Transition into Adulthood for Students with TBI

1. Transition into Adulthood for Students with TBI Bonnie Todis, Ph.D. Center on Brain Injury Research and Training

2. 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

3. Typical Youth Transition Childhood Adulthood • School • Activities • Relationships • Quality of Life Adult Identity Employment Independence Relationships Quality of Life Transition

4. 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

5. Impact of TBI in Adulthood Road through Adulthood Sustains TBI Employment Independence Relationships Quality of Life • Return to • previous or • optimal or • acceptable lifestyle

6. 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

7. 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

8. 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

9. 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

10. 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?

11. 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

12. POST-SECONDARY OUTCOMESPROJECT(PSO)

13. 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

14. 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

15. Project PSO Purpose: • Systematic tracking of quantitative data on transition outcomes Methodology: • In-person/phone interviews with young adult, parent • 6-12-month intervals

16. 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

17. RESULTS

18. Life Transition Planning At initial interview

19. Written Transition Plan At initial interview Bonnie Todis, Ph.D. Center on Brain Injury Research and Training

20. Person Who Helped Plan Transition At initial interview

21. TRANSITION OUTCOMES

22. 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.)

23. 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

24. Employment Outcomes Ages 19-25

25. Post-Secondary Employment Outcomes 19-25

26. 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

27. Employment Outcomes by Gender

28. 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

29. Comparison with Typical Peers • Bureau of Labor Statistics of the U.S. Department of Labor, January 19, 2007

30. 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.

31. 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

32. 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

33. 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

34. 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

35. POST SECONDARY EDUCATION

36. Post-SecondaryEducation OutcomesAges 19-25 n (%)

37. Post-Secondary Education Outcomes Ages 19-25

38. 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

39. 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.

40. Independent Living Outcomes Ages 19-25 Bonnie Todis, Ph.D. Center on Brain Injury Research and Training n (%)

41. Post-SecondaryIndependent Living OutcomesAges 19-25

42. 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).

43. 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.

44. Qualitative Component

45. 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

46. Qualitative Methodology Methodology: • Unstructured recursive interviews • Participant observations with young adult • Interviews with knowledgeable others 1-to-6-month intervals

47. Qualitative Findings

48. Thematic Categories • High School Experiences • Employment • Post-Secondary Education • Community Integration

49. 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

50. 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