Cbirt. org We must be willing to get rid of the life we planned, so as to have the life that is...
-
Upload
aria-kitch -
Category
Documents
-
view
213 -
download
1
Transcript of Cbirt. org We must be willing to get rid of the life we planned, so as to have the life that is...
cbirt.org
We must be willing to get rid of the life we planned, so as to have the life that is waiting for us.
Joseph Campbell
TRANSITION INTO ADULTHOOD FOR STUDENTS WITH
TBI
Bonnie Todis, Ph.D.Center on Brain Injury Research & Training
cbirt.org
Our Questions:
What are the transition experiences of students with TBI? What are their transition outcomes? What factors are associated with positive
outcomes? What factors are associated with negative
outcomes? What is transition like for students and
families?
cbirt.org
Transition Services IDEA
Mandated, but not fully funded Students with TBI are under-identified
for special ed and transition services Transition services are highly variable
district to district disability to disability severity of disability
POST-SECONDARY OUTCOMES
PROJECT(PSO)
cbirt.org
Project PSO
8-year study of transition outcomes Funded by OSEP and NIDRR 90 students in Oregon and Washington Recruited at exit from high school Rolling recruitment over 2-3 years
School districts VR
cbirt.org
PSO Participants
77% had severe injuries 2/3 were identified for special education Half were injured while in high school Mean time since injury 7.7 yrs (range: 0-
19) 2/3 male
cbirt.org
Project PSO
Purpose: Systematic tracking of quantitative data
on transition outcomes Methodology: In-person/phone interviews with young
adult, parent 6-12-month intervals
cbirt.org
PSO Survey Domains
Education and training Education
accommodations Satisfaction ratings Employment history &
plans Type of work, pay,
hours Employment supports
& accommodations Living/rent
arrangements
Sources of community support
Satisfaction ratings Community integration
& activities Social relationships Health issues Life satisfaction
RESULTS
cbirt.org
Life Transition Planning
50%
48%
2%
Chart Title
No Yes Don't know
At initial interview
cbirt.org
Written Transition Plan
36%
61%
2%Chart Title
Yes No Don't know
At initial interviewBonnie Todis, Ph.D.Center on Brain Injury Research and Training
cbirt.org
Person Who Helped Plan Transition
Don't know
Other
Voc. Rehab
Community Trans Program
School Staff
Family member
0 5 10 15 20 25
Count
At initial interview
TRANSITION OUTCOMES
cbirt.org
Employment Outcomes Ages 19-25
Age 19(n = 54)
20(n = 74)
21(n = 85)
22(n = 86)
23(n = 84)
24(n = 75)
25(n = 55)
Employment 20 (37) 36 (49) 44 (52) 42 (49) 37 (44) 35 (47) 33 (60)
Male 17 (46) 23 (49) 34 (60) 34 (59) 29 (52) 26 (54) 26 (74)
Female 3 (18) 13 (48) 10 (36) 8 (29) 8 (29) 9 (33) 7 (35)
<20 hrs/week
11 (55) 18 (53) 13 (32) 14 (35) 11 (31) 10 (30) 9 (29)
≥20 hrs/week
9 (45) 16 (47) 28 (68) 26 (65) 25 (69) 23 (70) 22 (71)
cbirt.org
Post-Secondary Employment Outcomes 19-25
Age in Years0
10
20
30
40
50
60
70
19 20 21 22 23 24 25
Perc
en
t Em
plo
yed
cbirt.org
Closer Look:Employment at Age 25
60% employed 74% of males, 35% of females
Hours per week Mean 21-30 No one worked more than 30 hrs per week
cbirt.org
Employment Outcomes by Gender
19 20 21 22 23 24 250
10
20
30
40
50
60
70
80
MalesFemales
cbirt.org
Employment at Age 25
Wages Mean $8.22 per hour No difference between males and females
Type of Job 81.3% in menial, unskilled, or semi-skilled
categories The rest in skilled (11.3%) clerical/sales (5%)
or technicians (2.5%) None in the top 3 categories
cbirt.org
Comparison with Typical Peers
EMPLOYMENT RATE
WAGESPER WEEK
HOURS PER
WEEK TYPE OF JOB
PSO Sample 60%
$161-232 (male)$124-418 (female)
25.5 hrs
57%menial/unskilled
0%management/pro
Typical Young Adults
68%$485 (male)$418 (female)
35.8 hrs
36%menial/unskilled19%management/pro
• Bureau of Labor Statistics of the U.S. Department of Labor, January 19, 2007
cbirt.org
Factors Predicting Employment
Hierarchical Linear Modeling Results Family SES: Those with higher SES were less
likely to be employed at the beginning of the study, more likely to be employed over time
For every unit change in SES there was a 3.3% increase in the odds of employment and a .7% increase in the rate of change in employment over time.
cbirt.org
Factors That Impact Employment
1.00
2.00
3.00
4.00
5.00
Ty
pe
of
wo
rk c
ate
go
ry h
igh
=p
rofe
ss
ion
al
Work category by time sex age at injury
0 1.00 2.00 3.00 4.00
TIME
SEX = 0,AGEINJ3 = -5.985
SEX = 0,AGEINJ3 = 2.897
SEX = 0,AGEINJ3 = 5.119
SEX = 1,AGEINJ3 = -5.985
SEX = 1,AGEINJ3 = 2.897
SEX = 1,AGEINJ3 = 5.119
Later age)
Earlier age
Later age
Earlier age
Bonnie Todis, Ph.D.Center on Brain Injury Research and Training
Avg age
Avg age
Males
Females
Work Category by Sex and Age at Injury Over Time
Skilled manual labor
Clerical, sales
Semi-skilled
Unskilled work
Menial service
Job Category by Sex and Age at Injury
cbirt.org
5.94
7.20
8.46
9.72
10.98
Wa
ge
s
Wages over time by age at injury and severity
1.00 3.50 6.00 8.50 11.00
Time
AGEINJ3 = -5.985,SEVERE = 0
AGEINJ3 = -5.985,SEVERE = 1
AGEINJ3 = 5.119,SEVERE = 0
AGEINJ3 = 5.119,SEVERE = 1
Bonnie Todis, Ph.D.Center on Brain Injury Research and Training
Factors That Impact Employment
Early injury
Later injury
Wages Over Time by Age at Injury and Severity
Later injury
Severe
Mild/Moderate
Early injury
cbirt.org
0.00 1.001.72
2.32
2.91
3.50
4.09
SEVERE
Q2
A9
A1
hours worked per week
SEX = 0,AGEINJ3 = -5.985
SEX = 0,AGEINJ3 = 2.560
SEX = 0,AGEINJ3 = 5.119
SEX = 1,AGEINJ3 = -5.985
SEX = 1,AGEINJ3 = 2.560
SEX = 1,AGEINJ3 = 5.119
Bonnie Todis, Ph.D.Center on Brain Injury Research and Training
Factors That Impact Employment
Severity
Hours Worked per WeekIn
jure
d ea
rlier
late
r
Severity: M/M work > # Hrs.
Gender: Males> #hrs.
For both genders: Earlier age at injury = work fewer hours/week
Females
Males
Females
Males
Inju
red
earli
erla
ter
SevereMild/Mod
21 – 30hr
11-15hr
Hou
rs P
er W
eek
16-20hr
cbirt.org
-8.00 -6.00 -4.00 -2.00 02.80
2.98
3.17
3.35
3.54
time
ho
w h
ap
py
are
yo
u
AGEINJ3 = -4.211,SEVERE = 0
AGEINJ3 = -4.211,SEVERE = 1
AGEINJ3 = 2.575,SEVERE = 0
AGEINJ3 = 2.575,SEVERE = 1
AGEINJ3 = 4.296,SEVERE = 0
AGEINJ3 = 4.296,SEVERE = 1
Factors That Impact Employment
Later age
Later age
Early age
Avg age
Early age
Severe
Mild/Moderate
Job Happiness by Severity and Age at Injury
Avg age
Happy
Very Happy
Unhappy
POST SECONDARY EDUCATION
cbirt.org
Post-SecondaryEducation OutcomesAges 19-25
Age 19(n = 54)
20(n = 74)
21(n = 85)
22(n = 86)
23(n = 84)
24(n = 75)
25(n = 55)
Education 15 (28) 26 (35) 34 (40) 22 (26) 26 (31) 18 (24) 14 (25)
Male 7 (19) 17 (36) 20 (35) 11 (19) 15 (27) 7 (15) 6 (17)
Female 8 (47) 9 (33) 14 (50) 11 (39) 11 (39) 11 (41) 8 (40)
n (%)
cbirt.org
Post-Secondary Education Outcomes Ages 19-25
Nondisabled
PSO Sample
0
20
40
60
Chart Title
cbirt.org
Comparison with Peers
Non disabled young adults 18-25 46% enrollment (Pew 2007) 54% female (200?)
NLTS2 45% reported continuing to postsecondary ed within 4 years of leaving high school. 32% community colleges 23% vocational/tech 14% 4-year
cbirt.org
Factors That Affect Enrollment
Higher family SES, shorter time to enrollment
Females more likely to enroll Those injured later were more likely to
enroll. For every year increase in age at injury there was a 12.3% increase in likelihood of enrollment.
cbirt.org
Independent Living Outcomes Ages 19-25
Bo
nn
ie To
dis, P
h.D
.C
en
ter o
n B
rain
Inju
ry Re
sea
rch a
nd
T
rain
ingAge
19(n = 54)
20(n = 74)
21(n = 85)
22(n = 86)
23(n = 84)
24(n = 75)
25(n = 55)
Independent Living
12 (23) 26 (36) 28 (35) 37 (44) 35 (41) 37 (49) 29 (53)
Male 7 (20) 13 (28) 18 (33) 22 (39) 22 (39) 24 (49) 20 (57)
Female 5 (29) 13 (48) 10 (37) 15 (54) 13 (45) 13 (48) 9 (45)
n (%)
cbirt.org
Age in Years0
10
20
30
40
50
60
19 20 21 22 23 24 25
Perc
en
t En
rolled
Post-SecondaryIndependent Living OutcomesAges 19-25
cbirt.org
Comparison with Peers
Non-disabled peers 18-25 40% live with parents (Pew)
NLTS2 ages 17-21 25% have lived independently at some time since high school (65% of these lived in a college dorm or military housing).
cbirt.org
Factors That Affect Ind. Living
Age at injury: Those injured earlier take longer to achieve independent living status.
For each year older at injury, there is a 12.7% increase in odds of achieving independent living.
Qualitative Component
cbirt.org
Qualitative Component
Purpose: Access perspectives of youth with TBI
and their parents on the transition experience
Identify specific factors that promote positive outcomes
Investigate the details of transition services
cbirt.org
Qualitative Methodology
Methodology: Unstructured recursive interviews Participant observations with young
adult Interviews with knowledgeable others
1-to-6-month intervals
cbirt.org
Selection of Respondents
Selective sampling for factors of interest Resilience factors
Family support Access to/use of agency supports Community/social support
Range of high school experiences, severity, age at injury, disabilities, SES, urban/rural
Qualitative Findings
cbirt.org
Thematic Categories
High School Experiences Employment Post-Secondary Education Community Integration
High School Experiences
cbirt.org
Themes: High School Services
Students not identified for special education: Tested at or above grade level (didn’t
qualify) Injured junior or senior year, “helped” to
graduate on time
cbirt.org
Helped to Graduate: Academic
“My mom worked at the school and all the teachers loved me, so I didn’t have to do anything, they just passed me. All I had to do was come to class. They knew what had happened to me and they felt sorry for me. They thought I was a great kid. Did they do me a favor? Yes and no. I don’t think it was that great for going to [college], but yes, because I don’t think I would’ve graduated.”
~Kristi
cbirt.org
Themes: Not identified for SpEd
No transition services No IEP Graduated
No access to disability services post-graduation
Usually tried to follow pre-injury plan
cbirt.org
High School Services
Students identified for special education: Not identified TBI Two-track system Rarely received good transition services
cbirt.org
Not identified TBI
All of the transition services I got were through the school for the deaf, because I had a hearing impairment before the TBI. So one summer I went to camp there, and I got some cooking lessons. That was it.
~Tanya
cbirt.org
Themes: Two-track System
College Prep Focus on graduation requirements Learning problems not like those of LD Often need social and life skills training Minimal transition services
cbirt.org
Identification Issues
Because he presents well and isn’t a behavior problem, everybody thought I was nuts when I asked for so much support. But then at the very end of the year, a teacher called me, furious because Mike “belonged in a special class.” Every year I would tell staff this. They’d say, “Ok, ok.” and then mid-year, “Your kid’s got problems!” Then they would spend the last half of the year trying to get something in place, when he’s already missed the first half.
~Mike’s mom
cbirt.org
Identified for SpEd: Academic
He has these gaps. He can do math that he learned before the TBI, but I’m not sure he’s really learned anything since the injury, because his teachers don’t know how to deal with his learning problems.
~Jed’s mother
cbirt.org
Identified for SpEd: Academic
“I graduated with a B average. I can’t really read or write, though.”
~Jed
cbirt.org
Two-track System: Academic
Typical transition plan activities: Write a resume Take an aptitude test College visitation and meeting with
disability services coordinator No time for life skills
cbirt.org
What kids needNTLS2: Needs Life Skills
%
cbirt.org
Two-track System: Life Skills
3 to 4 years of in-school work experience supported employment life skills (bus training, social skills,
independent living self-advocacy
Little academic work No diploma
cbirt.org
Two Track System: Life Skills
“The teachers in my life skills program keep forgetting that I haven’t been this way my whole life. And I remember when I wasn’t this way. I can’t talk very well. I can’t walk very well. But I’m still smart. I know a heck of a lot…More than I should!”
~Mary, injured age 9
cbirt.org
Actual Transition Services
He’s in one of the best life skills programs in the state. I mean, they have everything. But he’s been in it for 4 years now, and every year they have to redo bus training, and he’s still not safe on the bus independently. He’s got a job at a grocery store for work experience, and he loves it, but there’s no indication the store will hire him for real when he’s 22.
~Mike’s mom
POST SECONDARY EDUCATION
cbirt.org
Themes: Pre-injury Plans
Those injured in high school, and their parents, tended to pursue preinjury plans for transition.
This often included college College was extremely challenging for
many participants
cbirt.org
Tina
Before the accident, [my friend April and I] basically had the same life. We were suppose to go away to UO together and be roommates, but because of the accident, I stayed home that year
cbirt.org
Tina
When she did go to the university the next year, she still, I think, maturity-wise, was probably like at about the level of a 15-year old. Everything was really compulsive. She gained weight because of stress. Drank too much, even though she knew she shouldn’t drink at all. She would drink a lot and just pass out. I never wanted to take her to parties.
~Tina’s friend April
cbirt.org
Tina
She lived with a total stranger in the dorm who didn’t know she had a car accident until after Christmas break. Tina chose not to tell her. I will say, the girls robbed her blind. Tina would think her leather coat was at home, then notice that her roommate was wearing one exactly like it. She didn’t figure out until much later that it was her coat.
~Tina’s mother
cbirt.org
Tina
I’d be like ‘Oh just come on! Let’s go out and do something.’ And she’d be like, ‘I have to study.’ And she did. I mean she studied relentlessly, and then she’d wake up the next morning and couldn’t remember what she studied. She couldn’t pass any classes. I don’t even know if she even got a credit. She might have gotten like a couple seminar credits, but I don’ think she passed a class.
~April
cbirt.org
Themes: Is it worth it?
“Will I be able to perform the job I am preparing for? I can’t sit here in my parent’s house forever until I pick out the perfect career. I have to go try.”
~Jack
cbirt.org
Strategies and Supports
Some participants modified their plans Some developed effective strategies Some accessed effective supports
SAM’S STORY
cbirt.org
Critical Features of Sam’s Story
Parent advocacy Achievable short term goals Manageable environments On-going support
Employment
cbirt.org
Employment Themes
Got job through Life Skills Family connections
Infrequent promotion Frequent job changes/unemployment
Uneven performance Inappropriate behavior Impulsivity/poor judgment
cbirt.org
Chelsea
History of quitting jobs if under pressureReceptionist job at community centerBoss remembered the article in the paperPart time, no benefits, minimum wageAccommodations:
schedule to work when office less busytask list, plan with boss before shift
cbirt.org
Chelsea
She’ll do a good job for you. I always left instruction about what she was supposed to do. She would ask a lot of questions, and she was frustrating for the people who worked with her. But once you give her the guidance, she’ll do exactly what you need her to do without a doubt. She may sometimes do it wrong the first time, but she’ll try to do it right. ~Chelsea’s boss
cbirt.org
Chelsea
Problems at work:Easily confused and over-whelmedTalked too loudCalled boss’s pager with trivial questionsPDAs with boyfriend in the officeLost her job when she couldn’t get time off
for a wedding—went anyway.
cbirt.org
Chelsea
At the end of the studyworking a few hours a week cleaning a friend’s house$7 per hour Cost $5-$6 for transportation/child careSelling belongings on Ebay
cbirt.org
Chelsea
If I don’t work full time, I can’t make enough money. If I get a full time job, it has to be something I know how to do or I’ll get overwhelmed. I get overwhelmed if I have to multi-task. And I need a break every 10-15 minutes. I get panic attacks, and I get sick a lot. My daughter gets sick a lot, too.
cbirt.org
Chelsea
Work must be structured and routine, but the risk is she will be bored, further eroding her self-confidence and self-esteem. She need to “pick the right supervisor.” She needs structure and accommodations, but also challenge.
~Chelsea’s neuropsychologist
cbirt.org
Employment Successes
Al: stable cleaning business
Jed: tire store
Jay: team trainer
cbirt.org
Critical Features of Success
Parent advocacy Life skills training (work experience,
social skills, money management) Communication with and training for
employer On-going family support
Community Integration
cbirt.org
Community Based Services
Pressure on families to access services when they are offered
Whether the young adult can benefit or not
Example: Section 8 Housing
cbirt.org
Clay, Joe, Ted
Section 8 apartments No cooking or house keeping skills “Friends” move in Social service personnel are critical of
family Young adult is unsafe, unhealthy Family wants young adult out of the house
cbirt.org
Disruption of the Empty Nest
High rate of divorce following TBI Step parent wants the young adult
[male] out Mom feels guilty Strain on the new marriage
cbirt.org
Stability in Living Situation
Family nearby (Sam, Al, Jed, Bethany) Spouse (Tom, Cody, Tanya, Jed) Living with family (Tina, Brittany, Jack) Supported living (Jenna, Tiger)
Promising TransitionPractices
cbirt.org
Promising Practices
From young adults with TBI and families From transition research From TBI Team members
cbirt.org
Strategies
Community College vs. 4-year college Modify timeline Access supports Reframe challenges as opportunities Live the life you have now
cbirt.org
Strategies: Acceptance
“Every day is different. Some days I can remember things, some days, not. I just take it as it comes, try not to get stressed about it.”
cbirt.org
Strategies: Reframing
“Don’t think of it as, ‘I’ve been working on a 2-year degree for 5 years.’ Think of it as doing something good for your brain, everyday.”
cbirt.org
Strategies: Manageable Goals
“I just try to take things as they happen and have little plans instead of big ones. I wish I didn’t have the problems with school that I do, and that I could have more of a plan. I wish I could do that, but because I can’t, then I just do what I can.”
cbirt.org
Evidence-Based Practices
Student-Focused Planning Student Development (life skills, career
and vocational curricula, self-advocacy) Interagency Collaboration Family Involvement (advocacy training
and counselors) Program Structure (program policy and
evaluation) www.NSTTAC.org
cbirt.org
Not Validated for Students with TBI
Of 131 studies examining effectiveness of these transition practices
6 involved students with TBI 10 participants out of a total of over 1500
cbirt.org
Modifying E-B PracticesE-B Practice TBI Challenge Modifications
Family Involvement
Pursuing preinjury planParent/student grieving/unawareStudent changing rapidly
Assess skills/share infoResearch on TBI outcomesAdjust activities to changing goals/plansProvide hope—what leads to good outcomes?
Student-centered planning
Lack of awarenessParents not ready to let go given recent dependenceMemory impairmentsExecutive function/planning Big One-shot meetings are over-whelming
On-going conversation to adjust plans to awareness, changesUse PCP to teach planning, making decisions, realistic expectationsMotivational Interviewing
cbirt.org
E-B Practice TBI Challenge Modification
Self-Advocacy Student may not appear to have challengesStudent may need help one day, not nextMay have language deficits, impulsivity, impaired judgment that affect communication May confabulateLack of public awareness
Provide frequent practice opportunities in many situationsTrain employers and co-workers re: TBIUse “How Am I Doing? tool
Learning in Context
Problems with generalizationImpaired judgmentInitiation /impulsivityMemory/attn/organization
Environmental and behavioral supportsTrain co-workersInclude self-evaluation
cbirt.org
What’s different for students with TBI?
Relearning skills Dealing with personality changes Understanding how the recovering brain worksAccurately assessing new abilitiesMonitoring awareness, behavior, responses of others, physical condition and limits
cbirt.org
reflect on abilities, gain self awareness, self determination and self advocacy while evaluating their steps toward personal goals.
Helps students who have memory challenges recall goals and the steps they need to perform.
Explicit plans help:
cbirt.org
Explicit Plans Help:
Makes planning for the future more tangible and understandable.
Highlights connection between actions and the outcome of those actions. (If you don’t go to practice you cannot swim on the team and are less likely to get the swimming scholarship or a spot on the Olympic Swim Team).
use of visual supports to enhances new learning and cognitive flexibilty35.
cbirt.org
Janell
Janell, a junior with TBI wanted to attend college but wasn’t exactly sure what courses she wanted to take. She was on track to get a standard diploma, but was unable to complete the course work in her most recent classes.
Janell had a work experience placement in an office near her high school. She believed she was doing well in this placement and started planning to attend college with the goal of being a secretary. However, she was unaware that that her co-workers didn’t think she had the potential to be a secretary and were providing a high level of support for her in her work experience as an office assistance.
cbirt.org
On the job—How am I doing with Problem Solving?
Given a job tryout, Jennell will offer possible solutions to everyday problems as they arise over the course of her day. She will rate herself as a (1) 90% of the time over 2 consecutive weeks with inter-rating agreement from supervisor, colleague or teacher—this goal would not appear on the form as written in the IEP. Keep wording student friendly and student driven.
Jenell
1no help/solution
worked
2encouraged to solve the
problem/solution worked
3someone gave me solutions
to choose from/solution worked
My thoughts
Monday
Tuesday
Wednesday
Thursday
Friday
Supervisor
1no help/solution
worked
2encouraged to solve the
problem/solution worked
3someone gave me solutions
to choose from/solution worked
My thoughts
Monday
Tuesday
Wednesday
Thursday
Friday
Colleague
1no help/solution
worked
2encouraged to solve the
problem/solution worked
3someone gave me solutions
to choose from/solution worked
My thoughts
Monday
Tuesday
Wednesday
ThursdayFriday
cbirt.org
Development and Training
B.R.A.I.N. Program [email protected] Adolescent Executive Functions-Lyn
Turkstra College Students with TBI: Mary
Kennedy NIDRR Development Project: Defining
Success
cbirt.org
Transition Web Project
cbirt.org
Todis B. & Glang, A. (2008). Redefining Success: Results of a qualitative study of post-secondary transition outcomes for youth with traumatic brain injury. Journal of Head Trauma Rehabilitation, 23(4), 252-263.
Todis, B. Glang, A., Bullis, M., Ettel, D., & Hood, D. (2011). Longitudinal Investigation of the Post-High School Transition Experiences of Adolescents with Traumatic Brain Injury. Journal Head Trauma Rehabilitation, 26(2), 138-149.
cbirt.org
Contact me
Bonnie Todis, PhDCenter on Brain Injury Research and
TrainingTeaching Research InstituteWestern Oregon [email protected]