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
 Community integration outcomes



Qualitative Findings
Educational Interventions
cbirt.org
Typical Youth Transition
Childhood
Adulthood
School
Activities
Relationships
Quality of Life
Adult Identity
Employment
Independence
Relationships
Quality of Life
TRANSITION
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Youth Transition Goals
Childhood
School
Activities
Relationships
Quality of Life
ALTERED
Development
Sustains
TBI
Return to
previous or optimal childhood
Adulthood
Adult Identity
Employment
Independence
Relationships
Quality of Life
cbirt.org
Impact of TBI in Adulthood
Road through Adulthood
Employment
Independence
Relationships
Quality of Life
Sustains
TBI
Return to
previous or
optimal or
acceptable lifestyle
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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
cbirt.org
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

cbirt.org
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

cbirt.org
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
cbirt.org
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?
cbirt.org
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

cbirt.org
POST-SECONDARY
OUTCOMES
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

cbirt.org
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: 019)
2/3 male
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Project PSO
Purpose:
 Systematic tracking of quantitative data
on transition outcomes
Methodology:
 In-person/phone interviews with young
adult, parent
 6-12-month intervals
cbirt.org
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
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RESULTS
Life Transition Planning
48%
50%
2%
No
Yes
Don't know
At initial interview
cbirt.org
Written Transition Plan
2%
37%
61%
Yes
Bonnie Todis, Ph.D.
Center on Brain Injury Research and Training
No
Don't know
.
cbirt org
At initial interview
Person Who Helped Plan Transition
Family member
School Staff
Community Trans Program
Voc. Rehab
Other
Don't know
0
5
10
15
Count
20
25
cbirt.org
At initial interview
TRANSITION
OUTCOMES
Two level longitudinal growth model:
Measurement occasion nested within
participant
Level 1: Repeated measurement occasions
γij = β0j + β1j timeij + eij
Level 2 : Participants
β 0j = γ00+ γ00Xj + δ0j
Level 1 = Outcomes at
times 1 – t
Level 2 = participant
characteristics
β1j = γ10+ γ11Xj + δ1j
β 0j = intercept of group j
β 1j = 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.)
cbirt org
.
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
cbirt.org
Employment Outcomes Ages 19-25
19
20
21
22
23
24
25
(n = 54)
(n = 74)
(n = 85)
(n = 86)
(n = 84)
(n = 75)
(n = 55)
Employment
20 (37)
36 (49)
44 (52)
42 (49)
37 (44)
35 (47)
33 (60)
Male
17 (46)
23 (49)
34 (60)
34 (59)
29 (52)
26 (54)
26 (74)
Female
3 (18)
13 (48)
10 (36)
8 (29)
8 (29)
9 (33)
7 (35)
<20 hrs/week
11 (55)
18 (53)
13 (32)
14 (35)
11 (31)
10 (30)
9 (29)
≥20 hrs/week
9 (45)
16 (47)
28 (68)
26 (65)
25 (69)
23 (70)
22 (71)
Age
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Post-Secondary Employment
Outcomes 19-25
Percent Employed
70
60
50
40
30
20
10
0
19
20
Age in Years
21
22
23
24
25
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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

cbirt.org
Employment Outcomes by
Gender
80
70
60
50
Males
40
Females
30
20
10
0
19
20
21
22
23
24
25
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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

cbirt.org
Comparison with Typical Peers
EMPLOYMENT
RATE
PSO
Sample
WAGES
PER WEEK
HOURS
PER
WEEK
$161-232
60%
(male)
$124-418
TYPE OF JOB
25.5 hrs
57%
0%
menial/unskilled
management/pro
35.8 hrs
36%
19%
menial/unskilled
management/pro
(female)
Typical
Young
Adults
68%
$485 (male)
$418 (female)
• Bureau of Labor Statistics of the U.S. Department of Labor, January 19, 2007
cbirt.org
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.

cbirt.org
Factors That Impact Employment
Work category
by
time
sex
age
at Over
injuryTime
Work
Category
Sexand
and
Age
Injury
Job Category
bybySex
Age
atatInjury
Type of work category high=professional
Clerical, sales
5.00
SEX = 0,AGEINJ3 = -5.985
SEX = 0,AGEINJ3 = 2.897
SEX = 0,AGEINJ3 = 5.119
SEX = 1,AGEINJ3 = -5.985
SEX = 1,AGEINJ3 = 2.897
SEX = 1,AGEINJ3 = 5.119
Skilled
4.00
manual labor
Later age)
Avg age
Earlier age
Semi-skilled3.00
Later age
Avg age
2.00
Unskilled work
Menial
service
Females
1.00
Males
Earlier age
0
1.00
Bonnie Todis, Ph.D.
Center on Brain Injury Research and Training
2.00
TIME
3.00
4.00
cbirt.org
Factors That Impact
Employment
Wages
er time
atat
injInjury
ury and
sev
erity
Wagesov
Over
Timebybyage
Age
and
Severity
Later injury
10.98
AGEINJ3 = -5.985,SEVERE = 0
AGEINJ3 = -5.985,SEVERE = 1
AGEINJ3 = 5.119,SEVERE = 0
Mild/Moderate
AGEINJ3 = 5.119,SEVERE = 1
9.72
Wages
Early injury
Later injury
Severe
8.46
Early injury
7.20
5.94
1.00
3.50
6.00
8.50
11.00
Time
Bonnie Todis, Ph.D.
Center on Brain Injury Research and Training
cbirt.org
Factors That Impact Employment
Hours Worked per Week
Severity: M/M work > # Hrs.
Gender: Males> #hrs.
21 – 30hr
Hours Per Week
For both genders: Earlier age at injury
= work fewer hours/week
16-20hr
Males
Males
Females
11-15hr
Females
Mild/Mod
Bonnie Todis, Ph.D.
Center on Brain Injury Research and Training
Severity
Severe
cbirt.org
Factors That Impact Employment
Job Happiness by Severity and Age at Injury
3.54
how happy are you
Very3.35
Happy
Early age
Avg age
3.17
AGEINJ3
AGEINJ3
AGEINJ3
AGEINJ3
AGEINJ3
AGEINJ3
=
=
=
=
=
=
-4.211,SEVERE = 0
-4.211,SEVERE = 1
2.575,SEVERE = 0
2.575,SEVERE = 1
4.296,SEVERE = 0
4.296,SEVERE = 1
Severe
Later age
Early age
Happy
2.98
2.80
-8.00
Unhappy
-6.00
-4.00
time
-2.00
Avg age
Later
0 age
Mild/
Moderate
cbirt.org
POST
SECONDARY
EDUCATION
Post-Secondary
Education Outcomes
Ages 19-25
Age
19
20
21
22
23
24
25
(n = 54) (n = 74) (n = 85) (n = 86) (n = 84) (n = 75) (n = 55)
Education
15 (28)
26 (35)
34 (40)
22 (26)
26 (31)
18 (24)
14 (25)
Male
7 (19)
17 (36)
20 (35)
11 (19)
15 (27)
7 (15)
6 (17)
Female
8 (47)
9 (33)
14 (50)
11 (39)
11 (39)
11 (41)
8 (40)
n (%)
cbirt.org
Post-Secondary Education Outcomes
Ages 19-25
Comparison with typical young adults ages
18-25 (Pew Research Center, 2007)
60
40
20
0
Nondisabled
PSO Sample
cbirt.org
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
cbirt.org
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.
cbirt.org
Independent Living Outcomes
Ages 19-25
20
21
22
23
24
25
(n =
54)
(n =
74)
(n =
85)
(n =
86)
(n =
84)
(n =
75)
(n =
55)
Independent
Living
12
(23)
26 (36)
28 (35)
37 (44)
35 (41)
37 (49)
29 (53)
Male
7 (20)
13 (28)
18 (33)
22 (39)
22 (39)
24 (49)
20 (57)
Female
5 (29)
13 (48)
10 (37)
15 (54)
13 (45)
13 (48)
9 (45)
Bonnie Todis, Ph.D.
Center on Brain Injury Research and
Training
Age
19
n (%)
cbirt.org
Post-Secondary
Independent Living Outcomes
Ages 19-25
Percent Enrolled
60
50
40
30
20
10
0
19
20
Age in Years
21
22
23
24
25
cbirt.org
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).
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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.
cbirt.org
Qualitative
Component
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
cbirt.org
Qualitative Methodology
Methodology:
 Unstructured recursive interviews
 Participant observations with young
adult
 Interviews with knowledgeable others
1-to-6-month intervals
cbirt.org
Qualitative
Findings
Thematic Categories




High School Experiences
Employment
Post-Secondary Education
Community Integration
cbirt.org
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

cbirt.org
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
cbirt.org
Not identified for SpEd

No transition services
No IEP
 Graduated



No access to disability services postgraduation
Usually tried to follow pre-injury plan
cbirt.org
Receiving SpEd Services

Students identified for special education:
Not identified TBI
 Two-track system
 Rarely received good transition services

cbirt.org
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
cbirt.org
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
cbirt.org
What kids need
NTLS2: Needs Life Skills
%
cbirt.org
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
cbirt.org
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
cbirt.org
POST
SECONDARY
EDUCATION
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
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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.”
~Jack
cbirt.org
Strategies and Supports



Some participants modified their plans
Some developed effective strategies
Some accessed effective supports
cbirt.org
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
cbirt.org
Employment
Employment Themes

Got job through
Life Skills
 Family connections



Infrequent promotion
Frequent job changes/unemployment
Uneven performance
 Inappropriate behavior
 Impulsivity/poor judgment

cbirt.org
Employment Successes

Al: stable cleaning business

Jed: tire store

Jay: team trainer
cbirt.org
Critical Features of Success




Parent advocacy
Life skills training (work experience,
social skills, money management)
Communication, training for employer
On-going family support
cbirt.org
Community
Integration
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
cbirt.org
Critical Features of Success




Family nearby
Spouse
Living with family
Supported living
cbirt.org
Promising
Transition
Practices
Promising Practices


From young adults with TBI and families
From transition research
cbirt.org
Strategies





Community College vs. 4-year college
Modify timeline
Access supports
Reframe challenges as opportunities
Live the life you have now
cbirt.org
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.”
cbirt.org
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.”
cbirt.org
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.”
cbirt.org
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)
www.NSTTAC.org
cbirt.org
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
cbirt.org
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
cbirt.org
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

cbirt.org
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.
cbirt.org