Traumatic Brain Injury and Personality Change
By Marc Fowler & Paul C. McCabe
Traumatic brain injury (TBI) is the leading cause of death and lifelong disability in the United States for individuals below the age of 45. Current estimates from the Center for Disease Control (CDC) indicate that at least 1.4 million Americans sustain a TBI annually (Langlois, Rutland–Brown, & Thomas, 2005). TBI affects 475,000 children under age 14 each year in the United States alone. Ninety percent of patients are treated in emergency departments and released; however, more than 47,000 hospitalizations per year are a direct result of these injuries. On average, 2,685 children die annually from TBIs, and more than 30,000 children per year acquire lifelong disabilities. The CDC believes these figures are an underestimate of the actual number of people living with TBI, because the data only include individuals who die or obtain medical services in hospitals and emergency departments (Langlois et al., 2005).
TBI severity is defined by the duration of loss of consciousness (LOC), altered mental status (e.g., confusion), and posttraumatic amnesia (PTA). It is important to note, however, that the severity of functional impairments after TBI often is not related to the severity of the injury. Patients are classified as having a moderate–to–severe TBI if they have an LOC over 30 minutes or altered mental status greater than 24 hours (Rosenthal, Bond, Griffith, & Miller, 1990). Mild TBI is defined as a blow to the head followed by an LOC of less than 30 minutes, or an altered mental status with PTA of less than 24 hours (Rosenthal et al., 1990). It is often assumed that recovery from mild TBI is rapid; however, there may still be permanent damage.
Physical Effects of TBI
Specific regions of the brain are subject to damage resulting from TBI. Focal lesions include intracerebral hemorrhages, ischemic infarcts (e.g., from rupture of the cerebral vasculature), and contusions. The latter occur beneath a skull fracture site, directly beneath (coup) or contralateral to the site of impact (contrecoup). Damage also occurs in areas where the swirling motion of the brain impacts on bony protuberances of the calvarium, typically the anterior and inferior surfaces of the frontal and temporal lobes (Gennarelli & Graham, 1998). Diffuse injuries result from the differential motion of the brain within the skull. The resultant stretching and twisting of neuronal axons produce a spectrum of damage referred to as diffuse axonal injury (Gennarelli & Graham, 1998). The above injuries, occurring at the time of impact and as a direct result of the physical forces applied to the brain, are referred to as primary injuries. However, not all brain injuries occur at the time of impact. Secondary injury is initiated at the moment of injury but evolves over a period of time. Types of secondary injury include hematomas, cerebral edema, increased intracranial pressure, ischemia, and various injury cascades (Gennarelli & Graham, 1998). The frontal lobe area is of particular functional interest when examining damage from TBIs. The frontal lobes are involved in motor function, problem solving, spontaneity, memory, language, initiation, judgment, impulse control, and social and sexual behavior. Because of their large size and location at the front of the brain adjacent to bony protuberances, frontal lobes are particularly vulnerable to insult. Magnetic resonance imaging (MRI) studies have shown that the frontal area is the most common region of injury following mild to moderate traumatic brain injury (McAllister, Sparling, Flashman, & Saykin, 2001).
Classification models have been created in an attempt to more precisely define problems associated with the frontal lobes. One of the first categorizations of patients with TBI identified two distinct types of personality disorders (PD) that were predicted to result from damage to different regions within the frontal lobes (Blumer & Benson, 1975). The "pseudodepressed" personality, attributed to lesions in the dorsolateral frontal region, is characterized by apathy, lack of drive, inability to plan ahead, and limited insight. However, the "pseudopsychopathic" personality presented with reduced social awareness, puerile jocular attitude, and sexually disinhibited humor. Subsequent models have expanded on this work by dividing the frontal lobe into five parallel circuits, three of which have been linked to clinically distinct behavioral syndromes (Warriner & Velikonja, 2006). Disruption of the dorsolateral prefrontal circuitry was thought to be predominantly associated with executive cognitive dysfunctions, whereas ventral medial and orbital prefrontal circuitry were hypothesized to result in behavioral disturbances in initiation and/or motivation and inhibition and/or emotional regulation, respectively (Blair, 2004). TBI damage often results in interruption of multiple circuits, making these distinctions difficult to objectively quantify and clinically distinguish. Recent research in individuals with relatively selective injuries sustained in early childhood and in adulthood supports this behavioral distinction, although some evidence has been provided for the added role of the dorsolateral prefrontal region in states of affective dysregulation, especially dysphoric reactions (Blair, 2004).
The frontal lobes are the emotional control center and are most closely tied to an individual’s personality or personhood. Neuroscientists have been concentrating on the prefrontal region of the brain as a source of personality change but recent studies have introduced greater specificity in conceptualizing associated neuropsychological impairments (Obonsawin et al., 2007).
The consequences of TBI are often devastating to the individual and his or her loved ones. Changes in cognitive, behavioral, and emotional functioning are widespread. Studies examining these changes have been consistent in their findings. In a 30–year follow–up study of patients who experienced a TBI, prevalence rates of Axis I and Axis II psychopathology were high (Koponen et al., 2002). The most common diagnoses at follow–up were major depression, alcohol abuse or dependence, panic disorder, specific phobia, and psychotic disorders. Many patients also had at least one PD, with avoidant, paranoid, and schizoid being the most prevalent. A distinct, disinhibited organic personality syndrome was also identified in these patients, which was specifically associated with frontal lesions (Koponen et al., 2002).
As many as two thirds of TBI subjects are affected by significant personality changes for periods enduring up to 15 years and more (Oddy, Coughlan, Tyerman, & Jenkins, 1985). Two studies found a very high prevalence of post–TBI PDs, the so–called acquired PD (Gagnon, Bouchard, Rainville, Lecours, & St–Amand, 2006). Van Reekum, Bolago, Finlayson, Garner, Links (1996) found that 39% of subjects with TBI without any premorbid psychiatric history received a total of 22 PD diagnoses. The most common were borderline PD (22%) and avoidant PD (28%). Confirming these initial observations, using a larger sample, Hibbard et al. (2000) observed that as many as 55% of a subgroup of subjects without pre–TBI PD received an acquired PD diagnosis after the injury.
Prominent behavioral characteristics in TBI patients have included altered emotion (including restricted emotions with occasional inappropriate or uncontrolled emotional outbursts); impaired judgment and decision–making (including difficulty arriving at decisions as well as poor decisions); impaired initiation, planning, and organization of behavior; and defective social comportment (including egocentricity and impaired empathy). These impairments tend to be accompanied by a marked lack of insight. The abnormalities often are not evident in interviews or over brief time frames, but rather become apparent when the patient’s behavior is considered over a period of months or even years (Barrash, Tranel, & Anderson, 2000).
Impaired recognition of facial expressions in patients with TBI was reported in several studies. Jackson and Moffat (1987) showed that the recognition impairment was not specific to faces as their patients were equally impaired at recognizing emotions from body postures. They speculated that a systematic impairment in the accurate recognition of such social cues might promote the genesis and maintenance of poor social skills and antisocial behavior commonly found following severe head injury (Milders, Fuchs, & Crawford, 2003).
Despite consistent results showing a connection between TBI and substantial personality change, there are important criticisms of the measurement methods used in these studies. First, characterization of personality changes in neurological patients has most often been based on clinical observation, rather than on solid empirical evidence. That is, assessment with these instruments, utilizing information from both patients and informants who knew them well, failed to reflect the presence of marked psychosocial dysfunction generally, or to characterize specific types of personality change (Barrash et al., 2000). Secondly, the scores yielded by these instruments almost universally refer to the level of a disturbance—that is, the degree to which a characteristic is problematic—but they do not actually assess change. Thirdly, reliability is a significant concern (Kreutzer, Marwitz, Seel, & Devany Serio, 1996). Ratings are typically left to the subjective judgment of the rater, without benefit of a behavioral measuring stick. Lastly, concerns may be raised regarding validity of many instruments (Kreutzer et al., 1996). For example, some scales are based on the implicit assumption that the frequency of a behavior, or the number of endorsed items, is an index of the severity of a personality disturbance, an assumption that is not necessarily warranted (Barrash et al., 2000).
Implications for School Psychologists
Hooper (2006) found that school psychologists maintain a slightly better knowledge base in the area of pediatric TBI when compared to the general public. This is surprising considering that school psychologists are often expected to take the lead in reintegrating students with TBI into the school setting. It also illustrates the importance of being familiar with the most current literature and relevant recovery issues.
An important issue for school psychologists is timely and thorough assessment of the aftermath of a student’s injury, required educational environment, current cognitive functioning, and family support system. Preferably, these assessments would begin prior to the time that the student returns to the classroom (Clark, Russman, & Orme, 1999). Collaboration with other professionals, including physicians and rehabilitation specialists, is necessary. A copy of all relevant reports, including neuropsychological and speech and language evaluations, should be requested and, if the injury is severe, arrangements should be made to meet with hospital staff. This information may be helpful for establishing goals and developing modifications (Clark et al., 1999). The successful reintegration of students into the school environment requires early identification of (a) the student’s deficits and skills, (b) the teacher’s management style and tolerance for inappropriate behavior, (c) the level of classroom structure, and (d) the degree of classroom control. It is important to determine what the teacher knows about brain injuries and how appropriate the physical environment is for accommodating the specific needs of the student (Clark, 1996; Clark et al., 1999; D’Amato & Rothlisberg, 1997).
The goal of assessment is to ensure a continuum of regular education services, determine the need for special education and related services, maintain suitable levels of academic performance, and establish and support positive social relationships (Clark & Hostetter, 1995; Clark et al., 1999). Evaluation of actual task performance in settings where the student’s adaptive skills are called into play is critical, because relying solely on assessments given under ideal conditions do not reflect the kinds of difficulty a student may face in a busy classroom with less guidance and structure (Savage, Depompei, Tyler, & Lash, 2005).
Functional domains that may need to be assessed include motor skills, perception, processing speed and style, cognitive skills, language, academic achievement, emotions, behaviors, and physical concerns (D’Amato & Rothlisberg, 1997; Clark, Russman, & Orme, 1999). Because standard academic tasks and psychological measures may not be sensitive to postinjury effects, some schools are relying on computerized neuropsychological test batteries to help monitor recovery and determine when a student is asymptomatic. One such battery is the ImPACT system. This computerized assessment has norms for children and adolescents as well as clinical cutoff scores for normal, suspicious, and impaired functioning (Lewandowski & Rieger, 2009).
In addition to gathering information in the school setting, consultation with parents provides a means to gather information about the child’s ability to function in the home and in the community, including relationships with siblings and peers, as well as social activities. It may also provide useful information about how the family is adjusting to the child’s injury (Clark et al., 1999).
After the initial assessment has been performed, interventions may be necessary to address the student’s issues. Not all students who sustain a TBI require special education services; in fact, most are likely to be served under Section 504 of the Education for All Handicapped Children’s Act or accommodated in the regular classroom. Interventions generally address one of three areas: cognitive, behavioral, or social. Cognitive rehabilitation strategies include training to increase auditory and visual attention, verbal memory, and reading comprehension (Franzen, Robert, Schmits, Verduyn, & Manshadi, 1996; Mateer, Kerns, & Eso, 1997). Key components to cognitive training include task analysis to ensure that the requirements are well within the student’s capabilities, integration of the task in regular class assignments to ensure generalization, and the training of students in self–management techniques (Clark et al., 1999).
Because behavioral adjustment after TBI is related to academic performance in the classroom, it is a vital component of assessment and intervention (Carney & Gerring, 1990; Clark, 1996). The emotional and behavioral adjustment of children with TBI should be assessed on an ongoing basis, preferably beginning prior to school reentry, and appropriate plans should be made to address any behavior problems that are identified (Yeates and Taylor, 2006). In addition to the externalizing behaviors (noncompliance, aggression, inattention, emotional outbursts) that children with TBI are reported to show, many have internalizing problems as well. McKinlay, Brooks, Bond, Martinage, and Marshall (1981) found that approximately 70% of their sample displayed irritability, which is often a precursor to more disruptive and assaultive behaviors. Recognition and alleviation of stressful environmental demands can be an effective method of reducing the student’s external and internal behavioral problems.
For the student with a TBI, poor social skills are often associated with injury–related cognitive deficits and behavioral difficulties and result in peer rejection and decreased social contact. According to Russman (1997), to ensure success of social interventions there must be a focus upon increasing awareness and perception of social situations, improving retrieval of rules for social interaction, developing the ability to take another’s perspective, initiating and maintaining conversations, and monitoring and inhibiting inappropriate verbalizations and behaviors. Social skills training can consist of modeling, role–playing, performance feedback, homework contracts, and positive reinforcement procedures (Clark et al., 1999).
Whether interventions are needed from an academic or psychosocial perspective (or both), documenting them in an Individualized Educational Plan (IEP) is important. The nature of the IEP will depend largely on the evaluation results, including a detailed characterization of the student’s difficulties and an accurate determination of their likely etiology. After the IEP has been initiated, the effectiveness of the accommodations or instructional practices should be evaluated. Data–based information should be gathered and analyzed to determine if the student is making gains and, if not, what further accommodations or teaching strategies can be implemented (Savage, Depompei, Tyler, & Lash, 2005).
Upon school reentry, it is important to educate everyone working with the child (Lewandowski & Rieger, 2009). One of the ways to do this is to provide inservice training for key school personnel. Tyler and Mira (1993) stressed that inservice training should include both general information about TBI and specific information about the particular student’s deficits and educational needs. Given the nature and sequelae of TBI, it is important for school personnel to understand that the student with TBI will likely have changes in how he or she learns, thinks, feels, and interacts socially, and to anticipate these changes (Utah TBI Task Force, 1994; D’Amato & Rothlisberg, 1997).
Despite the prevalence of TBI, no controlled research is available to direct a student’s reengagement into school after TBI. Research has not supported specific programming strategies or instructional practices that are beneficial for students who have sustained TBI of any severity (Savage et al., 2005). Educators must rely on best teaching practices and interventions shown to be successful for students with special needs in general, and then tailor these to the student based on assessment information (Kirkwood et al., 2008). Despite the absence of empirical evidence, methods exist that may yet prove to be effective. For example, protocols have been developed to organize the transition of students with TBI back to school from a hospital setting (Kirkwood et al., 2008; Ylvisaker, Feeney, & Mullins, 1995).
School psychologists can also play an important role by encouraging and supporting a strong parent–school partnership. When children suffer TBI, parents may be overwhelmed with information from medical doctors, neuropsychologists, and other professionals. Evaluation and integration of this information is vital, particularly as it impacts the child’s functioning at school. Doing so may help to minimize the tensions between parents and schools that are often created when complicated health and academic issues arise.
The prevalence of TBI is an important issue for mental health professionals. Familiarity with the biological implications that result in personality, social, and cognitive changes will empower school psychologists to help survivors adjust from both short– and long–term effects.
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Marc Fowler is a graduate student in the school psychologist graduate program at Brooklyn College of the City University of New York (CUNY). Paul C. McCabe, PhD, NCSP, is an associate professor in the school psychologist graduate program at Brooklyn College–CUNY, Brooklyn, NY, and a contributing editor for Communiqué.