care of important matters early in the day, while he or she is still fresh, and to plan to have a period of relaxation and decreased activity during the late afternoon. Second, it is also important fi)r family members to help the injured individual monitor his or her fatigue levels during the course of the day, provide feedback, and encourage the use of rest periods. Some families of brain injured individuals have reported that the provision of a quiet, distraction-free area that the injured individual can retire to during periods of rest has substantially decreased the individual's level of fatigue. A third change that can help to reduce fatigue in the family setting is the establishment of a daily routine. Individuals with brain injury often have problems with organization and planning and are sensitive to distraction. As a result, these individuals often expend great amounts of energy engaged in activities that are not goal oriented and

that contribute significantly to fatigue. Families that have instituted daily schedules and organized household routines have reported a decrease in the injured individual's symptoms of fatigue.

CONCLUSION Behavior changes are a frequent by-product of acquired brain injury, and many of these changes are perceived as problems by members of the injured individual's family. Although the nature and extent of behavioral problems vary from person to person, such problems often pose a serious impediment to community reintegration. Behavioral disturbances also have a deleterious effect on family functioning and are generally of greater concern to family members than are physical limitations. We have interviewed a large number offamilies living with the effects of acquired brain injury and learned of specific examples of problems that were resolved. The examples presented here highlight the creative ways that families, in coordination with rehabilitation staff, have dealt with behavior changes following TB1. Since we wished to emphasize the successes that families have had, we decided against presenting cases in which behavioral interventions have failed; however, there is little doubt that behavioral techniques employed outside of the rehabilitation setting do not work for every type of behavioral problem or every family situation. It is an unfortunate fact that families living with the effects of brain injury are often without access to professional assistance. In many of the families that we interviewed, behavior problems were dealt with using trial and error rather than through the use of a planned behavior management program. In order for behavior change to be permanent and consistent with the goals of community reintegration, rehabilitation professionals must make greater efforts to coordinate the treatment programs developed in the inpatient setting with those implemented by family members in the home.

Practical Issues for Family Members

49

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