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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

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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



  • 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



  • School

  • Activities

  • Relationships

  • Quality of Life

Adult Identity




Quality of Life


Youth transition goals

Youth Transition Goals




  • School

  • Activities

  • Relationships

  • Quality of Life

Return to

previous or optimal childhood




Adult Identity




Quality of Life

Impact of tbi in adulthood

Impact of TBI in Adulthood

Road through Adulthood






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

Post secondary outcomes project pso


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


  • Systematic tracking of quantitative data on transition outcomes


  • 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

Person who helped plan transition

Person Who Helped Plan Transition

At initial interview

Transition outcomes


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, age@injury, 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

Employment outcomes ages 19 25

Employment Outcomes Ages 19-25

Post secondary employment outcomes 19 25

Post-Secondary Employment Outcomes 19-25

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 outcomes by gender

Employment Outcomes by Gender

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


Later age


Earlier age

Avg age


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



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


Bonnie Todis, Ph.D.

Center on Brain Injury Research and Training


Hours Per Week


Injured earlier

Injured earlier









Factors that impact employment3

Factors That Impact Employment

Job Happiness by Severity and Age at Injury

Very Happy

Early age



Later age


Early age




Later age


Post secondary education


Post secondary education outcomes ages 19 25

Post-SecondaryEducation OutcomesAges 19-25

n (%)

Post secondary education outcomes ages 19 251

Post-Secondary Education Outcomes Ages 19-25

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 (%)

Transition into adulthood for students with tbi

Post-SecondaryIndependent Living OutcomesAges 19-25

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 component

Qualitative Component

Qualitative component1

Qualitative Component


  • 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


  • Unstructured recursive interviews

  • Participant observations with young adult

  • Interviews with knowledgeable others

    1-to-6-month intervals

Qualitative findings

Qualitative Findings

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.”


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

What kids need ntls2 needs life skills

What kids needNTLS2: Needs Life Skills


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

Post secondary education1


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.”


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 integration

Community Integration

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 transition practices

Promising TransitionPractices

Promising practices

Promising Practices

  • From young adults with TBI and families

  • From transition research



  • 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)


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

Transition into adulthood for students with tbi

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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