Modifying Clinical 

Interventions for TBI 

BRIEF | December 2022 

Considerations & Best Practices 

for Diagnostic Procedures 

Epidemiology of psychiatric disorders 

People with traumatic brain injury (TBI) present with 

a range of psychiatric disorders and often at a 

higher rate than the general population. Common 

diagnoses include mood disorders (major 

depressive, dysthymic and bipolar disorder), anxiety 

disorders (generalized anxiety, post-traumatic 

stress, obsessive-compulsive, panic, acute stress 

disorders, and agoraphobia and social phobia), 

psychotic disorders, and substance use disorders. 

People with TBI may also present with personality 

changes (apathy, affective lability, aggression, 

behavioral disinhibition), impaired self-awareness, 

suicidality, and socially inappropriate behavior. 

Children and adolescents experience many of the 

same emotional and behavioral difficulties post-TBI 

as adults, with children most commonly 

experiencing depression, anxiety, personality 

changes (affective instability, aggression, 

disinhibited behavior, and apathy), 

psychosis/paranoia, secondary attentiondeficit/hyperactivity disorder, oppositional defiant 

disorder/conduct disorder, posttraumatic stress 

disorder and mania/hypomania. 

Risk of misdiagnosis 

People with TBI may seek mental health services, 

either without disclosing their TBI status to the 

provider or without inquiring whether the provider 

has familiarity with the clinical profile of TBI. As a 

result, they may not be accurately diagnosed. A 

proper diagnosis is essential for effective treatment. 

Misdiagnosis can occur because the presenting 

psychiatric symptoms are not considered in the 

context of TBI but are instead diagnosed in 

isolation. For example, people with TBI may 

experience emotional lability and behavioral 

dysregulation because of disruption in their 

executive functions. These symptoms, however, 

may resemble those of bipolar disorder. If a person 

with TBI is diagnosed with bipolar disorder, they 

may receive inappropriate and ineffective 

treatment, which may also have a negative impact 

on the provider’s prognosis and the patient’s 

experience with the mental health system. 

Neurological vs. psychogenic causes 

The origins of the emotional and behavioral 

symptoms that people with TBI present may be 

neurological or psychogenic in origin. Symptoms 

could be caused by the direct impact of the injury 

on neurological functioning (e.g., lesions, axonal 

damage, infection, neurochemical disruption, 

cerebrovascular changes). However, symptoms 

could also be psychogenic in nature. In this case, 

depression may be a reaction to the broader losses 

a person with TBI experienced after the injury: loss 

of autonomy and independence, loss of 

employment and income, or loss of social 

connections and outlets. 
Psychiatric Diagnostic Assessments of People with TBI 

1. Read aloud instructions for the patient. 

2. Ask the patient to repeat instructions to ensure they understand. 

3. Read the items of a self-administered measure to the patient and record their responses. 

4. Obtain corroborating information from significant others. 

While it may not be possible to accurately identify 

the cause of the emotional or behavioral 

disturbance, it is important that both be explored 

and addressed. Focusing on either the neurological 

or the psychological while ignoring the other may 

render the treatment ineffective. In pediatric TBI, 

the interaction between brain dysfunction and 

ongoing developmental processes can impact the 

onset and presentation of symptoms and further 

complicate diagnosis and treatment decisions. 

Administering diagnostic instruments 

Diagnostic methods and procedures do not 

generally differ for patients with TBI. Similar to 

other clinical populations, an in-depth interview with 

the patient and collateral sources, clinical 

observations, and use of screening and 

assessment tools and measures are ideal in 

helping providers make accurate diagnoses. Mental 

health providers already use many of the screening 

and assessment tools recommended in assessing 

mental health difficulties for those with TBI (e.g., 

SCAT-5, BDI-II, BAI, MMPI-2). However, it is 

important for providers to understand the limitations 

of these measures when used in a TBI population. 

Reduced cognitive functioning after TBI can 

complicate the diagnostic process. Problems with 

attention, short- and long-term memory, reading 

comprehension, or verbal fluency may render a 

diagnosis incomplete or invalid. These cognitive 

challenges may impact a patient’s ability to provide 

accurate information during a clinical interview 

and/or their ability to complete assessments. 

Selection of diagnostic instruments 

Asking the client during the interview if they 

experience any cognitive challenges in daily life, as 

well as completing a brief cognitive screening 

measure (e.g., the Montreal Cognitive Assessment 

[MoCA], Mini-Mental Status Exam [MMSE]) could 

help identify any potential cognitive challenges and 

determine if a referral for a more thorough 

neuropsychological assessment would facilitate 

diagnosis and treatment. If cognitive deficits are 

suspected, referral to a neuropsychologist is 

recommended. 

A comprehensive neuropsychological evaluation 

can help providers better understand the client’s 

cognitive challenges and how they might impact 

psychological functioning. If screening measures 

Modifying Clinical Interventions for TBI 2 
such as MoCA or the MMSE will be used, the 

provider is encouraged to receive training in their 

administration. 

Listed below are resources available to clinicians to 

facilitate the selection of measures and tools when 

assessing psychological outcomes post-TBI. These 

resources include adult and pediatric measures to 

assess psychiatric disorders in clinical settings. 

They also provide information about the validity 

limitations of the measures in the population, 

domains, and measures of common data elements. 

Helpful Resources for Clinicians 

•	 The National Institute of Neurological 

Disorders and Stroke (NINDS) Common 

Data Elements (CDE). (n.d.). Traumatic 

Brain Injury. 

www.commondataelements.ninds.nih.gov 

/Traumatic%20Brain%20Injury#pane-89 

•	 Searchable database of instruments for 

clinicians and researchers for various 

medical conditions, including TBI. 

Shirley Ryan AbilityLab (2022). 

Rehabilitation measures database. 

www.sralab.org/rehabilitation-measures 

Considerations & Best Practices 

for Clinical Interventions 

Delivering treatment to people with TBI 

1. Cognitive impairments. People with TBI may 

experience reduced cognitive functioning that 

ranges in duration and severity. While specific 

cognitive rehabilitation interventions exist to target 

problems in cognitive functions like attention, 

memory, and executive functioning, TBI-related 

cognitive deficits can interfere with the 

effectiveness of mental health services when these 

services are not combined with cognitive rehabilitation. 

2. Impaired self-awareness. People with TBI may 

present with deficits in self-awareness, which could 

range from anosognosia (lack of awareness that 

mental functions are impaired and disruptive to 

daily functioning) to poor anticipation of 

consequences (unable to predict that a certain 

maladaptive behavior will cause further problems). 

It is important for providers to a) assess the level of 

self-awareness through standard measures or 

collateral interviews with caregivers and/or other 

providers, and b) determine whether self-awareness 

is the target or a by-product of treatment. It is not 

uncommon to expect that as self-awareness 

increases, psychiatric symptoms may be exacerbated 

as the person becomes more cognizant of the 

challenges and losses incurred due to TBI. 

Modifying Clinical Interventions for TBI 3 
Modifying Existing Interventions	 

The tables that follow show challenges related to brain injury and recommendations on how to modify the 

provider’s approach to accommodate for the impairment. 

CHALLENGES RECOMMENDATIONS 

Remembering appointments. 

Memory problems may prevent people with TBI from 

keeping their scheduled appointments. Skipping 

appointments may be disruptive for the continuity of 

care and may also be a source of frustration for 

providers. 

• Encourage consistent use of a calendar, set up 

alerts and reminders on a smartphone, send 

reminder emails or texts, and explore other 

memory aids (e.g., sticky notes). 

Remembering content of sessions. 

Memory problems may make it difficult to recall the 

content of a session between visits. People with TBI 

may fail to apply and generalize the insights gained 

and coping skills demonstrated during sessions beyond 

the therapeutic context. As a result, the presenting 

problems may persist, requiring extended duration of 

treatment. 

•	 Break down important information into 

manageable chunks and summarize the highlights 

of a session. 

•	 Encourage the client to keep a journal to record 

these highlights. 

•	 Help them enter the information in the journal 

at the end of the session and review the entry 

at the beginning of the next session. 

Remembering to do homework. 

Assigning homework is important for skill transfer and 

generalization. Memory problems may interfere with 

the completion of homework assignments because the 

client may forget about an assignment or its specific 

requirements. 

•	 If homework is assigned, ensure it is 

assigned consistently (e.g., for every session), 

as opposed to sporadically. 

•	 Provide clear instructions and ensure the client 

understands the assignment. 

•	 Have the client write down instructions somewhere 

that increases the probability they 

will locate the information between sessions 

(e.g., session journal, calendar, to-do list, 

homework notebook). 

•	 Review the assigned homework during the 

following session to make it an integral component 

of the session. 

•	 If possible, send an email or text reminder ahead 

of time to check progress on the homework. 

Modifying Clinical Interventions for TBI 4 
CHALLENGES RECOMMENDATIONS 

Staying focused. 

Challenges with sustained attention may make it 

difficult to stay focused for prolonged periods during 

the session. People with TBI may drift in and out of the 

session, may miss important points due to inattention, 

or may become mentally fatigued more easily. 

•	 Make sessions shorter. 

•	 Give breaks during the session. 

•	 Periodically check in with the client to ensure they 

remain focused. 

Easily distracted. 

Clients may be easily distracted by extraneous triggers, 

such as sounds, movements, or objects in the 

environment, which will interfere with their focus on 

session content. 

•	 Hold sessions in a less visually “busy” setting 

(e.g., have the client face wall art instead of a 

crowded bookshelf). 

•	 

Slow rate of comprehension. 

Reduced processing speed may interfere with how 

quickly a person with a TBI can understand a complex 

concept or learn a skill. 

Reduce the amount of ambient noise or sounds 

that might distract the client. 

•	 Engage in slower and more deliberate 

communication. 

•	 Use multiple modalities to present information and 

repeat concepts and instructions. 

Slow rate of response. 

Slow processing speed leads to delays in responding 

because more time is required to access information 

from long-term memory, organize thoughts and ideas, 

and formulate a response. 

This may be frustrating to the provider and may make 

the client seem more impaired or less engaged. 

•	 Allow clients ample time to respond to a question 

or to describe an event or experience. Indicate that 

there is no pressure to provide a response quickly. 

Difficulty making decisions. 

People with TBI often report feeling “stuck” because 

they have difficulty engaging in problem-solving and 

decision-making. 

They may present as overthinking a problem or, 

conversely, avoiding a task or abandoning a goal. 

•	 Help the client clarify the decision to be made. 

•	 Facilitate decision-making by using strategies like 

a “pros and cons” analysis. 

•	 Engage the client in an evidence-based problemsolving approach. Help the client generate viable 

choices. 

Modifying Clinical Interventions for TBI 5 
CHALLENGES RECOMMENDATIONS 

Difficulty initiating behavior. 

People with TBI may have difficulty initiating 

conversations and bringing up relevant topics. 

They may fail to follow through with homework 

assignments or to practice recommended coping 

strategies. 

•	 Make sessions more structured (e.g., set up a 

Q&A format). 

•	 Ask clients (or family, if relevant) to keep notes or 

compile questions during the week, which can 

provide content for the session and help recall. 

•	 Set up motivators that encourage clients to 

complete tasks. 

Easily overwhelmed. 

People with TBI may feel easily overwhelmed and 

experience cognitive “flooding,” even in the presence 

of minimal stressors. They may have difficulty 

accomplishing daily tasks because of the distress. 

•	 Focus on just a few topics during sessions. 

•	 Encourage the use of to-do lists. 

•	 Recommend against engaging in multitasking. 

•	 Teach relaxation and mindfulness techniques. 

Photosensitivity. 

People with TBI may present with sensitivity to bright 

lights, which may interfere with their ability to focus. 

•	 Adjust the lighting in the room or encourage the 

person to wear photoprotective gear, such as 

sunglasses or visors. 

Fatigue. 

Both physical and cognitive fatigue can interfere with 

treatment. The physical effort of traveling to the 

treatment setting may affect attendance and 

participation. The client may only be able to process a 

limited amount of information. 

It is not uncommon for people with TBI to feel fatigued 

for several days after a day of strenuous physical or 

mental activity. 

•	 Make sessions shorter. 

•	 Give breaks. 

•	 Help clients manage their activity level to prevent 

the onset of debilitating fatigue. 

•	 Schedule manageable treatment-related activities 

between sessions. 

Alexithymia. 

The neurological impairment of the brain injury may 

leave a person with TBI unable to recognize, process, 

and be aware of their own affective responses. In 

addition, they may misread or ignore emotional cues in 

other people. 

•	 Be cautious not to interpret lack of emotional 

awareness as a psychiatric symptom (e.g., 

anhedonia) or as an attempt of denial. 

•	 Inquire about the person’s emotional state without 

expecting them to accurately label their emotions. 

•	 If possible, focus the treatment on increasing 

emotional awareness. 

Modifying Clinical Interventions for TBI 6 
Evidenced-based Mental Health 

Treatments for People with TBI	 

While existing interventions could be modified for 

delivery to people with TBI, research involving 

people with TBI has yielded several evidencebased practices for a range of psychiatric disorders, 

some of which are included below. 

Adults 

•	 Cognitive behavioral therapy for post-TBI 

depression.1,2,3 

•	 Mindfulness-based cognitive therapy for postTBI depression.4 

•	 Modified cognitive behavioral therapy (CBT plus 

motivational interviewing and/or nondirective 

counseling) for post-TBI depression and 

anxiety.5 

•	 Cognitive behavioral therapy for post-TBI 

hopelessness.6 

•	 Acceptance and commitment therapy for postTBI psychological distress.7 

•	 Goal management training (with external cuing 

and an emotional regulation module) improves 

post-TBI emotion-regulation skills and quality of 

life.8 

•	 Emotion-regulation intervention for post-TBI 

emotion dysregulation.9 

Children 

•	 Prolonged exposure treatment for children with 

post-TBI post-traumatic stress disorder 

(PTSD).10 

•	 Problem-solving treatment program for post-TBI 

psychosocial functioning (adolescent	 

internalizing behavior and depressive	 

symptoms).11	 

•	 Cognitive behavioral therapy for post-TBI 

psychological adjustment (self-management 

and compliance).12 

•	 Positive parenting skills program for post-TBI 

child behavior and parenting skills.13 

Couples or caregivers of adults 

and children 

•	 Problem-solving family intervention reduces 

psychological distress for caregivers of 

adolescents with TBI.14 

•	 TBI caregiver intervention for improving 

emotional, instrumental, and professional 

support, and brain injury knowledge.15 

•	 Family intervention for parental distress 

following pediatric TBI.16 

•	 Online problem-solving program for teens to 

improve problem-solving skills and reduce 

depressive symptoms for caregivers.17 

•	 Problem-solving intervention for improving selfefficacy and depression for caregivers of 

adolescents with TBI.18 

•	 Parenting skills program for psychological 

distress for caregivers of children with TBI.19 

•	 Parenting intervention for depression for 

caregivers of children with TBI.20 

•	 Therapeutic couples intervention for reducing 

unmet needs and burdens for caregivers 

following TBI.21 

•	 Couples intervention for improving dyadic 

adjustment and communication.22 

Modifying Clinical Interventions for TBI 7 
Source 

Content for this brief was drawn from Section V. Modifying Clinical Interventions for TBI, of the 

Administration for Community Living. 2022. Behavioral Health Guide: Considerations for Best 

Practices for Children, Youth, and Adults with TBI (acl.gov). The section was written by Theo 

Tsaousides, PhD, ABPP, clinical assistant professor, and Maria Kajankova, PhD, assistant 

professor, Department of Rehabilitation and Human Performance, Icahn School of Medicine at 

Mount Sinai. The Traumatic Brain Injury Technical Assistance and Resource Center is funded 

by the Administration for Community Living. The Human Services Research Institute and the 

National Association of State Head Injury Administrators administer it. For more information, 

visit: Traumatic Brain Injury (TBI) | ACL Administration for Community Living. 

References 

1 Ashman, T., Cantor, J. B., Tsaousides, T., Spielman, L., & Gordon, W. (2014). Comparison of cognitive 

behavioral therapy and supportive psychotherapy for the treatment of depression following 

traumatic brain injury. Journal of Head Trauma Rehabilitation, 29(6), 467–478. 

https://doi.org/10.1097/htr.0000000000000098 

2 Fann, J. R., Bombardier, C. H., Vannoy, S., Dyer, J., Ludman, E., Dikmen, S., Marshall, K., Barber, J., & 

Temkin, N. (2015). Telephone and in-person cognitive behavioral therapy for major depression 

after traumatic brain injury: A randomized controlled trial. Journal of Neurotrauma, 32(1), 45–57. 

https://doi.org/10.1089/neu.2014.3423 

3 Topolovec-Vranic, J., Cullen, N., Michalak, A., Ouchterlony, D., Bhalerao, S., Masanic, C., & Cusimano, 

M. D. (2010). Evaluation of an online cognitive behavioural therapy program by patients with 

traumatic brain injury and depression. Brain Injury, 24(5), 762–772. 

https://doi.org/10.3109/02699051003709599 

4 Bédard, M., Felteau, M., Marshall, S., Cullen, N., Gibbons, C., Dubois, S., Maxwell, H., Mazmanian, D., 

Weaver, B., Rees, L., Gainer, R., Klein, R., & Moustgaard, A. (2014). Mindfulness-based 

cognitive therapy reduces symptoms of depression in people with a traumatic brain injury. Journal 

of Head Trauma Rehabilitation, 29(4). https://doi.org/10.1097/htr.0b013e3182a615a0 

5 Ponsford, J., Lee, N. K., Wong, D., McKay, A., Haines, K., Alway, Y., Downing, M., Furtado, C., & 

O’Donnell, M. L. (2015). Efficacy of motivational interviewing and cognitive behavioral therapy for 

anxiety and depression symptoms following traumatic brain injury. Psychological Medicine, 46(5), 

1079–1090. https://doi.org/10.1017/s0033291715002640 

6 Simpson, G. K., Tate, R. L., Whiting, D. L., & Cotter, R. E. (2011). Suicide prevention after traumatic 

brain injury. Journal of Head Trauma Rehabilitation, 26(4), 290–300. 

https://doi.org/10.1097/htr.0b013e3182225250 

7 Sander, A. M., Clark, A. N., Arciniegas, D. B., Tran, K., Leon-Novelo, L., Ngan, E., Bogaards, J., Sherer, 

M., & Walser, R. (2020). A randomized controlled trial of acceptance and commitment therapy for 

psychological distress among persons with traumatic brain injury. Neuropsychological 

Rehabilitation, 31(7), 1105–1129. https://doi.org/10.1080/09602011.2020.1762670 

8 Tornås, S., Løvstad, M., Solbakk, A.-K., Schanke, A.-K., & Stubberud, J. (2016). Goal management 

training combined with external cuing as a means to improve emotional regulation, psychological 

functioning, and quality of life in patients with acquired brain injury: A randomized controlled trial. 

Archives of Physical Medicine and Rehabilitation, 97(11). 

https://doi.org/10.1016/j.apmr.2016.06.014 

9 Tsaousides, T., Spielman, L., Kajankova, M., Guetta, G., Gordon, W., & Dams-O’Connor, K. (2017). 

Improving emotion regulation following web-based group intervention for individuals with 

Modifying Clinical Interventions for TBI 8 
Traumatic Brain Injury. Journal of Head Trauma Rehabilitation, 32(5), 354–365. 

https://doi.org/10.1097/htr.0000000000000345 

10 Shorer, M., Segev, S., Rassovsky, Y., Fennig, S., Apter, A., & Peleg, T. P. (2020). Efficacy of 

psychological intervention for children with concurrent posttraumatic stress disorder and mild 

traumatic brain injury. Journal of Traumatic Stress, 33(3), 330–337. 

https://doi.org/10.1002/jts.22512 

11 Wade, S. L., Walz, N. C., Carey, J. A. C., & Williams, K. M. (2008). Preliminary efficacy of a web-based 

family problem-solving treatment program for adolescents with traumatic brain injury. Journal of 

Head Trauma Rehabilitation, 23(6), 369–377. 

https://doi.org/10.1097/01.htr.0000341432.67251.48 

12 Wade, S. L., Carey, J., & Wolfe, C. R. (2006). An online family intervention to reduce parental distress 

following pediatric brain injury. Journal of Consulting and Clinical Psychology, 74(3), 445–454. 

https://doi.org/10.1037/0022-006x.74.3.445 

13 Antonini, T. N., Raj, S. P., Oberjohn, K. S., Cassedy, A., Makoroff, K. L., Fouladi, M., & Wade, S. L. 

(2014). A pilot randomized trial of an online parenting skills program for pediatric traumatic brain 

injury: Improvements in parenting and child behavior. Behavior Therapy, 45(4), 455–468. 

https://doi.org/10.1016/j.beth.2014.02.003 

14 Petranovich, C. L., Wade, S. L., Taylor, H. G., Cassedy, A., Stancin, T., Kirkwood, M. W., & Maines 

Brown, T. (2015). Long-term caregiver mental health outcomes following a predominately online 

intervention for adolescents with complicated mild to severe traumatic brain injury. Journal of 

Pediatric Psychology, 40(7), 680–688. https://doi.org/10.1093/jpepsy/jsv001 

15 Niemeier, J. P., Kreutzer, J. S., Marwitz, J. H., & Sima, A. P. (2019). A randomized controlled pilot 

study of a manualized intervention for caregivers of patients with traumatic brain injury in inpatient 

rehabilitation. Archives of Physical Medicine and Rehabilitation, 100(4). 

https://doi.org/10.1016/j.apmr.2018.07.422 

16 Wade, S. L., Carey, J., & Wolfe, C. R. (2006). An online family intervention to reduce parental distress 

following pediatric brain injury. Journal of Consulting and Clinical Psychology, 74(3), 445–454. 

https://doi.org/10.1037/0022-006x.74.3.445 

17 Wade, S. L., Walz, N. C., Carey, J. A., McMullen, K. M., Cass, J., Mark, E., & Yeates, K. O. (2012). A 

randomized trial of teen online problem solving: Efficacy in improving caregiver outcomes after 

brain injury. Health Psychology, 31(6), 767–776. https://doi.org/10.1037/a0028440 

18 Wade, S. L., Karver, C. L., Taylor, H. G., Cassedy, A., Stancin, T., Kirkwood, M. W., & Brown, T. M. 

(2014). Counselor-assisted problem solving improves caregiver efficacy following adolescent 

brain injury. Rehabilitation Psychology, 59(1), 1–9. https://doi.org/10.1037/a0034911 

19 Raj, S. P., Antonini, T. N., Oberjohn, K. S., Cassedy, A., Makoroff, K. L., & Wade, S. L. (2015). Webbased parenting skills program for pediatric traumatic brain injury reduces psychological distress 

among lower-income parents. Journal of Head Trauma Rehabilitation, 30(5), 347–356. 

https://doi.org/10.1097/htr.0000000000000052 

20 Raj, S. P., Shultz, E. L., Zang, H., Zhang, N., Kirkwood, M. W., Taylor, H. G., Stancin, T., Yeates, K. O., 

& Wade, S. L. (2018). Effects of Web-based parent training on caregiver functioning following 

pediatric traumatic brain injury: A randomized control trial. Journal of Head Trauma Rehabilitation, 

33(6). https://doi.org/10.1097/htr.0000000000000388 

21 Graham, K. M., Kreutzer, J. S., Marwitz, J. H., Sima, A. P., &; Hsu, N. H. (2020). Can a couples’ 

intervention reduce unmet needs and caregiver burden after brain injury? Rehabilitation 

Psychology, 65(4), 409–417. https://doi.org/10.1037/rep0000300 

22 Backhaus, S., Neumann, D., Parrott, D., Hammond, F. M., Brownson, C., &; Malec, J. (2019). 

Investigation of a new couples intervention for individuals with brain injury: A randomized 

controlled trial. Archives of Physical Medicine and Rehabilitation, 100(2). 

https://doi.org/10.1016/j.apmr.2018.08.174 

Modifying Clinical Interventions for TBI 9