PROJECT CAREER: USING TECHNOLOGY TO HELP STUDENTS

WITH TBI TRANSITION FROM COLLEGE TO EMPLOYMENT

Eileen Elias, MEd

APHA – HIIT Section

PROJECT CAREER

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Eileen Elias, MEdMarcia Scherer, PhD , MPH , FACRMAnne Leopold, MSc

Philip Rumrill, Jr., PhD, CRC Karen Jacobs, EdD, OTR/L, CPE, FAOTA, Deborah Hendricks, EdD, Elaine Sampson, MS, CRCAmanda Nardone, BS,Callista Stauffer, MEd

United States Department of EducationOffice of Special Education and Rehabilitation ServicesNational Institute on Disability and Rehabilitation Research (NIDRR) #H133A130066

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

Other/No Care

ED Visits

Hospitalizations

Deaths

0 500,000 1,000,000

1,370,000

275,000

52,000

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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• 313,816 medical diagnoses of TBI in U.S. forces

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• 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

TBI cont’d

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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• 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

TBI cont’d

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TBI may result in …

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• No two brains are alike • No two brain injuries are alike

TBI Symptoms

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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 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

Recovery from TBI cont’d

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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

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Identifying the problem and applying what we know – best practices …

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 post-secondary 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. 20

Assistive Technology

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• 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.

Cognitive Support Technologies

• Specialized vs Universal

Universal devices are used by individuals with and without disabilities..

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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. 25

Assistive Technology Use

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 2- and 4-year undergraduate institutions, including:

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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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WhoProject Career Team

Philip Rumrill, Jr., PhD, CRCProject Director, Kent State University

Callista Stauffer, MEdTechnology and Employment Coordinator, Kent State University

Eileen Elias, MEdAssessment and Technology Manager, JBS International

Anne Leopold, MScAssessment and Technology Expert, JBS International

Karen Jacobs, EdD, OTR/LSite Manager, Boston University

Amande Nardone, LCSWTechnology and Employment Coordinator, Boston University

Deborah Hendricks, EdDSite Manager, West Virginia University

Elaine Sampson, MS, CRCTechnology and Employment Coordinator, West Virginia University

Subject Matter ExpertsMarcia Scherer, PhD, MPH, FACRM

Assistive Technology Training

Consultant, University of Rochester

Physical Medicine and Rehabilitation

Joseph Cannelongo, MA, LPC, CRC

Vocational Services Consultant,

Advocare Incorporated

Brian McMahon, PhD, CRC, CCM, NCC

External Evaluator,

Virginia Commonwealth University

Medical Center

Advisory Board MembersAllie Murie, Robert Fraser, Marilyn

Spivack, Matthew Turk, Theresa Rankin,

Rick Briggs, Valerie Fletcher, & John

Kemp

How

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Comprehensive Assessment and Planning

Matching Person and Technology and Vocational Needs

Training and TA for CST use

Mentoring Internships Accommodations Seminar/Webinar

Post-Graduation Support

Cognitive Support Technology

iPad and Apps

Case Management

Individualized Services & Supports

Technology and Employment Coordinator

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?

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

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Experiences with Technologies

Assessment ofFunctional Need

 Objective Need

Knowledge and Information

Expectations ofBenefit

Personal Preferences and

Priorities

Person with Disability

 Assessment of Predisposition

 Subjective Need, incl.

• Task worthiness• AT use worthiness

 

 Follow-Up Use Realization of benefit Enhanced performance of activities Enhanced participation Subjective

well- being

Personal Factors Support Decision-Making & Selection

Device Comparison &

Trial use

• Device ratings

• Desired device

modifications• Training needs/desires• Written plan

Provider

• Social and Economic Priorities• Legislation & Laws• Attitudes of Family/Friends & Key Others• Support from Family/Friends & Key Others

• Availability of Products• Affordability of Products• Availability of appropriate professionals• Opportunities and services

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.

Matching Person and Technology (MPT) Model

Environmental Factors

MPT Assessment Process

MPTModel

Apps as CSTs

Attention/Memory• AudioNote• Notability• Voice Dream Reader

Emotion/Stress• Calm• Breath2Relax

Planning/Organization• Planner Plus• iThoughts• 30/30• Week Calendar

Reminders • Due• Alarmed

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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%

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GenderMale (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%)

Outcomes continued

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Year

Freshman (32.3%)Sophomore (19.4%)Junior (14.5%)Senior (25.8%)Other (8.1%)

• Full time students: 68%

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%)

• Year TBI incurred: 1981 – 2015

Outcomes continued

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• 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%

Problem due to TBI

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• 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

Problem due to TBI continued

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• Emotional– PTSD– Depression– Frustration– Anxiety– Agitation/Irritability– Impulsivity– Disinhibition– Lack of motivation– Lack of confidence

Problem due to TBI continued

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• 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

Outcomes continued

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• 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%

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

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Eileen Elias240-645-4534Cell: 230-380-0431eelias@jbsinternational.com