Employer acceptability of behavioral changes with traumatic brain injury.

Employer Acceptability of Behavioral Changes with Traumatic Brain Injury 

The perceived suitability of various entry level occupations for persons who have sustained traumatic brain injury (TBI) was evaluated with an employer questionnaire. For persons who show the behavioral sequelae of TBI, occupations in the agriculture/forestry and manufacturing/construction occupations are perceived as more suitable than retail or service occupations. This pattern is opposite to that found for persons with physical disabilities only. Distractibility was the behavior seen as least acceptable to the employers surveyed, while lack of initiative was seen as the most acceptable behavior surveyed. Results indicate that employer attitudes toward behavioral changes following TBI are very different from those toward changes imposed by physical limitations.

Each year an estimated 422,000 (or 200 per 100,000) Americans sustain closed head injuries which require hospitalization (Kalsbeek, McLaurin, Harris & Miller, 1980). Many survive injuries which, in the past, would have proven fatal (Becker, Miller, Ward, Greenberg, Young & Sakalas, 1977). Survivors of these injuries may be left with cognitive, psychological and psychosocial deficits ranging from mild to severe. Approximately one in 5,000 of these injuries are rated as of moderate or severe degree (Vogenthaler, 1987). However, even mild brain injuries with good physical recovery will result in many persons experiencing serious difficulty in resuming their day to day activities due to cognitive and behavioral deficits (Long, Gouvier & Cole, 1984).

Vocational outcome of persons with traumatic brain injury (TBI) is variable. As reported in a recent review (Ben-Yishay, Silver, Piasetsky, & Rattek, 1987), return to work rates as reported in 37 separate studies ranged from 100% after a three month follow-up period (Wrightson & Gronwall, 1980) to only 15% after three months (McKinlay, Brooks, & Bond, 1983). This variability may be due to a variety of factors, including heterogeneous samples with regard to severity of injury, and a lack of uniform criteria for defining what constitutes resumption of work (Ben-Yishay, Silver, Piasetsky, & Rattek, 1987). In studies in which severity of injury is clearly delineated and controlled, however, the rate of TBI patients returning to work becomes more clear. Ben-Yishay et al. (1987) reported that in four comparable groups of 30 to 50 chronic, traumatically head-injured young adults who had been followed for up to two years and involved in various rehabilitation programs, less than 3% had proved able to achieve employment at competitive levels. Many other studies report serious employment difficulties for injured persons even several years post-injury (Najenson, 1980; Hpay, 1970; and Bruckner & Randle, 1972).

Physical and mental deficits following TBI may both contribute to this failure, but the "...mental sequelae outstrip the physical as a cause of difficulty with rehabilitation, hardship at work, and social incapacity generally..." (Lishman, 1973). Mental sequelae must be addressed in the vocational rehabilitation process if efforts to obtain and hold employment are successful. Although a TBI survivor's mental deficits will vary depending on the location and severity of injury, a distinctive pattern of emotional and behavioral disturbance often emerges following TBI. This disturbance may contribute to prolonged functional disability even in cases in which there is no noteworthy neurological or intellectual deficit (Levin & Grossman, 1978). This behavioral impairment often includes a symptom constellation which may include any or all of the following: memory impairment, personality disturbance (including disinhibition and irritability), decreased motor control and fatigue, speech and language difficulties, attention and concentration deficits, and lack of initiative (Hpay, 1970; Levin & Grossman, 1978; Lezak, 1978; Lishman, 1973; Newcombe, 1982).

Obtaining stable occupational placement is often referred to as the ultimate goal and focus of vocational rehabilitation (May & Vieceli, 1983), and care must be taken in selection of appropriate vocational directions for traumatically brain injured persons. Initial attempts at preparing a person for return to work following TBI may include a detailed assessment of pre-injury job requirements, assuming that the person will return to previous employment. Activities in a cognitive rehabilitation program may be designed to approximate such requirements (Long, Gouvier & Cole, 1984). Such an approach may lead to a return to previous employment. However following TBI, it is frequently necessary to prepare for a new occupation.

Employer attitudes and perceptions are central to successful employment. In their survey of employer attitudes regarding various types of workers with disabilities, Fuqua, Rathbun & Gade (1983) found that employer attitudes varied toward specific types of disabilities. Employers were most concerned about hiring the blind and the mentally retarded. Least concern was indicated for hiring those with epilepsy. This finding is verified by English (1971) and by Hartlage and Taraba (1971), who found that employers prefer people with disabilities who have bodily impairments (e.g. amputees) over those with mental or sensory disorders (e.g. the blind and mentally retarded). This has implications for the TBI population, since the deficits of this population are generally non-visible and cognitive in nature.

The goal of this study was to identify suitable vocational options for the person who has sustained TBI, and who cannot return to their pre-injury occupation or is not yet in the work force. A questionnaire was used to examine employer attitudes regarding common behavioral sequelae of TBI: decreased motor control and fatigue, personality changes, memory problems, distractibility, and lack of initiative.

Method

Subjects

The subjects were 122 employers in the fields of manufacturing/construction, agriculture/forestry, wholesale and retail trade, and service. The field to which an employer was classed was defined by guidelines specified in the Dictionary of Occupational Titles (1977). Employers were selected from the Washington State Manufacturers Register (1986) and Contacts Influential (1986), a publication listing all Washington State employers and the nature of their business. Specific occupations surveyed were selected from the Dictionary of Occupational Titles (1977). Employers were asked to describe the acceptability of specified behaviors for the occupations within their industry. Employers, who were evenly distributed throughout the four groups, were selected from a three-county urban area in Washington State.

Materials

A two-page questionnaire designed to assess acceptability of selected behavioral sequelae of TBI was constructed. Each employer was asked to evaluate each behavior as "acceptable" or "not acceptable" for the job in question. A "positive" statement consisting of a relatively neutral behavior not associated with brain injury was included in each question. A sample question reads, "Mr. Smith does not act spontaneously and may have to be told what to do. He is, however, motivated to do a good job." Two descriptions were offered for each behavioral symptom. Content validity was determined by the authors based upon TBI literature and clinical experience. To reduce the effect of stereotyped beliefs regarding brain injuries on the part of the employers, neither the enclosed cover letter nor the questionnaire indicated that brain injured patients were the population in question.

Procedure

The attitude questionnaire was sent to 122 employers together with an addressed and stamped return envelope. Forty-four responses were received, and an additional four responses were received after a follow-up telephone call. Therefore, a total of forty-eight (39.3%) responses were received and included in the study. The reason for this somewhat low response rate is unclear. However, non-respondents were evenly distributed over the four employer groups.

Results

Employers in agriculture and forestry gave the greatest number of "acceptable" responses (Mean = 5.0). Employers in service industries gave the fewest "acceptable" responses (Mean = 2.4). Differences in mean number of "acceptable" responses between the four groups (agriculture/forestry, service, manufacturing/construction, wholesale and retail trade) were not statistically significant (Kruskal-Wallis test for k independent samples, p=.058).

Manufacturing/construction occupations were grouped with agriculture/forestry occupations to form a "general labor" group (N = 27; Mean "acceptable" responses = 4.9). Wholesale and retail trade were combined with service occupations to form a "service" group (N = 21; Mean "acceptable" responses = 2.4). These two groups differ in employer perception of behavioral acceptability (Mann-Whitney U test, p=.006), with the "general labor" employers providing a significantly greater number of "acceptable" responses.

The acceptability of each individual behavior was then calculated across fields. Lack of initiative was the most accepted behavior, followed by memory difficulties, movement/fatigue problems, personality disturbances, and distractibility.

Discussion

Employers in the manufacturing and construction, and agriculture and forestry industries find the behavioral symptoms of those who have sustained TBI more acceptable than employers in the retail and service fields. By contrast, persons with physical disabilities are more frequently employed in service occupations (Report of the Canadian Health and Disability Survey, 1983).

This study did not examine the minor speech and language problems frequently found in the TBI population. These problems might be expected to increase the vocational handicap for occupations in which public contact is important.

All fields of employment surveyed found distractibility to be the least acceptable symptom. This is encouraging as this attribute appears relatively amenable to improvement through cognitive retraining. Cognitive rehabilitation focused on sustained attention tasks should prove to be a valuable step in vocational rehabilitation. Lack of initiative was the behavioral symptom most acceptable to all employers. It should be noted, however, that the jobs surveyed in this study were entry level positions only.

These data have implications for the direction of the employment search for those who have sustained TBI. Following physical disability persons are somewhat more likely to obtain work in service delivery industries, as opposed to work requiring physical skill. Service industries are providing a growing sector of entry level positions. By contrast the behavioral changes associated with TBI appear to make successful employment in service occupations less rather than more likely. Vocational counselors working with disabled populations may need to incorporate this information in occupational planning.