Annalisa Stoddart Manager Brain Injury Vocational Rehabilitation Services Glasgow

1. Annalisa Stoddart Manager Brain Injury Vocational Rehabilitation Services Glasgow

2. Rehab 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.

3. Introduction • Brain Injury – the facts • Brain Injury – the effects • Case study 1 • Vocational rehabilitation and supported employment • Case study 2 • Conclusion

4. 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

5. Brain Injury – the causes • Road traffic accidents (including bicycles) • Assaults • Falls • Sports/industrial accidents • Alcohol

6. 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

7. 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

8. Brain Injury – delayed complications • Post traumatic epilepsy • Hydrocephalus

9. 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

10. 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

11. 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

12. 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

13. Brain Injury: physical effects • Visual impairment • Loss of sense of smell • Loss of sense of taste • Impaired hearing • Swallowing problems • Dysarthria ( difficulties forming words )

14. 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

15. Rigidity of thought • Problems with initiation/motivation • Problems with planning/organising • Difficulties with problem solving and decision making • Word finding problems • Difficulties understanding language • Dyslexia and literacy problems

16. Brain Injury – emotional effects • Agitation • Anger and frustration • Anxiety • Depression • Mood swings • Reduced tolerance/increased irritability • Loss of feeling/empathy • Loss of confidence

17. Brain Injury – behavioural effects • Agitation/aggression • Impulsivity • Disinhibition • Withdrawal

18. 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)

19. 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

20. 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

21. 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

22. 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

23. 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

24. CASE STUDY 1: Implications for Vocational Rehabilitation • Loss of confidence in services and lack of trust • Programme had to be reactive rather than proactive initially • Vocational re-evaluation rather than retention • Need to address secondary psycho-social problems before vocational rehabilitation was possible • Lack of insight • Family denial

25. Case 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

26. 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

27. CASE STUDY 1: INDIVIDUAL PROGRAMME PLANNING • Vocational 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

28. CASE STUDY 1: OUTCOME • Passed Diploma Thesis in Architecture: June 2001 • Employed by Architects Office: September 2001

29. Vocational 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)

30. Vocational 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)

31. 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

32. 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 lobes • Transferred to The Southern General Hospital( no surgery – conservative treatment • Returned to GRI • PTA 2-3 days. Length of hospitalisation, 2 weeks

33. CASE STUDY 2: EFFECTS OF HEAD INJURY • Headaches • 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

34. CASE STUDY 2: SUPPORT PROVIDED PRIOR TO REFERRAL TO VRP • Information regarding head injury and its effects • Regular 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

35. 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

36. CASE STUDY 2: INDIVIDUAL PROGRAMME PLANNING • 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

37. CASE STUDY 2: INDIVIDUAL PROGRAMME PLANNING • 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

38. 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 intervention • Case Study 2 : Information and support at an early stage facilitated effective intervention, trust in service providers and family involvement/commitment

39. 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

40. 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