Annalisa Stoddart Manager Brain Injury Vocational Rehabilitation Services Glasgow

The effects of Brain Injury on employment

Annalisa Stoddart

Manager

Brain Injury Vocational Rehabilitation Services

Glasgow

The effects of Brain Injury on employmentRehab Scotland – Brain Injury Vocational Rehabilitation

Services

Aim:

To enable people with acquired brain injury to participate in further education/further training and/or employment opportunities.

This is achieved by working with clients using a multi-disciplinary team approach in order to enable clients to address brain injury related problems which might present barriers and to clarify and test out training/employment goals.


Introduction

Brain Injury – the facts

Brain Injury – the effects

Case study 1

Vocational rehabilitation and supported employment

Case study 2

Conclusion


Brain Injury – the facts

Approximately 1 million in Britain each year

Per year, per 100,000 of the population

*10 – 15 severe

*15 – 20 moderate

*250 – 300 mild

One family in every 300 will be affected by the long term effects


Brain Injury – the causes

Road traffic accidents (including bicycles)

Assaults

Falls

Sports/industrial accidents

Alcohol


Brain Injury – prevalence

3:1 male/female ratio

2/3 of head injuries are aged under 30 years old

Residence in urban areas where social inclusion predominates

Income poverty

Unemployment

Lack of educational attainment

High levels of crime

Substance misuse


Brain Injury – types of injury

Primary injury occurs at the moment of impact, being caused by the blow

Secondary injury occurs as a result of systemic complications, which are potentially treatable

Primary: skull fracture, cerebral contusions, diffuse axonal injury

Secondary: intracranial haematoma, brain swelling, infection, raised intracranial pressure, respiratory failure, hypotension, ischaemic brain damage


Brain Injury – delayed complications

Post traumatic epilepsy

Hydrocephalus


Brain Injury – severity

Mild head injury (75%): loss consciousness <15 minutes/no loss of consciousness

Moderate head injury: loss of consciousness between 15 minutes and 6 hours/post traumatic amnesia up to 24 hours

Severe head injury: loss of consciousness >48 hours/post traumatic amnesia>24 hours


Brain Injury- disability

Thornhill and Teasdale – 2000

Study of 3000 people admitted to hospital with head injury

Follow up of 1000 at one year post injury

78% of severe head injuries experienced disability

54% of moderate head injuries experienced disability

51% of mild head injuries experienced disability


Brain Injury – lack of follow up

Most head injured receive no follow up after discharge

Less than 50% were seen in hospital after discharge

Only 28% received any form of rehabilitation

Only 15% had contact with Social Work

Most common service was physiotherapy


Brain Injury – physical effects

Headaches

Paralysis/mobility problems

Balance problems

Dizziness

Epilepsy

Reduced stamina

Problems with co-ordination

Ataxia (shakiness)

Dyspraxia (message from brain to limb is blocked)

Problems with continence

Reduced/increased libido


Brain Injury: physical effects

Visual impairment

Loss of sense of smell

Loss of sense of taste

Impaired hearing

Swallowing problems

Dysarthria ( difficulties forming words )


Brain Injury – cognitive/executive/communication effects

Impaired memory

Impaired concentration

Increased sensitivity to noise/stimuli

Reduced speed of information processing

Perseveration

Confusion/disorientation

Lack of insight

Difficulties with visual - spatial judgment


Rigidity of thought

Problems with initiation/motivation

Problems with planning/organisingDifficulties with problem solving and decision making

Word finding problemsDifficulties understanding languageDyslexia and literacy problems


Brain Injury – emotional effects

Agitation

Anger and frustration

Anxiety

Depression

Mood swings

Reduced tolerance/increased irritability

Loss of feeling/empathy

Loss of confidence


Brain Injury – behavioural effects

Agitation/aggression

Impulsivity

Disinhibition

Withdrawal


Brain Injury – social effects

Reduced ability to understand and cope with social interactions

Interpersonal/relationship difficulties

Impaired communication/social skills

Family/relationship breakdown

Social isolation

Reduced work/educational performance

Loss of role/identity

Loss of employment/loss of income(less than 30%of head injured people will return to work without specialist rehabilitation and

support)


Case Study 1 - Injury Details

Injury sustained in 1996

Male aged 28 years

Fall ( 70 Feet )

Alcohol

Orthopaedic injuries/respiratory and renal complications

Diffuse head injury

PTA: approximately 6 weeks

Length of hospitalisation: 8 weeks


CASE STUDY 1 – EFFECTS OF BRAIN INJURY

Sleep disturbance and low levels of stamina

Visuospatial impairment

Word finding problems

Disorientation

Memory impairment

Poor Concentration

Executive Dysfunction

Slowed information processing

Emotional and behavioural problems


CASE STUDY 1 –REINTEGRATION

Effects of trauma

Effects of head injury

No information or support

Stress of adjustment

Stress of reintegration into family,social life, education and work


CASE STUDY 1: SECONDARY PROBLEMS

Reduced ability to self monitor

Impaired social skills and relationship difficulties

Increased stress and and loss of self confidence

Difficulties balancing work and leisure

Impaired work performance

Reduction in earnings

Housing problems

Anger/frustration

Loss of social/work identity/status

Alcohol dependency


CASE STUDY 1: OUTCOME

Exhaustion

Psychiatric admission

Loss of employment/income

Loss of home/independence

Loss of role and achievement

Family and relationship breakdown

Alcohol dependency

Increasingly chaotic lifestyle

Academic failure


CASE STUDY 1: Implications for Vocational Rehabilitation

Loss of confidence in services and lack of trust

Programme had to be reactive rather than proactive initiallyVocational re-evaluation rather than retention

Need to address secondary psycho-social problems before vocational rehabilitation was possible

Lack of insight

Family denial

The effects of Brain Injury on employmentCase Study 1 – vocational rehabilitation: a multi disciplinary

team approach

Manager

Clinical Neuropsychologist

Assistant Psychologist

Work Related Social Skills Tutor

Employment Liaison Officer

Job Coach

Occupational Therapist/Job Coach


CASE STUDY 1: INDIVIDUAL PROGRAMME PLANNING

Assessment

Induction

Introduction to structured environment and activity

Brain Injury Awareness Training

Training cognitive and executive skills

Stress, anxiety and relaxation training

Social reintegration and leisure activities

Work Related Social Skills Training

Individual psychological support and Liaison with Community Psychologist

Family information and support

Referral to Housing Department

Welfare rights advice


CASE STUDY 1: INDIVIDUAL PROGRAMME PLANNINGVocational profiling

Vocational exploration

Job Seeking Skills Training

Liaison with university

Liaison with an architects’ business

Setting educational/vocational goals

Supported study for diploma thesis in Architecture

Study Skills Training

Work Placement in an architects’ office, supported by a specialist job coach


CASE STUDY 1: OUTCOME

Passed Diploma Thesis in Architecture: June 2001

Employed by Architects Office: September 2001

The effects of Brain Injury on employmentVocational rehabilitation and supported employment – ideal

model

Information, advice and support to client and family

Early intervention

Employer liaison

Community integration

Holistic assessment with other agencies, family and client input

Neuropsychological/occupational therapy assessment as required

Individual programme planning (multi disciplinary approach)

The effects of Brain Injury on employmentVocational rehabilitation and supported employment – ideal

model

Psychosocial rehabilitation

Training in compensatory strategies for physical problems/ stamina building

Flexible and realistic vocational profiling and exploration

Information technology training

Graded work experience placements with job coaches as transitional specialists

(place and train model)


Vocational rehabilitation and supported employment

Regular review of work goals

Specific vocational training as required/study skills training

Job seeking skills training and intensive job search

Marketing to employers

Ideal job match

Back to work benefits advice

Transitional/through care support in employment

Optimal use of natural supports in the workplace

Independence in the workplace/supported employment


CASE STUDY 2 - INJURY DETAILS

Injury sustained in May 1998

Male aged 34 years old

Fall down stairs, circumstances unclear

Admitted to Glasgow Royal Infirmary.

CT brain scan: left subdural haemorrhage with significant mass effect and oedema

2 small intracerebral haematomas in the right and left frontal lobesTransferred to The Southern General Hospital( no surgery – conservative treatment

Returned to GRI

PTA 2-3 days. Length of hospitalisation, 2 weeks


CASE STUDY 2: EFFECTS OF HEAD INJURYHeadaches

Sleep disturbance and low levels of stamina

Dizziness and positional vertigo

Impaired memory and poor concentration

Slowed information processing

Difficulties in initiating, planning and organising tasks

Word finding problems

Low mood and irritability

Increased sensitivity to noise

Low levels of motivation

High levels of anxiety/panic attacks

Low confidence and social isolation

The effects of Brain Injury on employmentCASE STUDY 2: SUPPORT PROVIDED PRIOR TO

REFERRAL TO VRP Information regarding head injury and its effectsRegular home support visits

Allocation of a support worker to assist community integration activities, including travel management

Liaison with employer/negotiation of medical retirement

Benefits advice and assistance

Anxiety management

Information about/support to implement compensatory strategies for memory impairment

Carer support/information

Referral to and assistance to attend The Head Injuries Trust for Scotland

Referral to Rehab Scotland, Brain Injury Vocational Rehabilitation Programme


CASE STUDY 2: Assessment of needs at referral

Dizziness/balance problems

Headaches

Poor stamina

Memory impairment

Difficulties with concentration( especially divided attention)Difficulties initiating, planning and organising tasks

Anxiety

Low mood

Low levels of motivation

Lack of hope/goals in relation to returning to work



Induction

Gradual introduction to a structured, simulated work routine/environment

Neuropsychological assessment

Brain Injury Awareness Training

Cognitive training for memory/concentration problems

Rehabilitation strategies for executive problems

Stress,anxiety and relaxation training

Individual psychology support re anxiety and low mood

Work Related Social Skills Training



Social Re-integration and leisure activities

Individual Resource Project: Teaching others to play guitar

Family information and support (e.g childcare)

Client representative training

Information Technology Training ( Certificate)

Vocational profiling and exploration

Specific vocational training in Lifting and Handling

2 Work Experience Placements ( Support Worker)

Review of work goal and Job Seeking Skills Training. (Cert)

Intensive Job search

Outcome: Employment, August 2000 as a concierge with Glasgow City Council, Housing Department


The benefits of early intervention, facilitated by an integrated pathway approach which promotes joint

working:Case Study 1: Significant gap between brain injury and return to employment (5 years)

Case Study 2: Reduced gap between brain injury and employment

(2 years)Case Study 1: Significant secondary problems affecting mental health, family relationships and readiness/willingness of client/family for specialist interventionCase Study 2 : Information and support at an early stage facilitated effective intervention, trust in service providers and family involvement/commitment


Range of employment outcomes

Architect – City centre practice

Concierge – Glasgow City Council

Support worker – Turning Point

Support worker – Care Line

Warehouse assistant – Index

Project Co-ordinator – Glasgow Play Scheme Association

Support worker – Key Housing

Warehouse assistant – Clothing factory

Sports centre assistant – National Sports Centre - Largs


Vocational rehabilitation – benefits

Cost effective (80% employment/15% further education/training)

Addresses specialist problems

Empowers

Feedback mechanism which captures performance targets

Promotes personal/professional development

Reduces psychosocial problems

Promotes social and economic inclusion

Documents

Annalisa Stoddart Manager Brain Injury Vocational Rehabilitation Services Glasgow