The Role of Neuropsychology in the Process of Vocational and Educational Re-Entry

1. The Role of Neuropsychology in the Process of Vocational and Educational Re-Entry Howard Mangel, Ed.D. Neuropsychology & Counseling Associates Somerset & Colts Neck Mark J. Chelder, Ph.D. Bacharach Institute for Rehabilitation

2. Objectives • Identify the role of the neuropsychologist in vocational/educational rehabilitation; • Identify goals of consumer driven vocational and educational rehabilitation; • Discuss pertinent clinical research regarding return to work outcomes. • Present functional tools to help meet our clients’ goals.

3. Important Facts Regarding TBI • Over 1.7 million cases of TBI are reported annually; • Every 21 seconds, one person in the U.S. sustains a Traumatic Brain Injury (From Centers for Disease Control & Prevention data, 2006-2010)

4. Important Facts Regarding TBI • Approximately 5.3 million Americans currently live with disabilities resulting from TBI (approximately 2% of the population) (From Centers for Disease Control & Prevention data, 2006-2010)

5. Causes of Traumatic Brain Injury (From Centers for Disease Control & Prevention data, 2006-2010)

6. Important Facts Regarding TBI • Males are approximately 1.5 times as likely as females to sustain a TBI • The three age groups at highest risk for TBI are 0–4, 15–19 & 65+ years old • After one brain injury the risk for a second injury is three times greater; third injury is eight times greater

7. Impact on Society • Returning to work after TBI • Significant variability in rates of return to work • Unemployment numbers can range from 10 percent to 78 percent following TBI • These numbers appear to depend on the definition of employment used by the individual researchers • Kreutzer, J.S., et.al (2003)

8. Impact on Society • Returning to work after TBI • Kreutzer, J.S., et.al (2003) found that after 1, 2, 3, or 4 year follow-ups: • 34% were stably employed • 27 % were unstably employed • 39% were unemployed

9. Impact on Society • Returning to work after TBI • Walker, W.C., et.al. (2006) looked at RTW in specific employment categories. They found that: • Professional/Managerial employees returned to work at a rate of 56% • Skilled labor employees at 40% • Manual labor employees at 32%

10. Impact on Society • Returning to work after TBI • Common risk factors for unemployment after TBI: • More severe injury • Higher age at injury • Male gender • Lower levels of pre-injury educational and/or occupational success

11. Impact on Society • Returning to work after TBI • Common risk factors for unemployment after TBI: • Lower levels of social support from friends, family, etc. • Significant physical, psychosocial, or cognitive impairments • Ethnic minority • History of substance abuse

12. Impact on Society • Returning to work after TBI • Other risk factors for unemployment after TBI involve the interaction between the individual and their environment: • Lack of worthwhile job prospects • Financial disincentives • Lack of transportation West, M.D. et.al. (2013), in Brain Injury Medicine

13. Impact on College after a Traumatic Brain Injury • Recent input from Rutgers suggests that: • Out of an estimated 1,200 students receiving Disability coordinator attention (out of reported 31,000 plus undergraduate students), 40-50 id’ed Traumatic Brain Injury as reason for assistance

14. College after Traumatic Brain Injury snapshots: • This does not include student athletes who have sustained concussions • Of those, currently, about half sustained their brain injuries since enrolling at college • It is likely there are more students who are recovering from TBI than requesting/getting disability services

15. College after TBI snapshots: • Causes of their injuries include, in estimated order of frequency: • MVA related injuries • Veterans returning to college • Falls • Assaults

16. College after TBI snapshots: • This past Winter, due to icy weather, estimated 15-20 more students sustained concussions with lingering cognitive, behavioral and/or physical symptoms

17. Assessing Neurobehavioral Functioning • The NJ DVRS Model • Based on a functional neurocognitive approach to assessment; • Aims to be cost and time effective; • Standardizes the assessment battery and report format for clarity and consistency; • Focuses on neurobehavioral strengths and weaknesses

18. Assessing Neurobehavioral Functioning • The NJ DVRS Model • Assesses the following areas of function: • Intellectual Ability • Memory, Learning and Attention Skills • Language Functions • Motor and Sensory Functions • Visual and Spatial Functions • Executive Functions

19. Assessing Neurobehavioral Functioning • The NJ DVRS Model • Assesses the following areas of function: • Academic Skills • Mood and Behavior • Career Interests

20. Assessing Neurobehavioral Functioning • The NJ DVRS Model • Quantitative assessment findings are then integrated with: • Background information • Educational Level • Prior work history • Medical history • Psychosocial history • Vocational Interests/Goals • Observations of behavior during the evaluation

21. Assessing Neurobehavioral Functioning • The NJ DVRS Model • Conclusions are based on: • The overall level of the individual’s performance; • The profile of neurobehavioral strengths and weaknesses; • History of vocational/academic success; • Whether the individual’s abilities and career interests are consistent with one another.

22. Assessing Neurobehavioral Functioning • The NJ DVRS Model • Recommendations may include: • Further rehabilitative treatment • Medical treatments • Psychological support • Job development • Introducing workplace supports - All geared to prepare the individual for work re-entry

23. Assessing Neurobehavioral Functioning • Alternative Assessment Models • Experiential and Situational Assessments • Can combine traditional evaluation techniques with job simulations and/or real job activities • Volunteer work • Job Shadowing/Modeling

24. Assessing Neurobehavioral Functioning • Alternative Assessment Models • Experiential and Situational Assessments • Advantages: • Observe the individual in a real work environment • Can assess for issues that might go unnoticed during an in-office assessment (i.e. socialization, stamina, sustained attention, etc.) • Promote and assess learning of specific job tasks • Greater ecological validity over traditional neuropsychological testing • Disadvantages: • Costly • Time consuming • Limited selection of job tasks available

25. Placement Alternatives • Independent Employment • May include the individual’s pre-injury job • May require more independent use of strategies • Supported Employment • Usually involves a job coach to assist in skill acquisition/maintenance • Coaching can be gradually faded

26. Placement Alternatives • Sheltered Workshop • Most restrictive • Usually involves fairly routine tasks • Supervision is more readily available

27. Continuity of Care VR/Academic Counselor Physician Client/ Student Neuropsychologist Job Coach Cognitive Rehabilitation Specialist

28. Continuity of Care • Successful vocational and academic re-entry depends on ongoing: • Vocational/Academic counseling & case management; • Management of medical issues; • Neuropsychological support; • Cognitive rehabilitation; • Job coaching

29. Continuity of Care • Vocational/Academic counseling & case management • Referrals for appropriate services; • Monitoring successful implementation of the program; • Providing support and guidance; • Consulting with team members regarding overall progress toward goals

30. Continuity of Care • Management of medical issues • Monitoring ongoing recovery; • Monitoring medication use/effects; • Assessing physical functioning; • Prescribing further medical/rehabilitative services; • Consulting with team members regarding medical status

31. Continuity of Care • Neuropsychological support • Improving coping with change/stress; • Monitoring health behaviors; • Consulting with team members regarding neuropsychological functioning; • Advocating for client’s needs

32. Continuity of Care • Cognitive rehabilitation • Monitoring use of compensatory strategies; • Adapting strategies to changing needs; • Consulting with team members regarding cognitive functioning

33. Continuity of Care • Job coaching • Applying learned strategies; • Assisting in development of new strategies; • Immediate reinforcement/re-direction of behaviors; • Consulting with team members regarding vocational issues

34. Continuity of Care • Ongoing care might be needed • Placement and doing well at a job or academic setting may not be the end! • Job loss or change (corporate takeovers, downsizing) can lead to the need to revise the school/work plan – including bringing the team back together to revise or adjust goals, strategies, accommodations, job search

35. Workplace/Academic Supports • Accommodations may be necessary for the client to perform work tasks more efficiently: • Modified work schedule • Modified work environment • Adaptive equipment • Job restructuring • Use of compensatory strategies

36. Intervention with college students (504 plan or equivalent): • When student has already had a Traumatic Brain Injury (post acute phase of recovery): • Reduced course load (2-3 courses per semester vs. 4) • Extra time on exams • Quiet testing locations • Note taking assistance in classes • Tutoring services • Academic coaching

37. Intervention with college students (504 plan or equivalent): • Development of interventions for newly injured students can be a big challenge: • Implications-for current semester- of medical directions to stop use of PCs, other tech to reduce effects of light/noise disturbances • Evolution of evaluation and support when some clinical guidelines suggest reduced activity during acute period • Cannot perform Neuropsychological testing too early in recovery process

38. Resources for education & vocational team members • BIANJ’s series of publications about brain injuries, specifically written for vocational rehabilitation professionals, job coaches and others • Download at BIANJ’s website: • http://bianj.org/special-education-and-college • http://bianj.org/vocational-rehabilitation-and-work • http://bianj.org/vocational-resources

39. Case Examples 1) “Dan” 2) “LeAnne”

40. Thanks & Acknowledgement • For taking the time to speak with us about their observations in working with persons w/Traumatic Brain Injury to return to work or school:

41. Thanks to: • Janice Fishbein, MA, CRC, Manager, Middlesex County & Somerset/Hunterdon Counties offices of Division of Vocational Rehabilitation Services • Kathy Loder-Murphy, MA, CBIS, CRC, Coordinator, Rutgers University Office of Disability Services, New Brunswick

42. Selected References Centers for Disease Control and Prevention (www.cdc.gov) Kreutzer, J., Marwitz, J., Walker, W., Sander, A, Sherer, M., Bogner, J., Fraser, R., & Bushnik, T. (2003). Moderating factors in return to work and job stability after traumatic brain injury. Journal of Head Trauma Rehabilitation, 18, 2, 128-138. Long, C.J. & Ross, L.K. (Eds.). (1992). Handbook of head trauma. New York: Plenum.

43. Selected References Walker, W.C., Marwitz, J., Kreutzer, J.S., Hart T., Novack, T.A. (2006). Occupational categories and return to work after traumatic brain injury: A multicenter study. Archives of Physical Medicine and Rehabilitation, 87, 12, 1576-1582 Zasler, N.D., Katz, D.L. & Zafonte, R.D. (Eds.) (2013) Brain injury medicine: Principles and practice, 2nd ed. New York: Demos Medical Publishing.