Embed Size (px)
Citation preview
TRANSITION INTO ADULTHOOD FOR STUDENTS WITH
TBIBonnie Todis, Ph.D.Center on Brain Injury Research and Training
cbirt.org
Overview
Transition under IDEA Quantitative Findings of PSO Project
Employment outcomes for students with TBI
Post-secondary education outcomes Community integration outcomes
Qualitative Findings Educational Interventions
cbirt.org
Typical Youth Transition
SchoolActivitiesRelationshipsQuality of Life
Childhood
Adult Identity
EmploymentIndependence RelationshipsQuality of Life
Adulthood
TRANSITION
cbirt.org
Youth Transition Goals
SustainsTBISchool
ActivitiesRelationshipsQuality of Life
Childhood
Return toprevious or optimal childhood
ALTEREDDevelopment
Adult Identity
EmploymentIndependence RelationshipsQuality of Life
Adulthood
cbirt.org
Impact of TBI in Adulthood
SustainsTBIEmployment
Independence RelationshipsQuality of Life
Road through Adulthood
Return to previous or optimal or acceptable lifestyle
cbirt.org
Transition Services IDEA
A coordinated, results-oriented set of activities for a child with a disability.
Based on the individual child’s Needs Strengths Preferences Interests
cbirt.org
Transition Services IDEA
Post school activities include: Postsecondary education Vocational education Integrated employment
Including supported employment
Continuing and adult education Adult services Independent living or community
participation
cbirt.org
Transition Services IDEA
Instruction Related services Community experiences Development of employment and other
adult living objectives When appropriate
acquisition of living skills functional vocational evaluation
cbirt.org
Transition Services IDEA
Begin no later than age 16 Students on IEPs are eligible to receive
special education services through age 21
Once a student graduates with a regular diploma, he is no longer eligible for transition services
Eligible for disability-related supports from other agencies
cbirt.org
Our Questions:
What are the transition experiences of students with TBI? How does high school prepare them for
transition? 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 education 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
Two level longitudinal growth model:Measurement occasion nested within participant
Level 1: Repeated measurement occasions
γij = β0j + β1j timeij + eij
Level 2 : Participants
β 0j = γ00+ γ00Xj + δ0j
β1j = γ10+ γ11Xj + δ1j
β 0j = intercept of group jβ 1j = slope of TIME of group j * (time for participant ij)eij = residual for measurement i within participant jγ00 and γ10 are intercepts (of initial status and rate of change)γ01and γ11 are slopes (regression coeff) predicting β 0j and β 1j from variable Xj. Xj= Level 2 person variables (gender, age@injury, severity, etc.)
Level 1 = Outcomes at times 1 – t
Level 2 = participant characteristics
cbirt.org
Advantages of modern longitudinal methods are that we can:
Use data with different #s data points and waves of data, can use all cases, and multilevel data structures [meas occasion within person within community]
Evaluate changes over time [within-person variance]: Does employment increase, decrease, stay same over time?
Model the effects of participant characteristics as predictors [between-person variance]: gender, age at injury, severity
Test cross-level interactions of person variables(L2) with time (L1) : Does gender(L2) effect rate of change in employment over time (L1)?
Key advantages: Flexibility and use of multi-level data
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
Comparison with typical young adults ages 18-25 (Pew Research Center, 2007)
cbirt.org
Comparison with Peers
Non disabled young adults 18-25 46% enrollment (Pew 2007) 54% female (2005)
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
Qualitative Findings
cbirt.org
Thematic Categories
High School Experiences Employment Post-Secondary Education Community Integration
cbirt.org
What Happens in High School?
Students not identified for special education: Tested at or above grade level 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
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
Receiving SpEd Services
Students identified for special education: Not identified TBI Two-track system Rarely received good transition services
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
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 Students with TBI often don’t fit in
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
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
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
cbirt.org
Critical Features of Success
Parent advocacy Linkages with campus/community
supports Achievable short term goals Manageable environments
Community college Live at home or in small group
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
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, 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
Critical Features of Success
Family nearby Spouse Living with family Supported living
Promising TransitionPractices
cbirt.org
Promising Practices
From young adults with TBI and families From transition research
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
instruction, career and vocational curricula)
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
TBI Transition Tool Kit
Pilot study through MCH State Improvement Grant
Developed and piloted in Central Oregon Evidence-based transition practices Adapted for students with TBI
Training for TBI School Team members
cbirt.org
Development and Training
NIDRR Development Project: Defining Success
IES Personnel Prep Development Grant with YTP Give transition professionals info about TBI
and Transition Strategies Provide consultation, community of
practice, resources
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.
