Facilitating Employment Success for Persons with Traumatic Brain Injury

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Facilitating Employment Success for Persons with
Traumatic Brain Injury

• Presented by
• Laura Owens, Ph.D.
• University of Wisconsin-Milwaukee
• Creative Employment Opportunities, Inc.
• December 2, 2003
• RSA Region V CRP-RCEP414-277-8506lowens_at_uwm.edu

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Brain Injury Issues

• What tools do you need to achieve success with
  individuals with TBI?
• Injury Knowledge
• Self Knowledge
• Clear knowledge of individuals desired outcome

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Traumatic Brain Injury (TBI) Defined

• AKA - Craniocerebral trauma
• Any injury to brain caused by fracture or
  penetration of the skull (e.g., vehicle accident,
  fall, gunshot wound), a disease process (e.g.,
  infections, tumors, metabolic abnormalities), or
  a closed head injury (e.g., Shaken Baby Syndrome,
  rapid acceleration/deceleration of the head)

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Annually in the US

• 1.5 million Americans sustain a TBI each year
• 80,000 people annually experience the onset of
  long-term disability following TBI
• 50,000 people die every year as a result of TBI
• Incidents of TBI outnumber Breast Cancer
  (175,000), Spinal Cord Injury (11,000), HIV/AIDS
  (16,273), Multiple Sclerosis (10,400)
• 5.3 million Americans live with TBI-related
  disabilities

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TBI Causes/Statistics

• Motor vehicle accidents (50)
• Among elderly, falls are second only to motor
  vehicle accidents (Heath, 1994)
• Child abuse (64)
• 50,000 children sustain bicycle related brain
  injuries annually
• Higher rates of TBI among adolescents, young
  adults, and people older than age 75
• Males between 14-24 have highest rates of injury
• Males are two times more likely to have TBI than
  females
• African American population has higher rate than
  any other ethnic minority group in the US

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Cost of TBI

• Survivor typically faces 5-10 years of intensive
  services estimated cost of 4 million/year
• Economic cost of TBI in US estimated 48
  billion/year

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TBI Employment Statistics

• 75 of individuals with TBI who return to work
  lose their jobs within 90 days if they do not
  have supports

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General Brain Functions

• Frontal lobe
• Temporal lobe
• Parietal lobe
• Occipital lobe
• Cerebellum

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Changes Caused by TBI

• Decreased alertness arousal
• Inadequate attention concentration
• Confusion disorientation
• Impaired memory for new information
• Impaired sequential memory of past information

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Changes Caused by TBI

• Expressive language problems
• Receptive language problems
• Agitation irritability
• Catastrophic reaction reactive depression
• Exacerbation of pre-injury mental health issues
  or decrease of pre-injury mental health issues

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Changes Caused by TBI

• Impaired adaptive behavior
• Syndromes
• Frontal lobe left or right
• Aphasia
• Amnesiac
• Emotional

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Inconsistencies the Individual Experiences

• Everyone says you look good and are doing well
• Mirror says I look good
• No retrograde amnesia, so I can remember all the
  things I have done and can do
• The doctors say I will continue to improve

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Inconsistencies the Individual Experiences (cont.)

• Impairments may block understanding of
  self-information (right hemisphere)
• Affect of fatigue often compounds effects of
  injury
• Cant walk and chew gum and the same time
• Too many choices decisions (frontal lobe)

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Tyrone

• Average intelligence, good verbal abilities
• Place on jobs where multi-tasking and independent
  decisions required.
• Lost all jobs
• After 5th job, support agency finally got the
  picture

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Inconsistencies the Individual Experiences (cont.)

• Higher functioning are often more aware of
  small short comings, which magnifies the
  impairments
• Major memory impairment and adequate intellectual
  capacity often has impairment as focus of
  treatment versus use of preserved skills
• Minor memory impairments often are ignored as not
  important

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Understanding Denial

• Two types of denial
• Emotional something happened that is so terrible
  or frightening the individual does not want to
  deal with it
• Changes to the Brain the brain literally refuses
  to process certain types of information

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Community Issues

• Care givers (family, community support systems or
  both), are not prepared or ready for the
  individual
• Lack of understanding of functional deficits, or
  too much understanding of the deficits block
  community success
• Normal verbal abilities /or IQ often down
  play impairment or ignoring the impairment as not
  important

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Community Issues (cont.)

• What does brain injury mean to you?
• Supports not available due to funding or lack of
  supports
• Underlying pre-existing mental health /or life
  style issues ignored or become focus
• Unclear of how to treat individual (e.g., Can I
  set limits? What should I say when? We dont want
  to get him upset)

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Assessing a Person with TBI

• Awareness of injury in a functional sense
  ongoing
• Functional and verifiable knowledge of strengths
• Functional and verifiable knowledge of weaknesses
• Risk taking to develop new skills or verify
  existing skills
• Planned failure in the community setting to
  assist in learning process

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WHY?

• How can we expect individual to change if s/he
  does not know what is wrong
• When individual knows, easier to take
  responsibility for self versus listening to
  others tell them what/why they need to change
• How we grew to understand prior to injury

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Assessing a Person with TBI

• Pre-injury vocational competence motivation
• Did the individual show stable school/work
  history for at least 12 months prior to injury?
• Did the individual show an interest in a specific
  career or opportunities for advancement in a
  specific career?
• Did the individual have any specific vocational
  skills?

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Assessing a Person with TBI

• Post-injury vocational competence motivation
• The 12-month period after hospital release is a
  time when individuals experience discouragement,
  frustration, anger and indecision about work
• No data to support suggest it is better to wait
  until these feelings are resolved or provide work
  experiences right away
• In many cases, people with TBI require 2-5 job
  placements before stability is established

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Identifying Vocational Goals Expectations

• Concentrate on individuals interests and
  preferences
• What kind of work is the individual interested in
  doing?
• What type of work at home or in the community has
  the individual done pre-injury? Post-injury?
• What are the familys work expectations?
• What are the individuals existing skills and
  support needs?
• What support does the individual use now?
• What is the individuals ability to learn new
  skills?
• What teaching strategies seem to work best?

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Situational Assessment (Internships)

• Actual community work settings
• Identifies interests in job duties
• Analyzes work environment/culture
• Identifies skills
• Determines individuals responses to training
• Identifies support needs
• Helps determine a feasible vocational direction,
  explore career options, and to provide
  opportunities to enhance self-determination
  skills

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Ray

• Ray was a carpenter prior to accident
• Wanted to do the same type of job, but was told
  he couldnt due to significance of injury
• Internship at local furniture maker
• Made adaptations and provided 40 hour internship
• Ray was hired part time

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Job Characteristics

• Individuals with TBI are finding jobs in a
  variety of settings, including technology,
  scientific, self-employment, and government.
  These features in jobs tend to provide greater
  success
• Regular daily schedules
• Routine tasks
• Low levels of distractions (noise, light,
  temperature)
• Limited number of co-workers
• Regular breaks

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Employment Supports

• Writing Functional Resume
• Helpful for individual to clarify and define
  vocational goals
• Functional resume portrays broad skill areas
  developed as a result of employment, volunteer,
  recreational, and educational experiences
• Effective way of focusing on the unique
  abilities, interests, and characteristics
  individual can bring to job

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Application Interviewing Supports

• Take application home
• Make sure interviewing site is accessible
• Mock interview with another employer
• Write a list of job related questions
• Rephrase questions
• Decrease distracters
• Do a walk through or a tour prior to interview
• Decrease the number of introductions
• Explain job in a sequence

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Cognitive Supports

• Determine learning style written, verbal,
  demonstration, combination.
• Allow individual to set up own work station
• Reduce distractions in work area
• Allow for white noise sound machines or music
• Divide large assignments into smaller tasks
• Make daily to do lists
• Use calendar or electronic organizer
• Schedule weekly meetings with supervisor
• Use watch or pager with time capability
• Tape record meetings
• Allow additional training time
• Provide written checklists
• Provide environmental cues to assist memory for
  location of items (labels, color coding, bulletin
  boards)
• Post instructions

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Memory Supports

• Internal strategies
• Use of mental supports (verbal rehearsal)
• Use of associations, mneumonic devices, rhymes
• External strategies
• Break task into smaller bits - chunking
• Checklists, flowcharts, maps, graphic cues,
  reference manuals, assignment board, script log,
  location markers, electronic devices
• If person refuses to use, keep in mind they may
  be communicating the discomfort with using it,
  does not know how to use it, or was not involved
  in developing it.

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Communication Supports

• Writing notes
• Taking extra time to allow person to speak or
  listen
• Typing what needs to be said (using technology
  such as email or an augmentative communication
  device)
• Communication cards
• Write out long and short term goals

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Perceptual (visual sensory) Supports

• Provide written information (large print if
  needed)
• Change fluorescent lights to high intensity,
  white lights
• Increase natural lighting
• Provide a glare guard for computer
• Use tactile cues

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Regulatory Supports

• Flexible scheduling
• Allow longer or more frequent breaks
• Provide self-paced workload
• Identify work during time periods when person
  feels most energetic
• Provide a personal fan or heater
• Allow snacks at work area

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Behavior

• Separate organic problems from others
• Usually do not end up with more than what you
  started with (e.g., were the behaviors
  pre-existing?)
• View all behaviors in context of environment
• If not successful assisting individual in
  changing behavior, try changing environment

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Behavioral/Emotional Supports

• Provide praise and positive reinforcement
• Allow phone calls during work to talk with
  employment consultant or case manager
• Provide sensitivity training to
  co-workers/supervisor
• Provide 1-1 feedback in a non-threatening manner
  (immediately following incident)

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Behaviors Corrective Strategies

• Paranoia
• Self-centeredness or egocentrism, impulsiveness,
  or lack of inhibition

• Investigate cause of insecurity
• Explain why thoughts are misguided
• Instruct co-workers to provide direct feedback
• Establish key phrase chill out to be repeated
  when s/he feels loss of control
• Identify short phrase that signals the individual

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Behaviors Corrective Strategies

• Agitation, irritability, or verbal outbursts

• Model calm behavior, keep nonverbal cues relaxed
• Acknowledge the feelings/frustrations and provide
  time for further discussion after work
• Comment on the behavior not the person
• Teach relaxation techniques
• Identify work stressors
• Provide structure to minimize frustration

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Summary of Supports

• Use lists to compensate for memory (pocket
  notebook or appointment book or listings where
  particular tasks or behavior should occur)
• Use individual auditory or visual cues (tape
  recorded messages or instructions, different
  colored containers or files).
• Accommodate endurance levels and stress tolerance
  by sequencing tasks
• Use physical adaptations (trays, jigs, electric
  staplers, rubber band holders, laminated work
  materials)

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Summary of Supports

• Schedule reminders (voice mail message, pager,
  alarm clock)
• Stop watch for time management
• Scheduled rest breaks to prevent stimulus
  overload
• Supportive phone calls before and after work
• Role playing job situations
• Mentoring by a co-worker
• More frequent evaluation by supervisor

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Instructional Strategy
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Brian

• Worked as a maintenance assistance and animal
  care attendant at local vet
• Obtained a job as microfilm processor at local
  insurance company
• Brian learned the job quickly, but had difficulty
  with work quality, forgetting the steps, slow
  production, difficulty operating the equipment,
  and identifying errors
• Provided written post it notes as visual cues,
  pen caps placed on switches of the machine to
  prevent hitting the incorrect switch, large paper
  clips were substituted, electric stapler, and
  plexiglass dividers were used to assist Brian.

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Final Thought

• Ive missed more than 9000 shots in my career.
• Ive lost more than 300 games.
• 26 times Ive been trusted to take the game
  winning
• shot, and missed.
• Ive failed over and over and over again in my
  life,
• Thats why I succeed.
• MICHAEL JORDAN
• 9 time All Star
• 4 time MVP
• 2 time Olympic Gold Medalist
• The man who shackled gravity and courted flight