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1 This Presentation prepared by Maryland Department of Health and Mental Hygiene Maryland TBI Implementation Project Brain Injury Association of Maryland.

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Presentation on theme: "1 This Presentation prepared by Maryland Department of Health and Mental Hygiene Maryland TBI Implementation Project Brain Injury Association of Maryland."— Presentation transcript:

1 1 This Presentation prepared by Maryland Department of Health and Mental Hygiene Maryland TBI Implementation Project Brain Injury Association of Maryland Vocational Issues After Brain Injury 2003 updated 2009

2 2 Learning Objectives… After this training you should be able to answer the following questions: What is a brain injury? How does brain injuryimpact daily functioning? Why does brain injury impact a person’s employment status?

3 3 …Learning Objectives After this training you should be able to answer the following questions: Why does brain injury impact a person’s employment status? How can brain injury affect learning, behavior and relationships on the job? What can be done to help consumers with brain injury find and keep a job?

4 4 Presentation Overview The Challenges of Brain Injury in the Work Environment Barriers to Employment Role of the Vocational Counselor The Successful Vocational Program and Candidate

5 5 The Challenges of Brain Injury in the Work Environment

6 6 Specific Challenges for the Vocational Specialist Job coaches, vocational counselors and other employment specialists may never have received specific training in brain injury Individuals with brain injury may have an array of needs making it a challenge to be placed in an appropriate working environment Brain injuries may be undiagnosed and under-reported Traditional vocational evaluations may not accurately assess the consumer’s vocational potential

7 7 Barriers to Employment

8 8 Possible Impairments After Brain Injury Barriers to Employment Physical Social/Emotional/Behavioral Cognitive

9 9 Changes after Brain Injury Could Include Physical Impairments Mobility Impairments Reduced Coordination Speech Impairments Fatigue Seizures Sensory changes

10 10 Mobility Impairments & Reduced Coordination : Difficulty with walking, balance, dizziness, spasticity, paralysis, rigidity,coordination Review medical records including physical and occupational therapy reports Determine if adaptive devices may be needed Re-evaluation of physical and occupational therapy might be necessary Evaluate accessibility of workplace Access work hardening program after specifics of employment are known Ask about medications consumer may be on

11 11 Speech Impairments: Speech or language pathology that makes it difficult for the person to speak or to be understood Review speech/language pathology reports Request an evaluation if appropriate Encourage client to speak slowly and repeat as necessary Assist the consumer in establishing consistent non- verbal cues for use at workplace Encourage the use of additional means of communications ( ; fax; memos)

12 12 Fatigue: Tiredness related to organic changes in the brain or may be related to over-stimulation. May also result from sleep disturbances common after TBI Obtain a list of medical restrictions from physician Reduce length of work day if possible. Gradually increase time as consumer tolerates Assist employer and consumer to plan for the gradual increase of working hours and workload Encourage consumer and supervisor to schedule work breaks Allow extra time to complete task

13 13 Seizures: A medical condition that may occur after brain injury and can be caused by a disruption in brain cell activity Identify seizure protocol with consumer’s physician and ascertain employer policy Educate employer, supervisor, other workers as to seizure protocol (w/consumer’s consent) Assist consumer in obtaining a medical identification bracelet or necklace Help consumer to establish reminders to take anti-seizure medication as prescribed

14 14 Possible Sensory Changes: Vertigo: Minimize visual stimulation. Refer if necessary to a neuropthamologist or behavioral optometrist Hearing: Evaluation of hearing problems by specialist (Speech/Language Pathologist, Audiologist) Vision: Accommodate visual deficits. Assist consumer in the placement of materials for optimal viewing

15 15 Possible Changes After Brain Injury Social-Emotional Impairments Irritability/Aggression/Mood Swings Anxiety Communication Difficulties Poor Social Judgment/Skills Denial/Lack of Self-Awareness Rigidity/Inflexibility

16 16 Impulsivity: Poor Judgment; Reduced ability to modify or inhibit words and actions Decrease distractions (partitions, reduce noise…) Teach strategies to maintain/regain focus (checklists; daily planner) Break down tasks into smaller steps Identify mentor/colleague to assist consumer Provide cues to re-direct consumer Modify work load Increase pace of work assignments gradually

17 17 Irritability/Aggression/Emotional Lability: Difficulty in controlling emotions; Mood swings and inappropriate behavior may occur Provide clear expectations for behavior Plan and role-play social interactions that might occur at job site Encourage consumer to slow down and think through responses. Outline strategies for controlling temper (count to five….) Evaluate consumer behavior and review possible alternative responses with client

18 18 Anxiety: Individuals may have difficulty matching emotions to the situation at hand. This is especially true in novel situations. Plan Outline strategies Provide feedback as soon as possible Encourage consumer to slow down and think through responses. Evaluate Teach relaxation techniques Explore medication when appropriate

19 19 Communication: Difficulties with initiating and maintaining conversations; talking too much; talking too little Encourage consumer to practice expressing thoughts in safe environment Role play possible conversations with others in the workplace Encourage consumer to ask for time to organize thoughts Teach consumer active listening techniques, such as repeating what they heard from the other person Educate mentor/supervisor on specific communication difficulties and the way that he or she can assist consumer

20 20 Social Judgment/Skills: Difficulty in reading social cues and understanding humor. Decreased awareness of social rules and roles. Demonstrates inappropriate manners that may result in isolation from co-workers. Educate co-workers on brain injury aftermath Identify co-worker who will work with consumer to prompt and redirect as needed Identify possible problems in real-work situations Plan and rehearse social interactions Review workplace interactions with consumer and identify appropriate responses Assist employer/supervisor to identify difficulties and use feedback in a positive way (privately; calmly; clearly)

21 21 Denial/Lack of Awareness: Inability to realistically and accurately assess one’s abilities; limited self-awareness and insight Anticipate consumer’s lack of awareness Assist consumer in identifying and accepting limitations Promote questioning by consumer in work situations when they are unsure of what to do Identify feedback needs and strategies for supervisor Supportive therapy as available and needed

22 22 Rigidity/Inflexibility: Difficulty in accommodating changes in routine and making transitions throughout the day Break job tasks into small steps Use a daily schedule to be reviewed prior to and at the end of the day Assign a specific co-worker or supervisor to be the point of contact Use alarm watch

23 23 Possible Changes After Brain Injury Cognitive Impairments Executive Functioning deficits Attention and Concentration Comprehension and Memory Self-Awareness Initiating/Motivating

24 24 A deficit in executive skills might look like the inability to plan and organize or it might look like... (Capuco & Freeman-Woolpert) Uncooperativeness, stubbornness Lack of follow through Laziness Irresponsibility

25 25 Executive Functioning : Reduced ability to devise a plan of action and systematically implement it Create templates of routine work tasks Stress the need for daily job log Log should be completed each day and reviewed each night Questions and/or comments for job coach/boss/co- worker should be written down as well as the answer provided

26 26 An attention deficit might look like trouble paying attention or it might look like … (Capuco & Freeman-Woolpert) He keeps changing the subject She doesn’t complete tasks He has a million things going on and none of them ever gets completed When she tries to do two things at once she gets confused and upset

27 27 Attention and Concentration: Easily distracted. Difficulty in attending to tasks, focusing or maintaining attention (may be internal or external) Identify mentor/colleague to assist consumer Decrease distractions (partitions, reduce noise…) Teach strategies to maintain/regain focus (checklists; daily planner) Break down tasks into smaller steps Provide cues to re-direct consumer Modify work load Increase pace of work assignments gradually

28 28 A memory deficit might look like trouble remembering or it might look like…… (Capuco & Freeman-Woolpert) She frequently misses appointments- avoidance, irresponsibility He says he’ll do something but doesn’t get around to it She talks about the same thing or asks the same question over and over-annoying He invents plausible sounding answers so you won’t know he doesn’t remember

29 29 Comprehension and Memory: Reduced ability to understand, process and recall what is being said or read Provide written and verbal instruction Model tasks whenever possible Encourage the individual to paraphrase instructions back to the speaker Enter instructions in job log Use a tape recorder to enter reminders and instructions to review/reinforce later

30 30 Self-Awareness: The inability to take a self-critical stance resulting in an overestimation of skills and abilities Use of feedback both verbally and written Videotape for self-observation The establishment of a pre-agreed upon signal to give feedback if behavior/speech or work efforts are inappropriate or incorrect Use of a contract prior to placement that clearly states roles and responsibilities

31 31 Motivation/Initiation: Difficulty in initiating a task. May appear disinterested or unmotivated Observe if individual responds better to visual or verbal cues Use consistent cues and checklists that foster self- monitoring. Include individual in planning these cues Teach self-prompting techniques Use a co-worker to cue behaviors Use a daily written assignment sheet/job log Break tasks down into simple steps

32 32 Role of the Vocational Counselor

33 33 Possible Prevocational or Concurrent Vocational Needs u Psychotherapy u Substance Abuse Program u Cognitive Remediation via Rehabilitation therapies (OT,SLP.PT) and/or a Community re-entry program u Neuropsychiatric/Neuropsychological Evaluations u Work hardening program u Driving evaluation/retraining

34 34 Substance Abuse & Brain Injury Alcohol Use & TBI-Incidence Analysis of the Literature (Corrigan 1995) Alcohol, the drug of choice-Corrigan and his colleagues report that for 70% of the individuals they work with who use substances, alcohol is the preferred substance Intoxication at time of injury-7 studies looked at incidence of intoxication (BAL equal or exceeding 100mg.dL)at time of injury. Intoxication ranged from 36% to 50% History of Substance Abuse-Findings suggest that for adolescents and adults in rehabilitation following a TBI, as much as 60% of this population have histories of alcohol use or dependence.

35 35 Substance Abuse & Brain Injury How does Incidence and History Impact on Recovery & Outcomes? Studies Suggest….. Alcohol may negatively affect the process of dendrite profusion thus impede ability of the remaining neurons to compensate for the neurons that have been damaged (Corrigan, NASHIA webcast 2003) Alcohol use after brain injury may increase the risk of seizure post TBI Increased brain atrophy observed in patients with a positive BAL and or history of moderate to heavy pre-injury use (Bigler et al 1996 & Wilde et.al 2004)

36 36 Subsequent Use 5-10% of those with TBI develop substance abuse problems after their injury (Corrigan 2009) “A person with a preinjury history of two drinks a day would not have had a reason to seek alcohol-related treatment before his or her accident. But once that same person becomes brain-injured, the continuation of that drinking pattern has the potential to cause major problems” Robert Karol, Ph.D.

37 37 Taking Advantage of the “Honeymoon” Period Individual in an inpatient and/or highly structured outpatient setting resulting in detoxification Physical and cognitive disabilities make access to substances difficult Families are instructed to provide supervision due to physical needs and judgement concerns Individual is remorseful over past use, related behavior, blames self for accident and vows to change

38 38 Screen CAGE Questionnaire Brief Michigan Alcoholism Screening Test (BMAST) AUDIT According to brain injury researchers, the above tools are appropriate and valid for use with individuals with brain injury

39 39 ……..and Intervene Modify 12 Step Program components to accommodate cognitive and behavioral concerns Incorporate substance abuse education into cognitive remediation, prevocational and employment services If you ask, they will tell, self report according to researchers is a reliable measure of risk and use Don’t assume staff can easily identify who is currently using or at risk Discard old stereotypes e.g. “he has to hit rock bottom before any intervention will work”

40 40 Characteristics of a Successful Vocational Candidate Rehabilitation therapies (OT,SLP,PT)- carry over of strategies learned Able to manage frustration and anger Awareness of deficits and the ability to generalize compensatory strategies in a variety of situations Exhibits a desire to please others/work ethic Supportive family/social network May be years post-injury

41 41 “I had a job, I had a girl, I had something going mister in this world, I got laid off at the lumber yard, Our love went bad, times got hard. Now I work down at the car wash, where all it ever does is rain. Don’t you feel like you’re a rider on a downbound train” Bruce Springsteen quoted by young man living with a brain injury for over ten years

42 42 Happy Ending Six months of outpatient brain injury rehabilitation, received speech, OT, mental health, & group therapy With a employment specialist’s support, hired at a golf course-grounds keeper After several years, wanted more money,new challenge, took a job w/ an auto parts company as a delivery truck driver, received a few months of supported employment funded by the Division of Rehabilitation Services

43 43 Job Loss Factors Lack of Social Skills Poor Executive Functioning Memory Impairments

44 44 Lack of Social Skills Dress and/or personal hygiene is inappropriate to the work environment Egocentric in speech Discloses personal information Inappropriate sexual behavior Unable to modify speech and behavior as appropriate ( too familiar with boss) Unable to pick up nonverbal social cues

45 45 Executive Functioning Work space is messy and unorganized Unable to work on several projects/tasks concurrently Get caught up in extraneous details Unable to modify a solution to a problem as the situation changes and shifts

46 46 Memory Impairments Unable to retain coworkers names Unable to recall work routines Unable to generalize knowledge/routines Inconsistently able to utilize notes to support memory

47 47 Inappropriate Workplace Behaviors Being late Interrupting Talking too much Arguing, fighting and yelling Leaving without permission/notice Preventing others from getting their work done

48 48 Appropriate Workplace Behaviors Show others respect Address supervisors and other superiors appropriately (Sir, Ms) Listen when someone is talking Avoid interrupting Maintain focus—don’t go off on tangents Be prompt (check watch and map out plan to get to work on time) Notify supervisor if going to be late Any of the following may be a possible focus for vocational counseling:

49 49 The Vocational Counselor Needs to Provide Structure Support Strategies

50 50 Remember “Success at work requires two basic components: The Skills necessary to perform the job, and the proper attitude, motivation, awareness, and consistency of behavior to function effectively on the job apart from and in addition to the particular skills required.” Saralyn Silver (1988)

51 51 Additional Resources on Brain Injury

52 52 Additional Resources… Print Materials Books and Articles Understanding Brain Injury A Guide for Employers by Mayo Clinic (2000) Vocational Rehabilitation for Persons with Traumatic Brain Injury by Paul Wehman & Jeffrey S. Kreutzer (Eds.) (1990) Brain Injury Source, Brain Injury Association of America, Volume 5, Issue 1. Moderating Factors in Return to Work and Job Stability after Traumatic Brain Injury. Kreutzer et. al Journal of Head Trauma Rehabilitation, 18(2),

53 53 …Additional Resources… Research and Training Center, Stout Vocational Institiute, University of Wisconsin-Stout. Brain Injury Association of America Traumatic Brain Injury Model System Centers University of Washington Traumatic Brain Injury Model System National Association of State Head Injury Administrators to download employment fact sheet go to The Disability Rights Center of New Hampshire has published a short guide for job seekers with a history of brain injury, entitled Five Things You Should Know When Returning to Work After a Traumatic Brain Injury. The document is available at:

54 54 …Additional Resources- Substance Abuse Ohio Valley Center For Brain Injury Prevention and Rehabilitation, , Rehabilitation Research and Training Center on Traumatic Brain Injury Interventions & New York Traumatic Brain Injury Model System at the Mount Sinai School of Medicine and the Mount Sinai Rehabilitation Research and Training Center

55 55 …Additional Resources… Brain Injury Association of Maryland (BIAM) To contact BIAM: Call: (410) Toll Free in Maryland: (800) Write or visit: BIAM 2200 Kernan Drive Baltimore, MD Website:

56 56 Recommended Reading I am the Central Park Jogger: A Story of Hope and Possibility by Trisha Meili, 2003 Every Good Boy Does Fine: A Novel by Tim Laskowski, 2003 Over My Head: A Doctor’s Own Story of Head Injury from the Inside Looking Out by Claudia Osborn, 2000

57 57 Acknowledgements The Maryland Traumatic Brain Injury Project wishes to thank the following individuals for their contributions to this vocational training: Sharon Cullinane Anastasia Edmonston Fran Forstenzer Jerri Fowler Stefani O’Dea Diane Triplett Amy Welch John Capuco, Psy.D & Julia Freeman-Woolpert M.Ed. Project Response, New Hampshire Special thanks and acknowledgement to Saralyn Silver MS CRC formerly of the New York University Head Trauma Program and Patricia Price of the Florida Brain Injury Demonstration Project for their contributions to the field brain injury and vocational rehabilitation. Alice Marie Stevens, PhDc, Editor, Vocational Issues After Brain Injury 2003 and Director, Maryland TBI Implementation Project, Baltimore, MD Additions and modifications by Anastasia Edmonston, MS CRC Project Director MD TBI Partnership Implementation Project, 2009.

58 58 Acknowledgements This training and its associated training materials are supported in part by the TBI State Grant Program, Grant Number 4 H21 MC , from the Department of Health and Human Services (DHHS) Health Resources and Services Administration, Maternal and Child Health Bureau. The contents are the sole responsibility of the authors and do not necessarily represent the official views of DHHS. In the public domain, please copy and distribute widely Disclaimer: Information given within this training does not imply endorsement by BIAM or DHMH or any other party associated with this training. Listings in this training may not represent all the possible services or resources available.

59 59 Project Contact Anastasia Edmonston, MD TBI Project Director. Please contact for information about the Project’s resource coordination and training activities ,

60 60 Thank you for participating! Please complete your evaluation form and leave it with your speaker

61 61 References Ezrachi., O., Ben_Yishay., Kay, T., Diller, L., Rattok, J. (1991). Predicting Employment Brain Injury Following Neuropsychological Rehabilitation. Journal of Head Trauma Rehabilitation, 6(3), Jacobs, H. (1997). The Clubhouse: Addressing Work-Related Behavioral Challenges Through a Supportive Community. Journal of Head Trauma Rehabilitation,12(5), Kay, T., Silver, S. (1989). Closed Head Trauma: Assessment for Rehabilitation. In M. Leazak (Ed.), Assessment of the Behavioral Consequences of Head Trauma. (pp ). New York: Alan R. Liss, Inc. Malaec, J., and Basford, Jr. (1996). Postacute Brain Injury Rehabilitation. Archives of Physical and Rehabilitation Medicine, 77, Corrigan JD. (1995). Substance Abuse as a Mediating Factor in Outcome from Traumatic Brain Injury. Archives of Physical Medicine and Rehabilitation Vol. 76, April: Bombardier, CH., Temkin, NR., Machamer, J., Dikmen SS.(2003), The Natural History of Drinking and Alcohol-Related Problems After Traumatic Brain Injury Archives of Physical Medicine and Rehabilitation Feb;84(2): Bombardier C., Davis, C. (2001). Screening for Alcohol Problems Among Persons with TBI. Brain Injury Source. Fall Corrigan J., et. al (1998) Utilities for Community Professionals. Ohio Valley Center for Brain Injury Prevention and Rehabilitation


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