Traumatic Brain Injury & The ADA Strategies & Supports in the Workplace

1. Traumatic Brain Injury & The ADAStrategies & Supportsin the Workplace Anastasia B. Edmonston MS CRC MD TBI Projects Director MD Mental Hygiene Administration & The Mental Health Management Agency of Frederick County, Inc. & the Howard County Mental Health Authority

2. The fact that someone is living with a brain injury is often hidden, especially in the workplace

3. Hidden ( & not so hidden) Physical SequelaAdapted from McNamee et. Al, in the Journal of Rehabilitation Research & Development 2009 • Headaches • Pain Syndromes • Dizziness • Postural instability • Seizure disorder • Fine motor deficits • Hearing deficits (common among returning service members)

4. Hidden ( & not so hidden) Physical SequelaAdapted from McNamee et. Al, in the Journal of Rehabilitation Research & Development 2009 • Visual deficits • Insomnia • Fatigue • Side affects of certain medications (some seizure medications administered in the morning can induce sleepiness).

5. Living with Brain Injury, what it Might Feel Like:The Processing Exercise

6. Have They or Haven’t They?All but one of these prominent Americans is Working and living with a Brain Injury • Ben Vereen • Bob Woodruff • Jason Priestly • George Clooney • Anne Hathaway • Ben Roethlisberger

7. According to…Richard C. Hunt, MD, FACEPDirector, Division of Injury ResponseNational Center for Injury Prevention and ControlIn remarks made at the NASHIA public policy conferenceMarch 26,2009…..

8. Economic Burden of Injury and Traumatic Brain Injury (TBI)Source • Cost of injury in the US = $400 Billion • Lifetime costs of TBI = $60 Billion • $39 Billion for fatalities • $17 Billion for hospitalization • $4 Billion for non-hospital care Source: Finkelstein, Corso, Miller, et al. Incidence and economic burdenof injuries in the United States. Oxford University Press, 2006

9. Return to Work-The Big PictureResearch findings are variable • "Accounting for differences in measurement and the impact of injury severity on the probability of returning to work, it appears that more than half of survivors of TBI become unemployed as a consequence of their condition”Evidence Report 1999 • One study found that 75% of individuals with traumatic brain injury who return to work lose their jobs within 90 days without supports. (Sniezek)

10. Return to Work-The Big PictureResearch findings are variable (courtesy of D. Burnhill, DORS ABI Initiative) • Employment rates become higher over time. (Schonbrun, Sales & Kampfe, 2007) • In a 2003 study, Johnston and colleagues reported for 35 individuals followed, employment decreased from 69%-31% one year post injury and average monthly income declined by 51% • Nationally TBI (during 1st year post injury) is associated w/ an est. $642 million in lost wages, 96 million in lost income taxes and US dollars, 353 million in increased public assistance

11. Oklahoma Vocational Rehabilitation Training(curriculum for State VR) • 35% to 71% of persons with TBI return to some level of employment • The presence of neurobehavioral symptoms, memory deficits, and the severity of physical limitations are general predictors of work outcome • Work outcome is otherwise difficult to predict as outcome depends on motivation to succeed and the ability to match job demands and employer understanding and compassion with residual skills.

12. Oklahoma Vocational Rehabilitation Training • What the Employment Specialist Should Keep in Mind... • Four neuropsychological disability characteristics: • slower learning curves • lowered capacity for generalization • need for constant practice • vulnerability to change These characteristics may appear to be behaviorally/personality driven when in fact they are organically based

13. Return to Work-The Maryland Picture • For the nearly 250 individuals served by the Maryland TBI Project 7.03-6.10, unemployment rates ranged from @ 67%-87% any given year. Of those, the majority were employed worked part time • The DORS Acquired Brain Injury Program, initiated in 2006 has provided comprehensive prevocational, vocational and long-term supported employment services to individuals with brain injury. The overall rehabilitation rate for consumers closed from service status & beyond is 76.5%. (av. wage $9.86 per hr, av. of 24.3 hrs per week) data from ABI statistical report 3.3.11

14. Sequelae of TBI • What often underlies the challenges in return to work, school and major role are problems in: • cognition (including memory and judgement) • impulse control • modulation of affect • regulation of mood. These areas are often referred to as the neurobehavioral cluster…….

15. AKA, Executive Skill Dysfunction related to Frontal Lobe Injury

16. Functional Manifestations ofLiving with a Brain Injury

17. 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 perservation • He invents plausible sounding answers so you won’t know he doesn’t remember

18. 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

19. 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

20. Unawareness might look like…(Capuco & Freeman-Woolpert) • Insensitivity, rudeness • Overconfidence • Seems unconcerned about the extent of her problems • Doesn’t think she needs supports • Covering up problems (“everything’s fine…”) • Big difference in what he thinks and what everyone else thinks about his behavior • Blaming others for problems, making excuses

21. Executive Skills in Action:The “Widget” Factory

22. What does the Widget Factory Address?

23. Strategies-Cognitive Adapted for the Work Place - Create templates of routine work tasks/daily schedule or “to do” lists • Use of a daily job log/calender/contact sheet used in manual or electronic format • Label items - 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

24. Strategies-Cognitive Adapted for the Work Place • Identify mentor/colleague to assist individual • Decrease distractions (partitions, reduce noise…) • Teach strategies to maintain/regain focus (checklists; planner) • Break down tasks into smaller steps • Provide cues to re-direct consumer (work flow charts) • Modify work load & Increase pace of work assignments gradually

25. Strategies-Cognitive Adapted for the Work Place - Provide written and verbal instruction - Model tasks whenever possible - Encourage the individual to paraphrase instructions back to the speaker (use of email to summarize expectations) - Enter instructions in job log • Use a digital recorder to enter reminders and instructions to review/reinforce later • Use a highlighter (red) • Alarm watch/cell phone

26. Strategies-Cognitive Adapted for the Work Place • 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 daily written assignment sheet/create a daily schedule

27. Strategies-Behavioral Adapted for the Work Place(the following behavioral strategies maybe more pertinent to an employment specialist working with the individual) • Provide clear expectations for behavior • Plan and role-play social interactions that might occur at job site • Encourage individual to slow down and think through responses. • Outline strategies for controlling temper (count to five….) • Evaluate behavior and review possible alternative responses with individual

28. Strategies-Behavioral Adapted for the Work Place • Encourage individual to practice expressing thoughts in safe environment • Role play possible conversations with others in the workplace • Encourage individual to ask for time to organize thoughts • Teach individual active listening techniques, such as repeating what they heard from the other person

29. Strategies-Behavioral Adapted for the Work Place • Educate mentor/supervisor on specific communication difficulties and the way that he or she can assist individual • Educate co-workers on brain injury aftermath • Identify co-worker who will work with individual to prompt and redirect as needed

30. Strategies-Behavioral Adapted for the Work Place • Plan and rehearse social interactions • Review workplace interactions with individual and identify appropriate responses • Assist employer/supervisor to identify difficulties and use feedback in a positive way (privately; calmly; clearly)

31. Strategies-Behavioral Adapted for the Work Place • Anticipate possible lack of awareness • Assist individual in identifying and accepting limitations • Promote questioning by the individual in work situations when they are unsure of what to do • Identify feedback needs and strategies for supervisor

32. “Returning to Work After Brain Injury, A strategy guide for job coaches”Additional Tips from the Brain Injury Association of New Jersey 2009 • Develop a list of safe topics that can be used to start a conversation, e.g. recent ball game, movie, TV show or weekend activities. Practice these topics. • When asking a question to a supervisor or co-worker, develop a canned phrase, “do you have a minute now? Can you help me with ____?” • Suggest that the individual ask others what they think in order to promote two-way conversations. • If necessary, develop a list of work-appropriated topics with the individual. Discuss how this is different than social-and family-appropriate topics for outside the workplace

33. Keep in Mind- Returning work post a Brain Injury • Traditional vocational assessments penalize individuals with a history of brain injury secondary to poor cognitive processing/motor speed • Situational assessments are far more valid in determining vocational skills • Individuals with a hx of brain injury may have difficulty generalizing from one situation to another

34. Even for individuals with poor new learning capacity, the three R’s ReviewRehearse&RepeatCan lead to mastery of tasks as they eventually enter into memory

35. Spot the Strategies! Watch this scene from the 2007 Movie The Lookout What are the character’s injury imposed barriers? What are his strengths? What are the strategies he is using to compensate?

36. Return to Work after Severe Traumatic Brain Injury,One Person’s Journey

37. Brain Injury the Long Term Consequences

38. Brain Injury the Long Term Consequences Thank you Gary Trudeau http://www.doonesbury.com/strip/dailydose/

39. Resource Coordination Services in Maryland • Charlotte Wisner, Resource Coordinator for Frederick & Washington Counties, call 301-682-6017 • Lauren Dorsey, Resource Coordinator for Baltimore & Howard Counties, call 301-529-1508 • Catherine Reinhart Mello, Resource Coordinator for Montgomery County, call 301-586-0900 • Any questions regarding resource coordinator or free training on brain injury related topics, call Anastasia Edmonston, Project Director 410-402-8478

40. ResourcesSee Handout for additional resources • Brain Injury Association of America 703-236-6000, www.biausa.org • Brain Injury Association of Maryland 410-448-2924, www.biamd.org • Ohio Valley Center For Brain Injury Prevention and Rehabilitation, 614-293-3802, www.ohiovalley.org. • www.headinjury.com. Good resource for memory aides and tips

41. Resources staff training…. The Michigan Department of Community HealthWeb-Based Brain Injury Training for Professionals www.mitbitraining.org This free training consists of 4 modules that take an estimated 30 minutes each to complete. The purpose of the training is twofold, to “ensure service providers understand the range of outcomes” following brain injury and to “improve the ability of service providers to identify and deliver appropriate services for persons with TBI”

42. Acknowledgements...This presentation is a product of the Maryland TBI Projects, a collaboration of the MD Mental Hygiene Administration & the Mental Health Management Agency of Frederick County, and the Howard County Mental Health AuthoritySupport is provided in part by project H21MC06759 from the Maternal and Child Health Bureau (Title V, Social Security Act), Health Resources and Services Administration, Department of Health and Human ServicesSpecial thanks to: New Hampshire’s Project Response and the participating consultants of the Maryland TBI Post Demonstration II Project

43. Anastasia Edmonston MS CRCMD TBI Projects Directoraedmonston@dhmh.state.md.us410-402-8478