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

1. 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, CBIS • Vocational Program Director, Mary T. Maryland

2. 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

3. 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.

4. Possible Physical Changes Affecting Work • Motor skills/Balance • Hearing • Vision • Spasticity/Tremors • Speech • Fatigue/Weakness • Seizures • Taste/Smell

5. Possible Cognitive (Thinking) Changes Affecting Work • Memory • Attention • Concentration • Processing • Aphasia/receptive and expressive language • Executive skills • Problem solving • Organization • Self-Perception • Perception • Inflexibility • Persistence

6. Possible Mood/Personality/Behavior Changes Affecting Work • Depression • Social skills problems • Mood swings • Problems with emotional control • Inappropriate behavior • Inability to inhibit remarks • Inability to recognize social cues • Problems with initiation • Reduced self-esteem • Difficulty relating to others • Difficulty maintaining relationships • Difficulty forming new relationships • Stress/anxiety/ frustration and reduced frustration tolerance

7. Attention Deficit May Look Like Not Paying Attention or It May Look Like…..(Capuco & Freeman-Woolpert) • He keeps changing the subject • She doesn’t complete tasks • He has a million things going on and none of them ever gets completed • When she tries to do two things at once she gets confused and upset

8. 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

9. Executive Skills Deficit Might Look Like the Inability to Plan and Organize or It Might Look Like…..(Capuco & Freeman-Woolpert) • Uncooperativeness, stubbornness • Lack of follow through • Laziness • Irresponsibility

10. Unawareness Might Look Like…..(Capuco & Freeman-Woolpert) • Insensitivity, rudeness • Overconfidence • Seems unconcerned about the extent of her problems • Doesn’t think she needs supports • Covering up problems (“everything’s fine…”) • Big difference in what he thinks and what everyone else thinks about his behavior • Blaming others for problems, making excuses

11. 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”

12. 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)

13. 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)

14. 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 behaviors • Functional 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.

15. 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)

18. 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”

19. 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.

20. 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.

21. 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.

22. 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

23. 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

24. 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

25. Basic Responsibilities of a Job Coach • Demonstrate positive work behaviors (show up and be on time) • Be a positive and interactive trainer • Develop a relationship with the employee • Develop a relationship with the employer and co-workers of the employee • Educate others about how to best work with the employee • Use creative compensatory strategies to support learning tasks and job duties • Learn the learn job duties well and be able to teach them in a way that will support learning • Get and give constructive feedback periodically

26. 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

27. Essential Relationships

28. Essential Relationships Employee Job Coach The 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 Employee The 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.

29. Essential Relationships Employee 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 Employee The 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.

30. Essential Relationships Job 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 Coach The 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.

31. 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.

32. Giving and Getting Feedback The purpose of feedback is: • To emphasize what is going well • To identify areas in need of improvement • To reinforce corrections • To point out actions that need to be corrected through further practice

33. 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

34. 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.

35. 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

36. 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 months • As needed, upon request or if a problem is suspected **See Handouts

37. Steps for Teaching Job Duties Focus –Decrease Distractions THEN Explain and Demonstrate Use Strategy Observe Give Feedback

38. Checklists as Strategies • Checklists 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

39. Checklists as a Pre-Work Strategy

40. Checklists as a Pre-Work Strategy

41. Picture Checklists as a Work Task Strategy

42. Written Chart Checklists as a Work Task Strategy

43. Actual Picture Checklists as a Work Task Strategy

44. Pictures as a Work Safety Strategy

45. Pictures as a Work BehaviorStrategy 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

46. 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.

47. 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)

48. 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.

49. 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.

50. 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.