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Mild brain injury: critical factors in vocational rehabilitation.

The definition of mild brain injury as used in this article is a practical rather than neurological one. It refers to resulting in a transient alteration of consciousness, and a sometimes, but not always, brief hospitalization. The trauma may involve a fall, a blow to the head, or whiplash injury from a motor vehicle accident. Two major groups of injuries, diffuse mild brain injury and focal mild head injury, are considered. Deficits associated with diffuse injuries include: reduced speed and capacity of information processing; difficulties with complex attention; impaired memory and learning; and problems with abstract thinking. Deficits associated with focal injuries are primarily in the areas of learning and memory; planning and organization; attention and concentration; and emotional control. The injuries, however, are not mutually exclusive and may both be present in the same individual (Kay, 1986).

Review of Related Literature

It has been demonstrated that mild brain injury can result in significant changes not only physically, but cognitively as well (Rimel, Giordani, Barth, Ball, & Jane, 1981 and Stuss, Hugenholtz, Richard, LaRochelle, Poirier, & Bell, 1985). In addition, O'Hara (1988) has detailed the psychosocial difficulties associated with adjustment to a mild brain injury. As may be anticipated, deficits in the cognitive, psychosocial, and physical realms significantly impact future vocational success. Despite growing evidence that mild brain injuries comprise a substantial percentage of all brain traumas (Kraus & Nourjah, 1989), little attention has been directed toward the vocational rehabilitation needs of this population.

Recently, Hallauer, Prosser, and Swift (1989) described the importance of the neuropsychological evaluation in providing vocational rehabilitation counselors with a systematic assessment of functional deficits secondary to mild brain injury. Veach and Taylor (1989) outlined the significance of job trials, physical reconditioning, and psychosocial counseling to the vocational success of these individuals. This article will go a step further by outlining a model for delivery of vocational rehabilitation to this population.

Implications of Mild Brain Injury

Physical

Physical sequelae secondary to mild brain injury may include: (a) chronic fatigue due to general deconditioning and effortful cognitive processing; (b) impaired balance and coordination; (c) seizure activity; (d) chronic pain; (e) impaired motor skills; and (f) visual difficulties. The impact of impairment in these areas on vocational potential is often significant.

Most troublesome is the effect of chronic fatigue on physical stamina and work tolerances. Work endurance of only three to four hours per day is not uncommon. Many individuals also experience chronic, debilitating head and neck/back pain that contribute to fatigue and impact the ability to work an 8-hour day. Difficulties with balance and coordination may prohibit working at jobs that require climbing, working at unprotected heights, and walking on uneven terrain. Balance problems and seizure activity may impact the individual's ability to move quickly in hazardous situations and to safely operate machinery and/or equipment. Impaired motor skills in the areas of manual and finger dexterity may impact the person's ability to proficiently complete job tasks requiring the use of the hands or fine manipulation. Lastly, blurred and/or double vision may impact the individual's ability to work at occupations which require visual acuity.

Cognitive

Cognitive impairments may manifest in a variety of difficulties both on and off the job. The following list, although not exhaustive, outlines some of the typical problems. Memory deficits may impact the ability to learn new information and remember job tasks. Attention/concentration problems may result in difficulty staying on task due to distractibility; difficulty paying attention to more than one task or aspect of a task simultaneously; and difficulty returning to task after an interuption. Many individuals may also experience slowed speed of task performance and thus, the quantity of work may be below competitive levels. In the area of visual processing, the individual may be error-prone due to misinterpretation of visual information. Impaired auditory processing may result in difficulty comprehending verbal instructions and a need for repeated instructions at the work site. Reduced ability to organize, plan, goal set, and monitor behavior may result in the individual being easily overwhelmed by complex or non-repetitive tasks. Likewise, impaired reasoning skills may impact a person's ability to grasp abstract concepts and apply these to specific tasks.

Low frustration tolerance and lack of initiation are frequently seen in individuals with mild brain injury and may pose additional barriers to successful work performance. Frustration problems may manifest as irritability, impatience, and angry outbursts directed at supervisors and/or co-workers. Lastly, initiation difficulties may create the need for more supervision/directives from others in the work environment.

Psychosocial

The phyiscal and cognitive changes experienced by an individual with a mild brain injury can result in altered perceptions of self, as well as other psychosocial issues that directly impact potential for successful return to work. O'Hara (1989) maintains that the emotional adjustment of persons who have sustained mild head injury is of even greater importance than that of individuals who have suffered more severel trauma. She defines several factors that appear to contribute to this phenomena. First, individuals are often unaware of "why" they are experiencing cognitive, physical and psychosocial problems due to minimal explanation of symptomology by medical providers. This lack of awareness may result in emotional distress and confusion. Second, many individuals are told that all of their symptoms will disappear over time. This may result in a premature return to work and a subsequent failure experience. Third, individuals with mild brain injury, because of relatively intact cognition, may have a heightened awareness of changes in their cognitive, physical and psychosocial status. This often creates intense stress and anxiety. And lastly, individuals often experience a delay in diagnosis and treatment. This, too, can result in anger and frustration as well as the opportunity for development of dysfunctional behaviors.

Premature return to work after injury, as mentioned previously, often results in a failure to meet former work performance standards. The consequence is quite frequently a severe decline in the individual's self-esteem and a marked reduction in confidence in work skills. It has been hypothesized that return to a stressful job, when cognitive recovery is incomplete, plays a significant role in the persistence of cognitive problems and the development of emotional difficulties (Wood, Novack, & Long, 1984).

Finally, denial of deficits may impact the individual's ability to critically evaluate work performance and to realistically set vocational goals. Musante (1983) has asserted that awareness of deficits and recognition of the impact of these problems on vocational status is the most critical factor in the vocational rehabilitation of individuals who have sustained a brain injury.

Critical Factors in Vocational Rehabilitation

Given the nature and extent of deficits associated with mild head injury, there appear to be six (6) critical factors in the vocational rehabilitation of this population. Of prime consideration is remediation of cognitive deficits and development of compensatory strategies to be utilized at the work site. Second, the individual needs to experience an improved acceptance of vocational limitations and a significant improvement in self-esteem and confidence in work skills. Third, the person must experience a reduction in fatigue and an increase in work tolerances. Fourth, it is strongly recommended the individual participate in a trial work experience prior to reentering competitive employment. Fifth, the individual's ability to tolerate frustration and regulate emotional responses at the work site must be increased. And finally, the worker should be provided intensive follow-up services upon return to employment.

Program Structure and Participants

As the previously mentioned studies point out, the rehabilitation and subsequent vocational success of individuals who have sustained a mild brain injury requires the integration of a variety of services to address the multiplicity of cognitive, psychosocial, and physical problems specific to mild brain injury. This paper outlines such a program and suggests a systematic model for delivery of vocational rehabilitation services.

The Mild Brain Injury Program at the Center for Cognitive Rehabilitation Good Samaritan Hospital, Puyallup, Washington, provides cognitive remediation, psychosocial counseling, and vocational rehabilitation services to assist individuals with mild brain injuries in their reintegration into the community. Vocational outcomes reported here involved twenty (20) individuals who participated in rehabilitation at the Center between August 1987 and October 1989.

Admission Guidelines

Admission guidelines for the program include: (a) between ages of 18-60; (b) neuropsychological evaluation prior to program entry; (c) potential for improvement in at least two of the three treatment areas-- cognitive, pyshosocial, and vocational; (d) ability to live independently in the community; (e) physical stamina to tolerate a three-to-four-hour treatment day; (f) able to participate in two-way communication; and (g) abstinence from alcohol and other mind-altering drugs.

Typical presenting cognitive problems of the sample were: deficits in attention/concentration, memory and new learning, organization and planning, speed of information processing, and abstract thinking. Psychosocial difficulties included: low frustration tolerance; depression; anxiety; reduced ability to cope with stress; family problems; and reduced self-esteem.

Program participants involved in the sample ranged in age from 21-51, with a mean age of thirty-four (34). Sixty (60) percent were men, forty (40) percent women. Months post-injury ranged from eight (8) months to eight (8) years, with an average lenght of time since injury of 29.5 months.

The Mild Brain Injury Program (CCR-2) is an outpatient day treatment program designed to serve up to eight individuals during a six-to-ten-month period. Participants are involved in Center activities three to five days per week. A weekly treatment program typically includes: four hours of cognitive retraining; two hours of individual psychosocial counseling; one to two hours of individual vocational counseling; six to twenty hour of work station; and three hours of group therapy. Group sessions include: one hour of vocational or communications/cognitive group on alternating weeks, and two hours of psychosocial group weekly. In addition, some program participants concurrently maintain full or part-time employment.

The program is staffed by an interdisciplinary team representing: neuropsychology, cognitive therapy, occupational therapy, psychology, and vocational rehabilitation. Physical therapy and/or reconditioning, and recreation therapy services are also available, if needed, through other hospital departments.

Service Delivery Model

In this section, the service delivery model developed and currently utilized in the Mild Brain Injury Program is described and correlated with the critical factors outlined previously in this article.

This model involves close integration of services between the three program components-- cognitive, psychosocial, and vocational. Although each component maintains individual treatment goals specific to that discipline, all elements work together to attain the overall program goal of returning the individual to the highest possible level of productivity. The model for vocational intervention is divided into four phases designed to accomplish specific vocational counseling goals.

Development of Self Awareness

The first three to four months of treatment focus on assisting the individual in developing an awareness of who he or she is as a worker. Vocational intervention, via individual and group therapies, includes both formal vocational testing and experiential activities designed to clarify vocational strengths/limitations. Formal testing includes adminstration of interest and aptitude tests and work values and learning style inventories. In addition the individual independently completes a written transferrable skills analysis with assistance from the vocational counselor. During this initial phase of treatment, physical deficits are indentified and programming is implemented to address physical needs and build work tolerances.

Group work provides a forum for discussion of such topics as: (a) injury-related vocational losses such as loss of earning potential, status, seniority, benefits, promotions; (b) fears related to return-to-work, i.e., poor work performance, termination, lack of understanding of brain injury from supervisors/co-workers, and demotion; (c) needs/values as they relate to work; and (d) vocational limitations imposed by the injury. Concurrently, the individual is involved in cognitive retraining and intensive psychosocial counseling.

A critical adjunct to treatment during this period is the work station, a trial work experience utilized at the Center to assess cognitive and psychosocial carry-over to a functional work setting. Involvement in the work station provides the individual with an opportunity to rebuild self-confidence in work skills and to renew faltering self-esteem. The work station is also utilized by staff to assess work behaviours and to build work tolerances. Each work station is designed to continue for a minimum of eight weeks. An individual is typically involved in at least two different work stations over the course of treatment. Attempts are made to both increase the level of task difficulty while decreasing the amount of structure during the work station experience. Crucial to the success of the work station is the utilization of a job coach at the worksite during the initial training period and when new tasks are introduced. Job coaching on a continual basis is not typically necessary with this population, nor is it desirable, since many individuals with mild brain injury respond negatively to over-supervision. Renewed self-confidence in work skills tend to flourish as the individual realizes that he/she can adequately perform work tasks utilizing newly-learned compensatory strategies.

Center work stations are located in Good Samaritan Hospital as well as in the surrounding community. Every effort is made to develop work stations that meet the unique cognitive/psychosocial/physical needs of each individual program participant. Progress in the work station is monitored closely by the CCR vocational counselor on a weekly basis. Written evaluations of work station performance are completed monthly and shared with the staff and program participant. Important, also, to the success of the work station is the education/training provided to work station supervisors prior to the work experience.

Identification of Vocational Alternatives

During months four through six of treatment, vocational activities focus on identification of alternatives for future employment. As mentioned earlier, each program participant completes a written analysis of transferrable skills. An important facet of this activity is the individual's subsequent presentation of his/her skills to the vocational group. This is an informal oral presentation designed to assist the individual in learning to verbalize his vocational assets and limitations. Group members then provide feedback regarding skill levels and also brainstorm possible vocational goals given that person's unique work history. The dynamics of peer influence are especially effective here in assisting the individual in assessing the appropriateness of his/her goals given current cognitive difficulties. The feasibility of alternatives are then further assessed by the individual and the vocational counselor through work station involvement, job/task analysis, and administration of specific work samples. In addition, the cognitive and psychosocial therapists provide significant input regarding the feasibility of the vocational goal from their particular treatment perspective.

Development of Job-Seeking Skills

Concurrently with vocational goal selection, the individual is involved in job-seeking skills training via individual and group sessions. Extensive training is provided in interview skills utilizing role play and videotape. Other topics covered during this training include: resume construction; application completion; telephone techniques; finding job leads; and job search organization skills. Special attention is paid to teaching the individual how to answer disability-related questions from potential employers and how to self-advocate in the job market. Throughout the group process, the vocational counselor lays a supportive/instructional role, providing direction and needed structure.

Job Placement/Follow-up

The Center's goal for the majority of participants is return to the highest level of employment consistent with aptitudes, interests, transferrable skills, physical capacities, and cognitive/psychosocial abilities. Placement services are provided during the last sixty days of treatment. Crucial to successful placement are: (a) an on-site job analysis of the proposed occupation; (b) placement site education and training; (c) utilization of a job coach; and (d) extended follow-up at the work site.

Firstly, a job analysis, which incorporates the cognitive requirements of the position, is vital. At the Center, the job analysis form developed and currently utilized includes a section on ten specific cognitive skill areas, which correspond with typical deficit areas seen in mild brain injury. Areas of concern are: memory; attention/concentration; organizational skills; speed of performance; perceptual accuracy; initiation skills; motor skill; auditory processing; reasoning skills; and frustration tolerance. The level of supervision available to the worker and number/kind of environmental distractors are also delineated. An adequate job analysis, prior to actual job placement, increases the chances of a successful placement and job retention over time.

Second, the employer and line supervisor receive extensive education and training regarding mild brain injury. Educational efforts include discussion of: (a) the vocational implications of brain injury and impact on work performance; (b) the level of supervision required; (c) amount of initiative and adapability the person can be expected to exercise on the job; (d) ability to tolerate distractors; and (e) need for written compensatory strategies.

Third, the utilization of a job coach during the initial training period to assist the individual in adapting compensatory strategies to the specific work site, is strongly recommended. A job coach is also crucial when new tasks or procedures are introduced at future times. Ongoing duties of the job coach are to continue supervisor/co-worker education; assist in resolving cognitive/psychosocial difficulties as they arise; provide emotional support to the individual; and to identify needed accommodation.

Lastly, extended follow-up for an indefinite period of time is necessary to achieve long-term vocational adjustment. Although lenght of follow-up is determined by individual need, the average at CCR-2 is typically one year. In follow-up, the vocational counselor often provides crisis intervention services due to the individual's susceptibility to behavioral breakdown during times of personal and/or environmental stress. Such follow-up allows for immediate intervention as physical, cognitive, psychosocial, or task-related difficulties occur. Frequent contact by the vocational counselor with a supervisor and/or co-workers on the job results in timely resolution of work-related difficulties and a greater likelihood of adjustment to employment and long-term job retention.

Vocational Outcomes

The following outlines vocational outcomes at the Mild Brain Injury Program between August 1987 and October 1989. Of the twenty participants treated during this period, eighteen are currently employed at competitive levels (90%).

Of these 20, five were employed at program entry, but experiencing significant work difficulties which threatened job retention. All five (5) were able to remain with their employer, three (3) in less demanding positions and two (2) were promoted to jobs of greater responsibility.

Six other individuals returned to jobs with their previous employers; four to their job at a time injury and two to lower skill-level positions. In all cases, return to work was negotiated with the employer by the vocational counselor. The remaining eight program participants returned to different jobs with new employers.

Twelve of these individuals have been followed for a year post-discharge and have been able to successfully maintain adequate work performance levels. One individual was unable to continue employment due to chronic pain related to a back injury and one was re-injured sustaining a severe brain injury in a home accident.

Discussion

The purpose of this article has been to provide a structured, systematic approach to the vocational rehabilitation of individuals with mild brain injuries. It describes a model that provides rehabilitation counselors with information valuable to vocational planning with this particular population. Further research, however, utilizing a control group, is needed to determine if the service delivery model outlined is, in fact, a major factor in returning individuals with mild brain injury to employment. Such research might consider other confounding factors such as family support and employer attitudes on return to work rates.

References [Barth, J.T., Macciocchi, S.N., Dierdani, B. (1983). Neuropsychological sequelae of minor head injury. Neurosurgery, 13, 529-533. Blankenship, M. (1988). The role of the vocational rehabilitation specialist in assisting the person with a minor head injury. Cognitive Rehabilitation, 6,2. Clowers, M.R., & Stolov, W.C. (1981). Stroke and cerebral trauma: psychological and vocational aspects. Handbook of Severe Disability, 1,127-135. Dikmen, S., McLean, A. & Temkin, N. (1986). Neuropsychological and psychosocial consequences of minor head injury. Journal of Neurology, Neurosurgery & Psychiatry 49, 1227-1232. Headley, B. (1989). Delayed recovery: taking another look. Journal of Rehabilitation, 55 (3), 61-67. Jennett, B. (1978). The problem of mild head injury. Practitioner, 221, 77-82. Kay, T.(1986). Minor head injury: an introduction for professionals. National Head Injury Foundation Publication. Minderhoud, J., Boelema, M., Huizenga, J. (1980). Treatment of minor head injuries. Clinical Neurology and Neurosurgery, 82, 127-140. O'Hara, C. (1988). Emotional adjustment following minor head injury. Cognitive Rehabilitation, 6 (22), 22-24. O'Shaughnessy, E.J., Fowler, R.S., & Reid, V.(1984). Sequelae of mild closed head injuries. Journal of Family Practice, 18, 391-394. Prigatano, G.P., Fordyce, D.J., Zeiner, H.K., Roueche, J.R., Pepping, M., & Wood, B.C. (1984). Neuropsycological rehabilitation after closed head injury in young adults. Journal of Neurology, Neurosurgery, and Psychiatry, 47,505-513. Rimel, R. W., Giordani, B., Barth, J.T., Boll, T.J., & Jane, J.A., (1981). Disability caused by minor head injury. Neurosurgery, 9, 221-228.]
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Author:Hurt, Ginger D.
Publication:The Journal of Rehabilitation
Article Type:Editorial
Date:Oct 1, 1991
Words:3441
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