PROJECT CAREER: USING
TECHNOLOGY TO HELP STUDENTS
WITH TBI TRANSITION FROM
COLLEGE TO EMPLOYMENT
Eileen Elias, MEd
APHA – HIIT Section
PROJECT CAREER
United States Department of Education
Office of Special Education and Rehabilitation Services
National Institute on Disability and Rehabilitation Research (NIDRR)
#H133A130066
Eileen Elias, MEd
Marcia Scherer, PhD , MPH , FACRM
Anne Leopold, MSc
Philip Rumrill, Jr., PhD, CRC
Karen Jacobs, EdD, OTR/L, CPE, FAOTA,
Deborah Hendricks, EdD,
Elaine Sampson, MS, CRC
Amanda Nardone, BS,
Callista Stauffer, MEd
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Learning Objectives
• Describe barriers individuals with TBI face in academic
and work settings due to cognitive impairments.
• Identify how assistive technology can help compensate
for cognitive impairments.
• Explain the Matching Person and Technology Model
for effectively matching students with TBI to technology
(e.g., Apps).
• Evaluation of Project Career activities and identify
those that can help support students with TBI transition
from postsecondary academic settings to employment.
• Identify best practices and future research for
improving effective delivery of vocational rehabilitation
services for students with TBI.
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What is Traumatic Brain Injury
(TBI)?
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TBI
• TBI is a serious public health problem in the US
• ~ 1.7 millions Americans sustain a TBI annually
Deaths
52,000
Hospitalizations
275,000
ED Visits
1,370,000
???
Other/No Care
0
500,000
1,000,000
• 313,816 medical diagnoses of TBI in U.S. forces
Faul M, Xu L, Wald MM, Coronado VG. Traumatic Brain Injury in the United States: Emergency Department Visits,
Hospitalizations and Deaths 2002 – 2006. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury
Prevention and Control; 2010
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TBI cont’d
• Umbrella term that spans a wide continuum of
symptoms and severity
– Mild, moderate, severe
• Can result from falls, traffic accidents,
assaults, blasts/explosions, sports, etc.
• Leading cause of death and lifelong
cognitive disability among Americans under
the age of 45
Ashman, T.A., Gordon, W.A., Cantor, J.B., & Hibbard, M.R. (2005). Neurobehavioral consequences of traumatic brain injury. Mt
Sinai Journal of Medicine, 73(7), 999-1005.
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TBI cont’d
• Most individuals with TBI make a full
recovery—some quickly and others over
weeks, months or years
– Even mild TBI can have long-lasting
cognitive effects that impair the ability to
work and engage in usual activities
– Some 15 percent of those with mild TBI
experience long-term functional deficits
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TBI may result in …
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TBI Symptoms
• No two brains are alike
• No two brain injuries are alike
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Betty is a 21-year-old white female who acquired
a TBI during a motor vehicle accident when she
was 16. She was unconscious immediately
following the accident and was intubated for 5
days post trauma. She was sedated during her
intubation and for a total of 19 days because of
brain swelling. After sedation, her coherence and
cooperation gradually improved. She did, at this
point, develop increased agitation and
combativeness. Although the initial agitation and
combativeness decreased, she still deals with
anger management issues. She also reports
cognitive deficits and time management
difficulties. She is hesitant to use technology as it
leaves her frustrated and confused.
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Julie, a 22-year-old white female, was celebrating
and cheering on runners on April 15, 2013 when
she acquired her TBI from the Boston Marathon
terrorist attack bombings. She was only feet away
from the second bomb and was knocked
unconscious from the explosion. Since her injury
she had been experiencing forgetfulness, issues
with reading comprehension, difficulty
understanding what others are saying, trouble with
concentration, and anxiety.
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Recovery from TBI
Recovery is heterogeneous
• Service needs vary across individuals and
change throughout time
• Recovery to pre-injury levels range from
65% in the area of personal care to 40% in
cognitive domains
• Initial focus on physical and medical needs
• Limitation in communication, cognitive,
and emotional domains often remain
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Recovery from TBI cont’d
Recovery may be long-term
• Often continue to exhibit residual
cognitive and interpersonal deficits
• Regular and continuous services & support
are essential
• Environmental factors can
present barriers
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What remains …
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Outcomes for Individuals with TBI
• Devastating impact on the individual, family, and
society
– Limitation in communication, cognitive, and
emotional domains often remain
– Disparities in academic & employment outcomes
– Lower grades and higher dropout rates
– Difficulty attainting and keeping employment


62% employed at time of injury; 31% employed
2 years after injury
75% lose their jobs within 90 days if do not
have adequate supports
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Outcomes for Students with TBI
• College students with TBI face numerous
academic challenges due to cognitive and
psychosocial problems
– Creates transition challenges from college to
work
• 80% of students with TBI report problems
performing in their academic settings
– But less than half report using campus
disability services and only 20% report being
aware of community support services
• Veterans with TBI attending colleges/universities
are even less likely than civilians to request
classroom accommodations
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What can we do
Identifying the problem and
applying what we know – best
practices …
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Identifying the Problem
• Two of the most prominent barriers reported by
college students with TBI are (a) limited access to
supports to help them overcome cognitive and
academic limitations and (b) lack of career-related
services to prepare them for the world of work
after graduation
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Best Practices from Vocational
Rehabilitation
•
•
•
•
Case Management
Individualized plan for employment
Vocational goals and services to achieve goal
Comprehensive services, including: information and
referral, assessments, counseling and guidance,
physical restoration, vocational training or other postsecondary education, job search, job placement and
job coaching, supported employment.
• Develop relationships with employers
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Best Practices from the Assistive
Technology Field
• Assistive technology (AT)
– Generally defined internationally as: any item,
piece of equipment or product systems, whether
acquired commercially, off the shelf, modified or
customized, that is used to increase, maintain or
improve functional capabilities of individuals with
disabilities.
• Cognitive Support Technologies (CTS)
– a class of AT designed to help with cognitive
functioning - memory, attention, concentration,
planning, etc.
Scherer MJ. (2012). Assistive Technologies and Other Supports for People with Brain Impairment. New York: Springer
Publishing Co.
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Assistive Technology
• A formal, legal definition of assistive technology was
first published in the Technology-Related Assistance
for Individuals with Disabilities Act of 1988 (The Tech
Act). This act was amended in 1994; in 1998, it was
repealed and replaced with the Assistive Technology
Act of 1998 ("AT Act"). Throughout, the original
definition of assistive technology remained
consistent.
– “Any item, piece of equipment, or product system,
whether acquired commercially off the shelf, modified,
or customized, that is used to increase, maintain, or
improve functional capabilities of individuals with
disabilities."
• This definition focuses on functional capabilities and
not participation and contribution.
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Cognitive Support Technologies
• Specialized vs Universal
Universal devices are used by individuals with and
without disabilities..
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Assistive Technology Use
Advantages of everyday technologies
 User appears like everyone else, even “cool” (don’t
stigmatize the individual).
 They are becoming less expensive, more advanced, and
easier to use
 Because they are cheaper than specialized technologies,
they make an effective back-up or secondary device.
Disadvantages of everyday technologies
 They most likely will not be paid for by health insurance or
Centers for Medicare & Medicaid Services (CMS). The
rationale is that they are not exclusive to medical needs.
 They are made for the “average user’ and not those with
individual, particular needs.
Scherer MJ. (2012). Assistive Technologies and Other Supports for People with Brain Impairment. New York:
Springer Publishing Co.
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NIDRR – Project Career
Development of an Interprofessional Demonstration
to Support the Transition of Students with TBI from
Postsecondary Education to Employment
Cognitive Support Technologies
Vocational Rehabilitation
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What
 5 Years (2013-2018)
 150 civilian and military students with TBI attending 2and 4-year undergraduate institutions, including:
and institutions in proximity to the three universities
 Continuous quality improvement driven by regular
process and impact evaluation
 Regular Advisory Board Meetings to share lessons
learned and obtain feedback for addressing challenges
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Who
Project Career Team
Philip Rumrill, Jr., PhD, CRC
Project Director, Kent State University
Subject Matter Experts
Callista Stauffer, MEd
Technology and Employment Coordinator,
Kent State University
Marcia Scherer, PhD, MPH, FACRM
Assistive Technology Training
Consultant, University of Rochester
Physical Medicine and Rehabilitation
Eileen Elias, MEd
Assessment and Technology Manager,
JBS International
Joseph Cannelongo, MA, LPC, CRC
Vocational Services Consultant,
Advocare Incorporated
Anne Leopold, MSc
Assessment and Technology Expert,
JBS International
Karen Jacobs, EdD, OTR/L
Site Manager, Boston University
Brian McMahon, PhD, CRC, CCM, NCC
External Evaluator,
Virginia Commonwealth University
Medical Center
Amande Nardone, LCSW
Technology and Employment Coordinator,
Boston University
Advisory Board Members
Deborah Hendricks, EdD
Site Manager, West Virginia University
Allie Murie, Robert Fraser, Marilyn
Spivack, Matthew Turk, Theresa Rankin,
Rick Briggs, Valerie Fletcher, & John
Kemp
Elaine Sampson, MS, CRC
Technology and Employment Coordinator,
West Virginia University
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How
Technology and Employment Coordinator
Comprehensive Assessment and Planning
Matching Person and Technology and Vocational Needs
Cognitive Support Technology
iPad and Apps
Training
and TA for Mentoring
CST use
Internships
Case Management
Individualized Services &
Supports
Accommodations
Seminar/Webinar
Post-Graduation
Support
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Technology is an important
resource, but…
Too often we see device non-use. It
usually arises from…a poor match of
person and technology!
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Difficulties Encountered in Choosing
& Using Technology
• Bewildering array of options/Devices are often
complex
• Fragmented information & service system
• Limited understanding of resources & options
• Decision making is complex & involves
compromises
• Lack of follow-up & training on technology use
• Limited funding
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A successful outcome begins early with choosing
the most appropriate technology for a person.
How can we best do that?
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Address Personal Factors &
Get an Evaluation
All but the simplest
technology requires an
evaluation early in the
process of selecting
interventions and devices
Photo Source: Fort Hood Sentinel
Matching Person and Technology
(MPT) Model
Environmental Factors
•
•
•
•
Availability of Products
Affordability of Products
Availability of appropriate professionals
Opportunities and services
•
•
•
•
Social and Economic Priorities
Legislation & Laws
Attitudes of Family/Friends & Key Others
Support from Family/Friends & Key Others
Support DecisionMaking & Selection
Personal Factors
Assessment of
Functional Need
Experiences with
Technologies
Provider
Objective Need
Knowledge and
Information
Expectations of
Benefit
Personal
Preferences and
Priorities
Device
Comparison &
Trial use
• Device ratings
• Desired device
Person with
Disability
modifications
Assessment of
Predisposition
Subjective Need, incl.
• Training
needs/desires
• Written plan
• Task worthiness
• AT use worthiness
Adapted from Scherer, M., Jutai, J., Fuhrer, M., Demers, L. & DeRuyter, F. (2007). A framework for modeling the
selection of assistive technology devices (ATDs). Disability and Rehabilitation: Assistive Technology, 2(1), 1-8.
Follow-Up
 Use
 Realization of
benefit
 Enhanced
performance of
activities
 Enhanced
participation
 Subjective wellbeing
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MPT Assessment Process
Person
Milieu
MPT
Model
Tech
Apps as CSTs
Attention/Memory
• AudioNote
• Notability
• Voice Dream Reader
Planning/Organization
• Planner Plus
• iThoughts
• 30/30
• Week Calendar
Reminders
• Due
• Alarmed
Emotion/Stress
• Calm
• Breath2Relax
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Outcomes After 2 Years
• 62 Participants
– 8 dropped out
– 6 graduated and are still receiving services
• Age range: 18-52 (Mean=27)
• Military: 26%
Gender
Male (59.7%)
Female (40.3%)
Race/Ethnicity
Caucasian/White (87.1%)
African American/Black (6.5%)
Hispanic/Latino (8.1%)
American Indian/Alaska Native (3.2%)
Other (3.6%)
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Outcomes continued
• Full time students: 68%
Year
Freshman (32.3%)
Sophomore (19.4%)
Junior (14.5%)
Senior (25.8%)
Other (8.1%)
• Year TBI incurred: 1981 – 2015
Cause of TBI
Motor Vehicle Accident (40.3%)
Combat/IED (17.7%)
Sports (14.5%)
Fall (12.9%)
Assault/Gun Shot (6.5%)
Other (8.1%)
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Outcomes continued
• Type of Medical Insurance
– Private: 46.8%
– Medicaid: 27.4%
– Veteran Insurance: 22.6%
– Medicare: 12.9%
– Student Insurance through college/university: 6.5%
• Support systems used by participant
– Family: 83.9%
– Friends: 61.3%
– Significant Other: 35.5%
– Support Group: 29%
– Co-Worker: 22.6%
– Student Association: 17.7%
– Church: 14.5%
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Problem due to TBI
• Cognitive
–
–
–
–
–
–
–
–
–
–
–
–
–
Forgetful/Poor memory – short-term and long-term
Difficulty concentrating, focusing
Impaired organization
Delayed thinking, processing
Short attention span
Impaired decision-making
Difficulty with comprehension or speaking
Difficulty with reading or writing
Difficulty with time management
Overwhelmed with too much information
Impaired reasoning
Impaired social skills
Exacerbated ADHD symptoms
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Problem due to TBI continued
• Emotional
– PTSD
– Depression
– Frustration
– Anxiety
– Agitation/Irritability
– Impulsivity
– Disinhibition
– Lack of motivation
– Lack of confidence
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Problem due to TBI continued
• Physical
– Decreased sensation, paralysis, difficulty with gait,
tremors
– Unable to stand for long periods of time, weakness
in legs
– Fatigue
– Vision problems, blindness
– Sensitive to noise or light
– Speech problems, stuttering, slurring
– Partial hearing loss
– Headaches, migraines
– Sleep problems
– Chronic pain
– Auditory and visual hallucinations
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Outcomes continued
• Agency involvement
– Student Disability Services: 75.8%
– Veterans Administration: 22.6%
– Social Security Administration: 24.2%
– Mental Health/Substance Use: 19.4%
– Career Services: 17.7%
• Services participants may be needing
– Training and assistance with assistive technology: 93.5%
– Job development (for internship or job placement): 91.9%
– Obtaining mentor: 91.9%
– Help with resume and cover letter: 91.9%
– Academic counseling: 82.3%
– Part-time/Summer employment assistance: 67.7%
– Assistance in understanding/using university system: 59.7%
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Trends to date…
• Career Decision Self-Efficacy
– On average, scores increased over time, suggesting an
increase in participants’ career decision self-efficacy;
however that increase is not statistically significant.
• Career Barriers
– On average, there is a trend of scores for encountering
barriers to increase over time and scores for barriers
hindering career progress to decrease over time. The
change over time is not statistically significant.
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Trends to date…
• Overall experiences with current technology uses
– There is a significant difference in scores between
baseline and follow up (p=0.003, ƞ2=0.267), indicating
that participants have more positive overall experiences
with technology use over time.
• Perspectives on technology use
– There is a significant difference in scores between
baseline and follow up (p=0.026, ƞ2=0.159), indicating
that participants have more positive perspectives on
technologies over time.
• Personal/social characteristics
– There is a trend in scores decreasing over time
indicating that participants indicate being more positive,
independent, social over time.
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App use
• On a typical day use for about 2.11 hours
• Always, nearly always, or about half the time go out into the
community with particular app = 62%
• App moderately or a lot:
– Improves their quality of life = 49.3%
– Enhances their comfort = 40.8%
– Enhances well-being = 31%
– Helps them get around or go out with others = 15.5%
– Helps perform academically = 71.8%
– Helps take care of personal errands = 39.4%
– Helps them keep in touch with others = 21.3%
– Helps them take care of their health = 19.7%
– Helps them be more active/involved in community = 16.9%
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Reason stopped using App
• My needs changed
• Change in academic program
• Too inconvenient to use
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Remember Betty …
After the first six months, Betty reported great
improvement in her comfort level with technology. She
uses her iPad regularly, including using FaceTime for
meetings. As a result of gaining a better understanding
and acceptance of technology, Betty has been able to
complete her online coursework and graduate from her
degree program. She also reports improvement in her
ability to remember people and events, to manage her
appointments and to pay attention. She is now working
on her job seeking process with the assistance of the
TEC. The TEC will continue to review her use of the
apps will help identify apps to use in the workplace.
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Insight from a participant
“I think the mentoring part of Project Career has been the
most beneficial thing for me. Even though I have work
experience and I've been in the Marines, I really did not
know much about the field of computer science or anyone
currently working in the field. My mentor talked with me on
the phone for over two hours the first time and as a result, I
completely changed the classes I'm taking this summer to
better fit what I actually want to do for a career. If it wasn't
for him, I would have wasted a lot of time on programming
classes that wouldn't have ultimately helped me that much.
I really encourage some of the younger students who may
be more hesitant to work with an experienced mentor. My
mentor has so much experience and has had a lot of
different jobs so I feel like I'm learning a lot from him and
now have a better sense of what I want to do.”
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Future Research
• Benefits of using universal CSTs in work
settings
• Potential of a “clearinghouse” and review
platform for Apps as CSTs and their
effectiveness
• Use of mentors/buddies at the work setting
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Questions & Thoughts
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Contact Information
Eileen Elias
240-645-4534
Cell: 230-380-0431
eelias@jbsinternational.com
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