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Transition into Adulthood for Students with TBI. Bonnie Todis , Ph.D. Center on Brain Injury Research and Training. Overview. Transition under IDEA Quantitative Findings of PSO Project Employment outcomes for students with TBI Post-secondary education outcomes

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transition into adulthood for students with tbi

Transition into Adulthood for Students with TBI

Bonnie Todis, Ph.D.

Center on Brain Injury Research and Training

overview
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
typical youth transition
Typical Youth Transition

Childhood

Adulthood

  • School
  • Activities
  • Relationships
  • Quality of Life

Adult Identity

Employment

Independence

Relationships

Quality of Life

Transition

youth transition goals
Youth Transition Goals

Childhood

Sustains

TBI

  • School
  • Activities
  • Relationships
  • Quality of Life

Return to

previous or optimal childhood

Adulthood

ALTERED

Development

Adult Identity

Employment

Independence

Relationships

Quality of Life

impact of tbi in adulthood
Impact of TBI in Adulthood

Road through Adulthood

Sustains

TBI

Employment

Independence

Relationships

Quality of Life

  • Return to
    • previous or
    • optimal or
    • acceptable lifestyle
transition services idea
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
transition services idea1
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
transition services idea2
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
transition services idea3
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
our questions
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?
transition services idea4
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
project pso
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
pso participants
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
project pso1
Project PSO

Purpose:

  • Systematic tracking of quantitative data on transition outcomes

Methodology:

  • In-person/phone interviews with young adult, parent
  • 6-12-month intervals
pso survey domains
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
life transition planning
Life Transition Planning

At initial interview

written transition plan
Written Transition Plan

At initial interview

Bonnie Todis, Ph.D.

Center on Brain Injury Research and Training

two level longitudinal growth model measurement occasion nested within participant
Two level longitudinal growth model:Measurement occasion nested within participant

Level 1: Repeated measurement occasions

γij = β0j + β1jtimeij + eij

Level 1 = Outcomes at times 1 – t

Level 2 = participant characteristics

Level 2 : Participants

β 0j = γ00+ γ00Xj + δ0j

β1j =γ10+ γ11Xj + δ1j

β0j = intercept of group j

β1j = slope of TIME of group j * (time for participant ij)

eij= residual for measurement i within participant j

γ00 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, [email protected], severity, etc.)

advantages of modern longitudinal methods are that we can
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

closer look employment at age 25
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
employment at age 25
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
comparison with typical peers
Comparison with Typical Peers
  • Bureau of Labor Statistics of the U.S. Department of Labor, January 19, 2007
factors predicting employment
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.
factors that impact employment
Factors That Impact Employment

Work Category by Sex and Age at Injury Over Time

Job Category by Sex and Age at Injury

Clerical, sales

Later age)

Skilled manual labor

Earlier age

Avg age

Females

Later age

Semi-skilled

Earlier age

Avg age

Males

Unskilled work

Menial service

Bonnie Todis, Ph.D.

Center on Brain Injury Research and Training

factors that impact employment1
Factors That Impact Employment

Wages Over Time by Age at Injury and Severity

Later injury

Severe

Mild/Moderate

Early injury

Later injury

Bonnie Todis, Ph.D.

Center on Brain Injury Research and Training

Early injury

factors that impact employment2
Factors That Impact Employment

Hours Worked per Week

Severity: M/M work > # Hrs.

Gender: Males> #hrs.

For both genders: Earlier age at injury = work fewer hours/week

21 – 30hr

later

Bonnie Todis, Ph.D.

Center on Brain Injury Research and Training

later

Hours Per Week

16-20hr

Injured earlier

Injured earlier

Males

Males

Females

11-15hr

Females

Mild/Mod

Severe

Severity

factors that impact employment3
Factors That Impact Employment

Job Happiness by Severity and Age at Injury

Very Happy

Early age

Severe

Avgage

Later age

Happy

Early age

Mild/

Moderate

Avgage

Later age

Unhappy

comparison with peers
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
factors that affect enrollment
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.
independent living outcomes ages 19 25
Independent Living Outcomes Ages 19-25

Bonnie Todis, Ph.D.

Center on Brain Injury Research and Training

n (%)

comparison with peers1
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).
factors that affect ind living
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 component1
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
qualitative methodology
Qualitative Methodology

Methodology:

  • Unstructured recursive interviews
  • Participant observations with young adult
  • Interviews with knowledgeable others

1-to-6-month intervals

thematic categories
Thematic Categories
  • High School Experiences
  • Employment
  • Post-Secondary Education
  • Community Integration
what happens in high school
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
helped to graduate academic
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

not identified for sped
Not identified for SpEd
  • No transition services
    • No IEP
    • Graduated
  • No access to disability services post-graduation
  • Usually tried to follow pre-injury plan
receiving sped services
Receiving SpEd Services
  • Students identified for special education:
    • Not identified TBI
    • Two-track system
    • Rarely received good transition services
themes two track system
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
two track system academic
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
two track system life skills
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
two track system life skills1
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

themes pre injury plans
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
themes is it worth it
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

strategies and supports
Strategies and Supports
  • Some participants modified their plans
  • Some developed effective strategies
  • Some accessed effective supports
critical features of success
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 themes
Employment Themes
  • Got job through
    • Life Skills
    • Family connections
  • Infrequent promotion
  • Frequent job changes/unemployment
    • Uneven performance
    • Inappropriate behavior
    • Impulsivity/poor judgment
employment successes
Employment Successes
  • Al: stable cleaning business
  • Jed: tire store
  • Jay: team trainer
critical features of success1
Critical Features of Success
  • Parent advocacy
  • Life skills training (work experience, social skills, money management)
  • Communication, training for employer
  • On-going family support
community based services
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

critical features of success2
Critical Features of Success
  • Family nearby
  • Spouse
  • Living with family
  • Supported living
promising practices
Promising Practices
  • From young adults with TBI and families
  • From transition research
strategies
Strategies
  • Community College vs. 4-year college
  • Modify timeline
  • Access supports
  • Reframe challenges as opportunities
  • Live the life you have now
strategies acceptance
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.”

strategies reframing
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.”

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.” Strategies: Manageable Goals
evidence based practices
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
not validated for students with tbi
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
tbi transition tool kit
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
development and training
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
slide80

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.

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