Career Readiness in Young Adult Brain Tumor Survivors

1. Career Readiness in Young Adult Brain Tumor Survivors David R. Strauser, Ph.D. Department of Kinesiology and Community Health October 19, 2009 1:00-2:30 p.m.

2. Overview • Overview of the problem • Overview of Cognitive Information Processing • Brief Review of foundational research • Initial results of current young adult career readiness study findings • Applications to service delivery

3. The Broad Problem • As the number of individuals surviving cancer continues to increase, career development and employment are becoming central factors that impact the individual’s community integration and well-being.

4. Cancer and Employment: Adults Employment rates of cancer survivors range from 41 to 84% Mean rate of 62% (Taskilia &Lindbohm, 2007) 16.8% of working age cancer survivors (vs. 5% for matched controls) are “unable to work because of physical, mental, or emotional problems” 7.4% (vs. 3.2% of matched controls) “were limited in the kind or amount of work they could perform” (Hewitt, Rowland, & Yancik, 2003) Long term cancer survivors One in five survivors reported “cancer related disabilities” with 50% continuing to work. 13% of all survivors had withdrawn from work for cancer related reasons within four years (Short et al, 2005)

5. Cancer and Employment: Adult Unequal employment practices are forms of discrimination for cancer survivors (Feuerstein, et al., 2007) More likely to file claims related to job loss and differential treatment Cancer combined with another impairment increases relationship problems at work Duration of sick leave associated with difficulties in returning to work in cancer survivors (Amir et al. 2007) Males use less sick leave then females Males have longer sick leave Sick leave used most by those economically deprived

6. Cancer and Employment: Young Adults Young adults who are childhood cancer survivors experience significant difficulty in obtaining employment Adult survivors of childhood cancer are twice as likely to be unemployed compared to their healthy controls 5 times more likely to be unemployed in CNS cancer survivors.(deBoer et al, 2006) Young adults who are childhood cancer survivors experience concerns about obtaining employment 19% with a history of childhood bone marrow transplant reported work as a major concern vs. 2% of their age matched controls (Bradley,2002) Co-Morbid health conditions (depression, anxiety, fatigue, cardiovascular disease, visual impairments, and impaired attention span) have been linked to difficulty in obtaining employment in childhood cancer survivors (deBoer et al, 2006)

7. Career Development and Cancer Survivorship • Career counseling has an important role with young cancer survivors • Cognitive Information Processing (CIP) provides a theoretical model regarding the provision of career services • Two core constructs • Information Processing Domains • Decision-Making Cycle

8. Theoretical Assumptions (CIP) • Career decision making involves both emotions (affect) and thoughts (cognition) • Knowledge-content of career choice • Process-what we need to do • Knowledge and Emotions are dynamic states • Impacted by health and disability (i.e. cancer) • Career problem solving and decision making are skills that can be learned • Can improve with practice • Career counseling and resources

9. Dysfunctional Career Thoughts • Dysfunctional career thoughts lead to… • Avoidance of career and other life decisions • Decreased life satisfaction • Depression and anxiety • Decreased job satisfaction • Increased job stress • Interpersonal relationship problems • Expressed through… • Behavior-poor performance • Verbal-negative statements and expressions • Emotions-depression and anxiety

10. Information Processing Domains Executive Processing Domain Meta-cognitions Decision-Making Skills Domain CASVE Cycle SelfKnowledge Environmental Knowledge Knowledge Domains

11. Self-Knowledge • Values, interests, skills, and employment preferences are influenced by • Personal characteristics • Life experience • Values, interests, skills, and employment preferences may be influenced by • Religious or spiritual beliefs • Cancer Related Issues • Symptom burden-fatigue, depression, anxiety, decreased concentration • Receptive and Expressive skills

12. Self-Knowledge • Stored in episodic memory • Perceptions rather than facts • Influenced by interpretation of past events • Influenced by present emotions

13. Environmental Knowledge • Knowledge of Environmental Demands • Direct experience or observing others • Expands over time • Components of Environmental Knowledge • Tasks • Tools & Technology • Knowledge (i.e. language, interpersonal) • Skills & Abilities • Work Activities (i.e. communicating, moving objects) • Work Context ( i.e. contact with others) • Work Styles (i.e. stress tolerance, dependability) • Work Values (i.e. relationship, support, achievement) • Interests • Expressive and Receptive demands

14. Occupational Knowledge • Stored in semantic memory • Verifiable facts rather than perceptions • Not influenced by interpretation of past events • Not influenced by present emotions

15. Decision-Making Cycle Communication Execution Analysis Valuing Synthesis

16. Meta-Cognitions (Executive Processing Domain) • Thoughts That Influence Decision Making • Self-Talk • Positive vs. Negative • Self-Awareness • Thoughts, Emotions and Behaviors • Reactions of self to significant others • Monitoring and Control • Where they are in the process • Purposeful engagement

17. Two Dimensions of Career Readiness • Capability • Cognitive and affective ability to engage in effective career problem solving and decision making • Career Thoughts Inventory (CTI) Subscales • Decision Making Confusion (DMC) • Commitment Anxiety (CA) • Complexity • Contextual factors, originating in the family, society, economy, or employing organizations that make it (more or less) difficult to solve career problems or make decisions • CTI Subscale • External Conflict (EC)

18. Two Dimensional Model of Readiness Complexity (High) Complexity (Low)

19. Foundational Research Career Readiness and Disability

20. Key Findings(Disability Specific) • People with disabilities have increased levels of dysfunctional career thoughts compared to controls (Strauser et al, 2002, Strauser et al., 2004) • The Career Thoughts Inventory (CTI) can be used with individuals with disabilities to identify their levels of career readiness (Lustig et al., 2003) • Cognitive and affective states negatively impact career readiness (Yanchak et al., 2005; Strauser et al., 2006a; Strauser et al., 2006b) • PWB is positively related to career readiness (Lustig et al, 2002; Lustig et al. 2008; Strauser et al, 2008)

21. Key Findings (Broader Career Literature) • Career services are effective in reducing negative career thoughts (Dipeolu et al. 2002) • Completion of higher education is related to less dysfunctional career thoughts (Reardon, et al., 2000) • Positive effect of Vocational and Career services for individuals with disabilities (Bolton & Akridge, 1995; Enright, 1995; Merz & Syzmanski, 2002)

22. Current Research in Career Readiness and Young Adult CNS Survivors

23. Purpose of Current Exploratory Study • The overall purpose of this exploratory study is two fold. • Examine the relationship between career readiness, vocational identify and relevant career and psycho-social outcomes in young adult brain tumor survivors • Enhancing career readiness can increase career and vocational functioning and career and psycho-social outcomes • Determine if we can classify brain tumor survivors according to their level of career readiness • Classifying survivors according to their level of career readiness can guide the implementation of clinical and vocational interventions focused on improving career and employment outcomes.

24. Aim 1 • Aim 1 • Examine the relationship between career readiness, vocational identity, and relevant work and psycho-social outcomes • Ho: There will be a significant and positive relationship between career readiness, vocational identify, and relevant work and psycho-social outcomes

25. Employment Outcomes Complexity Identity Community Integration Capability Individual Well-Being Conceptual Model Guiding Aim 1

26. Aim 2 • Aim 2 • Determine if it is feasible to classify brain tumor survivors according to their reported level of career readiness. • Ho: Brain tumor survivors can be classified according their reported level of career readiness. Specifically, we hypothesize that we will be able to classify individuals into three groups (High, Moderate, and Low) which then can be used to guide the type, level, and implementation of career intervention

27. Intervention Matrix for Aim 2 Complexity (High) Complexity (Low)

28. Procedures • Surveys distributed to young adult brain tumor survivors • Age 18-30 • IRB approval • Research packet contained • Demographic Form • Career Thoughts Inventory (CTI) • Contextual Work Behaviors (CWB) • Community Integration Scale (CIS) • Satisfaction with Life Scale (SWLS)

29. Participating Sites • Children’s Brain Tumor Foundation • St. Jude Children’s Hospital • Camp-Make-A-Dream • Hope Advocate Hospital-Chicago • L.A. Children’s Hospital-City of Hope

30. Study Demographics

31. Results Aim 1 Multiple linear regression (Stepwise) for total score and 3 subscale scores of Career Thoughts Inventory (CTI), predicting total score of Vocational Identity (MVS) (N= 37) Note: R2=.61, Dependent variables: Total score (Vocational Identity) of the My Vocational Situation; Predictor variables: CTI (Total) = Total score; CTI (DMC) = Decision Making Confusion; CTI (CA) = Commitment Anxiety; CTI (EC) = External Conflict.

32. Aim 1 Results When the four independent variables are entered using stepwise method, the total score of CTI alone significantly predicted the total score (Vocational Identity) of MVS, F= 58.110, p < .001. The adjusted R squared value was 0.613, indicating that 61.3% of the variance in the total score (Vocational Identity) of MVS was explained by this model. CTI Subscales (DMC, CA, and EC) did not make a unique contribution to the model

33. Multivariate Results Research Aim 1 Multivariate analysis procedure for Vocational Identity total score predicting the total scores of Contextual Work Behaviors (CWB), Community Integration Scale (CIS), and Satisfaction with Life Scale (SWLS) (N=37). Note: Dependent variables: CWB (Total) = total score of Contextual Work Behavior (CWB); CIS (Total) = total score of Community Integration Scale (CIS); SWLS (Total) = total score of Satisfaction with Life Scale (SWLS). Independent variable: VI (Total) = total score (Vocational Identity) of the My Vocational Situation (MVS).

34. Multivariate Results Aim 1 Result indicated that the overall model was significant (Pillai’s Trace F (3, 33) = 4.131, p = .014) Vocational Identify total score significantly predicted: CWB (R2 value = .186) 18.6% of the Variance CIS (R2 value = .106) 10.6% of the Variance SWLS (R2 value = .082) 8.2% of the Variance

35. Summary Aim 1 Findings • Career Thoughts significantly and positively related to vocational identity • Complexity and capability not a unique predictor at this time • Vocational identity significantly and positively related to: • Contextual Work Behaviors (CWB) • Community Integration (CIS) • Individual Well-being (SWLS)

36. Grouping Results Aim 2 • Cluster analysis (Ward’s method) was used to classify participants into three groups. • Results from Chi-square or F-statistics analysis indicated that all demographic characteristics, except were not significant (p > 0.05).

37. Grouping Results Aim 2 Table 4. Demographic Characteristics of Participants in Four Cluster Groups (N=37).

38. Grouping Results Aim 2 Note: Participants were clustered by the total score and three subscale scores (DMC, CA, & EA) of Career Thoughts Inventory (CTI)

39. Results Aim 2 • The GLM Multivariate procedure was computed by entering the raw total score, and three raw subscale scores of CTI as dependent variables and 3-cluster solution as fixed variable. • Result indicated that the overall model was significant (Pillai’s Trace F (8, 64) = 6.410, p < .001). • Test of between-subjects effects further indicated that the CTI Total, DMC, CA, and EC are all significant [F (2. 34) = 8.356- 98.478, ps < 0.001]. • Post-hoc analysis indicated that all pair-wise comparisons of all four variables across all three readiness groups are significantly different (ps < .05) • Except that there is no significant difference on EC score was found between Moderate and Low readiness groups (p = .478). • Generally speaking, the High readiness group tends to have lower negative career thoughts • lower DMC,CA, and EC than the other groups.

40. Differences on CTI across 3 Groups Figure 1. T-scores of the total score (CTI Total), and 3 subscale scores (Decision Making Confusion (DMC), Commitment Anxiety (CA), and External Conflict (EC) of Career Thoughts Inventory (CTI) across 3 readiness groups. Note: T-score conversion was based on the profile for adults as reference. Lower T-score reflected less negative career thoughts, less DMC, less CA, & less EC. In other words, lower T-score reflected better readiness.

41. Employment Outcomes Complexity Identity Community Integration Capability Individual Well-Being Conceptual Model

42. Mean total score of Contextual Work Behavior (CWB Total) across 3 readiness groups. Note: Participants were clustered by the total score and three subscale scores (DMC, CA, & EA) of Career Thoughts Inventory (CTI)

43. Mean scores of total score of Contextual Work Behavior (CWB) across 3 readiness groups.

44. Mean scores of total score of Community Integration Scale, across 3 readiness groups.

45. Mean scores of total score of Life Scale across 3 readiness groups.

46. Results Aim 2 • Able to group cancer survivors according to their level of career readiness • No differences in demographic variables • Ethnicity-may emerge as significant (Low Group) • Education-may emerge as significant (Low Group) • No difference across groups for • CWB-may emerge as significant • CIS-may emerge as significant • SWLS

47. Implications for Practice • Readiness assessment valuable as a means to identify level of career and vocational intervention • High Readiness- Self-help Services • Moderate Readiness- Brief Assisted Services • Low Readiness- Intensive Services

48. Implications • Improving Readiness may increase CWB • Job Maintenance behaviors • Handling stress • Making adjustments • Dealing with co-workers • Dealing with supervisors • Improving Readiness may increase Community Integration • Level of community support • Level of independence • Level of occupational participation

49. Questions? Comments ?

50. Research Team