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Challenging behavior associated with cognitive impairment represents neurobehavioral disability after traumatic brain injury (TBI). Clinical management of neurobehavioral disability occurs within a framework of contemporary learning theory, which provides a conceptual framework to understand the important relation between challenging behavior and environmental contingencies. Neurocognitive impairment—especially constraints on attention and memory that undermine learning, or executive weaknesses that undermine initiative and goal-directed behavior— mediates the development and maintenance of many behavior disorders (Wood and Worthington 2001). For example, impulsiveness and disinhibition in social situations are often driven by poor self-monitoring and inability to use feedback to regulate behavior. This results in a lack of “error awareness” and poor response to social cues, which can lead to frustration and aggression, especially when the patient has concurrent difficulties with response inhibition.
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