The Impact of Behavioral Deficits on Employment Retention: An Illustration from Supported Employment John Kregel, EdD Wendy Parent, MS Michael West, MEd Rehabilitation Research and Training Center on Supported Employment Virginia Commonwealth University Richmond, w.r Supported employment has emerged as a viable alternative to conventional rehabilitation approaches for tens of thousaruls of individuals previously excluded from employment opportunities. However, the ability to retain a job in business or industry for an extended period of time remains a challenge for many supported employment participants. An exploratory investigation of the reasons for job separation of 1,484 individuals participating in supported employment programs in eight states was completed to investigate behavioral characteristics that facilitate or hinder employment retention. Results illustrate that employment retention is affected by a wide variety of vocational, behavioral, economic, and external factors. A number of different approaches currently used to address behavioral difficulties in employment settings are discussed, including compensatory strategies, self-management, and co-worker supports. Keywords: Behavioral deficits; supported employment; job retention; brain injury; cerebral palsy; mental retardation

The U.S. Department of Education 1 estimates that between 13 and 18 million Americans have a mental or physical disability that prevents them from working or limits the type of work they are able to perform. It is further estimated that over half of the adult working-age population is unemployed at anyone time. 2 An inability to enter or reenter the work force affects an individual with a disability in many ways. Given the value placed on work This work was supported by Cooperative Agreement No. HI33B80052 from the National Institute on Disability and Rehabilitation Research, U.S. Department of Education. The opinions expressed in the article are strictly those of the authors and no official endorsement by NIDRR . should be inferred. Address reprint requests to John Kregel, Rehabilitation Research and Training Center, Virginia Commonwealth University, Box 20 II, Richmond, VA 23284-20 II.

in our culture, an inability to maintain employment may lead to a lowering of an individual's confidence, self-esteem, or status within his or her family. A lack of economic self-sufficiency may limit the individual's ability to live independendy in the residential situation of his or her own choosing. Further, individuals excluded from the workplace are often socially isolated and unable to benefit from the opportunities for friendships and social networks available in the work setting. While the present employment situation of individuals with disabilities appears bleak, a flurry of recent activity has occurred at the federal, state, and local level which is intended to promote the inclusion of these individuals into all segments of our society. These activities, coupled with current demographic trends and the emergence of new rehabilitation alternatives, provide a unique

NeuroRehabil 1994; 4(1): 1-14

Copyright © 1994 by Butterworth-Heinemann

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NEUROREHABILIlATION / JANUARY 1994

opportunity to enable individuals with disabilities to obtain and maintain successful employment.

FEDERAL LEGISLATIVE ACTIVITY The Americans with Disabilities Act of 1990 (ADA), viewed by many as the most significant piece of civil rights legislation in the last quarter century, prohibits employment discrimination against people with disabilities. The ADA requires employers to make necessary and reasonable accommodations to the job setting in situations where the accommodation can be made without the employer sustaining an "undue hardship." Among these potential accommodations are the services provided by a supported employment job coach or employment specialist, as well as various types of assistive technology devices. Other federal legislative initiatives will also support the efforts of individuals with disabilities to enter the work force, many for the first time. The Technology-Related Assistance for Individuals with Disabilities Act of 1988 (P.L. 100-4(7), is designed to stimulate the development of comprehensive statewide systems capable of meeting the needs of individuals with disabilities for assistive technology, rehabilitation engineering, or other services devised to improve the functional capabilities of individuals with disabilities. The recent amendments to the Rehabilitation Act, signed by then President Bush on October 29, 1992, contain several significant changes. Changes in eligibility criteria are designed to allow individuals previously denied vocational rehabilitation services due to the severity of their disability an opportunity to enter the program for the first time. Other changes focus on increasing individuals' ability to choose their own jobs and plan their own careers.

THE CHANGING WORK FORCE OF THE 19908 During the 1990s, important demographic and economic trends will change the nature of the American work force and place additional pressure on federal, state, and local governments to

assist individuals with disabilities as they strive to become contributing, tax-paying citizens. Significant demographic and economic changes will have a dramatic impact on rehabilitation programs for individuals with severe disabilities. The factors contributing to this change pose a challenge to individuals with disabilities, their families, and federal, state, and local agencies. In the 1990s the work force will grow more slowly, at a rate of about 1% per year, compared to the 2.5% annual growth rate that occurred during the 1970s and 1980s. Potential labor shortages, especially in service industries, may provide an opportunity f()r traditionally unemployed individuals to obtain and maintain employment. However, the educational demands of anticipated new jobs in the 1990s may make it extremely difficult for persons with disabilities to benefit from the changing employment outlook. For example, of all new jobs created in America between now and the year 2000, a third will require a college degree and more than halfwill require some postsecondary education. Simultaneously, the number ofjobs in the least-skilled j()b classes will decline dramatically over time. This may have a negative effect on the employment outlook f()r individuals with disabilities, many of whom remain locked in lowpaying, declining job categories.

THE DEVELOPMENT OF NEW REHABILITATION ALTERNATIVES In the United States, several new rehabilitation approaches were developed and implemented during the 1980s with favorable results. The most significant of these technologies is the emergence of supported employment as an alternative to traditional rehabilitation approaches for individuals with disabilities. The outcomes of the federal supported employment initiative indicate that we may now possess the technology necessary to allow large numbers of previously unemployable individuals to obtain and maintain meaningful employment in the private sector. For example, since the federal government initiated supported employment programs for people with disabilities in 1986 the number of people with disabilities who

The Impact of Behavioral Deficits on Employment Retention

have benefited from these services has increased tenfold, from less than 10,000 in 1986 to approximately 100,000 in 1993. The growth of supported employment programs as a preferred alternative to traditional rehabilitation approaches such as sheltered workshops or day activity programs has been widely documented. 3 - 5 From its beginnings in a series of university-based demonstration programs in the early 1980s, supported employment has evolved into a significant component of the federal/state vocational rehabilitation program. In supported employment programs, individuals with disabilities receive assistance from an employment specialist who facilitates placement into an appropriate job and provides training and support necessary to ensure employment retention. Supported employment is distinguished from traditional placement approaches in a number of ways. First, supported employment programs emphasize training and support services delivered to the individual after initial placement has occurred. This contrasts significantly with traditional approaches that require the individual to reach a certain level of "readiness" before placement can occur. Second, in contrast to less intensive approaches such as selected placement, 6 or the 'Job club", 7 supported employment provides a comprehensive approach to job placement that actively addresses the non-work-related factors (e.g., effect of employment on Social Security Administration (SSA) benefits, family concerns, transportation, etc.). Third, supported employment services are ongoing, not time-limited. Individuals are not "closed" or terminated from services after a period of several months, as is generally the case in most rehabilitation programs. Rather, an individual is able to receive systematically planned job retention and follow-up services throughout the course of his or her employment. Although developed initially as a program for persons with mental retardation, supported employment has now expanded to accommodate thousands of individuals with a wide variety of disabilities. Anthony and colleagues 8 •9 were among the first to demonstrate the effectiveness of this technology for individuals with long-term mental illness, and these individuals are currently enter-

3

ing supported employment programs in large numbers. Other recent efforts have fc:>eused on the inclusion of persons with brain injuries 10 and persons with cerebral palsy. II Research to date indicates that supported employment participation has a dramatic impact on the wages earned by persons with disabilities. For example, a 1989 study of 1,550 individuals 12 found that participation in supported employment programs dramatically increased individuals' earning power, regardless of their primary disability. Comparisons of wages prior to and after supported employment participation showed increases ranging from 280 to 574%. Largest increases were experienced by individuals with moderate or severe mental retardation and persons with physical or sensory disabilities. Despite the documented accomplishments of supported employment to date, a number of problems have been identified which may limit the program's ultimate success. Concerns have been raised that supported employment is not serving the individuals the program was intended to serve. 13 It is feared that many individuals with severe disabilities, particularly persons who display significant problem behaviors, remain excluded from supported employment. Another frequently cited concern 14 is that individuals placed into jobs through supported employment programs are often separated from their jobs after only a short period of time. It is feared by many that insufficient attention is being paid to strategies and techniques designed to promote the employment retention of supported employment partici pan ts.

REASONS FOR JOB SEPARATION Only a limited amount of research has been conducted to investigate the reasons why supported employment participants are separated from employment. Hill, Wehman, Hill, and Goodall 15 studied the reasons for job separation among 107 individuals with mental retardation who had been employed in the community. Reasons for separation were categorized into client-related (internal) separations and externally-related separations.

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NEUROREHABILITATION / JANUARY 1994

Client-related separations were the result of factors over which the individual might be expected to exert some control, such as tardiness or poor quality work. Externally-related separations were the result of factors over which the individual exhibited minimal control, such as changes in transportation arrangements or the onset of medical or health problems. Results indicated that individuals with mild mental retardation were more likely to be separated for client-related reasons. In contrast, individuals with moderate or severe mental retardation were more likely to lose their jobs as a result of external factors such as parental interference or economic layoffs. Lagomarcino l6 investigated the job separations of 285 individuals served in local supported employment agencies in Illinois. Job separations were grouped into six categories: (1) lack of job responsibility, (2) task production, (3) socialvocational behavior, (4) economy, (5) change in job status, and (6) other external factors. Lack of job responsibility and other external factors were most frequently cited as causes of separation. Results indicated that reasons for job separations varied significantly between individuals with mental retardation and persons with longterm mental illness. Sale and colleagues 17 focused on the reasons for job separation in a supported employment program for persons with brain injuries. Using qualitative research methods, five categories of reasons for separations were identified: (I) issues related to the employment setting, (2) interpersonal relationship problems, (3) mental health problems, (4) other problems, and (5) economic layoffs. Significantly, the study f(mnd that over three-fourths of all separations involved more than one major reason. The authors concluded that job loss was best viewed as a culmination of a series of events as opposed to the immediate outcome of a single precipitating incident. The purpose of the present investigation is to explore the extent to which behavior deficits and maladaptive behavior hinder the ability of supported employment participants to obtain and retain employment. Descriptive data will be presented from a sample of 1,484 individuals with disabilities who have been separated from a sup-

ported employment POSItIon. The effect of an individual's primary disability on separation reason will be explored and compared. Finally, three strategies frequently used to deal with behavior problems in vocational settings (work site modifications, self~management programs, and coworker support) will be described.

METHOD Participants Participants represented in the descriptive analysis consisted of individuals participating in supported employment programs tracked by the Supported Employment Information System (SEIS) at the Rehabilitation Research and Training Center on Supported Employment at Virginia Commonwealth University. The SEIS was established through a series of cooperative agreements between the Center and over 100 local supported employment programs in eight states. At the time ofthe study, 2,625 individuals were represented in the data base. Individuals were selected for participation in the present analysis if they met the following four selection criteria: (1) complete data were available on all facets of the individual's employment experience; (2) the person participated in the individual model (as opposed to group model) of supported employment; (3) the individual was a member of one of the five disability groups described in Table 1; and (4) the individual had been separated from employment. The application of these selection criteria resulted in an effective sample of 1,484 persons.

Instruments The SEIS is an individual consumer tracking system that collects information at various stages of the individual's employment experience. The system is comprised of 200 data elements on nine data collection forms that record consumer demographies, functional characteristics, employment outcome information, and reasons for separation. The System's Separation Report is completed by the individual's employment specialist Uob coach) after an individual leaves a specific job. Separation is first categorized into voluntary resignations,

The Impact of Behavioral Deficits on Employment Retention

employer-initiated terminations, layoffs, and leaves of absence. Specific reasons for separation of each placement are then selected from a prescribed menu of alternatives. Numerous steps are completed to verify the accuracy of the data obtained. Employment specialists are provided six hours of training in the completion of the forms. A comprehensive Data Management Operations Manual has been developed and provided to each participating employment specialist. When completing the Separation Form, employment specialists are encouraged to meet with the consumer, their family, and the employer to discuss the reasons for the sepa,ration. Frequently, the form is completed by a local interagency team which includes a service coordinator and/or rehabilitation counselor. Completed forms are sent to the Rehabilitation Research and Training Center (RRTC) for processing. Each form is visually inspected by a data management specialist for completeness and then entered for computer analysis using data entry programs contammg error-checking procedures designed to identify out-of-range or inconsistent values. The reasons for separation identified by the employment specialists were grouped into six categories. Each of these categories are described below. Poor work skills refer to behaviors which limited an individual's ability to meet the production demands or quality standards of a specific employment setting, an inability to perform a job independently even after extensive training has been delivered, or an inability to meet specific job requisites such as strength, endurance, or orientation skills. Insufficient motivation to work refers to individuals who exhibited excessive absenteeism rates, displayed a poor work attitude, or expressed a desire to terminate their employment. Aberrant or inappropriate behaviors refer to individuals who displayed unusual or insubordinate behaviors while on the job. This category also includes a small number of instances in which the individual engaged in aggressive or criminal behavior (assaults or theft) or poor social skills (e.g., inappropriate behavior toward members of the opposite sex) while at the job site.

5

Externalfactors include forces or events outside an individual's control which adversely affected their employment status. For example, a number of individuals experienced medical or health problems which necessitated their taking a leave of absence. In a few instances, parents or family members initiated an individual's resignation from the job. Other individuals had been terminated by employers uncomfortable with the supported employment situation. Finally, individuals who experienced disruptions in their transportation situation were included in this category. Economic layoffs refer to individuals who lost their jobs due to either seasonal layoffs or the temporary or permanent loss of job due to the economic situation of the business or industry.

RESULTS OF THE ANALYSIS OF JOB SEPARATIONS The key demographic and supported employment outcomes of this group of individuals are summarized in Table 1. The primary disabilities of the individuals in the sample were grouped into five categories. Individuals with mental retardation accounted for 80% of the entire sample and were therefore grouped into two subcategories-

Table 1.

outcomes.

Key demographic and employment

Mean Age of Participants Primary Disability of Participants Mild mental retardation Moderate/severe mental retardation Long-term mental illness Brain injury Cerebral palsy Mean Hours Worked Per Week Mean Hourly Wage Monthly Earnings Prior to Supported Employment Monthly Earnings During Supported Employment Mean Length of Employment

32.4 Years 46.4% 33.1% 13.6% 4.3% 2.6%

27 $3.82 $79 per month $113 per month

56 weeks

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Nt~UROREHABILnATION

/ JANUARY 1994

individuals with mild mental retardation and persons with moderate or severe mental retardation. This overrepresentation of individuals with mental retardation in supported employment programs is consistent with national trends. 4 Persons with long-term mental illness, brain injury, or cerebral palsy combined to make up slightly less than one-fourth of all participants in the sample. The individuals worked an average of 27 hours per week (74% worked less than 35 hours per week) and earned an average of$3.82 per hour. Individual's monthly earnings rose from $79 prior to participation in supported employment to $413 during supported employment, an increase of over 400%. Participants had worked an average of 56 weeks since entering supported employment. A total of 62% of all participants had worked a full year since entry into supported employment. Table 2 describes the reasons for job separation among all individuals in the sample. Insufficient motivation to work was the factor most frequently cited by the employment specialists. The second most common reason fex job separations was poor work skills, which accounted for 22% of all separations. A surprisingly large number of individuals (21%) were reported to have experienced economic layoffs. Many employment specialists, however, indicated that in their opinion, employers would occasionally attempt to identify economic layoff as the primary reason for separation, when in fact another reason may have been the underlying cause of more general employer dissatisfaction. External factors accounted for almost one in five separations. By far the largest single external factor identified by the employment specialists Table 2. Reasons for job separation-all respondents. (N = 1,641). Reasons for Job Loss Poor work skills Insufficient motivation to work Aberrant/Inappropriate behavior External factors Economic layoffs

Percentage 21.7 26.8 12.6 18.3 20.6

was medical or health considerations that prevented the individual from working. These problems alone accounted for over 5% of all separations. Separations due to aberrant or inappropriate behavior comprised approximately 13% of all separations. Within this category, insubordinate behavior directed toward the employer was the most frequently cited type of inappropriate behavior.

Relationship Between Primary Disability and Employment Outcomes Table 3 presents a cross-tabulation of job separations across various groups of individuals participating in supported employment. These results, however, should be interpreted with caution because of the skewed nature of the sample which prohibited statistical analyses (less than five individuals were represented in the cell for aberrant/ inappropriate behavior of persons with cerebral palsy). However, the sample size is extremely large (1,484) and the data represent the clinical appraisals of actual employment specialists, often made after consultation with consumers, employers, and family members. Based on these considerations, these findings may have their greatest utility as a base £i'om which to generate hypotheses and research questions for future investigation. When compared to other groups, individuals with mild mental retardation were considerably more likely to be separated from employment due to insufficient motivation to work. These individuals were twice as likely as any other group to display serious absenteeism or tardiness problems. Along with persons with long-term mental illness, individuals with mild mental retardation were more likely to express an unwillingness to continue employment. Persons with brain injuries were far more likely than any other group of individuals to be separated due to aberrant or inappropriate behavior. Individuals with brain injuries were twice as likely to have insubordinate behavior, unusual behavior, or criminal behavior cited as reasons for separation. Persons with cerebral palsy were somewhat less likely to engage in aberrant or inappropriate behavior.

The Impact of Behavioral Deficits on Employment Retention

7

Table 3. Percentage of individuals from various disability groups with identified reasons for job separation. (N = 1,484).

Reasons for Job Loss Poor work skills Insufficient motivation to work Aberrant/Inappropriate behavior External factors Economic layoffs

Mild Mental Retardation (N = 689)

Moderate/ Severe Ment. Retardation (N = 491)

Long-Term Mental Illness (N = 201)

Brain Injury (N = 64)

Cerebral Palsy (N = 39)

20.3% 30.2% 12.8% 16.1% 20.6%

23.9% 22.6% 12.6% 16.9% 24.6%

19.9% 27.9% 11.4% 26.4% 14.4%

25.0% 20.3% 23.5% 20.3% 10.9%

20.5% 23.1% 7.7% 28.2% 20.5%

Somewhat surprisingly, the groups varied little in terms of the percentage of individuals who were separated due to poor work skills. The present findings dispute the hypothesis that individuals with cerebral palsy, or moderate or severe mental retardation, might be more likely to be separated due to slow work, poor quality work, or inability to perform work tasks independently. Persons with long-term mental illness or cerebral palsy appear more likely to be separated from employment due to external factors beyond their control. Individuals with long-term mental illness were twice as likely as any other group to be separated from employment due to medical or health problems. Individuals with cerebral palsy were far more likely than members of any other group to have employer discrimination cited as the major cause of separation from employment. Less than 3% of all separations were reported to be initiated by parents or family members, a fairly low percentage given the large number of individuals with mental retardation represented in the sample. Individuals with long-tenn mental illness or brain injury were less likely to be separated due to economic layoffs. Since all placements occurred during the same time period and in the same communities, it is highly unlikely that the groups would be differentially affected by economic slowdowns. A plausible explanation might be that the types ofjobs in which the individuals with long-term mental illness or brain injury would be placed may be less susceptible to economic slowdowns. An alternative explanation, alluded to ear-

lier, may be that employers of individuals with mental retardation or cerebral palsy may be reluctant to terminate them and therefore indicate that the individual is being separated due to economic necessity.

IMPLICATIONS FOR EFFORTS TO ADDRESS BEHAVIOR DEFICITS IN EMPLOYMENT SETTINGS Every employment setting is unique in terms of the demands placed on workers for productivity, quality standards, social skills, and other unique factors. A behavior which may be tolerated in one employment setting may seriously jeopardize an individual's continued employment if displayed in another setting. The results of the present exploratory investigation illustrate the wide variety of often interrelated factors that combine to cause the employment separations for individuals traditionally excluded from the work force. The results of the descriptive analyses contained in Tables 2 and 3 should be reviewed with caution. First, while a number of the operational components of the data base are designed to promote reliability, such as formal face-to-face training sessions, development of an operations manual, use of committees and groups of individuals to review and discuss reasons for separation prior to data submission, and visual inspection of all data, the reasons specified remain the subjective clinical appraisals of individual employment specialists. Second, prior research, as well as the

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NEUROREHABILITATION! JANUARY 1994

present data, strongly illustrate that separation from employment is rarely caused by a single factor or single event in isolation. 17 The finding that "insufficient motivation to work" was the largest single category is somewhat disturbing. Many individuals, after an initial period of employment, simply indicated that they no longer wished to work. There are undoubtedly a number of factors that might cause an individual to lose the motivation to work. For many individuals, particularly those with mental retardation and cerebral palsy, the supported employment placement is their first opportunity to engage in vocational activities in a community-based setting. Due to a lack of prior experience and exposure to the community, these individuals may have been unaware ofthe demands and expectations of bus iness and industry and therefore no longer wished to work when the reality did not correspond to their expectations. Other individuals may lose their motivation for employment based on the economic implications of employment. For Social Security Disability Insurance (SSDI) recipients, for example, paid employment may result in the elimination of both financial and medical benefits. For Medicaid recipients residing in certain types of community-based settings, employment may not result in any actual increase in their discretionary income. Substance abuse or medical problems may be the cause of loss of motivation to work on the part of other individuals. Finally, for a small number of individuals, a loss of motivation to work may be the result of perceived discrimination or other factors experienced while on the job. The results clearly indicate that the vast majority of supported employment participants are "able to do the job." The fact that only 22% of all separations were due to poor work skills indicates that for the most part, individuals are able to achieve acceptable performance standards at the workplace. A small number of individuals are terminated because they were unable to work quickly enough, failed to meet employer expectations regarding accuracy or quality performance ratings, or were unable to work independently after the employment specialist was faded from the work

site. Other individuals manifested serious absenteeism or chronic tardiness problems. While a relatively small percentage of separations were due to aberrant or inappropriate behaviors, a small number of individuals did display aggressive behavior on the job site. An even smaller number of individuals engaged in criminal behavior, such as theft or drug use on the job site. Another small group of individuals displayed inappropriate social skills on the job site, particularly focusing on inappropriate interactions with customers or members of the opposite sex. The application of behavior management strategies in community-based employment settings presents an array of unique challenges. First, individuals are generally in the work environment for prolonged periods of time (40 hours or more per week). Therefore, strategies must be developed that do not rely on the ongoing presence of an external clinician. Second, interventions must occur in situations where there are a large number of co-workers, supervisors, and members of the community-at-Iarge, thereby limiting the range of procedures that may be employed without stigmatizing the worker. Third, in some situations, a single occurrence of an inappropriate behavior may lead to immediate and permanent exclusion from the job. While much needs to be done to develop strategies that will effectively promote the long-term retention of supported employment participants, a number of useful approaches have been employed. Among the most promising approaches are compensatory strategies, selfmanagement strategies, and co-worker supports.

Compensatory Strategies Compensatory strategies refer to a group of techniques, procedures or devices that allow an individual to overcome a cognitive, physical or emotional impairment and successfully perform a specific task or behavior. 18,19 Compensatory strategies have been used to promote the employment retention of many different groups of individuals participating in supported employment. For example, for individuals with brain injuries or other neurological impairments, compensatory strategies have been used most frequently to overcome

The Impact of Behavioral Deficits on Employment Retention

memory deficits that hinder an individual's independent work performance. Other types of compensatory strategies have been devised to enable individuals with mental retardation to overcome their inability to read, tell time, or perform mathematical computations. Individuals with longterm mental illness or seizure disorders have benefited from compensatory strategies designed to circumvent the side effects of medication on their cognition and behavior. Other types of strategies have been developed to address the mobility, gross motor, or fine motor deficits of individuals with disabilities. Compensatory strategies are particularly well suited to vocational applications fix two reasons. First, interventions can be designed and implemented on the job site. An individual does not need to be removed from the employment setting for preplacement or readiness training. This allows the individual to remain employed while intervention is underway. Second, the implementation of compensatory strategies often results in immediate improvement in production and self-esteem, thereby encouraging the further use of the technique or device. At least four distinct categories of compensatory strategies have been used in vocational settings: (l)job analysis, (2) environmental engineering, (3) prosthetic aids, and (4) cognitive orthotic devices. Each of these will be briefly discussed. Job analysis refers to the process of assessing the requirements and demands of an employment setting by identirying and breaking down the specific duties and tasks associated with a job. In a comprehensive job analysis, information is obtained on the cognitive, communication, social and physical demands of the job, the performance standards required by the employer, and the equipment and tools used to complete various tasks. It is also important to examine the social milieu of the work environment, paying particular attention to the presence of stress-provoking factors or conditions that may trigger inappropriate behaviors or exacerbate behavioral deficits. Results of a job analysis can be used in a number of different ways to overcome cognitive and behavioral deficits. Job carving,20 the process of eliminating certain duties or tasks from a person's

9

job description, or reassigning tasks to other employees, can be used to place an individual in a position that maximizes his or her likelihood for success. In other instances, job duties can be sequenced in a different order to space difficult or stressful tasks throughout the workday. Job analysis can also be used to identify alternative methods of performing an essential job duty or task in a manner that will allow the individual to complete all aspects of the job to employer satisfaction. Environmental engineering refers to manipulations made to the job site or work station that facilitate the individual's adaption to the work setting and promote independent task perf()rmance. 2! Redesigning a work station for an individual with a physical disability, modirying equipment for use by persons with vision or hearing impairments, or rearranging the work settings to eliminate stimuli that might otherwise distract an individual with mental retardation are all examples of environmental engineering. The provisions of the Americans with Disabilities Act that require employers to make reasonable accommodations to allow the employment of otherwise qualified workers with disabilities will greatly enhance the use of environmental engineering in the future. Prosthetic aid, involve the design and use of materials or devices that compensate for an inability to perform specific tasks ..For example, an accounts payable clerk who has difficulty distinguishing completed from uncompleted work was provided a plexiglass divided to separate finished from unfinished materials. Similarly, a greenhouse worker unable to remember the procedures to use in perf()rming plant maintenance activities was provided a resource book outlining procedures and decision rules for nourishing plants. A watch with an alarm was used to prompt the worker to terminate insecticide treatments. Parente and DiCesare!8 recommend a number of devices, including checklists, electronic signaling devices, telememo devices, personal directories, and microcassette recorders, which have been demonstrated to be effective as prosthetic aids in vocational settings. Cognitive orthotic devices refer to a specific type of prosthetic aid which performs a specific cognitive process or task required in a certain job. 2! Many of

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NEUROREHABILITATION I JANUARY 1994

these devices take the form of microcomputer software, such as expert system shells to guide decision-making and provide advice to individuals as they perform complex cognitive tasks. Other applications might include style checkers, dictionary machines, or spell checking applications. The widespread use of cognitive orthotic devices is limited by the cognitive deficits of many supported employment participants. However, fiJr persons with brain injuries, cerebral palsy, or other physical disabilities, the availability of writing aids and the immediate assistance provided by expert system shells can reduce frustration and allow successful performance of complex cognitive activities.

Self-Management Strategies The concept of self-management refers to the application of operant principles and behavior management strategies to modifY one's own behavior. 22 ,23 The term self-management is frequently used interchangeably with self-control or selfregulation in the literature. The potential of self~ management techniques to promote generalization and maintenance is particularly attractive to clinicians working with individuals in natural settings such as community-based work environments. 24 In their classic discussion of generalization technology, Stokes and Baer 25 delineate the potential of self~management strategies to "mediate" generalization. Self-management approaches have several important characteristics that make them ideally suited for application in vocational settings. First, work environments tend to value independence among employees. Self-management strategies, because they are implemented by the individual, can be used in settings where neither the employer nor the worker desire the physical presence of an employment specialist in the work setting. Second, external resources and controls are not always available in vocational settings. An employment specialist, co-worker, or supervisor may not always be present to observe behavior and provide reinforcement. In these situations, self-management may provide the only systematic behavior change approach available. Third, self~management approaches have the potential for resulting in more lasting and durable behavior change, since the

mediating variable (i.e., the individual) is present in every situation. Glynn, Thomas, and Shea 26 were among the first researchers to differentiate the various components of self-management. Among the components identified as frequently used in employment settings are self-recording, self-monitoring, functional assessment, self-instruction, and selfreinforcement. Each of these strategies are briefly defined below. Self-recording simply refers to the use of conventional observation and data collection strategies to measure one's behavior. F'or example, an individual attempting to meet a production standard of eight units per hour might simply record each unit as it is completed, Sowers and her colleagues 27 used self-recording in conjunction with picture cues to teach 13 vocational tasks to a group of adolescents with developmental disabilities. After pictures of individual tasks were presented in a photo album sheet to prompt independent performance, self-recording was used to check off each picture (task) as completed. Students quickly learned to use the picture sequencing and recording procedures to independently sequence and complete tasks. Performance was maintained after the physical presence of the investigator was removed £I'om the job site, Self-monitoring is similar to self~recording, except that in self~monitoring the individual generally compares his or her performance to some predetermined standard. For example, Ackerman and Shapiro 28 used self-monitoring to maintain productivity increases in the vocational performance of individuals with mental retardation. Productivity was initially increased through goalsetting and verbal praise, Subjects were then taught to record daily work rate and compare the rate to a standard. The self-monitoring procedure was successful in maintaining higher work rates, even when verbal praise was no longer provided. Functional assessment involves an examination of the setting events, antecedents, and consequences ofthe target behavior to determine the controlling stimuli and the function of the behavior itself For example, Eric, an individual who worked as stock clerk in a large department store indicated that he was having a problem getting along (having

The Impact of Behavioral Deficits on Employment Retention

arguments and shouting matches) with his coworkers. After agreeing to participate in a selfmanagement plan, he was first taught to keep simple Antecedent-Behavior-Consequence records of his interactions with co-workers. While examining his data with his employment specialist, he discovered that he most frequently had arguments with co-workers when he felt he was under pressure to meet a deadline established by his supervisor. Furthermore, Eric discovered that after arguments occurred, his co-workers tended to ignore him and not help him with his tasks, making it less likely that he would meet his supervisor's deadlines. Eric and his employment specialist were able to use this information to design a self~ management plan that involved self-recording and self-reinforcement and focused not only on his interactions with co-workers, but also on his ability to meet performance deadlines and request the assistance of his co-workers. Self-instruction refers to a number of strategies in self~management programs in which the individual delivers a visual or auditory prompt that sets the occasion for the targeted behavior to occur. For example, Rusch and his colleagues 29 used self~ instruction to promote on-task performance of two food service workers. Prior to intervention, both individuals were reported at risk ofjob termination due to an inability to perform three tasks to employer standards. Both workers were taught to provide a self-instructional set:10 in which they asked questions about the task to be performed, answered the questions (cognitive rehearsal) and then guided their own performance by verbalizing specific selfinstructional prompts. In the Rusch study, the individuals were able to learn the procedures quickly and maintain the procedures after training. The package had the further effect of markedly improving the individuals' on-task behavior. Other investigators have attempted to simpliry the traditional self-instructional paradigm for use with individuals with significant cognitive disabilities. Referred to as self-labeling,31 the procedure emphasizes only the verbalization of the specific self-instructional prompts while eliminating the more complex cognitive rehearsal components. Agran and his colleagues 32 combined picture cues with self-generated verbal prompts to teach in-

11

struction following skills to a group of adolescents with severe disabilities participating in a vocational skills training program. Shafcr 33 used verbal labeling to address the poor work skills displayed by two supported employment participants. The first individual, employed to clean doorways and escalators in a shopping mall, utilized a self-labeling procedure in which he verbalized the most critical components of the task. The procedure dramatically improved the quality of his work and maintained this gain for an extended period of time. For a second worker, employed as a porter in a large interstate truck stop, the verbal labeling procedure did not significantly improve his performance on the work task of cleaning shower stalls. A supervisor-mediated feedback procedure was then introduced to produce moderate improvements in his performance. Self-reinforcement techniques consist ofindividuals delivering reinforcers to themselves contingent on the performance (or absence) of particular target behaviors. While applying selheinforcement, the individual must be taught to evaluate him- or herself, or to determine whether or not the criterion for self-reinf()rcement has been met. In vocational settings, self-reinu)rcement is frequently used to address both production and behavior problems. For example, a motel maid assigned to clean 16 rooms might reward herself on a fixed ratio schedule with a ten-minute break after completing sets of {(mr rooms. Other individuals may reward themselves with compact discs, meals in restaurants, or other activities after arriving at work on time for a prescribed number of days. Designing self-management programs. Smith 34 provides some useful guidelines for use in designing self~management programs. First, the individual should be involved in setting the goal of the program. The goal must be practical and attainable. If an individual is not committed to the goal ofthe program, or does not feel a need to change his or her behavior, the likelihood of successfully designing and implementing a self-management plan is minimal. Second, when designing selfmanagement programs, it is important to remember that all the principles of behavior management apply to self~management programs as well. Principles such as reinforcement schedules, fading,

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NEUROREHABILITATION / JANUARY 1994

maintenance and generalization must all be considered and addressed in the design and implementation of the program. Third, it is not necessary to design a plan entirely by oneselfin order to be considered a behavior management program. In vocational settings, employment specialists, rehabilitation counselors, employers, and family members may all assist the individual with a disability to develop a plan appropriate to a particular situation. To be effective, however, the designers should be competent in the development of behavior management programs and the individual who will be implementing the program should also be involved in the design process.

Co-worker Supports As supported employment programs have expanded, substantial efforts have been made to increase the involvement of co-workers, supervisors, and other individuals present at the job site in the behavior change and maintenance process. Collectively termed "natural supports",20,35 these efforts have focused on the role of co-workers and other individuals in observing and recording worker behavior, providing feedback to the worker on his or her performance, or advocating on the worker's behalf The use of natural support strategies has two advantages. First, the coworkers, supervisors, or other individuals are always present at the job site. In the supported employment model the presence of the employment specialist is gradually removed from the job site over time, making it impossible for the employment specialist to always be available to provide feedback or reinforcement when necessary. Second, some supported employment workers, particularly those with long-term mental illness or brain injuries, feel that the presence of the employment specialist on the job site stigmatizes them among their co-workers. Therefore, they actively request that the employment specialist fade from the job site as rapidly as possible. In these situations the involvement and cooperation of co-workers can make the difference between successful employment and separation from the job. Shafer 36 has identified three functions coworkers can perform in order to promote job retention. Co-workers can serve as (1) observers

and recorders ofjob performance or inappropriate behavior, (2) trainers providing prompts or feedback to workers, or (3) advocates promoting the individual's social integration into the work setting. Rusch and his colleagues 37 identify association, training, evaluating, advocating, befriending, and data collection as potential roles of coworkers in supported employment situations. Rusch 38 provides an illustration of the potential role of co-workers in dealing with the inappropriate behaviors of a supported employment worker. In this study, an individual employed in a cafeteria setting engaged in verbal perseveration (repeating a topic or phrase over and over). After a period of time, this behavior began to threaten the social acceptance of the individual by both his co-workers and supervisors. The co-workers were requested to provide feedback to the individual each time he repeated a topic or phrase during lunch and break. Mter regularly prompting the co-workers to provide the feedback, the rate of the inappropriate behavior was dramatically reduced. As local supported employment programs are asked to serve larger numbers of individuals without commensurate increases in staff resources, the momentum to use co-workers and supervisors as behavior change agents in employment settings will continue to grow. 20 ,36,39 However, only a minimal amount of research has been done to assess the utilization of co-workers. The widespread use of these approaches remains a major research need within supported employment and consumer empowerment initiatives.

SUMMARY The reasons for job separation among individuals with disabilities are varied and complex. While over 60% of all separations result from poor work performance (either poor work skills, motivational problems, or inappropriate behaviors), it is also clear that external factors and economic pressures on business and industry playa major role in job retention. In reality, multiple factors often combine to make the employment setting unacceptable to either the worker or the employer. Although a number of promising approaches fl:>r

The Impact of Behavioral Deficits on Employment Retention

implementing behavior management strategies in vocational settings have been developed and demonstrated to be effective with a small number of individuals, we are far from having a "technology of employment retention." Future research

13

should focus on the ways in which multiple factors combine to cause employment separation, as well as identifYing ways in which job site interventions can be fully coordinated with ongoing counseling and subst.ance abuse programs.

REFERENCES 1. National Institute for Disability and Rehabilitation Research. Chartbook on work disability in the United States. Washington, DC: NIDRR, U.S. Department of Education, 1991. 2. McLaughlin Pj, Wehman P. Developmental disabilities: A handbook for best practices. Stoneham, MA: Andover Medical Publishers, 1992. 3. Kregel j, Shafer MS, Wehman P, et al. Policy development and public expenditures in supported employment: Current strategies to promote statewide systems change. Journal of the Association for Persons with Severe Handicaps 1989; 14(4):283-292. 4. Shafer MS, Revell WG, Isbister F. The national supported employment initiative: A three-year longitudinal analysis of 50 states. Journal of Vocational Rehabilitation 1991; 1(1):9-17. 5. West M, Revell WG, Wehman P. Achievements and challenges I: A five year report on consumer and system outcomes from the supported environment initiative. Journal of the Association for Persons with Severe Handicaps 1992; 17, 227-235. 6. Rubin SE, Roessler RT. Foundations of the vocational rehabilitation process. Baltimore: University Park Press, 1978. 7. Azrin NH, Besalel VP. Job club counselors rfUlnual. Baltimore: University Park Press, 1980. 8. Anthony WA, Blanch A. Supported employment for persons who are psychiatrically disabled: An historical and conceptual perspective. Psychosocial Rehabilitation Journal 1987; 11(2):5-23. 9. Danley KS, Anthony WA. The choose-get-keep approach to supported employment. American Rehabilitation 1987; 13(4):6-9,27-29. 10. Wehman P, Kreutzer j, West M, et al. Employment outcomes for persons following traumatic brain injury. Brain Injury 1989; 3(4):397-412. 11. West M, Callahan M, Lewis MB, et al. Supported employment and assistive technology for individuals with physical impairments. Journal of Vocational Rehabilitation 1991; 1(2):29-39. 12. Kregel j, Wehman P, Banks PD. The effect of consumer characteristics and type of employment model on individual outcomes in supported employment. Journal of Applied Behavior Analysis 1989; 22:407-415.

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