Martin Kerrigan Traumatic Brain Injury and the ADA August 11, 2011

Brain injuries are often classified as either traumatic or acquired. According to the Brain Injury Association of America (BIA), “An acquired brain injury (ABI) includes all types of traumatic brain injuries and also brain injuries caused after birth by cerebral vascular accidents (commonly known as stroke), and loss of oxygen to the brain” All brain injuries are acquired!

Acquired (ABI) Includes all brain injuries that have occurred after birth Includes “traumatic” and non-traumatic” brain injuries Can be result of stroke, hemorrhages, loss of oxygen to brain, drug overdoses, etc. Brain Injury Association of America, Caused by a bump, blow, or penetration to the head that results in an impairment in the function of the brain Categorized from “mild” to severe Includes concussions Traumatic (TBI)

According to the Brain Injury Association of America, “an estimated 1.7 million children and adults in the U.S. sustain a traumatic brain injury (TBI) and another 795,000 individuals sustain an acquired brain injury (ABI) from non-traumatic causes each year.” The association also reports “currently more than 3.1 million children and adults in the U.S. live with a lifelong disability as a result of TBI and 6.4 million have a disability due to stroke.”

A TBI is caused by a bump, blow or jolt to the head or a penetrating head injury that disrupts the normal function of the brain. Not all blows or jolts to the head result in a TBI. The severity of a TBI may range from “mild,” i.e., a brief change in mental status or consciousness to “severe,” i.e., an extended period of unconsciousness or amnesia after the injury. The majority of TBIs that occur each year are concussions or other forms of mild TBI.

An estimated 1.7 million people sustain a TBI annually. Of them: 52,000 die, 275,000 are hospitalized, and million, nearly 80%, are treated and released from an emergency department. According to Faul and associates; TBI is a contributing factor to a third (30.5%) of all injury- related deaths in the United States. In a report to Congress in 2003 the CDC found that “About 75% of TBIs that occur each year are concussions or other forms of mild traumatic brain injury (MTBI).” Direct medical costs and indirect costs of TBI, such as lost productivity, totaled an estimated $60 billion in the United States in 2000.

In a 1996 study Kraus and associates found the following: About two million head injuries of all types (including skull and facial fractures) occur each year in the U. S. (175 to 200 per 100,000 population). Over 1.5 million Americans suffer nonfatal traumatic brain injuries each year which do not require hospitalization. About the same number are reported to sustain a brain injury resulting in a loss of consciousness but not severe enough to result in long-term institutionalization (an annual rate of 618 per 100,000 person-years). Another 300,000 individuals suffer brain injuries severe enough to require hospitalization, with 99,000 resulting in a lasting disability. A total of 56,000 people die each year as a result of traumatic brain injury

Every brain injury is different Brain injury is often referred to as the silent epidemic Brain injuries can manifest themselves in many different ways and with varying degrees of severity The effects, or impact, of a brain injury varies from person to person and injury to injury There is no way to look at someone and tell whether or not they have been injured, or to what extent they have been injured

In two separate studies both Ip and colleagues and Greenspan and colleagues found that “the largest group of TBI survivors are young adults in their prime working years, many survivors, particularly those with a severe TBI, do not return to work. Estimates vary widely, ranging from a low of 12.5% to as high as 80% who do not return to work. The ability to return to work is highly correlated to the post-acute functional limitations of the survivor.”

While a brain injury does not discriminate and can happen to anyone, it is most common in males and with young adults followed by young children and the elderly. According to Kraus and MacArthur: TBI affects males at twice the rate of females. Higher mortality rates among males indicate that males are more likely than females to suffer severe injuries Individuals age 15 to 24 have the highest risk of TBI. The risk also increases after age 60.

While the costs associated with brain injury vary greatly Brain and Spinal Cord.org estimates annual costs of brain injury at estimated that a mild head injury costs $85,000, a moderate injury costs $941,000, and a severe injury costs $3 million. They also estimated “Overall, it is estimated that the cost of traumatic brain injuries in the United States weighs in at $48.3 billion annually. About $31.7 billion of that is spent on hospitalization costs, while the additional $16.6 billions goes toward costs associated with fatalities.”

Research has found that there is a disproportionately higher rate of individuals living with brain injury in these situations than in the general public: Incarcerated Chronically unemployed/under-employed Substance abuse issues Mental health issues such as clinical depression

Many times the individual with the brain injury has had some type of pre-morbid history with violence, drugs and/or alcohol. Once the brain injury has occurred traditional interventions usually do not work. Often times due to the consequences of their injury their self esteem is lowered as is their feelings of self worth.

One of the most commonly affected aspects of a persons life following a brain injury is their career Most employers do not understand brain injury The closer to the injury, the greater the impact of the injury

The individual’s assessment of their strengths and weaknesses may not be accurate The individual may not have gotten over the “loss” of previous skills Co-workers may not understand or get brain injury Drug and/or alcohol use may be an impediment to both recovery and employment

There are several things that can be done to improve the likelihood of successful employment: Job coaching Employer and workplace education Flexible working situations Consumer involvement and buy in

A job coach is described by the website America’s Heroes at Work as “a person, usually supplied by an outside agency, who provides specialized on-site training to employees with disabilities.” Individuals living with the effects of brain injury can have a variety of physical, cognitive, and emotional symptoms that can get in the way of work. The right job coach can help the individual with brain injury work around these symptoms.

By assisting the individual with brain injury through one-on-one mentoring, guidance, help, and assistance job coaches can help the employee with on the job success and can potentially lead to a greater sense of independence. Job coaches can also provide education to the employers regarding the individual with brain injury. Job coaching does not have to permanent and can be weaned away over time.

Most employers are familiar with the American’s with Disabilities Act (ADA), which includes brain injury As long as the accommodation is deemed “reasonable” any employee should be able to work as long as they are able to perform the basics of their job with accommodations. Disclosure of criminal history Tax benefits available

The increase of veterans returning home with brain injuries suffered while in combat has lead to an increased awareness of brain injury. The Mayo Clinic has published a Guide that can help employers when it comes to employees with brain injuries, Understanding Brain Injury: A Guide for Employers available at:

Depending on the needs of the individual and the requirements of the job, employers should be flexible. It might take some creative or “outside the box” thinking but many times solutions can be found.

No matter how great of a program is designed if the individual does not “buy” into it, or believe in it, the chances of success are low. The consumer needs to be an integral part of the process.

America’s Heroes at Work, Brain and Spinal Cord.org, Brain Injury Association of America, Center for Disease Control, Faul M, Xu L, Wald MM, Coronado VG. Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations and Deaths 2002–2006. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; Finkelstein E, Corso P, Miller T and Associates. The Incidence and Economic Burden of Injuries in the United States. New York (NY): Oxford University Press; Greenspan, A. I., Wrigley, J. M., Kresnow, M., Branche-Dorsey, C. & Fine, P. R. (1996) Factors Influencing Failure to Return to Work Due to Traumatic Brain Injury. Brain Injury, 10(3):

Ip, R. Y., Dornan, J. & Schentag, C. (1995) Traumatic Brain Injury: Factors Predicting Return to Work or School. Brain Injury, 9(5): Kraus, J. F, and MacArthur, D. L. (1996) Epidemiologic Aspects of Brain Injury. Neurologic Clinics, 14(2): Morton, M. V., & Wehman, P., (1995) Psychosocial and Emotional Sequelae of Individuals with Traumatic Brain Injury: A Literature Review and Recommendations. Brain Injury, 9(1): Report to Congress on Mild Traumatic Brain Injury in the United States: Steps to Prevent a Serious Public Health Problem. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; U.S. Dept. of Transportation, National Highway Traffic Safety Division (1997), Traffic Safety Facts 1996:Alcohol.Washington, DC: National Center for Statistics & Analysis, Research & Development.

Contact information: Martin Kerrigan