Fitness-For-Duty Fitness-For-Duty Evaluations:Evaluations:

A Tool For Financial A Tool For Financial and Safety Risk and Safety Risk ManagementManagement

Steven E. Rothke, Ph.D., ABPPSteven E. Rothke, Ph.D., ABPP

Definitions Definitions

NeuropsychologyNeuropsychology

Rehabilitation Psychology

(ADA) A limitation in physical, (ADA) A limitation in physical, cognitive (thinking), sensory, or cognitive (thinking), sensory, or emotional functioning which emotional functioning which significantly affects a person’s ability significantly affects a person’s ability to work, to learn, to manage personal to work, to learn, to manage personal or family responsibilities, to maintain or family responsibilities, to maintain relationships, or to participate in relationships, or to participate in recreational activities.recreational activities.

Definitions Definitions

Disability

““A specialized formal medical-legal A specialized formal medical-legal examination of an employee … with a examination of an employee … with a central purpose being the central purpose being the determination of whether the determination of whether the employee is able to safely perform a employee is able to safely perform a defined job.”defined job.”

Anthony V. Stone (2000) Anthony V. Stone (2000) Fitness For Duty: Principles, Fitness For Duty: Principles, Methods and Legal Issues.Methods and Legal Issues. Boca Raton, FL: CRC Press Boca Raton, FL: CRC Press

Definitions Definitions

Fitness-For-Duty Evaluation

Basic Standards Of Work

• To remember locations and work-like procedures

• To understand, remember and execute very short and simple instructions

• To maintain attention for extended periods

• To persist in the performance of simple tasks

Basic Standards Of Work

• To perform activities within a schedule• To maintain regular attendance and to

be punctual within customary tolerances

• To sustain an ordinary routine without special supervision

• To make simple work-related decisions

Basic Standards Of Work

• To work in coordination or in the presence of others without being distracted by them• To complete a normal workday and

work week without interruption from mental symptoms and to perform at a consistent pace without an unreasonable number of rest periods

Basic Standards Of Work

• To ask questions of request assistance• To accept instructions and respond

appropriately to criticism from supervisors

• To maintain socially appropriate behavior and to adhere to basic standards of neatness and cleanliness

• To respond appropriately to changes in the work setting

Job DescriptionJob Description

Essential functionsEssential functions Non-essential functions (accommodations)Non-essential functions (accommodations)

Ask about availability of other sites, other Ask about availability of other sites, other assignments, can you speak with assignments, can you speak with managers and/or coworkersmanagers and/or coworkers

FFDE: Informed Consent FFDE: Informed Consent IssuesIssues

Discussed at the outsetDiscussed at the outset

1)1) Who made the referral; Who made the referral; who is paying for the examwho is paying for the exam

2)2) What will the results be What will the results be used forused for

3)3) Confidentiality: Who will Confidentiality: Who will see the reportsee the report

4)4) Will the subject Will the subject (employee) be given (employee) be given feedback and from whomfeedback and from whom

Neuropsychological PerspectivesNeuropsychological Perspectives

Major Major Neuropsychological Neuropsychological

Evaluation ProceduresEvaluation Procedures Clinical InterviewClinical Interview

Wechsler Adult Intelligence Scale, 4Wechsler Adult Intelligence Scale, 4thth Edition Edition

(WAIS-IV)(WAIS-IV)

Wechsler Memory Scale, 4Wechsler Memory Scale, 4thth Edition (WMS-IV) Edition (WMS-IV)

Halstead-Reitan Neuropsychological Test BatteryHalstead-Reitan Neuropsychological Test Battery

Wisconsin Card Sorting TestWisconsin Card Sorting Test

Rey or California Verbal Learning TestsRey or California Verbal Learning Tests

Grooved Pegboard TestGrooved Pegboard Test

Symptom validity testsSymptom validity tests

Minnesota Multiphasic Personality Inventory Minnesota Multiphasic Personality Inventory

(MMPI-2)(MMPI-2)

The Clinical InterviewThe Clinical Interview

AppearanceAppearance

BehaviorBehavior

SpeechSpeech

AffectAffect

ThinkingThinking

PerceptionPerception

InsightInsight

JudgmentJudgment

Major Major Neuropsychological Neuropsychological

Evaluation ProceduresEvaluation Procedures Clinical InterviewClinical Interview

Wechsler Adult Intelligence Scale, 4Wechsler Adult Intelligence Scale, 4thth Edition Edition

(WAIS-IV)(WAIS-IV)

Wechsler Memory Scale, 4Wechsler Memory Scale, 4thth Edition (WMS-IV) Edition (WMS-IV)

Halstead-Reitan Neuropsychological Test BatteryHalstead-Reitan Neuropsychological Test Battery

Wisconsin Card Sorting TestWisconsin Card Sorting Test

Rey or California Verbal Learning TestsRey or California Verbal Learning Tests

Grooved Pegboard TestGrooved Pegboard Test

Symptom validity testsSymptom validity tests

Minnesota Multiphasic Personality Inventory Minnesota Multiphasic Personality Inventory

(MMPI-2)(MMPI-2)

What does a Neuropsychological Evaluation tell you What does a Neuropsychological Evaluation tell you about a patient or claimant?about a patient or claimant?

Orientation Attention / Concentration

Focus

Selective

Sustaining

Shifting

Speech / Language Naming Word finding

What does a Neuropsychological Evaluation tell What does a Neuropsychological Evaluation tell you about a patient or claimant?you about a patient or claimant?

Memory Immediate, short-term and long-term Verbal and nonverbal

Visuospatial Reasoning

Complex Motor

Abstract Reasoning

Emotional / Psychological

Executive Abilities

Executive AbilitiesExecutive Abilities

InsightInsight

JudgmentJudgment

Forethought/ Anticipation of Forethought/ Anticipation of

consequencesconsequences

Planning/SequencingPlanning/Sequencing

Executive AbilitiesExecutive Abilities

Self-monitoring capacity (error Self-monitoring capacity (error

awareness and correction)awareness and correction)

Awareness of impact on othersAwareness of impact on others

Strategy Shifting (flexibility)Strategy Shifting (flexibility)

Inhibition of impulses/ delay of Inhibition of impulses/ delay of

gratificationgratification

Issues in Test Issues in Test InterpretationInterpretation

AgeAge Educational backgroundEducational background Occupational backgroundOccupational background Premorbid psychiatric and medical Premorbid psychiatric and medical

conditionsconditions ETOH and recreational drug abuseETOH and recreational drug abuse Effects of medicationsEffects of medications

Issues in Test Issues in Test InterpretationInterpretation

Time Since OnsetTime Since Onset Effects of retestingEffects of retesting Effects of rehabilitation effortsEffects of rehabilitation efforts Incentives to perform poorlyIncentives to perform poorly Going beyond the bounds of the dataGoing beyond the bounds of the data Being overly localizationsiticBeing overly localizationsitic

Risk Factors To Risk Factors To AssessAssess

Evaluate: Factors That Limit Evaluate: Factors That Limit InhibitionInhibition

Intervene: To Enhance InhibitionIntervene: To Enhance Inhibition

History of Previous ViolenceHistory of Previous Violence

• Employee’s account of Employee’s account of eventevent• Emotional experience Emotional experience during eventduring event• Signs of remorse vs. Signs of remorse vs. blaming othersblaming others

Psychiatric HistoryPsychiatric History

• Sexual/physical abuseSexual/physical abuse• HospitalizationsHospitalizations• Episodes of depression, Episodes of depression, PTSDPTSD• Suicide attemptsSuicide attempts• Emotional traumas, lossesEmotional traumas, losses

Emotional StatusEmotional Status

The Affects of ViolenceThe Affects of Violence• FearFear• AngerAnger

Personality CharacteristicsPersonality Characteristics

Signs of Psychopathy and Signs of Psychopathy and

Antisocial Personality Antisocial Personality DisorderDisorder

• ManipulativenessManipulativeness• Lack of remorse for actionsLack of remorse for actions• Refusal to accept Refusal to accept responsibilityresponsibility• Lack of empathyLack of empathy• Pathological lyingPathological lying

Personality CharacteristicsPersonality Characteristics

Signs of Psychopathy and Signs of Psychopathy and

Antisocial Personality Antisocial Personality DisorderDisorder

• Sense of grandiositySense of grandiosity• ImpulsivityImpulsivity• Poor behavioral controlsPoor behavioral controls• Disregard for the welfare of Disregard for the welfare of othersothers• Criminal historyCriminal history

Thought DisorderThought Disorder

Psychotic FeaturesPsychotic Features• Delusions (paranoid)Delusions (paranoid)• Hallucinations (command)Hallucinations (command)

Thought DisorderThought Disorder

Threat Control/Override Threat Control/Override Features Features

1)1) Belief that your mind is Belief that your mind is dominated by forces dominated by forces outside your controloutside your control

2)2) Thought insertionThought insertion

3)3) Belief that people wish to Belief that people wish to harm youharm you

Substance AbuseSubstance Abuse

•Stimulants (cocaine):Stimulants (cocaine):•ParanoiaParanoia•GrandiosityGrandiosity•DisinhibitionDisinhibition

• Alcohol Alcohol •DisinhibitionDisinhibition

Combination of Substance Abuse Combination of Substance Abuse and Mental Disorder and Mental Disorder

• Mental Disorder in the US Mental Disorder in the US (19%)(19%)• Substance Abuse Disorder Substance Abuse Disorder (6%)(6%)• Combination (3%)Combination (3%)

U.S. Surgeon General (1999). Mental U.S. Surgeon General (1999). Mental Health: A Report of the Surgeon Health: A Report of the Surgeon General. General. www.surgeongeneral.gov/sgoffice.htm (Reports)(Reports)

Lifetime Prevalence of Lifetime Prevalence of Mental Disorder in the USMental Disorder in the US

• Anxiety Disorder (29%)Anxiety Disorder (29%)• Mood Disorder (21%)Mood Disorder (21%)• Impulse Control Disorder Impulse Control Disorder (25%)(25%)• Substance Abuse Disorder Substance Abuse Disorder (15%)(15%)

Kessler, RC et al (2005). Lifetime Kessler, RC et al (2005). Lifetime prevalence and age of onset prevalence and age of onset distributions of DSM-IV disorders .distributions of DSM-IV disorders .

Archives of General Psychiatry, Vol. 62, Archives of General Psychiatry, Vol. 62, pp. 593-602.pp. 593-602.

Medical/Neurological HistoryMedical/Neurological History• Traumatic Brain InjuryTraumatic Brain Injury

• high incidence in prison high incidence in prison populationpopulation• increased risk of increased risk of affective/impulsive violence affective/impulsive violence (Episodic Explosive Disorder)(Episodic Explosive Disorder)• reduced executive function, reduced executive function, reduced prefrontal activation, reduced prefrontal activation, decreased serotonergic decreased serotonergic functionfunction• treatment with treatment with anticonvulsants or SSRIs anticonvulsants or SSRIs

• Terminal illnessTerminal illness

Plan/IntentPlan/Intent

1) Wish to harm self and/or 1) Wish to harm self and/or othersothers

2) Frequency of thoughts or 2) Frequency of thoughts or statementsstatements

3) Sequence thought through3) Sequence thought through

4) Availability of weapons4) Availability of weapons

5) Experience with firearms5) Experience with firearms

6) Consequences considered6) Consequences considered

Malignant SignsMalignant Signs

• Feeling of “nothing to lose”Feeling of “nothing to lose”• Belief that an injustice Belief that an injustice (humiliation) has been done (humiliation) has been done to you (workplace violence)to you (workplace violence)

Coping SkillsCoping Skills

1) Self-Esteem1) Self-Esteem

2) Stress management 2) Stress management strategiesstrategies

3) How has the person dealt 3) How has the person dealt with prior losses/trauma with prior losses/trauma (is this the first bad thing (is this the first bad thing that has happened to that has happened to them)them)

Other Stressors/SupportsOther Stressors/Supports

• Ongoing legal difficulties Ongoing legal difficulties (divorce, bankruptcy, (divorce, bankruptcy, criminal)criminal)• Financial strugglesFinancial struggles• Marital/relationship strains Marital/relationship strains v. good family supportv. good family support• Social isolationSocial isolation• Prior job difficulties/fears of Prior job difficulties/fears of loss of jobloss of job

Assessment Tools

RAGE-V (Risk Assessment Guideline for Violence)

www.atapworldwide.org

Hit tab for Education, then scroll down to RAGE-V to download form. See other useful articles as well.

“Tarasoff Warnings: What is the Law in Illinois?

Mental Health & Developmental Disabilities Confidentiality Act (740 ILCS 110)

Available at: www.ilga.gov/legislation/ilcs/ilcs.asp

“Records and communications may be disclosed … when, and to the extent, a therapist, in his or her sole discretion, determines that such a disclosure is necessary to continue civil commitment proceedings or to otherwise protect the recipient [patient, examinee] or other person against a clear, imminent risk of serious physical or mental injury or disease or death being inflicted upon the recipient, or by the recipient on himself or another.”

Section 110/11 ii

“Records and communications may be disclosed … when, and to the extent, in the therapist’s sole discretion, disclosure is necessary to warn or protect a specific individual against whom a recipient has made a specific threat of violence where there exists a therapist-recipient relationship or a special recipient-individual relationship.”

Section 110/11 vii

“Tarasoff Warnings: What is the Law in Illinois?

Mental Health & Developmental Disabilities Code (405 ILCS 5)

Available at: www.ilga.gov/legislation/ilcs/ilcs.asp

“There shall be no liability on the part of, and no cause of action shall rise against, any person who is a physician, clinical psychologist, or qualified examiner based on that person’s failure to warn of and protect from a recipient’s threatened or actual violent behavior except where the recipient has communicated to the person a serious threat of physical violence against a reasonably identifiable victim or victims.”

Section 110/11 vii

Common Mental Common Mental Diagnoses of Workers Diagnoses of Workers

Referred for FFD ExamsReferred for FFD ExamsPost-Concussion Post-Concussion

Syndrome (PCS)Syndrome (PCS)

Traumatic Brain Injury Traumatic Brain Injury (TBI)(TBI)

DepressionDepression

Posttraumatic Stress Posttraumatic Stress Disorder (PTSD)Disorder (PTSD)

Anxiety/Panic DisorderAnxiety/Panic Disorder

DementiaDementia

Substance Abuse Substance Abuse Disorder Disorder

DIAGNOSIS DISABILITY

Accommodating Disabilities: Getting Accommodating Disabilities: Getting People Back to WorkPeople Back to Work

Concentration deficits, Concentration deficits, distractibilitydistractibility - enhance signal - enhance signal stimuli through use of stimuli through use of headphones, bold print or colors; headphones, bold print or colors; reduce distractions by modifying reduce distractions by modifying lighting, work location, lighting, work location, sound/visual barrierssound/visual barriers

Accommodating Disabilities: Getting Accommodating Disabilities: Getting People Back to WorkPeople Back to Work

Short-term memory impairmentShort-term memory impairment - - present information in multiple present information in multiple modalities (e.g., visual and oral; modalities (e.g., visual and oral; text and diagram), permit the use text and diagram), permit the use of cues and aids, repetitionof cues and aids, repetition

Accommodating Disabilities: Getting Accommodating Disabilities: Getting People Back to WorkPeople Back to Work

Perseveration, rigidityPerseveration, rigidity - enhance - enhance differences in task components by differences in task components by performing tasks in different parts performing tasks in different parts of work space or with different of work space or with different equipment. equipment.

Accommodating Disabilities: Getting Accommodating Disabilities: Getting People Back to WorkPeople Back to Work

PTSD/AnxietyPTSD/Anxiety - place worker - place worker closer to security, quieter work closer to security, quieter work area, no one behind them, remove area, no one behind them, remove reminders of trauma if possiblereminders of trauma if possible

Case Presentation

Luke -- predicting violence three years into the future

Illinois Psychologically Healthy Illinois Psychologically Healthy

Workplace Program (PHWA)Workplace Program (PHWA)

www.illinoispsychology.org

Click the link to the Psychologically Healthy Workplace ProgramClick the link to the Psychologically Healthy Workplace Program

www.phwa.org

Why Have a PHWA?Why Have a PHWA?

$300 Billion per year. That is the estimated annual aggregate cost to $300 Billion per year. That is the estimated annual aggregate cost to US businesses due to worker stress (stress leads to absenteeism, US businesses due to worker stress (stress leads to absenteeism, lost productivity, accidents, increased healthcare costs, turnover, lost productivity, accidents, increased healthcare costs, turnover, conflict and conflict and violence violence in the workplace, and “presenteeism” – being in the workplace, and “presenteeism” – being physically present but having your mind on something else). On any physically present but having your mind on something else). On any given day, nearly one million employees in the US miss work due to given day, nearly one million employees in the US miss work due to stress. These and other compelling data are available from the stress. These and other compelling data are available from the American Stress Institute (American Stress Institute (www.stress.org/job.htm). ).

www.illinoispsychology.orgwww.illinoispsychology.org

Psychologically Healthy Psychologically Healthy Workplace PracticesWorkplace Practices

Employee Involvement Work-Life Balance Employee Growth and Development Health and Safety Employee Recognition

See: MJ Grawitch, et al. (2006), The path to a healthy See: MJ Grawitch, et al. (2006), The path to a healthy workplace: A critical review linking healthy workplace: A critical review linking healthy workplace practices, employee well-being, and workplace practices, employee well-being, and organizational improvements. organizational improvements. Consulting Consulting Psychology Journal, Psychology Journal, Volume 58 (3), pp. 129-147.Volume 58 (3), pp. 129-147.

For More For More InformationInformation

Steven E. Rothke, Ph.D, ABPPSteven E. Rothke, Ph.D, ABPP

(847) 480-5744(847) 480-5744

s-rothke@northwestern.edus-rothke@northwestern.edu