• Balancing, lifting, walking

• Strength, coordination

• Vision, hearing, communication skills

• Pain and headaches

• Memory, organizational and planning ability, concrete thinking

• Attention span/distractibility

• Writing skills, reading skills, visual-spatial skills

• Lack of initiative, inflexibility, irritability

• Social judgment, maturity

• Social awkwardness

• Feelings of isolation, impulsiveness, aggressiveness

• Anger, depression, anxiety, low self-esteem

• Behavioral problems, suspiciousness

• Low self-care skills, low safety skills

• Problems handling money

• Inability to carry out previously learned tasks

• Slowness

Normally, it is not difficult to determine that an individual with TBI has a vocational impediment. These individuals often have numerous obvious physical complications and resulting functional limitations that can easily be tied to inability to perform job tasks. If they have worked prior to the injury, they may have tried to return to work and been unable to perform adequately. They often cannot generalize prior learning in new situations.

The counselor should be careful to assess those individuals who exhibit no obvious functional limitations. These individuals may present themselves quite well yet, upon assessment, you find severe job related deficits in cognitive, social, and behavioral areas. In general, anyone who has experienced unconsciousness can be expected to have functional and vocational limitations.

Many individuals feel that cognitive rehabilitation will result in an ability to carry out all premorbid function. Once again, there is a tremendous amount of controversy over this, although the general thinking is that a complete return to premorbid function is rare and cannot be expected routinely. The length of time the individual was unconscious usually gives some indication as to ultimate vocational success. The individual often presents difficulties in terms of processing, e.g., does not understand, forgetful, anxious, and lacking insight into why things are not working. The VR counselor should interview not only the individual with the injury, but also whoever is the functioning caretaker (family, nursing home, or hospital). Frequently, the physical presentation belies many subtle disorders of significance in rehabilitation planning.

The individual may appear to have one or two major problems that seem to be the most significant in terms of rehabilitation, e.g., speech, ambulation, or coordination. However, the counselor can expect that other areas in fact may be as significant or more so in terms of long-term employment. The three features that usually affect employability are perplexity, distractibility, and fatigue. These are related to cognitive functions that are related to psychological processes involved in the disability. Perplexity relates to confusion when facing new situations, and the tendency to withdraw or become angry about these new problems. Distractibility relates to the inability to attend to tasks within the environment, and the tendency to do activities that are not related to the activity at hand. Fatigue for many individuals causes the inability to carry out activities for any meaningful period. Short-term memory is another significant deficit that causes a major barrier to employment.

Considerations should be given to the expectations of the individual and the family. Many times these individuals have unrealistic expectations of their abilities or aptitudes and this should be explored during planning. The family is also the best source of information about the individual. It is time consuming, but often necessary, to bring both the client and his/her family to the point of considering alternative work possibilities as there is frequently an unrealistic desire to return to pre-injury work. Situational assessments and on-the-job evaluations will be more helpful in assessing work related skills than vocational evaluations that focus on cognitive and functional aptitudes.