Brain Injury, Work and Challenging Behavior~

Understanding the Potential Employee with Brain Injury and Techniques for Management

of Behavior

Joelle M. Ridgeway, CTRS, CBIS Executive Director, Mary T Maryland and

Deborah L. Cottrill, MS, CRC, CBISVocational Program Director, Mary T. Maryland

The Scope of TBI in Maryland Estimated 61,970 individuals living with a long-term

disability as a result of brain injury During 2008/2009, nearly 7,000 Maryland residents

were discharged from a Maryland hospital after inpatient treatment for TBI - an average of 19-20 discharges daily. The number of annual TBI-related discharges in 2009 had increased by about 5% over the number in 2005.

Maryland residents have increasingly sought treatment for TBI in the state’s Emergency Departments. During 2009, 40,725 TBI-related visits were recorded. This number is dramatically greater (68%) than the 24,312 observed just 4 years earlier (2005).

Source: Maryland TBI Advisory Board Annual Report 2011

Severity of Injury ◦ Mild injuries = 80%

(Loss of Consciousness < 30 min, Post Traumatic Amnesia <1 hour) Even though these individuals have less severe symptoms as a result of their injury, they may experience difficulty with the idea of working less hours, changing career paths, or accepting less pay than they did prior to the injury.

◦ Moderate = 10 - 13%(LOC 30 min-24 hours, PTA 1-24 hours) Moderate injuries can result in a wide variety of issues from anosagnosia (being unaware of their deficits), personality issues, memory, processing, organizational etc.

◦ Severe = 7 - 10%(LOC >24 hours, PTA >24 hours) Even though these individuals are considered severe, they can be good candidates for return to work and sometimes are more willing to accept a change in pay, hours and career path.

** Individuals who have incurred mild, moderate or severe brain injuries can have the potential for return to work, with the right supports in place. A good predictor of success, is work history prior to their injury.

Possible Physical Changes Affecting Work

Motor skills/BalanceHearingVisionSpasticity/TremorsSpeechFatigue/WeaknessSeizuresTaste/Smell

Possible Cognitive (Thinking) Changes Affecting Work

MemoryAttentionConcentrationProcessingAphasia/receptive

and expressive language

Executive skillsProblem solvingOrganizationSelf-PerceptionPerceptionInflexibilityPersistence

Possible Mood/Personality/Behavior Changes Affecting Work

DepressionSocial skills problemsMood swingsProblems with

emotional control Inappropriate

behavior Inability to inhibit

remarks Inability to recognize

social cues

Problems with initiationReduced self-esteemDifficulty relating to

othersDifficulty maintaining

relationshipsDifficulty forming new

relationshipsStress/anxiety/

frustration and reduced frustration tolerance

Attention Deficit May Look Like Not Paying Attention or It May

Look Like…..(Capuco & Freeman-Woolpert)

He keeps changing the subjectShe doesn’t complete tasksHe has a million things going on and

none of them ever gets completedWhen she tries to do two things at

once she gets confused and upset

A Memory Deficit May Look Like Having Trouble Remembering or It

May 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 perseveration

He invents plausible sounding answers so you won’t know he doesn’t remember

Executive Skills Deficit Might Look Like the Inability to Plan and

Organize or It Might Look Like…..(Capuco & Freeman-Woolpert)

Uncooperativeness, stubbornnessLack of follow throughLazinessIrresponsibility

Unawareness Might Look Like…..(Capuco & Freeman-Woolpert)

Insensitivity, rudenessOverconfidenceSeems unconcerned about the extent of her

problemsDoesn’t think she needs supportsCovering up problems (“everything’s fine…”)Big difference in what he thinks and what

everyone else thinks about his behaviorBlaming others for problems, making

excuses

General Management Guidelines Increase Rest time- fatigue is

a big issue in brain injury Keep the environment

simple- People with brain injury can get over stimulated

Keep instructions simple- be concrete and provide cues/instruction/prompts as needed

Give Feedback and set goals- positive reinforcement

Be calm and redirect to task Provide choices Decrease the chance of

failure

Person Centered Approach Be supportive Be consistent Be flexible Treat everyone with dignity

and respect Don’t talk down to people Don’t take things

personally Avoid Arguments Vary activities Over-plan Task analyze

See Handout: “Tips for Employers”

Applied Behavioral Analysis

(Wood and Anderson, 2011)

•An operant theory of learning•Behavior “operates” on the environment and is maintained by its consequences•Probability that a behavior occur again is based on

Whether or not it was rewarded (positive and negative reinforcement)

Withheld (extinction)Punished (positive punishment)

Applied Behavioral Analysis

(Wood and Anderson, 2011)Any combination of 3 reinforcement

contingencies can underpin challenging behavior◦ Social-positive reinforcement: behavior is

maintained by contingent delivery of environmental reinforces (i.e., social attention and tangible items such as food, favored objects, preferred activities)

◦ Social-negative reinforcement: behaviors serve to remove, postpone, or reduce adverse stimuli (i.e., escape and avoidance)

◦ Automatic reinforcement: non-environmental operant mechanisms that maintain behavior (i.e., internal stimuli that occur as a process of perceptual feedback, modulation of arousal, pain attenuation)

General Terminology in a Behavior Plan

Target Behaviors:◦ Adaptive: Positive behaviors we want to increase◦ Maladaptive: Negative behaviors we want to

decrease. These are generally the targeted behaviorsFunctional Assessment:

◦ Assessment to understand the function of the behavior

Reactive Strategies:◦ Proactive: Actions taken to decrease probability of

a behavior occurring. This is done before a behavior begins.

◦ Reactive: Actions taken to stop the behavior once it has already started. These are typically more restrictive in nature.

The ABC’s of Behavior

Antecedent: What happens before the behavior

Behavior: Specific action of the individual

Consequence: What happened as a result of the behavior (i.e., reward, + or – reinforcement)

Date Start Time End Time Antecedent Behavior Intensity Intervention Location Comments Staff

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Antecedents Behaviors Intensity Interventions

1. Staff Direction 1. Failure to Cooperate 1. Low 1. Setting Limits (verbal prompts, physical presence)

2. Denied Access/Request to Item/Activity 2. Inappropriate Social Behavior 2. Moderate

2. Modified Planned Ignoring

3. Transition 3. Verbal Aggression 3. High/Severe 3. Offered choice of another activity

4. Interruption of Activity 4. Aggression Towards Property   4. Offered choice of moving to another area

5. Particular Peer in Area 5. Physical Aggression   5. Modified environment to decrease the behavior

6. Loud Environment 6. Elopement   6. Physical Proximity and Body Positioning

7. Unengaged 7. Other   7. Shadowing Procedure for Elopement

8. Violation of Personal Space     8. Physical Redirection/Deflection

9. Violation of Personal Belongings     9. Physically Blocking access to targeted person

10. Introduction of an Unfamiliar or Difficult Task     10. Verbal Redirection to an Alternate Location

11. Unable to Communicate Wants/Needs     11. Physical Escort to an alternate location (must specify type utilized)

12. Illness     12. Physical Intervention (specify BPS stategies used)

13. Toileting Accident     13. Response Cost Procedure - Loss of Next Family Visit

14. Break Time     14. Other (Must Specify in Comment Section)

15. Other (Must specify in comment box)      

Proactive Strategies

Behavior Specific Praise: “I like how you went back to double check your work.”

Positive Prompting: Do not give attention to the negative behavior. ◦ Examples~

Person is distracted from work task: “You were just finishing this task, what is next?”

Person wanting to leave shift early: “You have worked for two hours, it is almost time for your break.”

Person yelling at co-worker: “Lower your voice please” Person being rough with equipment: “Let’s put the

mop down now.” Person grabs your arm: “Please keep your hands to

your self”

Proactive Strategies

Physical Presence: Never leave in the middle of a behavior. Always see a behavior through to the end. Need to monitor after behavior as well. An employer will rely on the job coach to be the calming factor in the equation.

Differential Reinforcement of Incompatible Behavior (DRI): Reinforcement of a behavior that is physically or functionally incompatible with targeted/maladaptive behavior. Job Coach should quickly redirect to a work task that the employee has shown great success and ease at completing – focusing on the strengths.

Proactive Strategies

Differential Reinforcement of Other Behavior (DRO): Rewards any specified form of positive/constructive behavior that occurs during the same time period as the targeted/maladaptive behavior. Ex. “You have done a great job getting all those carts together, you are working very hard today.”

Environmental Control: Modification of the environment the decrease behaviors. Ex. “We are going to break up the list of things to get done before you leave. Let’ see how many you can get through.” **Staff may need to advocate for the person by explaining the fatigue and behavior factor and giving a solution quickly.

Reactive Strategies Always begin with positive prompting Modified Planned Ignoring: Disengaging all social or casual

interaction with an individual while he/she engages in maladaptive behaviors, and refraining from providing any attention to the maladaptive behaviors, so as not to inadvertently reinforce the behaviors. The only interaction that will occur while implementing modified planned ignoring is interaction necessary to maintain the health and safety of the individual (and others in the environment), and/or to provide verbal prompts to the individual in order to help him/her de-escalate from the behavioral episode/engage in appropriate behaviors. For example, if an individual is refusing to continue working, and is engaging in verbal aggression by calling the job coach inappropriate names, the job coach will not acknowledge the name-calling by saying “don’t call me that name”, or “that’s not nice”; rather the job coach will only provide verbal prompts, separated by a specific period of time, related to the work task (i.e., “please finish putting the carts away”). Conversation does not deviate from the task at hand.

Reactive Strategies

More restrictive measures can include (but are limited by regulations and human rights committees): ◦ Alternate Location◦ Motion Sensors◦ Response Cost Procedures- A reductive procedure in

which a specified amount of available reinforces are contingently withdrawn following the response (behavior).

◦ Restitution- Requiring an individual to correct the consequences of his behavior by having him restore the situation to the same (or as close to the same as possible) state as it was prior to the behavior.

◦ Physical Redirection/Deflection◦ Physical Intervention

Case Examples

CR- Scheduled Breaks and Behavior – Cigarettes and Coffee◦ Environmental Control, Positive Prompts, Modified Planned

Ignoring, Compensatory Strategies (written reminders – pictures of clocks) and (CR - Pre-work checklist)

GM – Leaving Work Area – Incomplete Tasks ◦ Environmental Control, Positive Prompts, Modified Planned

Ignoring, Compensatory Strategies (picture schedule), Increased Communication with Supervisor and Co-workers

KP – Loaning Money to Peers and Behavior - Uniform◦ Environmental Control, Compensatory Strategies (sticker in

wallet “Do Not Loan Money to Anyone”) (KP Pre-work checklist)

KB – Public Urination/Defication and Cursing at Supervisors and Job Coach◦ Environmental Control, Restitution, Modified Planned Ignoring,

Alternate Location – still coming up with new strategies

Case Examples•AW- Refusal to Shower: Environmental control, positive prompts, modified planned ignoring•RC- Physical Aggression DRO•LH- SIB and Self Stimulation in Public: Environmental Control•DB- Urinating in Van, Corners, Bedroom: Environmental Control, Restitution•TW- Verbal Aggression: Modified Planned Ignoring, Alternate Location•VM- Refusal to Shower and Property Destruction DRO and DRI

Basic Responsibilities of a Job Coach

Demonstrate positive work behaviors (show up and be on time)

Be a positive and interactive trainerDevelop a relationship with the employeeDevelop a relationship with the employer and co-

workers of the employeeEducate others about how to best work with the

employeeUse creative compensatory strategies to support

learning tasks and job dutiesLearn the learn job duties well and be able to

teach them in a way that will support learningGet and give constructive feedback periodically

Characteristics of a Job Coach

Responsiveness: Expresses an interest in the employee, is a good listener, has good communication skills, accommodates individual differences, maintains a relaxed manner, is receptive to questions

Enthusiasm: Is energetic, optimistic, prepared and willing to commit time

Humor: Able to incorporate appropriate humor during training by using personal and/or real-life examples

Sincerity/Honesty: Takes every question seriously and does not pretend to know the answer if they don’t know

Flexibility: Able to eliminate, adjust, or change material during training according to the employee’s needs and time constraints

Tolerance: Able to accommodate different personalities and learning styles; accepts constructive criticism and does not take it personally

Essential Relationships

Employee

Job Coach

Employer

Essential Relationships

Employee Job CoachThe employee should understand why they have a job coach and

the benefits of having one. The employee and job coach should have an open relationship, based on trust. If there is something positive or negative to share, they should be able to do that without worrying about the consequences. They should be able to ask for help when needed. They should talk about any problems they are having on the job, so that a solution can be found.

Job Coach EmployeeThe job coach should be able to give constructive feedback to the

employee in order to make improvements on the job. The job coach should be creative about teaching compensatory

strategies to the employee. The job coach should model how to advocate for the employee. The job coach should always give

as much positive feedback as possible, along with areas in need of improvement.

Essential RelationshipsEmployee Employer

The employee should be able to communicate with his/her employer about their needs on the job (even if it is only

through the job coach). The employee should speak respectfully of the company, supervisors and co-workers

while at the worksite. The employee should demonstrate to the employer they are a hard worker and are thankful for being given the job. The job coach is the role model for

most of this behavior.

Employer EmployeeThe employer hired the employee, so they must have seen

something that they liked about the person. An employer should feel that they can give the employee an assignment

and it will get done to their satisfaction. The employer wants to see a committed employee who makes their business shine. At times the job coach becomes the

translator, facilitator, and/or reinforcer of information.

Essential RelationshipsJob Coach Employer

The job coach should explain to the employer the benefits of having one on site, of site, or available when needed. The job coach

should be a source of information for the employer on how to best work with the employee. The job coach should be able to talk openly with the employer about requests, accommodations,

suggestions and compensatory strategies used on site. The job coach should frequently check in with the employer about the

employee’s progress and communicate concerns quickly.

Employer Job CoachThe employer should be able to easily reach the job coach at a moments notice, know when they will be present and be able to

talk about anything - positive or negative. An employer should be able to communicate to the job coach about any changes that might be happening at the worksite, such as scheduling or job

duties. The employer should always know the contact information of the job coach and service provider. The employer should see

the job coach as an asset, to the employee, and to their company.

Communication Essentials That Can Prevent Negative Behavior

Vocational staff must develop trust and rapport with the individual with the brain injury, which is accomplished through honest and sincere communication.

The employee should understand why they have a job coach. Explaining as much as necessary what a job coach can do to support them is essential.

The individual and the employer should have the service provider/job coach’s current contact information.

Always communicate to the individual and the employer what will be accomplished while a job coach is on site – training, observing, getting feedback.

Always communicate if the job coach will not be present, will be phasing out, change in staff, etc.

Always give opportunities for open communication to and from the employee about his/her job satisfaction.

Giving and Getting Feedback

The purpose of feedback is:To emphasize what is going wellTo identify areas in need of

improvementTo reinforce correctionsTo point out actions that need to be

corrected through further practice

Feedback Do’s and Don'ts

Do ask for feedback about the employee’s work performance periodically

Do ask for feedback about the employee’s attitude and behavior

Do ask for feedback about attendance and punctuality

Do help the employee to digest the feedback in a private setting, to allow for real reactions (may include behavior)

Do remind the employee of why feedback is important

Don’t just assume because you have heard nothing from the employer that nothing is wrong

Don’t give negative feedback in front of co-workers or supervisor if at all possible

Don’t point out job performance of co-workers in comparison – focus on the employee’s work performance only

Feedback Techniques

Praise: Should always be sincere and given often.

Clarifying: Restate what the employee is saying to you and let them correct you if necessary.

Boomerang: Redirect a question back to the employee. Ex. “That’s a good question. What do you think you should do in that situation?”

Written: Written feedback is a way to show improvement over time, a way to document good work habits, a way to give perspective to an employee about their performance. This is essential for a person with a brain injury, if there are any issues with short term memory.

Written Feedback Goes a Long Way

Supervisor Feedback: The supervisor should have the opportunity to evaluate the employee regularly. Then the feedback should be shared with the employee privately.

Job Coach Feedback: The job coach should evaluate the employee regularly and compare it to the feedback from the supervisor. Again sharing the information with the employee.

Employee Feedback: The employee should assess themselves regularly. Their information should be compared to that of their supervisor and job coach. **See Handouts

Evaluating Performance

The job coach should evaluate the performance of the employee, the employee should do a self assessment, and the supervisor should be asked to evaluate performance at specific intervals.

After training period (30 Days)Every 6 monthsAs needed, upon request or if a problem is

suspected**See Handouts

Steps for Teaching Job Duties

Focus –Decrease Distractions

THENExplain and

DemonstrateUse StrategyObserveGive Feedback

Checklists as StrategiesChecklists can be great

compensatory strategies for pre-work, during or after work and can prevent negative behaviors

Checklists should be based off of what the employer has instructed should be done and reinforced to meet the needs of the employee

Checklists can be as simple as a list on a piece of paper, a picture schedule or a chart

Checklists as a Pre-Work Strategy

Checklists as a Pre-Work Strategy

Picture Checklists as a Work Task Strategy

Written Chart Checklists as a Work Task Strategy

Actual Picture Checklists as a Work Task Strategy

Pictures as a Work Safety Strategy

Simple Rules for a Great Worker

•Be Proud of the Work You Do•Ask for Help if You Need It•Always Be Polite•Stay on Task •Only Take Breaks When Needed •If you Don’t Get to a Job Duty Today Do It Tomorrow•Let Your Boss Know if You Need More Work•Be Thankful

Pictures as a Work Behavior Strategy

Compensatory Strategies That Can Decrease Negative Behaviors

Calendars: Whether it is a wall calendar, a pocket calendar, a calendar on a phone, or all of the above; keeping track of dates, appointments, and times is essential to job security.

Compensatory Strategies That Can Decrease Negative Behaviors Lists: Employee and job coach

should both have a list of essential contacts at the jobsite, with supervisors and co-workers names and phone numbers if appropriate.

Post it notes or Labels: Put them in places as reminders. (Ex. Bring a copy of check to work for direct deposit)

Compensatory Strategies That Can Decrease Negative Behaviors Notebooks: Carry a small

notebook in a pocket with a pen. Have the employee jot down reminders throughout the day.

Timers: Can be used to make sure job duties are done with a good work pace.

Compensatory Strategies That Can Decrease Negative Behaviors

Smart Phones and PDA’s: Most PDA’s and smart phones have calendars with notification modes. You can make checklists, set reminders and download apps to use on the worksite. Make sure to let the supervisor know when using.

Compensatory Strategies That Can Decrease Negative Behaviors Digital Voice Recorders: Can be used

with permission for trainings, group meetings, presentations or even doctor’s appointments. Some can be downloaded onto your computer or iPhone or iPod for listening to later, sharing or saving. A job coach can listen and create a checklist or summary from a recording.

Compensatory Strategies That Can Decrease Negative Behaviors

Simple Voice Recorders: There are many varieties from key ring sizes, mounts in your car or portable recorders. Abledata.com is one website for resources. Use it to remind yourself where you parked or that tomorrow is your boss’s birthday.

Compensatory Strategies That Can Decrease Negative Behaviors

GPS: In the past, getting to an interview, a work site or making a deliveries might have been a challenge for a person with a brain injury. GPS’s have helped with that, but always have a back up plan, just in case.

Compensatory Strategies That Can Decrease Negative Behaviors

Camera/Video: Taking pictures or video to make checklists, break down work tasks into small steps, or to demonstrate job duties can be very helpful. A person can review them as much as possible in order to learn the task. Again, make sure to get permission before taking pictures or video at a job site.

References

CDC. (2011). Retrieved from http://www.cdc.gov/traumaticbraininjury/

Wood, R.L., Alderman, N. (2011). Applications of Operant Learning Theory to the Management of Challenging Behavior After Traumatic Brain Injury. Journal of Head Trauma and Rehabilitation, 26(3), p. 202-211.

Maryland TBI Advisory Board Annual Report 2011. Retrieved from http://dhmh.maryland.gov/mha/Documents/TBI%20Board%20report%202011%20final.pdf

HELPS Screening Tool. Retrieved from https://www.hnfs.com/va/static/rmh/4_helps_tbi.pdf

Brain Injury, Work and Challenging Behavior~

Understanding the Potential Employee with Brain Injury and Techniques for Management of

Behavior

Joelle M. Ridgeway, CTRS, CBIS - joeller@marytinc.com Executive Director, Mary T Maryland and

Deborah L. Cottrill, MS, CRC, CBIS - debc@marytinc.com Vocational Program Director, Mary T. Maryland