Joelle M. Ridgeway, CTRS, CBIS Executive Director, Mary T Maryland and Deborah L. Cottrill, MS, CRC, CBIS

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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 MarylandEstimated 61,970 individuals living with a long-term disability as a result of brain injuryDuring 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 states 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 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 WorkMemoryAttentionConcentrationProcessingAphasia/receptive and expressive languageExecutive skillsProblem solvingOrganizationSelf-PerceptionPerceptionInflexibilityPersistence

Possible Mood/Personality/Behavior Changes Affecting WorkDepressionSocial skills problemsMood swingsProblems with emotional controlInappropriate behaviorInability to inhibit remarksInability 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 doesnt 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, irresponsibilityHe says hell do something but doesnt get around to itShe talks about the same thing or asks the same question over and over-annoying perseverationHe invents plausible sounding answers so you wont know he doesnt 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 problemsDoesnt think she needs supportsCovering up problems (everythings fine)Big difference in what he thinks and what everyone else thinks about his behaviorBlaming others for problems, making excuses

General Management GuidelinesIncrease Rest time- fatigue is a big issue in brain injuryKeep the environment simple- People with brain injury can get over stimulatedKeep instructions simple- be concrete and provide cues/instruction/prompts as neededGive Feedback and set goals- positive reinforcementBe calm and redirect to taskProvide choicesDecrease the chance of failure

Person Centered ApproachBe supportiveBe consistentBe flexibleTreat everyone with dignity and respectDont talk down to peopleDont take things personallyAvoid Arguments Vary activitiesOver-planTask analyze

See Handout: Tips for Employers

Applied Behavioral Analysis(Wood and Anderson, 2011)An operant theory of learningBehavior operates on the environment and is maintained by its consequencesProbability that a behavior occur again is based onWhether 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 behaviorSocial-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 PlanTarget Behaviors:Adaptive: Positive behaviors we want to increaseMaladaptive: Negative behaviors we want to decrease. These are generally the targeted behaviorsFunctional Assessment:Assessment to understand the function of the behaviorReactive 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 ABCs of BehaviorAntecedent: What happens before the behaviorBehavior: Specific action of the individualConsequence: What happened as a result of the behavior (i.e., reward, + or reinforcement)

DateStart TimeEnd TimeAntecedent BehaviorIntensityInterventionLocationCommentsStaff1 2 31 2 31 2 31 2 31 2 31 2 31 2 31 2 31 2 31 2 31 2 31 2 31 2 31 2 3AntecedentsBehaviorsIntensityInterventions1. Staff Direction1. Failure to Cooperate1. Low1. Setting Limits (verbal prompts, physical presence)2. Denied Access/Request to Item/Activity2. Inappropriate Social Behavior2. Moderate2. Modified Planned Ignoring3. Transition3. Verbal Aggression3. High/Severe3. Offered choice of another activity4. Interruption of Activity4. Aggression Towards Property4. Offered choice of moving to another area5. Particular Peer in Area5. Physical Aggression5. Modified environment to decrease the behavior6. Loud Environment6. Elopement6. Physical Proximity and Body Positioning7. Unengaged7. Other7. Shadowing Procedure for Elopement8. Violation of Personal Space8. Physical Redirection/Deflection 9. Violation of Personal Belongings9. Physically Blocking access to targeted person10. Introduction of an Unfamiliar or Difficult Task10. Verbal Redirection to an Alternate Location11. Unable to Communicate Wants/Needs11. Physical Escort to an alternate location (must specify type utilized)12. Illness12. Physical Intervention (specify BPS stategies used)13. Toileting Accident13. Response Cost Procedure - Loss of Next Family Visit14. Break Time14. Other (Must Specify in Comment Section)15. Other (Must specify in comment box)

Proactive StrategiesBehavior 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 pleasePerson being rough with equipment: Lets put the mop down now. Person grabs your arm: Please keep your hands to your self

Proactive StrategiesPhysical 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 StrategiesDifferential 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 StrategiesAlways begin with positive promptingModified 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 dont call me that name, or thats 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 StrategiesMore restrictive measures can include (but are limited by regulations and human rights committees): Alternate LocationMotion SensorsResponse 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/DeflectionPhysical Intervention

Case ExamplesCR- Scheduled Breaks and Behavior Cigarettes and CoffeeEnvironmental 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-workersKP Loaning Money to Peers and Behavior - UniformEnvironmental 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 CoachEnvironmental 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 ignoringRC- Physical Aggression DROLH- SIB and Self Stimulation in Public: Environmental ControlDB- Urinating in Van, Corners, Bedroom: Environmental Control, RestitutionTW- Verbal Aggression: Modified Planned Ignoring, Alternate LocationVM- Refusal to Shower and Property Destruction DRO and DRI

Basic Responsibilities of a Job CoachDemonstrate 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 CoachResponsiveness: Expresses an interest in the employee, is a good listener, has good communication skills, accommodates individual differences, maintains a relaxed manner, is receptive to questionsEnthusiasm: Is energetic, optimistic, prepared and willing to commit timeHumor: Able to incorporate appropriate humor during training by using personal and/or real-life examplesSincerity/Honesty: Takes every question seriously and does not pretend to know the answer if they dont knowFlexibility: Able to eliminate, adjust, or change material during training according to the employees needs and time constraintsTolerance: Able to accommodate different personalities and learning styles; accepts constructive criticism and does not take it personally

Essential Relationships

Essential RelationshipsEmployee 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 EmployerThe 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 EmployerThe 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 employees 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 BehaviorVocational 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 coachs 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 FeedbackThe 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 Dos and Don'tsDo ask for feedback about the employees work performance periodicallyDo ask for feedback about the employees attitude and behaviorDo ask for feedback about attendance and punctualityDo 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 importantDont just assume because you have heard nothing from the employer that nothing is wrong Dont give negative feedback in front of co-workers or supervisor if at all possibleDont point out job performance of co-workers in comparison focus on the employees work performance only

Feedback TechniquesPraise: 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. Thats 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 WaySupervisor 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 DutiesFocus 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 behaviorsChecklists should be based off of what the employer has instructed should be done and reinforced to meet the needs of the employeeChecklists 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 WorkerBe Proud of the Work You DoAsk for Help if You Need ItAlways Be PoliteStay on Task Only Take Breaks When Needed If you Dont Get to a Job Duty Today Do It TomorrowLet Your Boss Know if You Need More WorkBe ThankfulPictures 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 PDAs: Most PDAs 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 doctors 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 bosss 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. GPSs 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.

ReferencesCDC. (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.pdfHELPS 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 - [email protected] Executive Director, Mary T Maryland and Deborah L. Cottrill, MS, CRC, CBIS - [email protected] Program Director, Mary T. Maryland