Introduction

JAN’s Accommodation and Compliance Series is designed to help employers determine effective accommodations and comply with Title I of the Americans with Disabilities Act (ADA). Each publication in the series addresses a specific medical condition and provides information about the condition, ADA information, accommodation ideas, and resources for additional information.

The Accommodation and Compliance Series is a starting point in the accommodation process and may not address every situation. Accommodations should be made on a case by case basis, considering each employee’s individual limitations and accommodation needs. Employers are encouraged to contact JAN to discuss specific situations in more detail.

For information on assistive technology and other accommodation ideas, visit JAN's Searchable Online Accommodation Resource (SOAR) at http://www.jan.wvu.edu/soar.

Information about Post Traumatic Stress Disorder (PTSD)

What is PTSD?

PTSD is a debilitating condition that can occur after exposure to a terrifying event or ordeal in which grave physical harm occurred or was threatened. Traumatic events that can trigger PTSD include violent personal assaults such as rape or mugging, natural or human-caused disasters, accidents, or military combat. Traumatic events most often associated with PTSD are 1) for men: rape, combat exposure, childhood neglect, and childhood physical abuse, and 2) for women: rape, sexual molestation, physical attack, being threatened with a weapon, and childhood physical abuse (National Institute of Mental Health, 2008).

Many people with PTSD repeatedly re-experience the ordeal in the form of flashback episodes, memories, nightmares, or frightening thoughts, especially when they are exposed to events or objects reminiscent of the trauma. Anniversaries of the event can also trigger symptoms. Feelings of intense guilt are also common. Most people with PTSD try to avoid any reminders or thoughts of the ordeal (National Institute of Mental Health, 2008).

In November of 2001, the New England Journal of Medicine reported that 44% of the adults surveyed experienced one or more symptoms of stress during the week of September 11, 2001 (Drazen, 2001). It is predicted that many children and adults will be diagnosed with PTSD as a result of the terrorist attacks against the United States at the World Trade Center, the Pentagon, and in Pennsylvania. Other unfortunate and traumatic events in recent American history that caused people to be diagnosed with PTSD include: the 1995 Oklahoma City bombing, the shootings at 1999 Columbine High School in Colorado, the 1986 Space Shuttle Challenger explosion, and the Olympic Park bombing in 1996, and Hurricane Katrina in 2005.

How prevalent is PTSD?

The National Center for Post Traumatic Stress Disorder estimates 7.8 percent of Americans will experience PTSD at some point in their lives, with women twice as likely as men to have PTSD. About 30 percent of the men and women who have spent time in war zones experience PTSD. More than half of all male Vietnam veterans and almost half of all female Vietnam veterans have experienced clinically serious stress reaction symptoms. PTSD has also been detected among veterans of the Gulf War, with some estimates running as high as eight percent (National Center for Post Traumatic Stress Disorder, 2007).

What are the symptoms of PTSD?

According to the Anxiety Disorders Association of America, symptoms of PTSD can include:

• Re-experiencing the event, which can take the form of intrusive thoughts and recollections, or recurrent dreams;
• Avoidance behavior in which the sufferer avoids activities, situations, people, and/or conversations which he/she associates with the trauma;
• A general numbness and loss of interest in surroundings; this can also present as detachment;
• Hypersensitivity, including: inability to sleep, anxious feelings, overactive startle response, hyper vigilance, irritability and outbursts of anger.

Symptoms usually begin within three months of a trauma, although there can be a delayed onset and six months can pass between trauma and the appearance of symptoms. In some cases years can pass before symptoms appear. In this case the symptoms are often triggered by the anniversary of the trauma, or with the experience of another traumatic event. Symptoms may vary in frequency and intensity over time (Anxiety Disorders Association of America, n.d.).

PTSD and the Americans with Disabilities Act

Is PTSD a disability under the ADA?

The ADA does not contain a list of medical conditions that constitute disabilities. Instead, the ADA has a general definition of disability that each person must meet (EEOC, 1992). Therefore, some people with PTSD will have a disability under the ADA and some will not.

A person has a disability if he/she has a physical or mental impairment that substantially limits one or more major life activities, a record of such an impairment, or is regarded as having such an impairment (EEOC, 1992). For more information about how to determine whether a person has a disability under the ADA, visit http://www.jan.wvu.edu/corner/vol02iss04.htm.

Are employees with PTSD required to disclose their disability to their employers?

No. Employees need only disclose their disability if/when they need an accommodation to perform the essential functions of the job. Applicants never have to disclose a disability on a job application, or in the job interview, unless they need an accommodation to assist them in the application or interview process (EEOC, 1992).

Can an employer ask an employee with PTSD to submit to a medical examination?

Yes, if the need for the medical examination is job-related and consistent with business necessity. Typically, employers will ask an employee with PTSD to submit to a medical examination (also called a fitness-for-duty exam) after the employee had an incident on the job that would lead the employer to believe that this employee is unable to perform the job, or to determine if the employee can safely return to work, and if any accommodations will be needed on the job (EEOC, 1992).

Special note: Pre-job offer medical examinations or inquiries are illegal under the ADA. People with PTSD (or any disability) do not have to submit to a medical exam or answer any medical questions until after they are conditionally offered a job (EEOC, 1992).

Do employees with PTSD pose a direct threat to themselves or others?

People who have PTSD do not necessarily pose a direct threat to themselves or others. Employees who control their conditions through medication or therapy probably pose no current risk. Even if direct threat exists, employers should reducing or eliminating the threat by providing an accommodation (EEOC, 1992).

How and when does a person with PTSD ask for an accommodation?

An employee with PTSD can ask for an accommodation at any time when he/she needs an accommodation to perform the essential functions of the job. The employee can make a request verbally or in writing and is responsible for providing documentation of a disability (EEOC, 1992).

Can an employer discipline an employee with PTSD who violates conduct or performance standards?

Yes, an employer can discipline an employee with PTSD who violates conduct standards or fails to meet performance standards, even if the behavior being exhibited is caused by the employee's disability. However, an employer is obligated to consider reasonable accommodations to help the employee with PTSD meet the conduct or performance standards (EEOC, 1992).

Accommodating Employees with PTSD

Note: People with PTSD may develop some of the limitations discussed below, but seldom develop all of them. Also, the degree of limitation will vary among individuals. Be aware that not all people with PTSD will need accommodations to perform their jobs and many others may only need a few accommodations. The following is only a sample of the possibilities available. Numerous other accommodation solutions may exist.

Questions to Consider:

1. What limitations is the employee with PTSD experiencing?

 

2. How do these limitations affect the employee and the employee’s job performance?

 

3. What specific job tasks are problematic as a result of these limitations?

 

4. What accommodations are available to reduce or eliminate these problems? Are all possible resources being used to determine possible accommodations?

 

5. Has the employee with PTSD been consulted regarding possible accommodations?

 

6. Once accommodations are in place, would it be useful to meet with the employee with PTSD to evaluate the effectiveness of the accommodations and to determine whether additional accommodations are needed?

 

7. Do supervisory personnel and employees need training regarding PTSD?

Accommodation Ideas:

Memory:

• Provide written instructions
• Post written instructions for use of equipment
• Use a wall calendar
• Use a daily or weekly task list
• Provide verbal prompts and reminders
• Use electronic organizers or hand held devices
• Allow the employee to tape record meetings
• Provide written minutes of each meeting
• Allow additional training time

Lack of Concentration:

• Reduce distractions in the work environment
• Provide space enclosures or a private space
• Allow for the use of white noise or environmental sound machines
• Allow the employee to play soothing music using a cassette player and a headset
• Increase natural lighting or increase full spectrum lighting
• Divide large assignments into smaller goal oriented tasks or steps
• Plan for uninterrupted work time

Time Management/Performing or Completing Tasks:

• Make daily TO-DO lists and check items off as they are completed
• Divide large assignments into smaller tasks and steps
• Schedule weekly meetings with supervisor, manager, or mentor to determine if goals are being met
• Remind employee of important deadlines via memos or e-mail

Disorganization:

• Use  calendars to mark meetings and deadlines
• Use electronic organizers
• Hire a professional organizer or organizational coach
• Assign a mentor to assist employee

Coping with Stress:

• Allow longer or more frequent work breaks
• Provide backup coverage for when the employee needs to take breaks
• Provide additional time to learn new responsibilities
• Restructure job to include only essential functions
• Allow for time off for counseling
• Assign a supervisor, manager, or mentor to answer employee’s questions

Working Effectively with a Supervisor:

• Giving assignments, instructions, or training in writing or via e-mail
• Provide detailed day-to-day guidance and feedback
• Provide positive reinforcement
• Provide clear expectations and the consequences of not meeting expectations
• Develop strategies to deal with problems

Interacting with Co-workers:

• Encourage the employee to walk away from frustrating situations and confrontations
• Allow employee to work from home part-time
• Provide partitions or closed doors to allow for privacy
• Provide disability awareness training to coworkers and supervisors

Dealing with Emotions:

• Refer to employee assistance programs (EAP)
• Use stress management techniques to deal with frustration
• Allow the use of a support animal
• Allow telephone calls during work hours to doctors and others for needed support
• Allow frequent breaks

Sleep Disturbance:

• Allow the employee to work one consistent schedule
• Allow for a flexible start time
• Combine regularly scheduled short breaks into one longer break
• Provide a place for the employee to sleep during break

Muscle Tension or Fatigue:

• Build in “stretch breaks” during the workday
• Allow private space to meditate or do yoga
• Allow time off for physical therapy or massage therapy
• Encourage use of the company’s wellness program

Absenteeism:

• Allow for a flexible start time or end time, or work from home
• Provide straight shift or permanent schedule
• Modify attendance policy
• Example:  count one occurrence for all PTSD-related absences, or allow the employee to make up the time missed.

Panic Attacks:

• Allow the employee to take a break and go to a place where s/he feels comfortable to use relaxation techniques or contact a support person
• Identify and remove environmental triggers such as particular smells or noises 
• Allow the presence of a support animal

Diarrhea/Vomiting/Nausea:

• Allow flexible bathroom breaks
• Move employee to location where he/she can access the bathroom discreetly
• Provide space for storing extra clothing or personal hygiene products

Headaches:

• Provide alternative lighting
• Take breaks from computer work or from reading print material
• Practice stress-relieving techniques

Transportation Issues:

• Eliminate non-essential travel 
• Provide a driver
• Allow extra time for travel
• Allow the employee to bring a support person

Situations and Solutions:

An administrative assistant with PTSD works at a museum, which is currently under construction.  Construction workers, who were strangers, caused the employee extreme anxiety. As an accommodation, a JAN consultant suggested temporarily relocating the employee’s work space away from the construction area. The museum also developed an ID badge for construction workers and required them to sign in at their job locations.

A prison guard, recently attacked by an inmate, has PTSD and anxiety.  The prison guard was fearful of returning to the worksite, even to discuss her return-to-work options. A JAN consultant offered the following suggestions: allow the employee to bring a support person or support animal to the meeting, move the meeting to an alternative location, or allow the employee to attend the meeting via telephone.

An office worker who was stalked and harassed by a former employee now has a panic disorder. She is fearful of answering her office telephone.  JAN suggested these accommodations to her employer: use telephone with a caller ID function and/or call blocking function, change the tone or frequency of telephone ringer to reduce panic reaction, route all calls through a switchboard or receptionist, and disable this employee’s direct extension to prohibit direct calls.

A vocational school teacher with PTSD requested accommodations due to anxiety and flashbacks.  She taught in a building separated from the main school, and she had difficulty dealing with large classrooms of unruly students. As an accommodation, JAN suggested training the teacher on special behavior management techniques and providing administrative support for student disciplinary actions. The school also provided the teacher a two-way radio, which allowed her to contact an administrator quickly when she needed immediate assistance in her classroom.

A postal employee with PTSD requested accommodations to help him deal with recurring flashbacks. His flashbacks were triggered by the smell of gasoline and the noise from the mail truck. The employee tried wearing a respirator to give him a clean air supply. He also tried wearing headphones to reduce the noise from the truck, but he still experienced stress and edginess.  JAN suggested a position transfer as an accommodation. JAN also suggested allowing this employee to take a break when he experiences extreme anxiety and allow him to use relaxation and visualization techniques in a private space on the job.

A veteran who is now an office employee has PTSD and anxiety. He is easily frightened when being approached unsuspectingly. This employee works in a structured cubicle environment facing his computer and cubicle walls, with his back to the cubicle entrance.  He wants to be alerted when a coworker or supervisor walks into the cubicle behind him. JAN suggested using a monitor-mounted mirror, so he could see the entrance behind him. JAN also suggested placing a sensor mat at the entrance of the cubicle, which will make an audible alert when someone steps on it. 

Products:

There are numerous products that can be used to accommodate people with limitations. JAN's Searchable Online Accommodation Resource (SOAR) at http://www.jan.wvu.edu/soar is designed to let users explore various accommodation options. Many product vendor lists are accessible through this system; however, upon request JAN provides these lists and many more that are not available on the Web site. Contact JAN directly if you have specific accommodation situations, are looking for products, need vendor information, or are seeking a referral.

Resources

References

Anxiety Disorders Association of America. (n.d.)  Post traumatic stress disorder
(PTSD). Retrieved September 5, 2008, from http://www.adaa.org/GettingHelp/AnxietyDisorders/PTSD.asp

Drazen, J.M., Curfman, G.D., & Campion, E.W. (2001). After September 11. New England Journal of Medicine, 345, 1490.

National Institute of Mental Health. (2008). Reliving trauma: Post-traumatic stress disorder.  Retrieved December 22, 2005, from http://www.nimh.nih.gov/publicat/reliving.cfm

Equal Employment Opportunity Commission. (1992). A technical assistance manual on the employment provisions (title I) of the Americans with Disabilities Act.  Retrieved September 5, 2008, from http://www.jan.wvu.edu/links/ADAtam1.html

What is posttraumatic stress disorder? A national center for PTSD fact sheet. (2007). Retrieved September 5, 2008, from http://www.ncptsd.va.gov/ncmain/ncdocs/fact_shts/fs_what_is_ptsd.html

Updated 09/05/08