What’s Different about Transition for Students with TBI? Bonnie Todis, Ph.D. Center on Brain Injury Research & Training

What’s Different about Transition

forStudents with

TBI?Bonnie Todis, Ph.D.Center on Brain Injury Research & Training

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Objective:

Increase your awareness of Cognitive/Behavioral Identity Family issues

Demonstrate how and why these issues impact transition

Tell you about resources to improve transition outcomes

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Four Case Studies

Mike

Jed

Bethany

Jared

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Mike

Injury Abuse in infancy

Family Adopted by a single mom as a toddler

School experience

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Mike’s School Experience

Because he presents well and isn’t a behavior problem, everybody thought I was nuts when I asked for so much support. But then at the very end of the year, a teacher would call me, furious because Mike “belonged in a special class.”

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Every year I would tell staff this. They’d say, “Ok, ok.” And then mid-year, “Your kid’s got problems!”Then they would spend the last half of the year trying to get something in place, when he’s already missed the first half.

Mike’s mom

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Mike’s Transition Experience

He’s in one of the best life skills programs in the state. I mean, they have everything. But he’s been in it for 4 years now, and every year they have to redo bus training, and he’s still not safe on the bus independently. He’s got a job at a grocery store for work experience, and he loves it, but there’s no indication the store will hire him for real when he’s 22.

Mike’s mom

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Mike’s Transition Experience

He got a job stocking shelves at a market. His boss did not respond when he asked for more hours, nor, a couple of years later, when he asked for a promotion to a more interesting job.

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Jed

Injury: fell out of a tree, age 5

Family: 4 adopted kids w/ special needs and one biological brother

School Experience

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Jed’s School Experience

I felt like he might slip through the cracks because he was so nice, so quiet, and he still to this day will not ask for help. So I pretty much would go to advocate for him.

Jed’s mom

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He still struggles with reading. He’s probably at a 4th grade level. Math is better, but not if there’s a reading component. I don’t think he really learned anything at school after third or fourth grade.

Jed’s mom

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I graduated with a B average. I can’t really read and write, though.

Jed

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Jed’s Transition Experience

Voc Rehab provided tuition, tools and transportation for a community college training program in auto repair.

Unable to get a job in auto repair because he works too slowly.

Employed at Les Schwab.

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Jed’s Transition Experience

Full time job. Wife and young child.

He has done very very well. He still needs some assistance with things like income tax. His wife now does a lot of stuff that we were doing.

Jed’s Mom

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Bethany

Injury: Pedestrian vs. MVs, age 13

Family

School Experience

Transition Experience

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Bethany’s Transition

She can’t handle an academic schedule, so Life Skills is probably the best option for her. But in my Life Skills classes, she’s really nothing like the other kids. She’s kind of the shining star. Whenever I need a spokesperson or a model for the other kids, I turn to Bethany. So Life Skills isn’t a perfect fit, either.

Life Skills teacher

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“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!”

Bethany, injured age 13

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Several job opportunities were identified for Bethany in a nearby town where she could live in an apartment with a classmate. But her mom wanted Bethany to live at home. “I almost lost her once. I’m not letting her out of my sight. Besides, she’s very vulnerable…”

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No paying jobs were available for Bethany in her hometown, so she volunteered at a nursing home, folding napkins and helping set up for dinner. But an employee complained that Bethany was occupying a position someone could get paid for, so Bethany had to quit.

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Jared

Injury: MVA, age 16

Family

School experience

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Jared’s School Experience

Jared’s mom worked at the high school, and some teachers were very anxious to help Jared finish his credits and graduate. In fact, in most classes, he got As and Bs even though he was absent a lot and couldn’t finish tests. His mom tried to get these teachers to treat him more like a regular student, but with accommodations.

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One teacher refused to cut Jared any slack. He refused to let Jared have extra time on tests or assignments and wouldn’t allow him to use notes. Jared crammed for tests for days and managed to get Bs, which “proved” to the teacher that Jared didn’t need accommodations.

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I can think perfectly clear. I can analyze things fine, I just can’t remember it later. It’s not that the memory disappears, I just can’t retrieve it. Tomorrow I won’t recall what I did today, but if you call and say, “We talked about this,” then I’d go, “Oh, that’s right!”

Jared

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Jared’s Transition Experience

Jared had planned to go to a 4-year college like his brothers and sisters, but agreed to try community college and live at home. He registered for a full load, but ended up dropping all but one class. He had trouble finding his way around campus. “I lost my phone, my lap top and my GPS all in one week.”

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At this rate, it will take me about 10 years to get my AA degree. And I don’t even know if I’ll be able to perform whatever job I end up 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 something.

Jared

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I think his emotional maturity was stunted by the TBI. In order to mature, you have to have experiences, and since he doesn’t remember his experiences, it’s very difficult for him to mature. His old friends now treat him like a younger brother.

Jared’s mom

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The hardest part for me that just breaks my heart is, are we enabling him [by letting him live with us]? But at the same time, if I put him out there and he really isn’t capable, am I throwing him to the wolves?”

Jared’s mom

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What do these students have in common?

Childhood TBI that affected their learning and development

Schools that struggle to provide the right services for them

[Mostly] disappointing transition outcomes

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What are some differences between these students?

Age at injury Age when they entered special ed Expectations for transition

TRANSITION OUTCOMES

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Post-Secondary Employment Outcomes 19-25

Age in Years0

10

20

30

40

50

60

70

19 20 21 22 23 24 25

Perc

en

t Em

plo

yed

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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

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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

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Factors That Impact Employment

1.00

2.00

3.00

4.00

5.00

Ty

pe

of

wo

rk c

ate

go

ry h

igh

=p

rofe

ss

ion

al

Work category by time sex age at injury

0 1.00 2.00 3.00 4.00

TIME

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

Later age)

Earlier age

Later age

Earlier age

Avg age

Avg age

Males

Females

Work Category by Sex and Age at Injury Over Time

Skilled manual labor

Clerical, sales

Semi-skilled

Unskilled work

Menial service

Job Category by Sex and Age at Injury

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5.94

7.20

8.46

9.72

10.98

Wa

ge

s

Wages over time by age at injury and severity

1.00 3.50 6.00 8.50 11.00

Time

AGEINJ3 = -5.985,SEVERE = 0


AGEINJ3 = 5.119,SEVERE = 0



Early injury

Later injury

Wages Over Time by Age at Injury and Severity

Later injury

Severe

Mild/Moderate

Early injury

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0.00 1.001.72

2.32

2.91

3.50

4.09

SEVERE

Q2

A9

A1

hours worked per week

SEX = 0,AGEINJ3 = -5.985

SEX = 0,AGEINJ3 = 2.560

SEX = 0,AGEINJ3 = 5.119

SEX = 1,AGEINJ3 = -5.985

SEX = 1,AGEINJ3 = 2.560

SEX = 1,AGEINJ3 = 5.119


Severity

Hours Worked per WeekIn

jure

d ea

rlier

late

r

Severity: M/M work > # Hrs.

Gender: Males> #hrs.

For both genders: Earlier age at injury = work fewer hours/week

Females

Males

Females

Males

Inju

red

earli

erla

ter

SevereMild/Mod

21 – 30hr

11-15hr

Hou

rs P

er W

eek

16-20hr

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-8.00 -6.00 -4.00 -2.00 02.80

2.98

3.17

3.35

3.54

time

ho

w h

ap

py

are

yo

u








Later age

Later age

Early age

Avg age

Early age

Severe

Mild/Moderate

Job Happiness by Severity and Age at Injury

Avg age

Happy

Very Happy

Unhappy

POST SECONDARY EDUCATION

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Post-Secondary Education Outcomes Ages 19-25

Nondisabled

PSO Sample

0

20

40

60

Chart Title

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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.

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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

COMMUNITY INTEGRATION

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Independent Living Outcomes Ages 19-25

Bo

nn

ie To

dis, P

h.D

.C

en

ter o

n B

rain

Inju

ry Re

sea

rch a

nd

T

rain

ingAge

19(n = 54)

20(n = 74)

21(n = 85)

22(n = 86)

23(n = 84)

24(n = 75)

25(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)

n (%)

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Age in Years0

10

20

30

40

50

60

19 20 21 22 23 24 25

Perc

en

t En

rolled

Post-SecondaryIndependent Living OutcomesAges 19-25

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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.

AGE AT INJURYIDENTITYFAMILY

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How does age at injury affect transition outcomes?

Developmental Lag

Cognitive Impairment

Previous learning returns, new learning is more difficult

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Growing Up

Per

form

ance

Normal Development

Development Without TBI

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Development after Brain Injury

Developmental lag

Growing Up

Per

form

ance

Brain Injury

Normal Development

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Case Studies

Mike: Injured in infancy More generalized cognitive impairment Little prior learning to recover

Jed: Injured age 5 No prior academic learning to recover Poor learning of new material, esp. verbal Uses compensatory strategies

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Bethany: Injured age 13 Recovered prior learning New learning and language impaired Awareness of deficits, memory of prior life

Jared: Injured age 16 Good prior learning Uses accommodations for memory Poor social development

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What else is different: cognitive

Impairments can be both specific and general. Specific: language impaired but not math General: overall organizational impairment

Swiss cheese phenomenon Good days/bad days Got it one day, not the next

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What else is different?

Other kids out-grow (develop out of) organizational and social deficits. Students with TBI need interventions. “All 7th grade boys…..”

Social deficits maybe organically (not just developmentally) based Can still be remediated May need specific supports in class, on job

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What else is different?: Family

Your 12th grade student (and his parents) may be new to special ed and transition.

It is likely that your student almost died. It is likely your student made a

miraculous recovery. It is likely the family expects that

recovery to continue.

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What else is different?: Family

They may expect special ed to produce full recovery.

Family may be affected by recurring grief and guilt.

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What else is different?: Identity

Student may avoid subjects he is still good at, because he’s not as good as he used to be.

Still feels like the same kid, people treat him differently. (Lack of awareness of deficits)

Has changed significantly, people have same expectations. (Lack of awareness of TBI)

PROMISING TRANSITIONPRACTICES

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Promising Practices

From young adults with TBI and families From transition research From TBI Team members

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Strategies

Community College vs. 4-year college Modify timeline Access supports Reframe challenges as opportunities Live the life you have now

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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.”

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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.”

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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.”

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Strategies: Work-arounds

Jed’s phone message strategy Assistive technology Tape recorder Family support Peer support

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Evidence-Based Practices

Student-Focused Planning Student Development (life skills, career

and vocational curricula, self-advocacy) Interagency Collaboration Family Involvement (advocacy training

and counselors) Program Structure (program policy and

evaluation) www.NSTTAC.org

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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

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Modifying E-B Practices

E-B Practice TBI Challenge Modifications

Family Involvement

Pursuing preinjury planParent/student grieving/unawareStudent changing rapidly

Assess skills/share infoResearch on TBI outcomesAdjust activities to changing goals/plansProvide hope—what leads to good outcomes?

Student-centered planning

Lack of awarenessParents not ready to let go given recent dependenceMemory impairmentsExecutive function/planning Big One-shot meetings are over-whelming

On-going conversation to adjust plans to awareness, changesUse PCP to teach planning, making decisions, realistic expectationsMotivational Inter-viewing

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Modifying E-B Practices

E-B Practice TBI Challenge Modification

Self-Advocacy Student may not appear to have challengesStudent may need help one day, not nextMay have language deficits, impulsivity, impaired judgment that affect communication May confabulateLack of public awareness

Provide frequent practice opportunities in many situationsTrain employers and co-workers re: TBIUse “How Am I Doing? ToolCarry self-advocacy script

Learning in Context

Problems with generalizationImpaired judgmentInitiation /impulsivityMemory/attn/organization

Environmental and behavioral supportsTrain co-workersInclude self-evaluation

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Reflect on abilities, gain self awareness, self determination and self advocacy while evaluating their steps toward personal goals.

Helps students who have memory challenges recall goals and the steps they need to perform.

Explicit Plans Help:

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Explicit Plans Help:

Makes planning for the future more tangible and understandable.

Highlights connection between actions and the outcome of those actions. (If you don’t go to practice you cannot swim on the team and are less likely to get the swimming scholarship or a spot on the Olympic Swim Team).

Use of visual supports to enhances new learning and cognitive flexibilty35.

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Sam

Injury: Assault, age 15

Family

School Experience


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Sam’s Transition Experience

Sam’s dream was to be a video technician, but after visiting a video shoot with his mom he realized he couldn’t handle the job, physically. “I watched him just quietly put that dream away.”

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VR arranged for him to attend an optician training program.Students housed together in a dorm on one corner of a larger campus.

“It was college, but it was manageable.”

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Sam set a series of employment goals and as he achieved them, he set new goals.Get a job as an optician.Work in a cooler shop.Work in the coolest shop in Seattle.Go to 4-year college with girlfriend.Take courses at community college to prepare……

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Al

Injury: MVA, TBI + anoxia, 15 mo.

Family

School experience


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Al’s Transition Experience

Throughout high school he worked for a neighbor, cleaning her stable. Toward the end of his transition program, the family proposed setting up a small business.

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VR helped with the cost of setting up the business. Bought a small tractor and trailer and a trailer for transporting both. Al’s father takes Al and his equipment to neighbor’s farms where he does routine barn/stable cleaning.

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Al lives in a trailer on his parent’s property.

He enjoys rock polishing, swimming, bowling and camping.

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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.

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Contact me

Bonnie Todis, PhDCenter on Brain Injury Research and

TrainingTeaching Research InstituteWestern Oregon [email protected]

Documents

What’s Different about Transition for Students with TBI? Bonnie Todis, Ph.D. Center on Brain Injury Research & Training