Accommodation and Compliance Series:
Employees with Brain Injuries
JAN’s Accommodation and Compliance Series is designed to help employers determine effective accommodations and comply with Title I of the Americans with Disabilities Act (ADA). Each publication in the series addresses a specific medical condition and provides information about the condition, ADA information, accommodation ideas, and resources for additional information.
The Accommodation and Compliance Series is a starting point in the accommodation process and may not address every situation. Accommodations should be made on a case by case basis, considering each employee’s individual limitations and accommodation needs. Employers are encouraged to contact JAN to discuss specific situations in more detail.
For information on assistive technology and other accommodation ideas, visit JAN's Searchable Online Accommodation Resource (SOAR) at http://askjan.org/soar.
What is a TBI?
According to TBI Recovery Center (2006), “TBI is any injury to the brain caused by trauma to the head. If there is trauma to the brain, but the skull is not broken, the TBI is known as a closed head injury. This could occur, for example, if a person in an automobile accident hits his head on the steering wheel, but does not have a skull fracture. If an object such as a bullet penetrates the skull and injures the brain, the TBI is known as a penetrating head injury.” There are several different types of TBI (TBI Recovery Center, 2006):
Concussion: A concussion is the most minor and common type of TBI. A concussion is caused when the brain receives a somewhat minor trauma from an impact, such as a hit to the head by an object or person or from a sudden change in momentum, such as a fall. It may or may not result in a short loss of consciousness (not exceeding 20 minutes) and can be diagnosed by observing common symptoms such as headache, confusion, and vomiting. Difficulty with thinking skills (e.g., difficulty “thinking straight,” memory problems, poor judgment, poor attention span, a slowed thought processing speed) (Brain Injury Association of America, 2006a; TBI Recovery Center, 2006).
Skull Fracture: A skull fracture occurs when the skull cracks or breaks. A depressed skull fracture occurs when pieces of broken skull press into the tissue of the brain. A penetrating skull fracture occurs when something pierces the skull and injures the brain (Brain Injury Association of America, 2006a; TBI Recovery Center, 2006).
Contusion: A contusion is bruising or bleeding of the brain (Brain Injury Association of America, 2006a; TBI Recovery Center, 2006).
Hematoma: A hematoma is a collection of blood inside the body (Brain Injury Association of America, 2006a; TBI Recovery Center, 2006).
How prevalent are TBIs?
The Brain Injury Association of America (2006a) estimates that every year about 1.4 million Americans experience a traumatic brain injury.
What are the causes of TBI?
Half of all TBIs are due to accidents involving automobiles, motorcycles, bicycles, and pedestrians. Motor vehicle accidents are the major cause of TBI in people under age 75. For those 75 and older, falls cause the majority of TBIs. Approximately twenty percent of TBIs are due to violence, such as gunshots and child abuse. About three percent are due to sports injuries. Alcohol use is associated with half of all TBIs (TBI Recovery Center, 2006).
Another type of brain injury is called Acquired brain Injury. This describes damage to the brain not associated with trauma to the head or skull and typically involves the entire brain. Common causes of acquired brain injury are loss of oxygen to the brain due to drowning, toxic exposure to carbon monoxide, as well as heart attack and stroke (Brain Injury Association of America, 2006b).
What are the signs and symptoms of TBI?
There are various levels of TBI, including mild and moderate or severe TBI (TBI Recovery Center, 2006).
Mild TBI: Symptoms of mild TBI include headache; confusion; lightheadedness; dizziness; blurred vision or tired eyes; ringing in the ears; bad taste in the mouth; fatigue; a change in sleep patterns; mood changes; and trouble with memory, concentration, attention, or thinking. The injury may or may not result in a brief period of unconsciousness.
Moderate or Severe TBI: Symptoms of moderate to severe TBI may be similar to symptoms of mild TBI, but they may also include a headache that gets worse or does not go away, repeated vomiting or nausea, convulsions or seizures, inability to awaken from sleep, dilation of one or both pupils of the eyes, slurred speech, weakness or numbness in the arms or legs, loss of coordination, increased confusion, restlessness, or agitation.
Most workplace difficulties are the result of cognitive functional limitations such as remembering, organizing, learning, and planning skills. (Hirsh et al., 1996).
Are TBIs disabilities under the ADA?
The ADA does not contain a list of medical conditions that constitute disabilities. Instead, the ADA has a general definition of disability that each person must meet (EEOC Regulations . . ., 2011). Therefore, some people with TBIs will have a disability under the ADA and some will not.
A person has a disability if he/she has a physical or mental impairment that substantially limits one or more major life activities, a record of such an impairment, or is regarded as having an impairment (EEOC Regulations . . . , 2011). For more information about how to determine whether a person has a disability under the ADA, visit http://AskJAN.org/corner/vol05iss04.htm.
Are employees (or applicants) with TBIs required to disclose their disability to their employers?
No. Employees need only disclose their disability if/when they need an accommodation to perform the essential functions of the job. Applicants never have to disclose a disability on a job application, or in the job interview, unless they need an accommodation to assist them in the application or interview process (EEOC, 2000; EEOC, 1995).
Can an employer ask an employee with TBI to submit to a medical examination?
Yes, if the need for the medical examination is job-related and consistent with business necessity. Special note: pre-job offer medical examinations or inquiries are illegal under the ADA. People with brain injuries (or any disability) do not have to submit to a medical exam, or answer any medical questions until after they have been conditionally offered a job (EEOC, 2000; EEOC, 1995).
Note: People with TBIs may develop some of the limitations discussed below, but seldom develop all of them. Also, the degree of limitation will vary among individuals. Be aware that not all people with TBIs will need accommodations to perform their jobs and many others may only need a few accommodations. The following is only a sample of the possibilities available. Numerous other accommodation solutions may exist.
Questions to Consider:
- What limitations is the employee with a TBI experiencing?
- How do these limitations affect the employee and the employee’s job performance?
- What specific job tasks are problematic as a result of these limitations?
- What accommodations are available to reduce or eliminate these problems? Are all possible resources being used to determine possible accommodations?
- Has the employee with a TBI been consulted regarding possible accommodations?
- Once accommodations are in place, would it be useful to meet with the employee with a TBI to evaluate the effectiveness of the accommodations and to determine whether additional accommodations are needed?
- Do supervisory personnel and employees need training regarding TBIs?
- Physical Limitations:
- Install ramps, handrails, and provide handicap parking spaces
- Install lever style door handles
- Clear pathways of travel of any unnecessary equipment and furniture
- Visual Problems:
- Provide written information in large print
- Change fluorescent lights to high intensity, white lights
- Increase natural lighting
- Provide a glare guard for computer monitors
- Consult a vision specialist particularly with someone who has lost part of or all of their vision
- Maintaining Stamina During the Workday:
- Permit flexible scheduling, allow longer or more frequent work breaks
- Provide additional time to learn new responsibilities
- Provide self-paced workload
- Provide backup coverage for when the employee needs to take breaks
- Allow for time off for counseling
- Allow for use of supportive employment and job coaches
- Allow employee to work from home during part of the day
- Provide for job sharing opportunities
- Allow part-time work schedules
- Maintaining Concentration:
- Reduce distractions in the work area
- Provide space enclosures or a private office
- Allow for use of white noise or environmental sound machines
- Allow the employee to play soothing music using a cassette player and headset
- Increase natural lighting or provide full spectrum lighting
- Reduce clutter in the employee’s work environment
- Plan for uninterrupted work time
- Divide large assignments into smaller tasks and steps
- Restructure job to include only essential functions
- Difficulty Staying Organized and Meeting Deadlines:
- Make daily TO-DO lists and check items off as they are completed
- Use several calendars to mark meetings and deadlines
- Remind employee of important deadlines via memos or e-mail or weekly supervision
- Use a watch or pager with timer capability
- Use electronic organizers
- Divide large assignments into smaller tasks and steps
- Assign a mentor to assist employee in determining goals and provide daily guidance
- Schedule weekly meetings with supervisor, manager, or mentor to determine if goals are being met
- Memory Deficits:
- Allow the employee to tape record meetings
- Provide type written minutes of each meeting
- Use notebooks, calendars, or sticky notes to record information for easy retrieval
- Provide written as well as verbal instructions
- Allow additional training time
- Provide written checklists and use color-coding to help identify items
- Post instructions close to frequently used equipment
- Problem Solving Deficits:
- Provide picture diagrams of problem solving techniques, e.g., flow charts
- Restructure the job to include only essential functions
- Assign a supervisor, manager, or mentor when the employee has questions
- Working Effectively with Supervisors:
- Provide positive praise and reinforcement
- Provide written job instructions
- Write clear expectations of responsibilities and the consequences of not meeting them
- Allow for open communication with managers and supervisors
- Establish written long term and short term goals
- Develop strategies to deal with problems before they arise
- Provide written work agreements
- Develop a procedure to evaluate the effectiveness of the accommodation
- Difficulty Handling Stress and Emotions:
- Provide praise and positive reinforcement
- Refer to counseling and employee assistance programs
- Allow telephone calls during work hours to doctors and others for needed support
- Provide sensitivity training to coworkers
- Allow the employee to take a break as a part of a stress management plan
- Attendance Issues:
- Provide flexible leave for health problems
- Provide a self-paced work load and flexible hours
- Allow employee to work from home
- Provide part-time work schedule
- Issues of Change:
- Recognize that a change in the office environment or of supervisors may be difficult for a person with a brain injury
- Maintain open channels of communication between the employee and the new and old supervisor in order to ensure an effective transition
- Provide weekly or monthly meetings with the employee to discuss workplace issues and productions levels
Situations and Solutions:
A police officer was returning to work following surgery for a brain aneurysm. He had partial paralysis to the left side and could no longer use both hands for word processing. Accommodation suggestions included: transferring the individual to a vacant position that involved computer research and providing a one-handed keyboard.
A professional whose work required the use of a computer returned to work following a brain injury. As a result of his injury he was unable to read past the midline when reading from left to right. Accommodation suggestions included: changing the margin settings of his word processing program for 80 to 40 to limit right side reading or purchasing software that can split the computer screen left to right and black out the right side, redesigning his workstation to place equipment on the left, and providing task lighting.
A therapist who had short-term memory deficits had difficulty writing case notes from counseling sessions. Accommodation suggestions included: allowing the therapist to tape record sessions and replay them before dictating notes, scheduling 15 minutes at the end of each session to write up hand written notes, and scheduling fewer counseling sessions per day.
A laborer working in a noisy factory had difficulty concentrating on job tasks. Accommodation suggestions included: erecting sound absorbing barriers around his workstation, moving unnecessary equipment from the area to reduce traffic, and allowing the employee to wear a headset or ear plugs.
There are numerous products that can be used to accommodate people with limitations. JAN's Searchable Online Accommodation Resource (SOAR) at http://askjan.org/soar is designed to let users explore various accommodation options. Many product vendor lists are accessible through this system; however, upon request JAN provides these lists and many more that are not available on the Web site. Contact JAN directly if you have specific accommodation situations, are looking for products, need vendor information, or are seeking a referral.
Brain Injury Association of America. (2006a). What is brain injury? Retrieved February 9, 2006, from http://www.biausa.org/
Brain Injury Association of America. (2006b). Causes of brain injury. Retrieved September 4, 2008, from http://www.biausa.org/
Equal Employment Opportunity Commission. (2000). Enforcement guidance on disability-related inquiries and medical examinations of employees under the Americans with Disabilities Act. Retrieved September 4, 2008, from http://www.eeoc.gov/policy/docs/guidance-inquiries.html
Equal Employment Opportunity Commission. (1995). Pre-employment disability-related questions and medical examinations. Retrieved September 4, 2008, from http://www.eeoc.gov/policy/docs/preemp.html
Hirsh, A., Duckworth, K., Hendricks, D.J., & Dowler, D. (1996). Accommodating workers with traumatic brain injury: Issues related to TBI and ADA. Journal of Vocational Rehabilitation, 7, 217-226.
TBI Recovery Center, (2006). What is a traumatic brain injury? Retrieved September 4, 2008, from http://www.tbirecoverycenter.org/whatis.htm