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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. Our Questions:.

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we must be willing to get rid of the life we planned so as to have the life that is waiting for us

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

our questions
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?
transition services idea
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
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

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


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


comparison with peers
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
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


  • 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

selection of respondents
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
thematic categories
Thematic Categories
  • High School Experiences
  • Employment
  • Post-Secondary Education
  • Community Integration
themes high school services
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
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.”


themes not identified for sped
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
high school services
High School Services
  • Students identified for special education:
    • Not identified TBI
    • Two-track system
    • Rarely received good transition services
not identified tbi
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.


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
identification issues
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

identified for sped academic
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

identified for sped academic1
Identified for SpEd: Academic

“I graduated with a B average. I can’t really read or write, though.”


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
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

actual transition services
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

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

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


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


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


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.


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 sam s story
Critical Features of Sam’s Story
  • Parent advocacy
  • Achievable short term goals
  • Manageable environments
  • 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

History of quitting jobs if under pressure

Receptionist job at community center

Boss remembered the article in the paper

Part time, no benefits, minimum wage


schedule to work when office less busy

task list, plan with boss before shift


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


Problems at work:

Easily confused and over-whelmed

Talked too loud

Called boss’s pager with trivial questions

PDAs with boyfriend in the office

Lost her job when she couldn’t get time off for a wedding—went anyway.


At the end of the study

working a few hours a week cleaning a friend’s house

$7 per hour

Cost $5-$6 for transportation/child care

Selling belongings on Ebay


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.


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

employment successes
Employment Successes
  • Al: stable cleaning business
  • Jed: tire store
  • Jay: team trainer
critical features of success
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 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

clay joe ted
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
disruption of the empty nest
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
stability in living situation
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 practices
Promising Practices
  • From young adults with TBI and families
  • From transition research
  • From TBI Team members
  • 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, career and vocational curricula, self-advocacy)
  • 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
what s different for students with tbi
What’s different for students with TBI?

Relearning skills

Dealing with personality changes Understanding how the recovering brain works

Accurately assessing new abilities

Monitoring awareness, behavior, responses of others, physical condition and limits

explicit plans help
Explicit plans help:
  • 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 help1
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.

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.

development and training
Development and Training
  • B.R.A.I.N. Program julie.krupa@choa.org
  • Adolescent Executive Functions-Lyn Turkstra
  • College Students with TBI: Mary Kennedy
  • NIDRR Development Project: Defining Success

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.

contact me
Contact me

Bonnie Todis, PhD

Center on Brain Injury Research and Training

Teaching Research Institute

Western Oregon University