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Brain Injury Effects And Practical Advice
Brain Injury Common Effects
Practical Issues
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(Typical settlement amount - up to £100,000+)

In the mid-nineteenth century, Phineas Gage was an unremarkable railway laborer. He achieved fame, however, following a freak accident that left him something of a household name. According to witnesses, Mr. Gage was using a railway spike to press gunpowder deep into a crevice when the half-prepared charge suddenly exploded.  The explosion acted like the charge in a cannon and fired the spike upwards. The spike entered Mr. Gage’s head just under his ear, tore through the frontal portion of his brain, and emerged through the top of his head. Remarkably, he survived the accident and continued to work for the railway – but he was not the same person. Mr. Gage, once mild-mannered and well-liked, became argumentative and prone to violence, was no longer active in the Church, and began to drink immoderately.

Today, Phineas Gage is known as the first well-documented example of the consequences of a severe brain injury, but his story is not the rarity that it once was. Due to an ever growing variety of dangerous activities, coupled with new advances in medicine, treatment and rehabilitation, an increasing number of people survive accidents as serious – if not as colourful – as Mr. Gage’s.

Despite these advances in medical science, however, brain injuries remain poorly understood. While even doctors cannot predict how an injury may affect a person’s ability to function, the unfortunate reality is that front-line service providers often have very little insight into the effects of injury, or how best to deal with such individuals.  This article is designed to be read by any service provider who may encounter individuals with brain injuries in their line of work.  In particular, because brain injuries can result in poor insight and understanding of consequences, police officers, lawyers and other members of the justice system may deal with a disproportionate number of such individuals – and often receive inadequate training to do so.

Despite the uncertain and often misunderstood nature of such injuries, there are a number of consistencies in the effects of head injuries on the brain, and doctors generally agree that there is a common pool of symptoms and consistent changes in behavior that result. This consistency is particularly evident were there is damage to the frontal and temporal lobes of the brain.

Common effects of brain injuries

The most common causes of brain injuries in the modern context are motor vehicle accidents, assaults, and falls from heights. In these accidents, the frontal lobes are most commonly injured because this area is in a vulnerable position, and is covered with an uneven surface of bone that may cause injury. A blow to the front, back, or side of the head may cause damage to the frontal lobe. Even a whiplash type injury has been seen to cause injury to this area.

Non-impact accidents may also damage the frontal lobes because this region of the brain is particularly susceptible to oxygen deprivation. As examples, partial drownings, heart attacks, drug overdoses and attempted suicides may cause brain injuries if they deprive the brain of oxygen.  These latter type of injuries are termed “anoxic” brain injuries.

The primary role of the frontal lobes of the brain is regulation of higher thought and behavior. The frontal lobes understood to coordinate attention, memory, language, perception and social behaviors, and as a result, certain problems are known to result from an injury to this area. Any or all of these issues may occur to varying degrees, and how they are manifested is dependent not only on the type injury suffered, but also on the personality of the person before the injury. The most important variable, however, is a person’s own awareness of their injury and their ability to learn new behaviors. Both these factors are very difficult for doctors to assess, as is how the brain may be able to recover.

1. Lack of Insight and Impulsiveness

The most complex consequence of brain injuries may be the effect they have on a person’s thought processes. Brain injured people often have great difficulty reviewing their actions, or recognizing and accepting changes in thinking and behaviour. The relationship between act and consequence may not be fully understood.  For example, once brain injured people have an impulse, they may be unable or unwilling to change their mind. The result is that brain injured people may appear to have one-track minds that operate on a very superficial level. They may repeat themselves and become argumentative.

A related problem is impulsiveness, which is manifested differently in each person. Some have aggressive responses that they cannot control, while others may take items on impulse, or may touch people in a sexual manner that is inappropriate. All these responses may be impulses that the non-brain injured person would unconsciously resist.

Therapists deal with insight problems by providing frequent clear instructions. One of the rules often given to higher functioning people is “stop, think, act.” Anger management may be necessary.  Some individuals are prescribed medication such as mood stabilizers, depressants, anti-depressants, and other cognitive medications.

2. Memory Problems

This is the most common effect of brain injuries, and it is particularly severe in anoxic brain injuries. People may have trouble remembering names, appointments or where articles have been put. At higher severity, they may forget activities they have planned, or what they are doing from moment to moment. For example, a person may not remember how to get to a particular store, even if they go there regularly.

Brain injured people may deal with this problem by relying on a notebook and using lists or maps to assist them. One problem is that learning to remember to rely on a list is a learned response that may be difficult for some to master consistently.

3. Poor Concentration

Brain injured people have a tendency to get distracted from what they are doing. Tasks that require concentration may be frustrating or impossible. For example, previously favorite activities such as reading or watching TV may be difficult, if not impossible.  Note that this problem exists alongside and in contrast to the uni-directional thought problems connected to a lack of insight.

This problem is most often addressed by controlling the environment. If activities require concentration they should be of short duration, and free of distractions. Many activities may be adjusted, such as reading short stories or magazines instead of books. Other activities may be impossible.

4. Slowed Responses

Brain injured people are often slow to answer questions and make decisions. The result of this problem is that brain injured people may have difficulty in group situations, as they cannot keep up with conversation. Another common effect of this problem is that their responses may be misinterpreted by people who do not know of their condition. They could, for example, be seen, incorrectly, to be impaired by alcohol or a drug, or they may seem unresponsive in a disrespectful or hostile manner.

Response time is dealt with through medication and by controlling the person’s environment. This is most important where a person could put themselves at risk. For example, some brain injured people are not permitted to drive, and may require supervision at times.

5. Lack of Initiative and Poor Problem Solving

Many brain injured people lack initiative. In spite of their intentions, they may have trouble starting even simple activities such as bathing or cooking. They may have difficulty starting interaction with others, even if that is exactly what they hope for.

A related problem is that brain injured people have great difficulty making decisions, and they may be unable to plan a sequence of activities. Open-ended decision making, such as independently finding a solution to problem, may be impractical unless it can be broken down into discrete and concrete components.

Therapists deal with initiative and planning problems with tools such as lists of tasks and alarm clocks to prompt the person to start the activity. Breaking all decisions and activities down into component parts is also helpful.

6. Emotional Rollercoaster

Brain injured people may have difficulty controlling their emotions in the same manner that they cannot control their thoughts or behaviour. They may laugh or cry at inappropriate times or more than is reasonable. In spite of this overly dramatic reaction, the underlying emotion may not be as strong as the reaction. For example, brain injured people may appear very angry when they are only mildly so. They may laugh hysterically at something that they know is only mildly amusing.  Like many of the problems experienced by brain injured people, emotional responses are handled most often with understanding, frequent repetition and common sense.

7. Depression and Dependency

Depression is very common among brain injured people because most have a degree of insight into their deficits and may recall how they functioned before their injury. Specifically, most may be aware that they cannot process information properly and that their behaviour is inappropriate. Similarly, they may know that they cannot cope with social situations because of their slowed responses, lack of initiative and emotional reactions. More generally, they may become distressed because they lack the ability to consider their problems in a reasoned way, or to decide on practical solutions.  Deepened depression is also a serious concern where brain injuries are caused by suicide attempts initially motivated by depression.

One of the consequences of depression in injured individuals is that they are known to become very dependent on family or friends. They may be manipulative in order to secure the support or security they crave.

Depression and emotional dependency may be treated through counseling, if a person has the cognitive ability and memory to benefit from it. Otherwise, anti-depressants may be used. Nevertheless, an unfortunate reality is that brain injured people attempt suicide at a significantly higher rate than the general population.

Practical Issues in Working with Brain Injured People

The above noted review of possible symptoms or effects of a brain injury highlights the practical issues in assisting or representing a brain injured person. For every person, the first practical step should be to determine, in a general way, which symptoms a particular person has. For example, does this a person have a memory deficit such that written instructions are required for everything? Does this person have an initiative problem such that you should be scheduling and following up on all tasks? Does this person have difficulty concentrating so that meetings will need to be short?  Other general suggestions for non-medical, lay persons include:

Be safe: Some brain injured people can be violent or unpredictable. There may be signs for this behaviour that are recognized by experienced medical people, but others may not recognize them. Keep your own safety in mind.

Be patient: Brain injured people require repetition, and they can be very frustrating, both to themselves and to people working with them. Keep your sense of humor – brain injured people require understanding, not simply supervision or direction. Bear in mind that most are aware of their deficits, and they do not deserve to be treated as children, but with respect.

Be positive: It is easy to feel discouraged or negative after working with brain injured people. Criticism and negativity are not productive, however. Instead, those working with brain injured people should try to be positive. See the accomplishments rather than the deficits. The term used by therapists is “non-conditional positive regard.”

Do not argue: Frustration and anger may make the deficits of brain injured people more apparent. It is best to be clear, matter of fact, and calm at all times. Reason may or may not be effective, but arguing almost certainly is not if the person has a serious brain injury.

Break difficult matters into components: Brain injured people need time to make decisions and they may need assistance with to understand the pros and cons, or likely consequences of a decision or an action.

Do your research: The clues to the behaviour of a brain injured person are often found in their personal background and history. Also, if the information is available, what medications are they using, or not using?

Do not over-react: A brain injured person may have emotional responses that are inappropriate. It may not be necessary to address these, as the reactions may not reflect the underlying emotion. Similarly, the person may, themselves, be aware that the reaction is inappropriate.

Do not be manipulated: Some brain injured people are very self-centered and manipulative. For example, they may lie about themselves, their circumstances, or their ability to understand and follow directions. Do not feel obligated to give them the reaction they are seeking. Do not become the only friend of a brain injured person. They need more support than you can provide, so introduce them to new people.

Do not create limits: Despite their injuries, most high functioning brain injured people are able to learn, understand, and develop new behaviors. They may not have the confidence or initiative, but they should be challenged. Be realistic, but try to expect the best. If they fail, encourage them to understand and to learn.

Conclusion

Understanding the deficits caused by brain injuries is a first step toward more effective service of brain injured people. While this article is far from complete or conclusive, it should provide those who encounter brain injured individuals with some basic understanding and insight into the difficulties such people face.