This Presentation prepared by

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Vocational Issues After Brain Injury 2003
updated 2009
This Presentation prepared by Maryland Department
of Health and Mental Hygiene Maryland TBI
Implementation Project Brain Injury Association
of Maryland




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Learning Objectives After this training you
should be able to answer the following questions
What is a brain injury? How does brain
injury impact daily functioning? Why does brain
injury impact a persons employment status?
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Learning Objectives After this training you
should be able to answer the following questions
Why does brain injury impact a persons
employment status? How can brain injury affect
learning, behavior and relationships on the
job? What can be done to help consumers with
brain injury find and keep a job?
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Presentation Overview
The Challenges of Brain Injury in the Work
Environment Barriers to Employment Role of the
Vocational Counselor The Successful Vocational
Program and Candidate
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The Challenges of Brain Injury in the Work
Environment

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Specific Challenges for the Vocational Specialist
Job coaches, vocational counselors and other
employment specialists may never have received
specific training in brain injury Individuals
with brain injury may have an array of needs
making it a challenge to be placed in an
appropriate working environment Brain injuries
may be undiagnosed and under-reported
Traditional vocational evaluations may not
accurately assess the consumers vocational
potential
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Barriers to Employment

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Barriers to Employment
Possible Impairments After Brain Injury
Physical Social/Emotional/Behavioral Cognitive
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Physical Impairments
Changes after Brain Injury Could Include
Mobility Impairments Reduced Coordination
Speech Impairments Fatigue Seizures
Sensory changes
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Mobility Impairments Reduced Coordination Diff
iculty with walking, balance, dizziness,
spasticity, paralysis, rigidity,coordination
Review medical records including physical and
occupational therapy reports Determine if
adaptive devices may be needed Re-evaluation
of physical and occupational therapy might be
necessary Evaluate accessibility of workplace
Access work hardening program after specifics of
employment are known Ask about medications
consumer may be on
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Speech Impairments Speech or language
pathology that makes it difficult for the person
to speak or to be understood
Review speech/language pathology reports Request
an evaluation if appropriate Encourage client to
speak slowly and repeat as necessary Assist the
consumer in establishing consistent non-verbal
cues for use at workplace Encourage the use of
additional means of communications (email fax
memos)
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Fatigue Tiredness related to organic changes
in the brain or may be related to
over-stimulation. May also result from sleep
disturbances common after TBI
Obtain a list of medical restrictions from
physician Reduce length of work day if possible.
Gradually increase time as consumer
tolerates Assist employer and consumer to plan
for the gradual increase of working hours and
workload Encourage consumer and supervisor to
schedule work breaks Allow extra time to complete
task
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Seizures A medical condition that may occur
after brain injury and can be caused by a
disruption in brain cell activity
Identify seizure protocol with consumers
physician and ascertain employer policy Educate
employer, supervisor, other workers as to seizure
protocol (w/consumers consent) Assist consumer
in obtaining a medical identification bracelet or
necklace Help consumer to establish reminders to
take anti-seizure medication as prescribed
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Possible Sensory Changes
Vertigo Minimize visual stimulation. Refer if
necessary to a neuropthamologist or behavioral
optometrist Hearing Evaluation of hearing
problems by specialist (Speech/Language
Pathologist, Audiologist) Vision Accommodate
visual deficits. Assist consumer in the
placement of materials for optimal viewing
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Social-Emotional Impairments
Possible Changes After Brain Injury
Irritability/Aggression/Mood Swings Anxiety
Communication Difficulties Poor Social
Judgment/Skills Denial/Lack of Self-Awareness
Rigidity/Inflexibility
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Impulsivity Poor Judgment Reduced ability
to modify or inhibit words and actions
Decrease distractions (partitions, reduce
noise) Teach strategies to maintain/regain
focus (checklists daily planner) Break down
tasks into smaller steps Identify
mentor/colleague to assist consumer Provide cues
to re-direct consumer Modify work load Increase
pace of work assignments gradually
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Irritability/Aggression/Emotional Lability
Difficulty in controlling emotions Mood
swings and inappropriate behavior may occur
Provide clear expectations for behavior Plan and
role-play social interactions that might occur at
job site Encourage consumer to slow down and
think through responses. Outline strategies for
controlling temper (count to five.) Evaluate
consumer behavior and review possible alternative
responses with client
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Anxiety Individuals may have difficulty
matching emotions to the situation at hand. This
is especially true in novel situations.
Plan Outline strategies Provide feedback as
soon as possible Encourage consumer to slow down
and think through responses. Evaluate Teach
relaxation techniques Explore medication when
appropriate
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Communication Difficulties with initiating and
maintaining conversations talking too much
talking too little
Encourage consumer to practice expressing
thoughts in safe environment Role play possible
conversations with others in the
workplace Encourage consumer to ask for time to
organize thoughts Teach consumer active
listening techniques, such as repeating what they
heard from the other person Educate
mentor/supervisor on specific communication
difficulties and the way that he or she can
assist consumer
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Social Judgment/Skills Difficulty in reading
social cues and understanding humor. Decreased
awareness of social rules and roles.
Demonstrates inappropriate manners that may
result in isolation from co-workers.
Educate co-workers on brain injury
aftermath Identify co-worker who will work with
consumer to prompt and redirect as
needed Identify possible problems in real-work
situations Plan and rehearse social
interactions Review workplace interactions with
consumer and identify appropriate
responses Assist employer/supervisor to identify
difficulties and use feedback in a positive way
(privately calmly clearly)
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Denial/Lack of Awareness Inability to
realistically and accurately assess ones
abilities limited self-awareness and insight
Anticipate consumers lack of awareness Assist
consumer in identifying and accepting
limitations Promote questioning by consumer in
work situations when they are unsure of what to
do Identify feedback needs and strategies for
supervisor Supportive therapy as available and
needed
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Rigidity/Inflexibility Difficulty in
accommodating changes in routine and making
transitions throughout the day
Break job tasks into small steps
Use a daily schedule to be reviewed prior to and
at the end of the day
Assign a specific co-worker or supervisor to be
the point of contact
Use alarm watch
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Cognitive Impairments
Possible Changes After Brain Injury

• Executive Functioning deficits
• Attention and Concentration
• Comprehension and Memory
• Self-Awareness
• Initiating/Motivating

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A deficit in executive skills 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

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Executive FunctioningReduced ability to
devise a plan of action and systematically
implement it

• Create templates of routine work tasks
• Stress the need for daily job log
• Log should be completed each day and reviewed
  each night
• Questions and/or comments for job
  coach/boss/co-worker should be written down as
  well as the answer provided

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An attention deficit might look like trouble
paying attention or it might look like (Capuco
Freeman-Woolpert)

• He keeps changing the subject
• She doesnt 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

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Attention and Concentration Easily distracted.
Difficulty in attending to tasks, focusing or
maintaining attention (may be internal or
external)
Identify mentor/colleague to assist
consumer Decrease distractions (partitions,
reduce noise) Teach strategies to
maintain/regain focus (checklists daily planner)
Break down tasks into smaller steps Provide
cues to re-direct consumer Modify work
load Increase pace of work assignments gradually
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A memory deficit might look like trouble
remembering or it might look like (Capuco
Freeman-Woolpert)

• She frequently misses appointments-avoidance,
  irresponsibility
• He says hell do something but doesnt get around
  to it
• She talks about the same thing or asks the same
  question over and over-annoying
• He invents plausible sounding answers so you
  wont know he doesnt remember

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Comprehension and Memory Reduced ability to
understand, process and recall what is being said
or read

• Provide written and verbal instruction
• Model tasks whenever possible
• Encourage the individual to paraphrase
  instructions back to the speaker
• Enter instructions in job log
• Use a tape recorder to enter reminders and
  instructions to review/reinforce later

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Self-Awareness The inability to take a
self-critical stance resulting in an
overestimation of skills and abilities

• Use of feedback both verbally and written
• Videotape for self-observation
• The establishment of a pre-agreed upon signal to
  give feedback if behavior/speech or work efforts
  are inappropriate or incorrect
• Use of a contract prior to placement that clearly
  states roles and responsibilities

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Motivation/Initiation Difficulty in initiating
a task. May appear disinterested or unmotivated
Observe if individual responds better to visual
or verbal cues Use consistent cues and
checklists that foster self-monitoring. Include
individual in planning these cues Teach
self-prompting techniques Use a co-worker to cue
behaviors Use a daily written assignment
sheet/job log Break tasks down into simple steps
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Role of the Vocational Counselor

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Possible Prevocational or Concurrent Vocational
Needs

• Psychotherapy
• Substance Abuse Program
• Cognitive Remediation via Rehabilitation
  therapies (OT,SLP.PT) and/or a Community
  re-entry program
• Neuropsychiatric/Neuropsychological
  Evaluations
• Work hardening program
• Driving evaluation/retraining

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Substance Abuse Brain Injury Alcohol Use
TBI-IncidenceAnalysis of the Literature
(Corrigan 1995)

• Alcohol, the drug of choice-Corrigan and his
  colleagues report that for 70 of the
  individuals they work with who use substances,
  alcohol is the preferred substance
• Intoxication at time of injury-7 studies looked
  at incidence of intoxication (BAL equal or
  exceeding 100mg.dL)at time of injury.
  Intoxication ranged from 36 to 50
• History of Substance Abuse-Findings suggest that
  for adolescents and adults in rehabilitation
  following a TBI, as much as 60 of this
  population have histories of alcohol use or
  dependence.

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Substance Abuse Brain Injury How does
Incidence and History Impact on Recovery
Outcomes? Studies Suggest..

• Alcohol may negatively affect the process of
  dendrite profusion thus impede ability of the
  remaining neurons to compensate for the neurons
  that have been damaged (Corrigan, NASHIA webcast
  2003)
• Alcohol use after brain injury may increase the
  risk of seizure post TBI
• Increased brain atrophy observed in patients with
  a positive BAL and or history of moderate to
  heavy pre-injury use (Bigler et al 1996 Wilde
  et.al 2004)

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Subsequent Use

• 5-10 of those with TBI develop substance abuse
  problems after their injury (Corrigan 2009)
• A person with a preinjury history of two drinks
  a day would not have had a reason to seek
  alcohol-related treatment before his or her
  accident. But once that same person becomes
  brain-injured, the continuation of that drinking
  pattern has the potential to cause major
  problems Robert Karol, Ph.D.

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Taking Advantage of the Honeymoon Period

• Individual in an inpatient and/or highly
  structured outpatient setting resulting in
  detoxification
• Physical and cognitive disabilities make access
  to substances difficult
• Families are instructed to provide supervision
  due to physical needs and judgement concerns
• Individual is remorseful over past use, related
  behavior, blames self for accident and vows to
  change

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Screen

• CAGE Questionnaire
• Brief Michigan Alcoholism Screening Test (BMAST)
• AUDIT
• According to brain injury researchers, the above
  tools are appropriate and valid for use with
  individuals with brain injury

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..and Intervene

• Modify 12 Step Program components to accommodate
  cognitive and behavioral concerns
• Incorporate substance abuse education into
  cognitive remediation, prevocational and
  employment services
• If you ask, they will tell, self report according
  to researchers is a reliable measure of risk and
  use
• Dont assume staff can easily identify who is
  currently using or at risk
• Discard old stereotypes e.g. he has to hit rock
  bottom before any intervention will work

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Characteristics of a Successful Vocational
Candidate
Rehabilitation therapies (OT,SLP,PT)- carry over
of strategies learned Able to manage frustration
and anger Awareness of deficits and the ability
to generalize compensatory strategies in a
variety of situations Exhibits a desire to please
others/work ethic Supportive family/social
network May be years post-injury
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I had a job, I had a girl, I had something going
mister in this world,I got laid off at the
lumber yard, Our love went bad, times got hard.
Now I work down at the car wash, where all it
ever does is rain. Dont you feel like youre a
rider on a downbound train Bruce Springsteen
quoted by young man living with a brain injury
for over ten years
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Happy Ending

• Six months of outpatient brain injury
  rehabilitation, received speech, OT, mental
  health, group therapy
• With a employment specialists support, hired at
  a golf course-grounds keeper
• After several years, wanted more money,new
  challenge, took a job w/ an auto parts company as
  a delivery truck driver, received a few months of
  supported employment funded by the Division of
  Rehabilitation Services

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Job Loss Factors

• Lack of Social Skills
• Poor Executive Functioning
• Memory Impairments

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Lack of Social Skills

• Dress and/or personal hygiene is inappropriate to
  the work environment
• Egocentric in speech
• Discloses personal information
• Inappropriate sexual behavior
• Unable to modify speech and behavior as
  appropriate ( too familiar with boss)
• Unable to pick up nonverbal social cues

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Executive Functioning

• Work space is messy and unorganized
• Unable to work on several projects/tasks
  concurrently
• Get caught up in extraneous details
• Unable to modify a solution to a problem as the
  situation changes and shifts

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Memory Impairments

• Unable to retain coworkers names
• Unable to recall work routines
• Unable to generalize knowledge/routines
• Inconsistently able to utilize notes to support
  memory

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Inappropriate Workplace Behaviors
Being late Interrupting Talking too
much Arguing, fighting and yelling Leaving
without permission/notice Preventing others from
getting their work done
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Appropriate Workplace Behaviors
Any of the following may be a possible focus for
vocational counseling
Show others respect Address supervisors and
other superiors appropriately (Sir, Ms) Listen
when someone is talking Avoid interrupting Maintai
n focusdont go off on tangents Be prompt (check
watch and map out plan to get to work on
time) Notify supervisor if going to be late
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The Vocational Counselor Needs to Provide

• Structure
• Support
• Strategies

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Remember

• Success at work requires two basic components
  The Skills necessary to perform the job, and the
  proper attitude, motivation , awareness, and
  consistency of behavior to function effectively
  on the job apart from and in addition to the
  particular skills required.
• Saralyn Silver (1988)

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Additional Resources on Brain Injury

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Additional Resources
Print Materials Books and Articles Understanding
Brain Injury A Guide for Employers by Mayo
Clinic (2000) www.mayo.edu Vocational
Rehabilitation for Persons with Traumatic Brain
Injury by Paul Wehman Jeffrey S. Kreutzer
(Eds.) (1990) Brain Injury Source, Brain Injury
Association of America, Volume 5, Issue 1.
Httpwww.biausa.org/Pages/dbscip20source/vol.5.is
sue.1.html. Moderating Factors in Return to Work
and Job Stability after Traumatic Brain Injury.
Kreutzer et. al 2003. Journal of Head Trauma
Rehabilitation, 18(2), 128-138.

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Additional Resources
Research and Training Center, Stout Vocational
Institiute, University of Wisconsin-Stout.
http//cec.uwstout.edu/ Brain Injury Association
of America www.biausa.org Traumatic Brain Injury
Model System Centers http//www.tbindc.org/registr
y/ University of Washington Traumatic Brain
Injury Model System http//dept.washington.edu/reh
ab/tbi/projects/html National Association of
State Head Injury Administrators www.nashia.org,
to download employment fact sheet go to
www.nashia.org/fs/VR.pdf The Disability Rights
Center of New Hampshire has published a short
guide for job seekers with a history of brain
injury, entitled Five Things You Should Know When
Returning to Work After a Traumatic Brain Injury.
The document is available at http//www.drcnh.org
/emptipstbi.htm

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Additional Resources-Substance Abuse

• Ohio Valley Center For Brain Injury Prevention
  and Rehabilitation, 614-293-3802,
  www.ohiovalley.org
• Rehabilitation Research and Training Center on
  Traumatic Brain Injury Interventions New York
  Traumatic Brain Injury Model System at the Mount
  Sinai School of Medicine and the Mount Sinai
  Rehabilitation Research and Training Center
  www.mssm.edu/tbinet

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Additional Resources
Brain Injury Association of
Maryland (BIAM) To contact BIAM Call
[phone] Toll Free in Maryland
[phone] Email info_at_biamd.org
Write or visit BIAM 2200 Kernan
Drive Baltimore, MD 21207 Website
www.biamd.org

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Recommended Reading

• I am the Central Park Jogger A Story of Hope and
  Possibility by Trisha Meili, 2003
• Every Good Boy Does Fine A Novel by Tim
  Laskowski, 2003
• Over My Head A Doctors Own Story of Head Injury
  from the Inside Looking Out by Claudia Osborn,
  2000

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Acknowledgements
The Maryland Traumatic Brain Injury Project
wishes to thank the following individuals for
their contributions to this vocational
training Sharon Cullinane Anastasia
Edmonston Fran Forstenzer Jerri
Fowler Stefani ODea Diane Triplett Amy
Welch John Capuco, Psy.D Julia
Freeman-Woolpert M.Ed. Project Response,
New Hampshire  Special thanks and
acknowledgement to Saralyn Silver MS CRC formerly
of the New York University Head Trauma Program
and Patricia Price of the Florida Brain Injury
Demonstration Project for their contributions to
the field brain injury and vocational
rehabilitation. Alice Marie Stevens, PhDc,
Editor, Vocational Issues After Brain Injury 2003
and Director, Maryland TBI Implementation
Project, Baltimore, MD Additions and
modifications by Anastasia Edmonston, MS CRC
Project Director MD TBI Partnership
Implementation Project, 2009.

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Acknowledgements
This training and its associated training
materials are supported in part by the TBI State
Grant Program, Grant Number 4 H21 MC 00008-04-03,
from the Department of Health and Human Services
(DHHS) Health Resources and Services
Administration, Maternal and Child Health Bureau.
The contents are the sole responsibility of the
authors and do not necessarily represent the
official views of DHHS. In the public domain,
please copy and distribute widely

Disclaimer Information given within this
training does not imply endorsement by BIAM or
DHMH or any other party associated with this
training. Listings in this training may not
represent all the possible services or resources
available.
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Project Contact

• Anastasia Edmonston, MD TBI Project Director.
  Please contact for information about the
  Projects resource coordination and training
  activities. 410-402-8478, aedmonston_at_dhmh.state.md
  .us

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Thank you for participating!

• Please complete your evaluation form and leave
  it with your speaker

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References

• Ezrachi., O., Ben_Yishay., Kay, T., Diller, L.,
  Rattok, J. (1991). Predicting Employment Brain
  Injury Following Neuropsychological
  Rehabilitation. Journal of Head Trauma
  Rehabilitation, 6(3), 71-84.
• Jacobs, H. (1997). The Clubhouse Addressing
  Work-Related Behavioral Challenges Through a
  Supportive Community. Journal of Head Trauma
  Rehabilitation,12(5), 14-27.
• Kay, T., Silver, S. (1989). Closed Head Trauma
  Assessment for Rehabilitation. In M. Leazak
  (Ed.), Assessment of the Behavioral Consequences
  of Head Trauma. (pp.145-170). New York Alan R.
  Liss, Inc. Malaec, J., and Basford, Jr. (1996).
• Postacute Brain Injury Rehabilitation. Archives
  of Physical and Rehabilitation Medicine, 77,
  198-207.
• Corrigan JD. (1995). Substance Abuse as a
  Mediating Factor in Outcome from Traumatic Brain
  Injury. Archives of Physical Medicine and
  Rehabilitation Vol. 76, April 302-309
• Bombardier, CH., Temkin, NR., Machamer, J.,
  Dikmen SS.(2003), The Natural History of Drinking
  and Alcohol-Related Problems After Traumatic
  Brain Injury Archives of Physical Medicine and
  Rehabilitation Feb84(2)185-91.
• Bombardier C., Davis, C. (2001). Screening for
  Alcohol Problems Among Persons with TBI. Brain
  Injury Source. Fall 16-19.
• Corrigan J., et. al (1998) Utilities for
  Community Professionals. Ohio Valley Center for
  Brain Injury Prevention and Rehabilitation