Brain Injury Professional: Traumatic Brain Injury and Work Re-Entry

BRAIN INJURY professional vol. 17 issue 3

Traumatic Brain Injury and Work Re-entry

BUILDING FUTURES THROUGH BETTER OUTCOMES For over 35 years, Learning Services has been Building Futures by delivering post-acute neurorehabilitation services for people with acquired brain injuries.

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BRAIN INJURY professional

vol. 17 issue 3

departments

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NORTH AMERICAN BRAIN INJURY SOCIETY CHAIRMAN Mariusz Ziejewski, PhD VICE CHAIR Debra Braunling-McMorrow, PhD IMMEDIATE PAST CHAIR Ronald C. Savage, EdD TREASURER Bruce H. Stern, Esq. FAMILY LIAISON Skye MacQueen EXECUTIVE DIRECTOR/ADMINISTRATION Margaret J. Roberts EXECUTIVE DIRECTOR/OPERATIONS J. Charles Haynes, JD MARKETING MANAGER Megan Bell-Johnston GRAPHIC DESIGNER Kristin Odom

Editor in Chief Message Guest Editor’s Message Expert Interview Useful Resources Technology Article

features

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Women with Brain Injury: Past, Present and Future Katherine Price Snedaker, LCSW

Exercise in Concussed Females

John Leddy, MD • Barry Willer, PhD

16

Traumatic Brain Injury Among Female Veterans

18

Brain Injuries We Overlook: TBIs From Intimate-Partner Violence

20

Clarity in Databases to Account for the Global Public Health Epidemic

22

Factors Affecting Recovery Trajectories in Pediatric Female Concussion

24 26

Maheen Mausoof Adamson, PhD • Odette A. Harris, MD, MPH

Eve M. Valera

Jonathan Lifshitz, PhD

Christina L. Master, MD, FAAP, CAQSM, FACSM • Natasha Desai, MD, FACEP, CAQSM

Refocusing Care in Girls with Post-concussion Symptoms

Nick Reed, MScOT, PhD, OT Reg (Ont)

Adolescent Females More Likely to be Diagnosed with an Endocrine Disorder After a TBI J. Bryce Ortiz, PhD

27

Natural Progression of Symptom Change and Recovery from Concussion in a Pediatric Population Andrée-Anne Ledoux, PhD

28

Provider Competencies for Disorders of Consciousness: Minimum Competency Recommendations Proposed by the ACRM-NIDILRR Workgroup Theresa Bender Pape, MA, CCC-SLP, Dr.PH, FACRM Nathan D. Zasler, MD, DABPM&R, FAAPM&R, FACRM, BIM-C, CBIST

Brain Injury Professional is a membership benefit of the North American Brain Injury Society and the International Brain Injury Association

BRAIN INJURY PROFESSIONAL PUBLISHER J. Charles Haynes, JD CO-EDITOR IN CHIEF Beth Slomine, PhD - USA CO-EDITOR IN CHIEF Nathan Zasler, MD - USA ASSOCIATE EDITOR Juan Arango-Lasprilla, PhD – Spain TECHNOLOGY EDITOR Stephen K. Trapp, PhD - USA EDITOR EMERITUS Debra Braunling-McMorrow, PhD - USA EDITOR EMERITUS Ronald C. Savage, EdD - USA DESIGN AND LAYOUT Kristin Odom ADVERTISING SALES Megan Bell-Johnston EDITORIAL ADVISORY BOARD Nada Andelic, MD - Norway Philippe Azouvi, MD, PhD - France Mark Bayley, MD - Canada Lucia Braga, PhD - Brazil Ross Bullock, MD, PhD - USA Fofi Constantinidou, PhD, CCC-SLP, CBIS - USA Gordana Devecerski, MD, PhD - Serbia Sung Ho Jang, MD - Republic of Korea Cindy Ivanhoe, MD - USA Inga Koerte, MD, PhD - USA Brad Kurowski, MD, MS - USA Jianan Li, MD, PhD - China Christine MacDonell, FACRM - USA Calixto Machado, MD, PhD - Cuba Barbara O’Connell, OTR, MBA - Ireland Lisandro Olmos, MD - Argentina Caroline Schnakers, PhD - USA Lynne Turner-Stokes, MD - England Olli Tenovuo, MD, PhD - Finland Asha Vas, PhD, OTR - USA Walter Videtta, MD – Argentina Thomas Watanabe, MD – USA Alan Weintraub, MD - USA Sabahat Wasti, MD - Abu Dhabi, UAE Gavin Williams, PhD, FACP - Australia Hal Wortzel, MD - USA Mariusz Ziejewski, PhD - USA EDITORIAL INQUIRIES Managing Editor Brain Injury Professional PO Box 131401, Houston, TX 77219-1401 Tel 713.526.6900 Email: mbell@hdipub.com Website: www.nabis.org ADVERTISING INQUIRIES Megan Bell-Johnston Brain Injury Professional HDI Publishers PO Box 131401, Houston, TX 77219-1401 Tel 713.526.6900 Email: mbell@internationalbrain.org NATIONAL OFFICE North American Brain Injury Society PO Box 1804, Alexandria, VA 22313 Tel 703.960.6500 / Fax 703.960.6603 Website: www.nabis.org ISSN 2375-5210 Brain Injury Professional is a quarterly publication published jointly by the North American Brain Injury Society and HDI Publishers. © 2020 NABIS/HDI Publishers. All rights reserved. No part of this publication may be reproduced in whole or in part in any way without the written permission from the publisher. For reprint requests, please contact, Managing Editor, Brain Injury Professional, PO Box 131401, Houston, TX 77219-1400, Tel 713.526.6900, Fax 713.526.7787, e-mail mbell@hdipub.com.

BRAIN INJURY professional 3

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from the

editor in chief

It is with great pleasure that I introduce this issue of Brain Injury Professional focused on TBI in work reentry and edited by my long-term colleague, Dr. Paul Wehman with coeditor Lauren Avellone. Dr. Wehman and his group at VCU have been responsible for long-term historical contributions to the field in vocational reentry for persons with disabilities including as relevant here to persons with TBI. Dr. Wehman was one of the pioneers in terms of the use of supported employment for getting people with cognitive and physical challenges employed.

We start off this issue with a message from the guest editor, Dr. Wehman outlining the importance of work for persons with traumatic brain injury and the challenges in not only getting people back to work but maintaining employment through various mechanisms including use of vocational supports and services.

Nathan D. Zasler, MD, DABPM&R, FAAPM&R, FACRM, BIM-C, CBIST

The feature article entitled, “Current research on return to work for veterans with TBI” by Christina Dillahunt-Aspilllaga and colleagues discusses TBI in the military and more specifically veteran unemployment. The article goes on to discuss the polytrauma system of care (PSC), which provides vocational rehabilitation services to military personnel including review of data on supported employment in this patient population and the role of cognitive rehabilitation.

The second article extends the discussion of the first article in his entitled “Polytrauma traumatic brain injury: Vocational rehabilitation supports for servicemembers and veterans within the polytrauma system of care” by Dr. Wehman and colleagues. The authors expanded discussion of the PSC in terms of its components, as well as the use of vocational rehabilitation counselors in this process. The last part of the article focuses more on barriers to work reentry and methodologies for maintaining employment once achieved after exiting the polytrauma program.

In the third article by Lynn Koch and colleagues, the authors provide an overview of challenges focused on improving employment and postsecondary educational outcomes in young adults with TBI. Specific topics covered including the use of assistive technology, provision of incentives for work, and counseling benefits in the context of outcome. Optimization. Additionally, the authors review job development and placement including provision of supports in the workplace.

The fourth article entitled “Customized employment and return to work for individuals with traumatic brain injury” by Holly Wittenburg and colleague discuss the concept of “customized employment”, a novel and relatively new paradigm for returning patients to competitive, integrated employment after acquired brain injury. The article explores in that context job creation, job carving and job-sharing technologies. The authors also comparing contrast supported employment with customized appointment models for vocational rehabilitation.

Our interview piece for this issue is with Cynthia Young, MS, CRC who is a vocational rehabilitation counselor from the STAR program at the Hunter Holmes McGuire VA Polytrauma Center.

Finally, Dr. Trapp, our technology editor, discusses a cognitive support technology program for postsecondary students with traumatic brain injury.

Editor Bio Nathan Zasler, MD, is an internationally respected physician specialist in acquired brain injury (ABI) care and rehabilitation. He is CEO and Medical Director of the Concussion Care Centre of Virginia, an outpatient neurorehabilitation practice, as well as, Tree of Life, a living assistance and transitional neurorehabilitation program for persons with acquired brain injury in Richmond, Virginia. He is board certified in Physical Medicine and Rehabilitation and fellowship trained in brain injury, as well as, Brain Injury Medicine certified.

Dr. Zasler is an Adjunct Professor of PM&R at VCU in Richmond, Virginia, as well as, an Adjunct Associate Professor of PM&R at the University of Virginia, Charlottesville, Virginia. He is a fellow of the American Academy of Disability Evaluating Physicians, and a diplomat of the American Academy of Pain Management.

Dr. Zasler has lectured and written extensively on neurorehabilitation issues in ABI. He is active in national and international organizations dealing with acquired brain injury and neurodisability, serving in numerous consultant and board member roles including currently serving as Vice-Chairperson of IBIA.

BRAIN INJURY professional 5

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from the

Dr. Paul Wehman

guest editor

Work is a critical part of adult life. Employment brings financial independence, socialization, a sense of purpose, and opportunity for personal growth. Therefore, disruption to employment following a traumatic brain injury (TBI) negatively impacts many life areas beyond simply employment status. Unfortunately, individuals with TBI experience substantially higher rates of unemployment than individuals without disabilities and are faced with difficult decisions about how, when, and where to return to work. While some individuals with TBI will resume employment at a previous position, others will need to consider pursuing work in different departments within the same company or in another industry altogether. The return to work process is different for each individual as some may be ready soon after injury while others may have a longer term, chronic disability and thus require more medical intervention before work becomes a possibility. The take-away message from this special “return to work issue” is that employment is possible and desirable for most patients with TBI. Approximately 30 years ago it was next to impossible to find articles documenting meaningful competitive employment outcomes for individuals with long term TBI, yet, over time this has changed.

We increasingly know that patients with TBI can successfully return to work through use of vocational supports and services.

This issue of Brain Injury Professional focuses on detailing the scope of the issue of unemployment for individuals with TBI along with presenting employment interventions that promote successful return to work for both military and civilian populations. The first article

by Dr. Dillahunt-Aspillaga and colleagues presents an overview of current research on the status of employment for Veterans with TBI. She includes important descriptions of services such as vocational case management, cognitive rehabilitation, vocational rehabilitation counseling engagement, and supported employment all with or without increased utilization of assistive technology, which show promise as effective interventions.

Next, my colleagues and I present a complimentary article to Dr. Dillahun-Aspillaga’s article by describing how Service Members and Veterans who have extensive polytrauma injuries are able to receive employment supports through the U.S. Department of Veterans Affairs polytrauma network.

The remaining two papers by Dr. Koch and colleagues, and Dr. Whittenburg and colleague focus on an array of interventions available to both civilian and military populations through state Vocational Rehabilitation agencies. These include services focused on assessment, onthe-job support, and intervention models such as supported and customized employment.

In particular, customized employment is an emerging practice with wide implications for individuals with TBI because it focuses on working with employers to create positions that mutually benefit the employer and the individual with TBI. Finally, an interview from the perspective of a Vocational Rehabilitation Counselor who has worked to return Veterans with TBI to employment is included. In the interview, Cynthia Young offers insight into some of the struggles and successes Veterans with TBI experience during the process of regaining employment.

Work offers a variety of benefits. Moving forward, there needs to be more research on the therapeutic impact of return to work on TBI. It is absolutely essential that such studies be conducted in the years ahead in order for physicians, psychologists, parents, patients and policymakers to understand the full benefits of work and to make return to work a priority.

Editor Bio Dr. Paul Wehman is a professor of special education and counseling at Virginia Commonwealth University (VCU) and a Director of the Rehabilitation Research and Training Center at VCU.

BRAIN INJURY professional 7

Current Research on Return to Work for Veterans with Traumatic Brain Injury Christina J. Dillahunt-Aspillaga, PhD • Kathleen F. Carlson, PhD • Terri K. Pogoda, PhD Acknowledgements: The authors would like to acknowledge the following individuals for their expertise, time and assistance with review of this article: Shana Bakken, PhD, CRC, Mr. Joseph Carlomagno, MEd, and Micaela Cornis-Pop, PhD, CCC-SLP Disclaimer: The views expressed in this article are those of the authors and should not be construed as official views of the US Department of Defense, US Department of Veterans Affairs or of the US Government.

Traumatic brain injury (TBI) is the “signature injury” of the post9/11 era of United States (US) military operations (Okie, 2005).

Rehabilitation of veterans and service members (V/SM) with TBI is a longstanding focus of the US government, most notably the Department of Veterans Affairs (VA) (Scholten et al., 2017; Warriors, 2007). This article focuses on return to work as an important reintegration outcome for V/SM with TBI. It describes current VA research and evidence-based practices related to vocational rehabilitation (VR). The VA includes the Veterans Health Administration (VHA) and the Veterans Benefits Administration and offers VR programs. We refer to VA when we are describing the research, health, and VR services that are provided in the VHA. The VA recognizes that employment plays a central role throughout the process of rehabilitation and recovery (Drebing et al., 2012).

Military TBI The nature of military places service members at risk of TBI (Ommaya et al., 1996). In addition to the “traditional” sources of TBI, blasts now cause a large proportion of service members’ TBIs, via barotrauma as well as blunt force injury (Taber et al., 2006).

Awareness of the negative effects of TBI increased during recent conflicts and has led to implementation of routine screening, evaluation and multidisciplinary rehabilitation following TBI (Sigford, 2008). Recent military reports showed over 413,000 (9%) active duty V/SM have been diagnosed with TBI; nearly 83% were mild (Carlson et al., 2013; Defense and Veterans Brain Injury Center, 2020).

Nearly 170,000 who use the VA are documented as having TBI (US Department of Veterans Affairs VHA Support Service Center, 2020).

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Post-TBI symptoms mirror those experienced among civilians with TBI; however, the conditions of military service and, particularly, combat deployments may impart unique patterns of comorbidity (Reid and Velez, 2015). Frequently co-diagnosed disorders are post-traumatic stress disorder (PTSD), depression, substance use disorders, and pain (Carlson et al., 2011; Carlson et al., 2010; O'Neil et al., 2014; Taylor et al., 2012). Depression, anxiety, and substance use disorders are prevalent, as is the combination of PTSD and pain (Taylor et al., 2015), coined the polytrauma clinical triad (Lew et al., 2009; Pugh et al., 2014).

Veteran Unemployment Unemployment is high among post-9/11 veterans with TBI who use VA services. More than 10,000 post-9/11 V/SM who completed a VA comprehensive TBI evaluation (CTBIE) (Pogoda et al., 2016) found that one-third were unemployed, and that many were seeking work. Men and women veterans had similar unemployment rates (40%). Suspected PTSD, depression, substance use, and various neurobehavioral symptoms, difficulties with affect and cognition, were related to unemployment. Factors predicting unemployment include older age, lower education, minority status, marital status, former active duty status, cause of injury, TBI severity, severity of neurobehavioral symptoms, sustaining more severe injuries, having longer duration of post-traumatic amnesia, having more psychiatric conditions, and lower motor and cognitive functioning at discharge from inpatient care (Carlson et al., 2018; Cohen et al., 2013; Dillahunt-Aspillaga et al., 2014; Dillahunt-Aspillaga et al., 2017; Pogoda et al., 2016; Pugh et al., 2018). Complex veterans’ symptom and comorbidity clusters may cause barriers to participation in VR employment programs (Dillahunt-Aspillaga et al., 2018; Pogoda et al., 2018; Wyse et al., 2018).

Work Work defines us as individuals and is a key indicator of successful community transition as it provides social status, identity, and income.

Persons with TBI have a well-documented history of challenges related to returning to work (Dillahunt-Aspillaga et al., 2017; Dillahunt-Aspillaga and Powell-Cope, 2018; Ezrachi et al., 1991; Saltychev et al., 2013; Wehman and Kreutzer, 1990). In addition to the frequent co-occurring health conditions, limitations can include being unaware of the injury, the symptoms of the injury, and the implications of the injury that pose employment challenges (Temkin et al., 2009; Tsaousides et al., 2009). These may negatively impact participation in rehabilitation, psychosocial adjustment, vocational outcome, and QoL -quality of life (Andelic et al., 2012; DillahuntAspillaga et al., 2015; Ponsford, 2013; Tsaousides et al., 2009).

Veteran Employment Many veterans with TBI would like to work, but there are challenges to obtaining and maintaining employment (Wyse et al., 2018).

Veterans may lose confidence in their ability to perform military jobs; many believe that military-related injuries affected them emotionally, physically, and cognitively. This translates into veterans needing to apply their skillsets in different ways and in different environments, (e.g. such as working at a slower speed, using electronic or other reminder systems to stay organized, or working in areas where noise or bright lights are reduced to accommodate their limitations).

Addressing Needs Polytrauma System of Care (PSC) teams provide VR, either directly or matrixed from the facility’s VR Service’s Compensated Work Therapy (CWT) program. For teams that do not have dedicated VR staffing, referrals can be made to the VA medical center’s Vocational Rehabilitation Service program. VR services (U.S. Department of Veterans Affairs, 2019) vary across VA sites (Ottomanelli, et al., 2019). Outpatient VR services typically provided across VA medical centers include (1) Vocational Assistance (vocational assessment, counseling, job search skills training, job clubs, and referrals to community employment services), (2) CWT Transitional Work, which offers vocational supports and resources in a work setting and is intended to prepare veterans for eventual competitive work in the community, and (3) CWT Supported Employment, an intensive program that focuses on competitive employment and is based on the Individual Placement and Support model (Drake et al., 2012).

Supported Employment Originally developed to serve persons with serious mental illness (Drake et al., 2012), SE is recognized as an evidenced-based practice.

This practice follows 8 person-centered key principles. These include: (1) focus on competitive jobs that are available to anyone, vs. those set aside for individuals with disabilities, (2) attention to the veteran’s job interests and preferences, (3) systematic job development in which the SE specialist’s visits employers in-person to engage employers and determine ideal job matches, (4) rapid job searches where the veteran has face-to-face contact with an employer within 30 days, rather than extensive prevocational training, (5) zero exclusion (regardless of diagnosis, symptoms, substance use, or legal problems), (6) time-unlimited support, in consultation with the veteran’s clinical team, who must agree that support is needed, (7) benefits counseling to understand impact of disability compensation or entitlements, and (8) integration between the SE and clinical teams to monitor veteran’s progress and discuss effective workplace supports.

Employment Research and Practice In 2006, 13 VA medical centers were given resources to provide SE to veterans with TBI. A survey of SE specialists from the VA found that V/SM with TBI experience employment challenges and would benefit from SE (Pogoda et al., 2018). VA data (2008-2009) found that approximately 2% of post-9/11 veterans with different health conditions used SE at least once (Twamley et al., 2013).

Another survey (Carlson et al., 2018) found that nearly half of the respondents reported a) being unemployed, b) indicated interest in SE if it were offered to them; very few were familiar with SE. SE has been used with veterans with PTSD (Davis et al., 2018; Davis et al., 2012), SCI (Ottomanelli et al., 2012), homelessness and substance use disorders (Rosenheck and Mares, 2007). Recipients of SE are more than twice as likely to obtain competitive employment compared to participation in other programs, generally work more hours and earn higher wages than compared to traditional VR services (Modini et al., 2016). In 2016, the VA’s VR program expanded SE focus to include more veterans with physical and other diagnoses (e.g. TBI, PTSD, SCI) (VHA Directive 1163, Psychosocial Rehabilitation and Recovery Services, 2019).

Cognitive Rehabilitation Cognitive problems create barriers to employment (Cicerone et al., 2019; Wehman et al., 2009). Cognitive Symptom Management and Rehabilitation Therapy (CogSMART) (Twamley et al., 2014) is a 12-week training that focuses on (1) managing post-concussive symptoms (e.g. sleep problems, fatigue, and headaches, (2) improving memory for tasks that need to be performed in the future, attention, learning/memory, and other types of executive functioning, and (3) education on learning to use compensatory strategies (e.g., calendars or smartphone reminders, note-taking, and problem-solving). CogSMART improvements were observed in memory, post-concussive symptoms, and veteran-reported QoL. Return to work in veterans was associated with lower disability ratings, more recent work history, having worked more months within the 5-year follow-up period, lower PTSD symptom severity, poorer verbal memory and better cognitive flexibility (Church et al., 2019).

A 12-session embedded cognitive rehabilitation program was developed for veterans with mTBI who had a diagnosed mental or behavioral health condition (O'Connor et al., 2016). Veterans receiving the intervention learned strategies to help with cognitive challenges in the workplace, recognize and control negative behaviors and emotions, and build positive relationships with coworkers and supervisors. Those receiving the intervention generally worked more days and earned more income.

Summary Return to work for veterans with TBI is facilitated by the knowledge and support of interdisciplinary teams and includes communication across all providers, including employment specialists. An intertwined model of health and vocational support involves employment specialists who serve as a conduit between the polytrauma team and the veterans by providing necessary supports to facilitate attainment of vocational goals and supporting reemployment (Wehman et al., 2019). Interdisciplinary polytrauma teams should use advancements in therapies and technology to promote independence on-the-job and in the community. Ongoing vocational support services are needed to meet the complex needs of veteran populations with TBI. Evidence-based SE services have yielded positive outcomes including gainful employment and support well-being.

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25. O'Neil ME, Carlson KF, Storzbach D, et al., Factors associated with mild traumatic brain injury in veterans and military personnel: a systematic review. Journal of the International Neuropsychological Society. 20(3): 249-261, 2014.

26. Ottomanelli L, Goetz LL, Suris A, et al., Effectiveness of supported employment for veterans with spinal cord injuries: results from a randomized multisite study. Archives of Physical Medicine Rehabilitation. 93(5): 740-747, 2012.

27. Ottomanelli L, Bakken S, Dillahunt-Aspillaga C, et al., Vocational rehabilitation in the Veterans Health Administration Polytrauma system of care: Current practices, unique challenges, and future directions. The Journal of Head Trauma Rehabilitation. 34(3): 158-166, 2019.

28. Pogoda TK, Stolzmann KL, Iverson KM, et al., Associations between traumatic brain injury, suspected psychiatric conditions, and unemployment in Operation Enduring Freedom/Operation Iraqi Freedom Veterans. Journal of Head Trauma Rehabilitation. 31(3): 191-203, 2016.

29. Pogoda TK, Carlson KF, Gormley KE, et al., Supported employment for veterans with traumatic brain injury: provider perspectives. Archives of Physical Medicine and Rehabilitation. 99(2): S14-S22, 2018.

30. Ponsford J, Factors contributing to outcome following traumatic brain injury. NeuroRehabilitation. 32(4): 803-815, 2013.

31. Pugh MJ, Swan AA, Carlson KF et al., Traumatic brain injury severity, comorbidity, social support, family functioning, and community reintegration among veterans of the Afghanistan and Iraq wars. Archives of Physical Medicine and Rehabilitation. 99(2): S40-S49, 2018.

32. Reid MR, Velez CS, Discriminating military and civilian traumatic brain injuries. Molecular and Cellular Neuroscience, 66: 123-128, 2015.

33. Rosenheck RA. Mares AS, Implementation of supported employment for homeless veterans with psychiatric or addiction disorders: two-year outcomes. Psychiatric Services 58(3): 325-333. 2007.

34. Saltychev M, Eskola M, Tenovuo O, et al., Return to work after traumatic brain injury: Systematic review.

Brain Injury. 27(13-14): 1516-1527, 2013.

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48. Wehman P, Gentry T, West M, et al., Community integration: current issues in cognitive and vocational rehabilitation for individuals with ABI. Journal of Rehabilitation Researh and Development. 46(6): 909-918, 2009.

49. Wehman P, Avellone L, Pecharka F, et al., Reintegrating Veterans with Polytrauma into the Community and Workplace. Physical Medicine and Rehabilitation Clinics, 30(1): 275-288, 2019.

50. Wehman P, Kreutzer JS, Vocational rehabilitation for persons with traumatic brain injury: Aspen Publishers, 1990.

51. Wyse JJ, Pogoda TK, Mastarone GL, et al., Employment and vocational rehabilitation experiences among veterans with polytrauma/traumatic brain injury history. Psychological Services.17(1), 65-74, 2018.

Author Bios Christina Dillahunt-Aspillaga, PhD, received her PhD in Rehabilitation Science from the University of Florida. She is a Certified Rehabilitation Counselor (CRC), a Certified Vocational Evaluator (CVE), a Certified Life Care Planner (CLCP), and a Certified Brain Injury Specialist Trainer (CBIST). Christina is employed as an Associate Professor in the Department of Child & Family Studies, Rehabilitation & Mental Health Counseling program in the College of Behavioral and Community Sciences at the University of South Florida. Her research interest areas include employment for persons with disabilities, resource facilitation, caregiving, and community re-integration for civilians and Veterans with TBI. Kathleen Carlson, MS, PhD, trained in injury epidemiology and health services research and has been conducting research with the VA since 2006. Her work examines the co-occurrence of physical and psychological trauma among returning Veterans and their post-deployment reintegration into families, work, and community.

Her current projects focus on the epidemiology and sequelae of traumatic brain injury (TBI), including vocational rehabilitation and employment outcomes, and the use of VA-paid Community Care services among Veterans with TBI. Dr. Carlson completed her BS in Biology at Oregon State University and her MS and PhD in Environmental Epidemiology at the University of Minnesota.

Terri K. Pogoda, PhD, has been conducting health services research at the VA Boston Healthcare System since 2005. Her research focuses on return to civilian life among Veterans with traumatic brain injury and posttraumatic stress disorder. She has a special interest in the implementation and outcomes of VA vocational rehabilitation services. Dr. Pogoda is also a Research Associate Professor at the Boston University School of Public Health. She completed her BA in Psychology at the University of Maryland in 1999, and her MS (2002) and PhD (2004) in Experimental Psychology at Tufts University.

Fourth International Conference on

Pediatric Acquired Brain Injury

Save the date!

For the first time in the United States, this interdisciplinary conference brings together professionals committed to improving the outcome of children and young people with brain injury!

A unique educational event promoting wellbeing in children and young people with acquired brain injury and their families

New York New Yorker Hotel October 6-9

2021 Administrative assistance from:

For conference information: www.internationalbrain.org For IPBIS information: www.ipbis.org

Polytrauma Traumatic Brain Injury: Vocational Rehabilitation Supports for Service Members and Veterans within the Polytrauma System of Care Paul Wehman, PhD • Lauren Avellone, PhD Cynthia Young, MS, CRC

Return to Work is an Important Part of Recovery for Service Members and Veterans sustaining a polytrauma injury. Polytrauma refers to injuries affecting more than one external body part or internal system (U.S. Department of Veterans Affairs, 2019). Due to heightened safety risks associated with deployment, military members often experience polytrauma injuries on-the-job (Wyse et al., 2018). Polytrauma injuries are frequently the result of combatrelated explosive events but can also occur due to other causes such as falls or motor vehicle accidents (Ropacki et al., 2018; Wyse et al., 2018). Commonly, polytrauma injury involves a traumatic brain injury (TBI). To illustrate, a study of 16,590 Polytrauma System of Care users through the U.S. Department of Veterans Affairs (VA) found that nearly half (48.6%) had a TBI diagnosis (Adams et al., 2019).

Polytrauma TBI occurs along with one or more other traumas such as amputation, damage to sensory modalities, spinal cord injury, or serious mental health conditions (e.g., post-traumatic stress disorder, anxiety, depression, substance disorder) that impair daily functioning (Adams et al., 2019; U.S. Department of Veterans Affairs, 2019). Due to the complex nature of TBI, particularly with polytrauma injuries, Service Members and Veterans often encounter difficulties with returning to major life areas such as independent residential living, social activities, and employment.

For example, approximately 60.4% of individuals with TBI are unemployed compared to a 3.5% national unemployment average (Cuthbert et al., 2015). Individuals with polytrauma TBI are likely to need specialized employment services to aid in successful return to work (Wehman et al., 2019). In this article, a review of the vocational rehabilitation procedures implemented at nationwide Polytrauma System of Care sites throughout the U.S. Department of Veterans Affairs is discussed in order to provide information on how Service Members and Veterans with polytrauma TBI are supported during work re-entry.

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Example services from one site, the Polytrauma Transitional Center (PTC) Service Member Transitional Advanced Rehabilitation (STAR) program in Richmond, Virginia are described.

Polytrauma System of Care

To assist with successful return to major life activities such as employment, the Department of Veterans Affairs developed a nationwide treatment model in 2005 known as the Polytrauma System of Care (PSC) which provides rehabilitative support for Service Members and Veterans who have experienced any level of polytrauma/TBI (Armstrong et al., 2019; Wyse et al., 2018). The PSC is a network of tiered levels of support offering inter-disciplinary services that help individuals with polytrauma injuries return to independent activities (Pogoda et al., 2018). A set of services is individualized based on each Service Member and Veteran’s needs but may include assessment and evaluation, treatment planning, case management, rehabilitation technology, employment services, family training, and social support (U.S. Department of Veterans Affairs, 2019).

The PSC comprises four component sites ranging from most to least levels of support. First, Polytrauma Rehabilitation Centers (PRCs) are intensive inpatient facilities which provide acute care for those with the most significant needs. Service Members and Veteran’s with polytrauma TBI typically travel to one of the five PRC locations in Virginia, Texas, Florida, Minnesota, and California (Armstrong, 2019). Once able to transition to a least intensive setting, the individual often begins receiving care from a Polytrauma Network Site (PNS) closer to their home using in-patient or out-patient services (U.S. Department of Veterans Affairs, 2019). Like PRCs and PNSs, the third tier of service offers a wide range of comprehensive supports except on an outpatient basis from a Polytrauma Support Clinic Team (PSCT). Lastly, more limited services are available from a Polytrauma Point of Contact (PCC) accessible through VA facilities (U.S. Department of Veterans Affairs, 2019). At each level, an interdisciplinary treatment team will work with the Service Member

or Veteran to determine treatment goals related to independent living, community participation and re-entry to employment.

Addressing Employment through the Polytrauma System of Care

Compensated Work Therapy (CWT) is a national vocational rehabilitation (VR) program operated by the Department of Veterans’ Affairs that partners with businesses and government agencies to support Service Members and Veterans during return to work (Pogoda et al., 2018). Each VA medical center across the U.S. has a CWT program (U.S. Department of Veterans Affairs, 2020).

As many as 65,000 veterans with a variety of mental and physical conditions participated in CWT across the U.S. in 2017 (Ottomanelli et al., 2019). To ensure quality services and outcomes, most are recognized by the Commission on Accreditation of Rehabilitation Facilities (CARF), an international health and human services agency (Ottomanelli et al., 2019). Participants in the CWT program are eligible for healthcare services from the VA, have a desire to return to work, and experience barriers that hinder obtaining and retaining employment through traditional avenues (U.S. Department of Veterans Affairs, 2020), such as those with polytrauma TBI injuries.

Each veteran with a polytrauma TBI will require different vocational services. Therefore, an important aspect of CWT is determining the correct employment components. Additionally, due to resources and demand, different components of CWT are offered at different VA medical centers (U.S. Department of Veterans Affairs, 2020). Examples include vocational support services, supported employment, supported self-employment, transitional work, supported education, and community-based employment services (Ottomanelli et al., 2019). Service Members and Veterans with polytrauma TBI work with a Vocational Rehabilitation Counselor (VRC) to create and accomplish employment goals. The unique role of the VRC is described below.

Vocational Rehabilitation Counselors at Polytrauma Centers

At polytrauma centers, VRCs are considered a core therapy, and VRCs are active members of the medical/therapeutic Interdisciplinary Team (IDT). The IDT is comprised of medical professionals including Physiatrists, Nurses, Physical, Occupational, and Speech therapists, Psychologists, Social Workers, Recreational Therapists, Vision Specialists, Health Coaches, program managers, hospital staff, and military liaisons (Wehman et al., 2019). During the weekly IDT meetings, VRCs communicate the patient’s vocational goals, and the therapy team targets their medical and therapeutic strategies in support of the patient’s vocational goals. From a patient care perspective, the VRCs provide case management and work with every patient who participates in the program. The VRCs are given a medical consult to treat each patient, and then schedule an initial intake meeting with the patient to develop an individualized strategic employment plan with goals, followed by providing daily vocational services throughout the participant’s time in the program.

The VRCs administer assessments to determine vocational interests and abilities including work aptitude, achievement, and values.

After that, the VRC’s services involve contacting businesses and arranging informational interviews, networking opportunities, job shadowing experiences, on-the-job assessments, providing transportation to these events, and using the results of these community interactions to further develop individualized vocational goals.

In-clinic VR sessions center around assisting the Service Member or Veteran with developing a professional portfolio with documents outlining his or her professional skills and work history. It includes identifying and researching careers, job leads or education programs in line with identified career goals. The VRCs also teach and arrange community partners to teach weekly classes on job-related skills including topics such as effective interviewing and assessment skills; developing tools for job searches; translating military job roles into civilian equivalents; creating targeted resumes; labor market research; and identifying barriers to employment and strategies to overcome these barriers.

Importantly, the VRCs provide patients with personal adjustment counseling about work-related stress, disability issues, utilizing job accommodations, assistive technology, and other compensatory strategies to facilitate a successful employment experience. These services successfully assist Service Members with returning to active duty, and successful transition out of the military into civilian employment and education.

Planning for Employment Retention of after Exiting a Polytrauma Center: Site Example As a service member or Veteran with polytrauma TBI returns to work, it is important to ensure that the supports and services needed to successfully retain employment are put in place.

Procedures for promoting employment retention vary by center.

Here is one example of processes utilized by the Polytrauma Transitional Center (PTC) Service Member Transitional Advanced Rehabilitation (STAR) program in Richmond, Virginia describing “check-ins” with veterans after they leave the program, and resources and organizations to which they are directed to at exit.

In 2018, The STAR program initiated a program follow-up survey to check-in with former patients. At program discharge, the patient is administered the follow-up survey as a baseline and informed that in 6 months, and a year, they will be contacted again to complete the survey. The survey asks the Service Member or Veteran to rate their level of satisfaction with the program and also asks if they are currently employed, seeking employment, or attending an education or training program. While the Service Member or Veteran is in the STAR program, efforts to establish business connections and employment supports are made. Patients often choose to join Veteran non-profit organizations who provide mentoring, support and activities within the person’s home community. A few that have been found to be very supportive include the Wounded Warrior Project (WWP) and American Corporate Partners (ACP) mentorship program (a non-profit organization engaged in national corporate career counseling for military personnel). Transition services through the Transition Center on the military base are excellent resources as well for both active duty Service Members and Veterans. In addition, the Marine for Life and Soldier for Life programs are very helpful with mentoring, networking, and connecting Veterans to employment opportunities. For those with entrepreneurship goals, SCORE at www.score.org is recommended because it is large network of volunteers and expert business mentors. Each patient also connects to industry-specific resources based on his or her career goals.

Lastly, it is also recommended that patients develop a LinkedIn profile, and the STAR program assists them with accessing LinkedIn tools and using this resource for continued networking.

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Barriers to Return to Work for Service Members and Veterans with Polytrauma TBI

During recovery, Service Members and Veterans with polytrauma TBI are faced with adjusting to many life circumstances all at once. In addition to following intensive treatment regimens for their injuries, they are often adapting to other changes such as needing assistance from others while healing, making difficult choices about their future, and deciding when and how to pursue different levels of community integration. Those sustaining injuries during deployment may also find the transition back to civilian life difficult and foreign (Demers, 2011). Here, a brief review of recognized barriers is presented.

Barriers to work re-entry for Service Members and Veterans are often unique to the demographics of the population. For example, consider the STAR program in Richmond, VA where 75%-80% of patients are active duty military Service Members in medical recovery while in the program (Service Member Transitional Advanced Rehabilitation Program. FY17 annual outcomes report; 2017). This impacts return to work in several ways including determining fitness for duty, possible exaggeration of conditions, and unrealistic expectations. For example, when a Service Member develops a medical condition, it may render him or her “Unfit for Duty.” In the STAR program, vocational rehabilitation efforts are then targeted toward work assessments that replicate job tasks to provide recommendations for return to duty.

On the other hand, assessments and therapies may reveal that the Service Member is not likely going to be able to return to duty The STAR program has assisted several Service Members with adjustment to disability after assessments demonstrated that the Service Member was not likely fit for duty, and would not likely be able to return to duty. In these cases, the vocational services shift to planning for military transition and determining viable civilian career goals. In several cases, the Service Member was not ready to acknowledge issues related to injury, nor consider transition to civilian employment. The goal of the STAR program is not to convince the patient of his deficits, but rather, provide assessment data as an indicator of the person’s actual current performance and provide vocational recommendations based on his strengths. In a few cases, the person was not ready to consider new employment options until after leaving the program.

Another barrier is when the person is waiting for surgery or to recover from orthopedic injuries and their employment transition is on hold. The STAR program addresses this barrier by offering career exploration that takes into account current and future career options. The biggest barrier to return to work tends to occur when an active duty patient is recovering from injury and enters the Integrated Disability Evaluation System (IDES) process because the Service Member may want to appear to be as “disabled” as possible while being examined by medical personnel in order to obtain a higher disability rating. For this reason, the Service Member may not fully engage in vocational services because he does not want to appear as if he is capable of working.

If the transition is from active duty to civilian employment, there are other barriers to consider as well. For example, many Veterans may feel unsure of where they fit within the climate of a business, or feel misunderstood since many civilians do not understand military culture (Demers, 2011). Many veterans with polytrauma TBI will have entered the military at a young age and therefore have limited civilian work experience (Wehman et al., 2019) which is problematic

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because there is often a lack of parallel positions between military and civilian jobs in terms of duties, industry, authority, salary, and training requirement (Wehman et al., 2019). Veterans may also have trouble adjusting to the differences in hierarchy and greater pressure to make decisions alone associated with civilian work compared to military work (Wehman et al., 2019). They may also hold themselves to a higher standard and have difficulty adjusting to decreased shows of respect in civilian jobs (Demers, 2011). As mentioned, barriers will differ across Service Members and Veterans so assessing these challenges prior to work re-entry is essential in promoting successful transition back to work.

Conclusion

Return to work for Service Members and Veterans with polytrauma TBI is a complex process that requires a treatment team who works collaboratively to establish and accomplish vocational goals. The PSC provides vocational rehabilitation services at VA medical centers nationwide which includes the provision of VRC services. The VRC works with the Service Member or Veteran to complete a myriad of critical work re-entry activities such as completion of vocational assessments, arrangement of work experiences, counseling for workrelated stress, and education on work skills and job securement.

Services extend beyond program enrollment as efforts are made to assist the Service Member or Veteran in obtaining long term supports and connections to community agencies that will aid in employment retention. While each individual experiences different types of barriers and varying levels of motivation and certainty regarding the work re-entry process, the PSC provides an array of services to overcome these barriers and help Service Members and Veterans with polytrauma TBI successfully return to work.

References 1.Adams RS, Larson MJ, Meerwijk EL, et al., Post deployment polytrauma diagnoses among soldiers and veterans using the Veterans Health Affairs Polytrauma System of Care and receipt of opioids, nonpharmacologic, and mental health treatments. Journal of Head Trauma Rehabilitation. 34(3): 167-175, 2019.

2. Armstrong M, Champagne J, Mortimer DS. Department of Veterans Affairs Polytrauma Rehabilitation Centers: Inpatient rehabilitation management of combat-related polytrauma. Physical Medicine Rehabilitation Clinics of North America. 30(1): 13-27, 2019.

3. Cuthbert JP, Harrison-Felix C, Corrigan JD, et al., Unemployment in the United States after traumatic brain injury for working-age individuals: Prevalence and associated factors 2 years postinjury. Journal of Head Trauma Rehabilitation. 30(3): 160-174, 2015.

4. Demers A. When veterans return: The role of community in reintegration. Journal of Loss and Trauma.

16(2): 160-179, 2011.

5. Ottomanelli L, Bakken S, Dillahunt-Aspillaga C, et al., Vocational rehabilitation in the Veterans Health Administration Polytrauma system of care: current practices, unique challenges, and future directions.

Journal of Head Trauma Rehabilitation. 34(3): 158-166, 2019.

6. Pogoda TK, Carlson KF, Gormley, KE, et al., Supported employment for veterans with traumatic brain injury: provider perspectives. Archives of Physical Medicine and Rehabilitation. 99(2): S14-S22, 2018.

7. Ropacki S, Nakase-Richardson R, Farrell-Carnahan L, et al., Descriptive findings of the VA polytrauma rehabilitation centers TBI model systems national database. Archives of Physical Medicine and Rehabilitation.

99(5): 952-959, 2018.

8. Service Member Transitional Advanced Rehabilitation Program. FY17 annual outcomes report, 2017.

9. U.S. Department of Veterans Affairs. Polytrauma/TBI system of care. Published March 7, 2019. Accessed July 9, 2020. https://www.polytrauma.va.gov/understanding-tbi/.

10. U.S. Department of Veterans Affairs. Compensated Work Therapy. Published March 3, 2020. Accessed July 9, 2020. https://www.va.gov/HEALTH/cwt/index.asp.

11. Wehman P, Avellone L, Pecharka F, et al., Reintegrating Veterans with polytrauma into the community and workplace. Physical Medicine and Rehabilitation Clinics of North America. 30(1): 275-288, 2019.

12. Wyse JJ, Pogoda TK, Mastarone GL, et al., Employment and vocational rehabilitation experiences among veterans with polytrauma/traumatic brain injury history. Psychological Services. 17(1): 65-74, 2018.

Author Bios Paul Wehman, PhD, Dr. Wehman is a VCU Professor in the School of Education’s Counseling and Special Education Department with a longtime appointment in the VCU Health System’s Physical Medicine and Rehabilitation. He is Director of both the VCU Rehabilitation Research and Training Center and the Autism Center for Excellence and Editor-in-Chief of the Journal of Vocational Rehabilitation.

Recognized as one of the 50 Most Influential People in Special Education for the millennium by Remedial and Special Education, his highly interdisciplinary background has made him a nationally recognized expert in transition, supported employment, brain injury, physical and developmental disabilities and autism.

Lauren Avellone, PhD, Dr. Avellone is a Board Certified Behavior Analyst (BCBA) with a PhD in Special Education and a MS in clinical psychology. She has broad experience working in both research and clinical settings with individuals with a variety of disabilities including autism, brain injury, psychiatric disorders and developmental disabilities. She has provided behavior analytic services in a variety of settings including hospitals, classrooms, and residential settings. In addition to amassing extensive clinical experience, she has conducted research in a wide range of disciplines including psychology, special education, and rehabilitation counseling.

Cynthia Young, MS, CRC, Cynthia Young is a Vocational Rehabilitation Counselor at the Central Virginia VA Health Care System in Richmond, Virginia. In 2011, she was a part of the team that developed the Service member Transitional Advanced Rehabilitation (STAR) Program, a polytrauma rehabilitation program for Service Members and Veterans (SM/V) recovering from injury or illness.

She provides individualized vocational services to assist SM/Vs with return to military service and with transition to civilian employment.

Cynthia received her Master’s Degree from Virginia Commonwealth University, is a Certified Rehabilitation Counselor (CRC) and the proud daughter of a U.S. Marine Corps Veteran.

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Effective Vocational Rehabilitation Services for Improving the Employment and Postsecondary Education Outcomes of Young Adults with Traumatic Brain Injuries Lynn Koch, PhD, CRC • Phillip Rumrill, PhD, CRC • Jia-Rung Wu, PhD • Stuart Rumrill, MS, CRC Kanako Iwanaga, PhD, CRC, LPC • Fong Chan, PhD

According to the Centers for Disease Control and Prevention (CDC, 2015), between 3.2 million and 5.3 million persons in the United States are living with traumatic brain injury (TBI) related disabilities.

Employment outcomes for individuals with TBIs lag far behind those of the general population. Unemployment is particularly profound among young adults with TBIs, as many of them face a range of complications, including cognitive impairments, behavioral problems, and social isolation, which can negatively affect their educational and vocational pursuits (Strauser et al., in press; Todis et al., 2011; Wehman et al., 2014). Patient data from the Traumatic Brain Injury Model Systems National Data and Statistical Center (TBIMS-NDSC) indicated that the prevalence of unemployment at two-year post-injury (2003–2012) for adults with TBIs was 60.4%, whereas the average unemployment rate for the U. S. population during the same period was 9.0%.

Unemployment prevents a large number of individuals with disabilities from community participation, stalls upward mobility, and greatly affects their physical health, mental health, and overall quality of life (Murali and Oyebode, 2004; U.S. Senate Committee on Health, Education, Labor and Pensions, 2012). Conversely, gainful employment enables individuals with disabilities to provide for themselves, raise a family, live with dignity, connect with people, and contribute as productive members of society (Fryers, 2006). Helping young adults with TBIs to find, stay in, and return to employment will significantly improve their health, well-being, and quality of life.

The state–federal Vocational Rehabilitation (VR) program serves over 1,000,000 people with disabilities per year, with an annual budget of $3.5 billion. It has a long history of assisting individuals with disabilities in achieving their independent living and employment goals (U.S. Department of Education, 2018). There is strong empirical evidence to support the effectiveness of the state-federal VR program in prompting employment (e.g., Bolton et al., 2000; Chan et al., 2006; Dutta et al., 2008; Gamble and Moore, 2003; O’Neill et al., 2015). Employment rates of those who have received state VR services have been consistently reported in the 55% to 60% range (Dutta et al., 2008; Kaye, 1998; Rehabilitation Services Administration, 2016; Rosenthal et al., 2006). State-federal VR agencies can be a valuable referral source for TBI rehabilitation and healthcare service providers. However, TBI service providers have been underutilizing state-federal VR services and may need accurate information about the benefits of work, assistive technology,

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reasonable accommodations, and the role of VR counselors in promoting better success in life for young adults with TBIs (Koch et al., 2012). The purpose of this article is to provide a brief review of effective VR services that can be used to improve outcomes in employment and postsecondary education (an avenue to employment) for young adults with TBIs.

Effective Vocational Rehabilitation Services Assistive Technology Limitations associated with cognitive impairments have repeatedly been cited as the most formidable barriers to employment and educational attainment for young people with TBIs (Hendricks et al., 2015; Nardone et al., 2015). Fortunately, with effective accommodations, especially cognitive support technology (CST), young people with TBIs have abundant achievement potential.

Rumrill et al. (2019) reported the outcomes of Project Career, a five-year initiative that served college students with TBIs by providing (a) training in CST in the form of iPads and cognitive enhancement applications or “apps” and (b) career preparatory services to promote academic and employment success. The 150 students who took part in the project utilized a total of 452 cognitive enhancement, study skills, and career preparatory apps; participated in a comprehensive Matching Person and Technology assessment protocol (Scherer, 2012) that yielded an individualized assistive technology plan for each student; and received consultation on classroom and workplace accommodations from the Job Accommodation Network (e.g., voice activation, screen readers, mobility aids, accessible work stations).

Owing partly to the intensive Project Career intervention, but mostly to their own personal resilience, Project Career students had a 91% retention rate in their degree programs. Their average GPA was 2.65 at the time they enrolled and 3.25 when they exited the program.

They also reported significant gains in career optimism, comfort and familiarity with assistive technology, acceptance of disability, life satisfaction, social capital, and utilization of technology to compensate for disability-related limitations. Of the 41 students who graduated from their degree programs during the project, 98% were competitively employed or attending graduate school at a 12-month follow-up (Rumrill et al., 2019).

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Effective Vocational Rehabilitation Services Work Incentives and Benefits Counseling For individuals with disabilities such as TBIs receiving Supplemental Security Income (SSI) benefits, work incentives and benefits counseling has been found to be an effective VR intervention that has a significant positive effect on employment outcomes (Schlegelmilch et al., 2019; Wilhelm and McCormick, 2013).

Specifically, SSI beneficiaries meet with certified benefits counselors who provide accurate and timely information about the impact of earnings on disability-based cash and healthcare benefits. Benefits counselors also help clients access important work incentives to keep their cash and healthcare benefits until they become gainfully employed. In terms of outcomes, researchers in the Wisconsin Promoting the Readiness of Minors in Supplemental Security Income (Wisconsin PROMISE) project reported that youth who received work incentives and benefits counseling had significantly higher work activity and explored a greater number of job opportunities than youth who did not receive work incentives and benefits counseling (Schlegelmilch et al., 2019). Additionally, 81% of Wisconsin PROMISE treatment youth with earnings above the Substantial Gainful Activity (SGA) level had met with a benefits counselor at least once.

Effective Vocational Rehabilitation Services Postsecondary Education

Postsecondary education has a significant positive effect on employment outcomes and lifetime earnings (Julian and Kominski, 2011; U.S. Department of Labor [USDOL], 2014). Research indicates that males with college degrees earn $900,000 more in median lifetime earnings than male high school graduates (Tamborini et al., 2015). Females with college degrees earn $630,000 more than female high school graduates (Tamborini et al., 2015). Individuals with some college, associate’s degrees, bachelor’s degrees, and higher also have significantly lower unemployment rates than people with only high school diplomas and high school dropouts (Federal Reserve Bank of St. Louis, 2019). For people with disabilities, higher levels of education significantly increase their job prospects and earnings (Jones et al., 2006; O’Neill et al., 2015; Kidd et al., 2000).

Recently, Chan and his colleagues (in press) conducted a nonexperimental causal comparative study to evaluate the effectiveness of VR-sponsored college and university training on employment outcomes and earnings of young adults with TBIs, using the Rehabilitation Services Administration Case Service Report (RSA-911) data. Results indicated that young VR clients with TBIs who received college or university training as part of their VR plans enjoyed significantly better employment outcomes than did a matched comparison group of young VR clients with TBIs who did not receive college or university training (60.4% employed vs. 42.4% employed, respectively). The college or university training group also earned significantly more than the no college or university training group ($381/week vs $261/week, respectively). These findings indicate that college and university training for VR clients with TBIs is a good investment.

Counselors in state-federal VR agencies can provide tuition support for young adults with TBIs to attend college and pre-employment transition services (e.g., self-advocacy training, social skills training, job interviewing, job seeking skills training) to help them develop psychological strengths and emotional efficacy to cope with the demands and challenges of college life and prepare for finding employment. These VR services can augment other services (e.g.,

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study skills training, time management training, and accommodation services) provided by disability service providers to maximize the probability that students with TBIs will persist with their career goals, graduate from college, and find gainful employment.

Effective Vocational Rehabilitation Services – Job Development and Placement, On-the-Job Supports, and Follow-Up

Once the young person with a TBI is ready to engage or reengage in competitive employment, barriers may occur in five areas: accessibility of the worksite (both physical and attitudinal), performance of essential functions and requirements of the job, relationships with employers and co-workers, employment policies, and necessary work supports. Regarding work supports, consideration of cognitive accommodations is especially important, and transportation services are also frequently required for VR clients with TBIs (Hendricks et al., 2015). Supported employment services such as job coaching and extended orientation to the worksite and to job tasks may be indicated for young workers with severe cognitive, mobility, or multi-systemic effects of TBI (Wehman et al., 2014). Supported employment is considered an evidence-based employment practice. Wehman et al., (2014) examined the effect of a supported employment intervention on the employment outcomes of transition-age youth with intellectual and developmental disabilities (including TBI) served by VR agencies using a case-control study design. Results of their study indicated that supported employment was associated with a number of positive employment-related outcomes including wages and level of labor force participation.

In targeting employment opportunities and arranging needed supports for young workers with TBIs, VR professionals consider invisible barriers (e.g., discriminatory behaviors of co-workers, workplace incivility) as well as those that are readily apparent. VR professionals also have to make adjustments in support provision and the employment opportunities targeted for individuals with TBI based on contemporary issues. For example, in the wake of the Coronavirus pandemic VR professionals have had to heavily consider telecommuting, the need for home-based employment, and new social distancing requirements that are likely to shape the American economy for many years to come.

Once on-the-job, VR clients with TBIs may need assistance requesting reasonable accommodations, documenting their disability status, and making formal complaints of employer discrimination if it occurs. Hendricks et al. (2015) reported that young people with TBIs are often unaware of their legal rights under Title I of the Americans with Disabilities Act (ADA) or procedures by which to invoke their rights. Employers may need clarification on assisting individuals with TBI as well. The state-federal VR program can also consult with employers to assist young people with TBI in seeking, securing, and maintaining employment (Rubin et al., 2016).

Employers may need assistance in addressing concerns such as job performance, reactions of co-workers, absenteeism, and reasonable accommodations. Employers also may need to be educated about the low cost and ease of most accommodations (e.g., flex-time, flexplace, telecommuting, natural supports) for workers with disabilities in general and for people with TBIs in particular.

The Job Accommodation Network (JAN) is a useful resource for exploring possible accommodations for individuals with TBIs. In fact, JAN features a TBI-specific portal called the Students, Technology, Accommodations, and Resources (STAR) network that serves as a

vehicle for electronic information and technical assistance related to postsecondary education and employment for people with TBIs (Rumrill et al., 2019). The STAR network provides TBI-related information regarding assistive technology supports and resources for postsecondary students and employees with TBIs, college and university personnel, rehabilitation professionals, occupational therapists, employers, and other stakeholders. The site features multiple filters that may be applied by users to target their most immediate needs. The site receives approximately 15,000 hits per month. Visit the STAR portal at http://www.projectcareertbi.org/

Conclusion

3. Chan F. Cheing G. Chan JYC. et al., Predicting employment outcomes of rehabilitation clients with orthopedic disabilities: A CHAID analysis. Disability and Rehabilitation, 28: 257-270, 2006.

4. Chan F. Rumrill P. Wehman P. et al., Effects of postsecondary education on employment outcomes and earnings of young adults with traumatic brain injuries. Journal of Vocational Rehabilitation, in press.

5. Dutta A. Gervey R. Chan F. et al., Vocational rehabilitation services and employment outcomes for people with disabilities: A United States study. Journal of Occupational Rehabilitation, 18: 326-334, 2008.

6. Federal Reserve Bank of St. Louis, Unemployment rate by educational attainment and age, monthly, not seasonally adjusted: 25 years and over. https://fred.stlouisfed.org/release/tables?eid=48713&rid=50.

Accessed 28 Apr. 2020.

7. Freyers T, Work, identity and health. Clinical Practice and Epidemiology in Mental Health, 2: 1-7, 2006.

8. Gamble D. Moore CL, The relation between VR services and employment outcomes of individuals with traumatic brain injury. Journal of Rehabilitation, 69: 31-38, 2003.

9. Hendricks DJ. Sampson E. Rumrill P, et al., Activities and interim outcomes of a multi-site development project to promote cognitive support technology use and employment success among postsecondary students with traumatic brain injuries. NeuroRehabilitation, 37: 449-458, 2015.

10. Jones MK. Latreille PL. Sloane PJ., Disability, gender and the British labour market. Oxford Economic Papers, 58: 407-449, 2006.

Employment outcomes for individuals with TBI continue to remain significantly lower than those experienced by the general population. The state-federal VR program is a valuable resource that offers a wide range of supports and services to help young people with TBIs in their vocational and educational pursuits. Healthcare professionals can aid in this process by refering people with TBIs to the state-federal VR program for valuable assistance and support.

Use of VR services such as assistive technology, work incentives and benefits counselling, college tuition assistance, job development and placement, on-the-job supports, and follow-up consultation promote educational success, positive employment outcomes, and long-term economic self-sufficiency for the growing numbers of young Americans who experience the effects of TBI.

11. Julian T. Kominski R, Education and synthetic work-life earnings estimates. American Community Survey Reports, ACS-14. U.S. Census Bureau, Washington, DC, 2011.

12. Kaye HS: Vocational rehabilitation in the United States (No. 20). US Department of Education, National Institute on Disability and Rehabilitation Research (NIDRR), 1998.

13. Kidd MP. Sloane PJ. Ferko I, Disability and the labour market: An analysis of British males. Journal of Health Economics, 19: 961-981, 2000.

14. Koch LC. Rumrill PD. Conyers L. et al., A narrative literature review regarding job retention strategies for people with chronic illnesses. Work, 46: 125-134, 2013.

15. Murali V. Oyebode F, Poverty, social inequality and mental health. Advances in Psychiatric Treatment, 10: 216-224, 2004.

16. Nardone A. Sampson E. Stauffer C. et al., Project Career: A qualitative examination of five college students with traumatic brain injuries. NeuroRehabilitation, 37: 459-469, 2015.

17. O’Neill J. Kang HJ. Sánchez J, et al., Effect of college or university training on earnings of people with disabilities: A case control study. Journal of Vocational Rehabilitation, 43: 93-102, 2015.

18. Rehabilitation Services Administration Report for Fiscal Year 2016. https://www2.ed.gov/about/reports/ annual/rsa/2016/rsa-2016-annual-report.pdf. Accessed 28 Apr. 2020.

19. Rosenthal DA. Hoyt WT. Ferrin JM. et al., Advanced methods in meta-analytic research: Applications and implications for rehabilitation counseling research. Rehabilitation Counseling Bulletin, 49: 234-246, 2006.

20. Rubin S. Roessler R. Rumrill P: Foundations of the vocational rehabilitation process, (7th ed.). Austin, TX: Pro-Ed, 2016.

References 1. Bolton BF. Bellini JL. Brookings JB, Predicting client employment outcomes from personal history, functional limitations, and rehabilitation services. Rehabilitation Counseling Bulletin. 44: 10-21, 2000.

2. Centers for Disease Control and Prevention, Report to congress on traumatic brain injury in the United States: Epidemiology and rehabilitation. National Center for Injury Prevention and Control; Division of Unintentional Injury Prevention.

GA, 4:03 2015 PM Page 1 Project19_Layout 1 Atlanta, 5/1/20

21. Rumrill P. Hendricks DJ. Elias E. et al., An organizational case study of a five-year development project to promote cognitive support technology use, academic success, and competitive employment among civilian and veteran college students with traumatic brain injuries. Journal of Applied Rehabilitation Counseling, 50: 52-72, 2019.

22. Scherer MJ: Assistive technologies and other supports for people with brain impairment. New York, NY: Springer Publishing Company, 2012.

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23. Schlegelmilch A. Roskowski M. Anderson C. et al., The impact of work incentives benefits counseling on employment outcomes of transition-age youth receiving Supplemental Security Income (SSI) benefits.

Journal of Vocational Rehabilitation, 51: 127-136, 2019.

24. Strauser D. Rumrill P. Greco C, A conceptual framework to promote career development for vocational rehabilitation consumers with traumatic brain injuries. Work: A Journal of Prevention, Assessment, and Rehabilitation, in press.

28. U.S. Department of Labor, Earnings and unemployment rates by educational attainment. http://data.bls. gov/cgi-bin/print.pl/emp/ep chart 001.htm, 2014. Accessed 28 Apr. 2020.

29. U.S. Senate Committee on Health, Education, Labor and Pensions. Unfinished business: Making employment of people with disabilities a national priority. https://portal.ct.gov//media/DDS/community/ CMSguidancearoundShelteredworkshops.pdf?la=en, 2012. Accessed 28 Apr. 2020.

25. Tamborini CR. Kim CH. Sakamoto A, Education and earnings in the United States. Demography, 52: 1383–1407, 2015

30. Wehman P. Chan F. Ditchman N. et al., Effect of supported employment on vocational rehabilitation outcomes of transition-age youth with intellectual and developmental disabilities: A case control study.

Intellectual and Developmental Disabilities, 52: 296-310, 2014.

26. Todis B. Glang A. Bullis M, et al., Longitudinal investigation of the post-high school transition experiences of adolescents with traumatic brain injury. Journal of Head Trauma Rehabilitation, 26: 138-149, 2011.

31. Wehman P. Chen CC. West M, et al, Transition planning for youth with traumatic brain injury: Findings from the National Longitudinal Transition Survey-2. NeuroRehabilitation. 34: 365-372, 2014.

27. U.S. Department of Education, Rehabilitation services-Fiscal year 2018 budget request. https://www2. ed.gov/about/overview/budget/budget18/justifications/i-rehab.pdf. Accessed 28 Apr. 2020.

32. Wilhelm S. McCormick S The impact of a written benefits analysis by Utah benefit counseling/WIPA program on vocational rehabilitation outcomes. Journal of Vocational Rehabilitation, 39: 219-228, 2013.

Author Bios Lynn Koch, PhD, CRC is a professor of Counselor Education in the Department of Rehabilitation, Human Resources and Communication Disorders at the University of Arkansas, Fayetteville. Dr. Koch received her Ph.D. in Rehabilitation Psychology from the University of Wisconsin-Madison in 1996. Prior to joining the faculty at the University of Arkansas-Fayetteville, she was a faculty member in the Rehabilitation Counseling Program and the Center for Disability Studies at Kent State University for ten years. Dr. Koch’s research interests include psychiatric rehabilitation, the persistence of students with disabilities in higher education, and the psychosocial and vocational impact of emerging disabilities.

Phillip Rumrill, PhD, CRC, is a Professor of Counselor Education and Director of Research and Training in the Human Development Institute at the University of Kentucky. Formerly, he was a faculty member and Director of the Center for Disability Studies at Kent State University in Ohio. Dr. Rumrill received a bachelor’s degree in Psychology from Keene State College in New Hampshire in 1989, a master’s degree in Counseling from Keene State College in 1991, and a Ph.D. in Rehabilitation in 1993. His research interests include workplace discrimination against Americans with disabilities, vocational rehabilitation services and outcomes for people with disabilities, and the employment implications of neurological disorders.

Kanako Iwanaga, Ph.D., CRC, LPC is an assistant professor in the Department of Rehabilitation Counseling, College of Health Professions, at Virginia Commonwealth University (VCU). She received her Ph.D. in rehabilitation counselor education from the University of Wisconsin-Madison and worked at Northern Illinois University prior to her arrival at VCU. Her research program has a focus on evidence-based rehabilitation counseling practices, demand-side employment, secondary transition, validation of psychological and vocational assessment instruments for people with disabilities from diverse backgrounds, and validation psychosocial intervention strategies to improve psychosocial and vocational outcomes of people with chronic health conditions and disabilities.

Jia-Rung Wu, PhD, is an assistant professor in the Department of Counselor Education, College of Education in Northeastern Illinois University. Dr. Wu received her PhD in rehabilitation psychology from UW-Madison in 2019. She is a certified rehabilitation counselor, and a licensed professional counselor in U.S.A. and licensed occupational therapist in Taiwan. Ms. Wu has more than 10 years of clinical rehabilitation experiences and published 25 refereed journal articles, and five book chapters. Her research interest areas including psychiatric rehabilitation, vocational rehabilitation, health promotion, the International Classification of Functionality, Disability and Health (ICF) model, demand-side employment, evidence-based practice, testing and assessment, and research methodologies.

Fong Chan, PhD, is the Norman L. and Barbara M. Berven Professor of Rehabilitation Psychology (Emeritus) in the Department of Rehabilitation Psychology and Special Education, University of Wisconsin-Madison (UW-Madison). Dr. Chan received his PhD in rehabilitation psychology from UWMadison in 1983. He has published over 300 peer-reviewed articles in the areas of neuropsychological assessment, multicultural rehabilitation, vocational and psychosocial adjustment to chronic health conditions and disabilities, demand-side employment, and research methodology.

Stuart Rumrill, MS, CRC, is a doctoral student in the Rehabilitation Counselor Education program at the University of Wisconsin-Madison. Stuart received his bachelor’s degree in Psychology at Kent State University in Ohio in 2017, and his master’s degree in rehabilitation counseling from the University of Arkansas in 2019. His research interests include employment and psychosocial aspects of people living with MS and TBI, transition-aged youth with disabilities, and co-occurring substance use disorders.

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Customized Employment and Return to Work for Individuals with Traumatic Brain Injury Holly Whittenburg, PhD • Jennifer McDonough, MS, CRC

In this paper, we will describe how customized employment (CE) can be used to support return to work for individuals with traumatic brain injury (TBI). Increased understanding of the CE process will allow medical and rehabilitation professionals to consider it as an option when planning collaboratively with patients, families, and rehabilitation professionals for return to work. We will also highlight ways in which medical and rehabilitation professionals can contribute to and participate in CE. In 2010, the year for which the most recent statistics are available, traumatic brain injury (TBI) accounted for approximately 2.5 million emergency department visits, hospitalization, and deaths for individuals in the United States (Centers for Disease Control and Prevention, 2015). While this statistic highlights the severity of medical problems for individuals experiencing TBI, challenges are often far-reaching and affect other critical areas such as employment, independent living, and personal relationships. TBIrelated symptoms, including memory issues, attention deficits, problems with executive functioning, and emotional dysregulation, can make a successful return to work post-injury challenging, with recent reported employment outcomes for individuals with TBI ranging from to 42.5% to 55% (Grauwmeijer et al., 2017; Scaratti et al., 2017). While previous research has extensively documented personal factors associated with return to work (i.e. severity of injury, cognitive functioning, educational attainment, employment status pre-injury; Ahonle et al., 2020; Mani et al., 2017; Scaratti et al., 2017; Wehman et al., 2005), we know less about service models that support a successful return to work.

Supported employment (SE) is an evidence-based practice that has been used since the 1980s to facilitate competitive, integrated employment outcomes for individuals with significant disabilities, including persons with TBI (Wehman et al., 2005). It is characterized by the use of qualified employment specialists who work with individuals with disabilities to get to know them, identify potential employment opportunities that match individuals’ interests, augment employer-provided training and implement needed workplace supports once hired, and promote job maintenance through regular contacts with the individual and employer (Wehman et al., 2018). More recently, CE has emerged as a new pathway to competitive, integrated employment for individuals with significant disabilities. CE focuses on the relationship between the job seeker and employer and meeting both parties’ needs.

22 BRAIN INJURY professional

It does this through informal observations/assessments to identify the individual’s strengths and interests and negotiating employment opportunities using job creation, job carving, and job sharing techniques (Jorgensen Smith et al., 2017). While these two service models are similar in some respects, they also differ substantively in their approaches. TABLE 1 provides descriptions of the essential features of SE and CE service models.

CE offers a new and promising approach in facilitating return to work for individuals with TBI for several reasons. First, it seeks to identify the job seeker’s strengths and interests, and then match the job seeker with businesses who have unmet needs that align with those strengths and interests. This approach changes the emphasis from searching for existing job openings to developing customized positions that are good fits for the job seeker and the business. In this way, CE opens up opportunities for successful employment for individuals with TBI who may not be able to perform all the essential functions of a standard position. Second, CE explicitly rejects the premise that individuals need to demonstrate they are ready for work before seeking employment, and instead focuses on providing individuals with the long-term supports and training they need to be successful within competitive, integrated work settings. This type of ongoing support and problem-solving may be helpful in addressing challenges individuals with TBI may experience over time after they return to work. Finally, CE has been used successfully with populations who have historically been excluded from employment, or who have been deemed “unemployable” through traditional vocational assessments. Individuals with moderate to severe TBI, who may have had similar assessment experiences post-injury, can benefit from this highly individualized and supportive approach to facilitating return to work.

Customized Employment and Return to Work

CE includes five essential, sequential components: discovery, vocational profile development, job development, job negotiation, and support after employment (Wehman, 2020). Each of these components can be utilized with individuals with TBI to support a successful return to work.

Discovery Discovery is the first step in CE, and it utilizes a qualitative approach to identify the job seeker’s strengths and interests. In contrast to traditional vocational assessments, discovery activities focus heavily on natural conversations with the job seeker and important people in their life and informal, but extensive, observations of the person in authentic settings in their community and neighborhood (Jorgensen Smith, 2017; Riesen et al., 2019). Qualitative data related to the job seeker’s hobbies, strengths, and interests obtained from these activities are used to identify vocational themes, which drive the development of the vocational profile and subsequent job development and negotiation.

When the discovery process is implemented with individuals with TBI, it shifts the focus from traditional, deficit-based vocational assessment to an individualized understanding of the person’s strengths and interests. Data obtained from interviews and observations in authentic settings the person frequents (e.g., favorite stores and restaurants, leisure activities, community organizations) are used to identify areas of career interest. This approach can be particularly helpful for individuals with TBI, who may have new interests post-injury, who may not know or be unable to convey their career aspirations, or who may be unsure about returning to work and could benefit from seeing how personal interests can be aligned with employment possibilities.

Vocational Profile Development The next step in the CE process focuses on development of the vocational profile. The vocational profile is a document that is created using the data obtained during discovery.

It highlights the job seeker’s strengths and interests, describes the ideal conditions for employment, and identifies several vocational themes (Riesen et al., 2019). These vocational themes form the basis of the plan for achieving employment (Jorgensen Smith et al., 2017) and can encompass specific areas of interest (e.g., health and nutrition, films, automobiles) and/or specific job seeker strengths (e.g., organizing, customer service, database management).

The creation of a vocational profile helps insure the interests and strengths of individuals with TBI are at the forefront of job development efforts. The vocational profile provides a roadmap for how strengths and interests will be incorporated into the job development process. It offers a planning tool the team can use to carefully consider the conditions that will be important for employment success (e.g., work hours, necessary training, on-thejob supports, work environment) and where the job search should be focused. This proactive planning facilitates a strong match between the individual with TBI’s strengths and the employer’s needs, which can promote job retention over time.

Job Development

Once the vocational profile has been created, job development begins. While traditional job development efforts focus on identifying existing job openings and finding candidates who meet the essential skill and knowledge requirements for those positions, job development in CE focuses on matching the job seeker’s strengths and interests with the unmet needs of employers. In other words, CE professionals do not scour websites to see who is hiring in order to find employment possibilities. Instead, they use the vocational profile to identify businesses where people with similar interests work (Griffin et al., 2008).

Table 1 Essential Features of Supported Employment and Customized Employment Supported Employment

Customized Employment

Brief situational assessments are used (i.e., trying out work tasks within employment settings to identify work interests and strengths) to identify potential job matches.

An intensive discovery process is used (i.e., open-ended interviews/conversations with the individual and important people in their lives, series of informal observations in settings that highlight the individual’s interests and strengths) to develop a vocational profile and identify employment themes.

Job development focuses on matching the individual’s employment interests and strengths with available job openings in the community.

Job development focuses on matching the individual’s strengths and interests with the unmet needs of employers. Through job negotiation, the individual’s representative works to customize a new position that meets the needs of both parties.

Job site training is used to help the individual master job tasks and responsibilities, enhance new employee training provided by the employer, and identify/put in place needed workplace accommodations and supports.

Job site training is used to help the individual master job tasks and responsibilities, enhance new employee training provided by the employer, and identify/put in place needed workplace accommodations and supports.

Planning for long-term supports and services occurs on an as-needed basis.

Planning for long-term supports and services occurs from the beginning of the customized employment process.

BRAIN INJURY professional 23

Then they arrange to spend time at those businesses to build relationships, learn more about business needs, and identify how the job seeker can help meet unmet needs of the business through job creation, job carving, and/or job sharing (Jorgensen Smith et al., 2017; Riesen and Morgan, 2018).

This approach has several advantages for individuals with TBI. It continues to ensure that the individual’s strengths and interests are prioritized. Importantly, it also removes barriers that may exist if the job seeker is unable to fulfill all of the essential skills and functions of a standard position in their area of interest. Finally, it provides for a deeper understanding of a specific business’ work processes, culture, and environment; knowledge of which can facilitate a strong employment match and the development of necessary supports for workplace success.

Finally, medical and rehabilitation professionals can advocate for and engage in additional research into the use of CE with individuals with TBI. Research is needed that systematically investigates the use of CE with individuals with TBI and identifies best practices for this population in order to improve return to work outcomes for individuals with TBI.

Job Negotiation

Once a match has been found between the job seeker’s strengths and interests and the unmet needs of an employer, the CE professional negotiates a customized position. This could be for an entirely new created position, a position that focuses on several existing key job tasks, or a position that re-assigns specific responsibilities from other employees. Job negotiation culminates in a written employment proposal, which describes job responsibilities, workplace supports and services, work schedule, job arrangement, and supervision structure for the customized position (Riesen and Morgan, 2018). After the proposal has been reviewed and accepted by the employer and the job seeker, the job seeker is ready to start work.

Jorgensen Smith T. Dillahunt-Aspillaga CJ. Kenney RM, Implementation of customized employment provisions of the Workforce Innovation and Opportunity Act within vocational rehabilitation systems. J Disabil Policy Stud. 27: 195-202, 2017.

References Ahonle ZJ. Barnes M. Romero S, et al., State-federal vocational rehabilitation in traumatic brain injury: What are predictors associated with employment outcomes? Rehabil Couns Bull. 63: 143-155, 2020.

Centers for Disease Control and Prevention. Report to Congress on traumatic brain injury in the United States: Epidemiology and rehabilitation. https://www.cdc.gov/traumaticbraininjury/pdf/TBI_Report_to_ Congress_Epi_and_Rehab-a.pdf 2015.

Grauwmeijer E. Heijenbrok-Kal M. Haitsma IK, et al., Employment outcome ten years after moderate to severe traumatic brain injury: A prospective cohort study. J Neurotrauma. 34: 2575-2581, 2017.

Griffin C. Hammis D. Geary, T, et al., Customized employment: Where we are; where we’re headed. J Vocat Rehabil. 28: 135-139, 2008.

Mani K. Cater B. Hudlikar, A, Cognition and return to work after mild/moderate traumatic brain injury: A systematic review. Work. 58: 51-62, 2017.

Riesen T. Hall S. Keeton B, et al., Customized employment discovery fidelity: Developing consensus among experts. J Vocat Rehabil. 50: 23-37, 2019.

Riesen T. Morgan RL. Employer views of customized employment: A focus group analysis. J Vocat Rehabil. 49: 33-44, 2018.

Scaratti C. Leonardi M. Sattin D, et al., Work-related difficulties in patients with traumatic brain injury: A systematic review on predictors and associated factors. Disabil Rehabil. 39: 847-855, 2017.

Wehman P: Essentials of Transition Planning, 2nd ed. P Wehman (ed.) Baltimore, Md: Paul H. Brookes, 2020.

Wehman PH. Targett PS. Avellone LE, Educational and vocational issues in traumatic brain injury. Phys Med Rehabil Clin N Am, 28: 351-362, 2017.

Wehman P. Targett P. West M, et al., Productive work and employment for persons with traumatic brain injury: What have we learned after 20 years? J Head Trauma Rehab, 20: 115-127, 2005.

Wehman P. Taylor J. Brooke V, et al., Toward competitive employment for persons with intellectual and developmental disabilities: What progress have we made and where do we need to go. Res Pract Persons Severe Disabl, 43: 131-144, 2018.

Support After Employment Involvement of Medical and Rehabilitation Professionals

Collaborative planning for patient discharge and return to work offers opportunities for medical and rehabilitation professionals to discuss CE with patients, families, and adult service providers.

Clinicians may want to consider CE with individuals whose severity of injury precludes them from returning to the same positions they performed pre-injury, who performed poorly on traditional vocational assessments, and/or who may not be able to perform all the essential functions of a standard position. Describing how job creation, job sharing, and job carving can be used in CE to facilitate return to work provides patients and families with critical information to consider as they plan for the future. If patients are interested in learning more about CE, then clinicians should have contact and referral information available for the local offices of their state vocational rehabilitation agency, as these agencies are the entities responsible for evaluating the need for and the provision of CE services.

It is also important for medical and rehabilitation professionals to maintain ongoing communication with teams as individuals are discharged and engage in the return to work process. For individuals with TBI who participate in CE services, continued collaboration between clinicians and service providers is critical. During the discovery process, clinicians can help teams identify the strengths and interests of the individual with TBI, based on their own informal observations of and interactions with the patient. Clinicians can also provide valuable information about any potential work restrictions, help evaluate the reasonableness of negotiated work tasks and responsibilities, indicate when return to work would be appropriate, and share information about possible workplace supports and accommodations (Wehman et al., 2017).

24 BRAIN INJURY professional

Author Bios Holly Whittenburg, PhD, is an assistant professor in the Department of Teaching and Learning at Washington State University. Before that, she worked as a research site coordinator for the Virginia Commonwealth University Rehabilitation Research and Training Center. Holly has also worked as a special education teacher, district-level administrator, and employment specialist.

Her research interests include interventions for teaching workrelated skills to students with developmental disabilities, the effect of federal and state policies on transition services for youth with disabilities, and approaches to improve employment outcomes for young adults with disabilities.

Jennifer Todd McDonough, MS, CRC, is a faculty member at Virginia Commonwealth University (VCU) and has been working in the field of employment for people with disabilities for over 20 years. She earned her M.S. from the Medical College of Virginia at Virginia Commonwealth University in Rehabilitation Counseling.

Ms. McDonough is the Associate Director of Training at VCU-RRTC. She is also the Project Director for two national research studies related to work and disabilities. Ms. McDonough is a national expert on Social Security Disability Benefits and Work Incentives.

She also serves as the Virginia Project SEARCH Statewide Coordinator.

Textbook of Traumatic Brain Injury, Third Edition Edited by Jonathan M. Silver, M.D., Thomas W. McAllister, M.D., and David B. Arciniegas, M.D.

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espite the increased public awareness of traumatic brain injury (TBI), the complexities of the neuropsychiatric, neuropsychological, neurological, and other physical consequences of TBI of all severities across the lifespan remain incompletely understood by patients, their families, healthcare providers, and the media.

Keeping pace with advances in the diagnosis, treatment, and science of TBI, the Textbook of Traumatic Brain Injury, Third Edition, comprehensively fills this gap in knowledge. Nearly all 50 chapters feature new authors, all of them experts in their field. The Textbook of Traumatic Brain Injury is a must-read for all of those working in any of the multitude of disciplines that contribute to the care and rehabilitation of persons with brain injury. This new volume is also a potentially useful reference for policymakers in both the public and private sectors.

2019 • 985 pages • ISBN 978-1-61537-112-9 • Hardcover • $195.00 • Item #37112 2019 • 985 pages • ISBN 978-1-61537-247-8 • eBook • $156.00 • Item #37247 Order @ www.appi.org Email: appi@psych.org | Phone:1-800-368-5777 20% Discount for American Psychiatric Association Members 25% Discount for APA Resident-Fellow Members

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Canoeing at Vinland’s main campus in Loretto, Minnesota

drug & alcohol treatment for adults with disabilities Vinland Center provides drug and alcohol treatment for adults with cognitive disabilities, including traumatic brain injury, fetal alcohol spectrum disorder and learning disabilities. We make all possible accommodations for cognitive deficits and individual learning styles.

Located in Loretto, Minnesota — just 20 miles west of Minneapolis.

(763)479-3555 • VinlandCenter.org BRAIN BRAININJURY INJURYprofessional professional 2521

Clearer photo?

BIP

expert interview

with Cynthia Young, MS, CRC Cynthia Young is a Vocational Rehabilitation Counselor at the Central Virginia VA Health Care System in Richmond, Virginia and a team member of the Service member Transitional Advanced Rehabilitation (STAR) Program.

You are a Vocational Rehabilitation Counselor at a Polytrauma Transitional Rehabilitation program. What is the role of a Vocational Rehabilitation Counselor in such a center?

As a Vocational Rehabilitation Counselor (VRC) at the Polytrauma Transitional Center (PTC) Service Member Transitional Advanced Rehabilitation (STAR) program, each day is an opportunity to lead, to collaborate and to create on a programmatic level, and to serve the Active Duty Service Members and Veterans (patients) of the STAR Program by providing comprehensive rehabilitation counseling services.

From a programmatic perspective, the STAR program VRCs are involved in the development and implementation of program priorities, marketing, researching, and creating and implementing outcome data. The most important and very rewarding role of the VRCs is providing daily, one-onone comprehensive vocational services to each patient/Service Member/Veteran in the program.

Could you describe a bit about what a veteran with TBI experiences during their stay at a polytrauma transitional rehabilitation program from the day of admittance to exit? How are return to different areas of life addressed, including employment?

The Polytrauma Transitional Center is a single-story, 20-bed transitional rehabilitation facility. The patients live in single-occupancy rooms, equivalent to a hotel room with a full-size bed, accessible bathroom, and typical hotel room furniture. The patients share the kitchen area, laundry room, and common areas. To qualify for our programs, the Service Member/Veteran needs to be moderately independent with Activities of Daily Living (ADLs), capable of participating in a rigorous 6-8 hour therapy day, and demonstrate motivation to engage in vocational and community-based therapies. The program ranges in duration from 45 – 90 days, based on the patient’s goals.

Within the first week, each patient is evaluated by the therapeutic team and is provided with the level of support needed to progress while in the program. A patient’s schedule is typically filled with one-hour therapy blocks, in addition to larger blocks of time allotted for Therapeutic Community Events (TCEs). The emphasis of our program is on community reintegration, therefore, we “treat” within the community as often as possible. For example, Occupational Therapy, Physical Therapy, Recreational Therapy, and Vocational Rehabilitation provide one-on-one and group sessions in-clinic and in the community to address the patient’s leisure, social, physical, daily living, mental health, and vocational goals.

An advantage to being a “residential” program is that our patients rarely miss a scheduled therapy session or neglect their homework assignments. As one patient jokingly put it, “I live here, what else am I going to do?” The residential setting also provides a patient milieu that tends to be a supportive aspect of the patient’s recovery. The patients often “hang out” together during meals and after therapies.

Regarding employment, our patient population is comprised of 80% active duty Service Members and 20% Veterans, therefore, from a vocational rehabilitation perspective, most of our patients are “employed” (still on active duty) upon entry and exit from the STAR program. For this reason, our vocational services are directed toward planning and preparation for transition from military to civilian employment and education, and toward assistance with identifying and connecting to community, business, and educational resources in line with the Service Member’s goals.

In your experience, what role does return to work play in a veteran’s physical and mental recovery following a polytrauma TBI injury?

Work plays a HUGE role in a Veteran’s overall physical and mental recovery after TBI. Our patients state that returning to work gives them “purpose to recover” and “gives hope.”

We administer various assessments including pre and post VR service surveys. In the “Work Perception Assessment” the patient rates 10 statements as either Strongly Agree, Agree, Disagree, or Strongly Disagree. The first statement, “Work is important to my well-being” is consistently rated as “Strongly Agree” as are other questions such as “Work gives me a sense of accomplishment and value” and “Work gives me purpose.” Many of the patients comment verbally and in writing on post-service surveys that if the work component were not integrated into the therapy program, their motivation to participate would be significantly diminished.

For example, a Navy officer recently came to our program from a large military medical center. From his perspective, that facility provided “good medical care,” but, the care only emphasized that he was “broken.”

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Pull out quote here.

In his first VR session he asked, “How am I going to take care of my wife and four children if I am not able to return to duty?” When he first arrived at our program, he acknowledged that he felt discouraged, hopeless, and was not actively engaging in the therapies. As a result of creating a viable vocational plan and introducing him to Veteran employment opportunities in his local community, he said, “Now, I feel like I have hope” and, “I like that I can try to see what I can accomplish as I recover.” He actively engaged in the therapies and made gains in his recovery to the point that when his wife visited, she said, “I honestly did not recognize him at first” (and she commented on how confident he was carrying himself). In his STAR program discharge paperwork he wrote, “Honestly, I feel wonderful about myself and my future again. Thank you. Thank you for your help.”

Over the course of your career, what advancements in technology or evidenced-based practices have you seen that have been most influential in helping veteran’s with polytrauma TBI injury return to work?

Advancements in technology are likely influencing Veteran’s return to work, however, it is important to acknowledge the employment climate we are currently in and how this assists Veterans with return to work issues. In her article, “Vet unemployment hit an all-time low in 2018.

Mission accomplished?” Natalie Gross stated, “leaders across federal and state governments, some of America’s most well-known companies and veterans services organizations sprang into action” about eight years ago when unemployment rates for Veterans were at an all-time high.

In fact, it was a little over eight years ago (January 2012) that our program, the STAR program, opened its doors in response to a need for more vocational rehabilitation and transition services within the active duty military rehabilitation process. It was in 2011 when the U.S. Chamber of Commerce Foundation launched the Hiring our Heroes (HOH) initiative. The Department of Defense (DoD) has the Operation Warfighter program, and around 2014, created the “Job Training, Employment Skills Training, Apprenticeships, and Internships (JTEST-AI) for Eligible Service Members DODI 1322.29” (also known as the “SkillBridge” program). These programs assist transitioning Service Members with internships and training opportunities that can lead to permanent employment. Beyond DoD initiatives, many companies have volunteered to create Veteran hiring initiatives. In Virginia, the “Virginia Values Veterans, V3 Program” has over 1100 certified companies that have completed trainings, and over 60,000 Veterans who have been hired by V3 certified companies.

In our program, we have the most success when we connect to Veteran groups within a company. For instance, we interact on a regular basis with representatives from Capital One’s Military Business Resource Group (BRG) and Northrop Grumman’s Operation IMPACT program. We have also found that even small companies often have an informal or formal military/Veteran group willing to assist transitioning Service Members and Veterans with career support.

The landscape of work is changing. More individuals are working remotely, working non-traditional hours, and changing careers later in life.

As you look to the future, are there any changes you expect to see in how your field assists veterans with polytrauma TBI to prepare for these differences when returning to work.

Changes in the employment landscape demand employment services stay connected to trends, technology, and remain flexible. Our program has an advantage with our emphasis on connecting to the community and individualizing the program to each person’s goals. For this reason, we are constantly meeting with employers and community resources and learning about new trends.

Previously, the ability to work remotely varied among companies and job titles. For instance, one of our patients, a retired Army Master Sergeant, went to work at the Defense Logistics Agency after retiring from the Army. DLA’s policy at that time required employees to work a year before being granted remote work access. Once he “earned” the ability to work from home, he shared that he works “more productively” when he is at home because he is able to eliminate distractions. I imagine that in the wake of the COVID-19 crisis where so many were required to work from home, remote work will be an option even in jobs where it was not previously an option.

About the Interviewer Lauren Avellone, PhD, BCBA, is an assistant professor at Virginia Commonwealth University (VCU) and staff member at the Rehabilitation Research and Training Center and VCU.

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A Cognitive Support Technology Program for Postsecondary Students with TBI Christina Dillahunt

Notably, more than 60percent of Project Career students had sustained TBIs that were classified as severe. Of the 50 Project Career students who graduated from their degree programs during the initiative, 49 are currently employed and/or pursuing further education. This constitutes a 98 percent rate of productive career engagement.

Funded by the National Institute on Disability, Independent Living, and Rehabilitation Research, Project Career (2013-2019) was a sixyear intervention development project that applied the Cognitive Support Technology (CST) model to the academic and career preparatory needs of postsecondary students with TBIs in Ohio, Massachusetts, and West Virginia. Project Career utilized iPads and cognitive-enhancement mobile applications or ‘apps’ as the CST platform, with the goal of improving participants’ prospects for academic success, competitive employment, and long-term quality of life. Following an in-depth assessment of their cognitive functioning and needs for CST strategies, Project Career students were provided with the following supports: •

An active network of professional mentors, faculty advisors, and employers in their chosen fields

•

Free use of iPad tablet computers and Internet access

•

A menu of more than 400 mobile apps that were used with their iPads to help them compensate for cognitive limitations, with each student selecting the specific apps that work best for him or her

•

Intensive vocational case management, assessment, job development and placement, field-based work experiences and internships, and assistance with classroom and on-thejob accommodations provided by Certified Rehabilitation Counselors

•

An electronic portal of TBI and employment resources housed at the Job Accommodation Network at West Virginia University.

Results from Project Career revealed that participating students (N=150) increased their mean grade-point average from 2.6 to 3.25; reported significant gains in life satisfaction, acceptance of disability, use of CST strategies, psychosocial adjustment, general health status, career preparatory activities, comfort with assistive technology, and social capital; and maintained their participation in their degree programs at an 87.5% rate of persistence.

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Mykal is a 26 year-old Army veteran who sustained a severe TBI while serving in Iraq. His symptoms include short-term and longterm memory deficits, problems with executive functioning, depression, and fine motor impairments. Mykal enrolled in Project Career in 2016, while he was pursuing a bachelor’s degree in computer science. Project Career case managers trained Mykal in the use of his iPad, and they identified seven commercially available apps to support his cognitive functioning, study skills, and career planning efforts. During his undergraduate studies, Mykal worked part-time with a computer software firm that develops billing systems for the healthcare industry. Mykal performed so well in this job that the company hired him into a full-time Software Analyst position upon his college graduation in 2019.

Mykal is living proof that widely available and low-cost technology can be used to combat TBI-related cognitive limitations and help people with TBI realize their educational and career goals. Mykal also demonstrates the resilience of the brain and the human spirit. The Project Career team is very proud of the remarkable accomplishments of Mykal and the other 149 individuals who took part in the initiative. Currently, the Project Career team is implementing a randomized clinical trial (RCT) at the intervention efficacy stage of knowledge generation with a new sample of 90 college and university students with TBI. For more information about Project Career or the ongoing RCT, please contact Dr. Phillip Rumrill of the University of Kentucky’s Human Development Institute at phillip.rumrill@uky.edu.

Author Bio Christina Dillahunt

Save the Date!

Inaugural Conference on

Disorders of Consiousness Abstract Submission Opens March 2021! www.internationalbrain.org

Program Committee

Caroline Schnakers, PhD (USA)

Roberto Llorens, PhD (Spain)

Nathan Zasler, MD (USA)

Enrique Noé, MD, PhD (Spain)

A joint conference organized by the International Brain Injury Association and the Universitat Politècnica de València

October29-October 27 – 29, 2021 September 1, 2020

Valencia, Spain

BRAIN INJURY INJURY professional professional 29 19 BRAIN

Restore-Ragland

Restore-Roswell

Restore-Lilburn

Restore Neurobehavioral Center is a residential, post acute healthcare organization dedicated exclusively to serving adults with acquired brain injury who also present with moderate to severe behavioral problems.

Services range from intensive inpatient neuro-rehabilitation and transitional community re-entry services to long term supported living services. Restore Neurobehavioral Center, located in a suburb north of Atlanta, is the site of our inpatient post acute neuro-rehabilitation program as well as one of our supported living sites. We operate two other community living sites, Restore-Lilburn (GA) and Restore-Ragland (AL).

www.restorehealthgroup.com 800-437-7972 ext 8251 BRAIN INJURY PROFESSIONAL

A Nationally Recognized Leader in Brain Injury Care and Research The Center for Brain Injury Recovery at Kennedy Krieger Institute is a leading research institution offering comprehensive brain injury care, from concussion to severe brain injury, including inpatient and outpatient services, and telehealth consultations and care.

To learn more or make an appointment at our Baltimore area locations, visit KennedyKrieger.org/BrainInjuryCenter or call 443-923-9400.

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NEUROREHABILITATION & RESEARCH HOSPITAL

BRAIN INJURY professional 31

PHOTO BY HERMAN PRIVETTE

Madison Schwartz, Stanford Law, Randall H. Scarlett, Randall A. Scarlett, Ronnie Pang, Olga Rios, Mary Anne Scarlett, and Brendan D. Nay.

SCARLETT LAW GROUP Scarlett Law Group is a premier California personal injury law firm that in two decades has become one of the state’s go-to practices for large-scale personal injury and wrongful death cases, particularly those involving traumatic brain injuries.

With his experienced team of attorneys and support staff, founder Randall Scarlett has built a highly selective plaintiffs’ firm that is dedicated to improving the quality of life of its injured clients. “I live to assist people who have sustained traumatic brain injury or other catastrophic harms,” Scarlett says. “There is simply no greater calling than being able to work in a field where you can help people obtain the treatment they so desperately need.”

To that end, Scarlett and his firm strive to achieve maximum recovery for their clients, while also providing them with the best medical experts available. “As a firm, we ensure that our clients receive both

the litigation support they need and the cutting-edge medical treatments that can help them regain independence,” Scarlett notes.

Scarlett’s record-setting verdicts for clients with traumatic brain injuries include $10.6 million for a 31-year-old man, $49 million for a 23-year-old man, $26 million for a 7-year-old, and $22.8 million for a 52-year-old woman. In addition, his firm regularly obtains eight-figure verdicts for clients who have endured spinal cord injuries, automobile accidents, big rig trucking accidents, birth injuries, and wrongful death.

Most recently, Scarlett secured an $18.6 million consolidated case jury verdict in February 2014 on behalf of the family of a woman who died as a result of the negligence of a trucking company and the dangerous condition of a roadway in Monterey, Calif. The jury awarded $9.4 million to Scarlett’s clients, which ranks as

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one of the highest wrongful death verdicts rendered in recent years in the Monterey County Superior Court.

“Having successfully tried and resolved cases for decades, we’re prepared and willing to take cases to trial when offers of settlement are inadequate, and I think that’s ultimately what sets us apart from many other personal injury law firms,” observes Scarlett, who is a Diplomate of the American Board of Professional Liability Attorneys.

In 2015, Mr. Scarlett obtained a $13 million jury verdict for the family of a one year old baby who suffered permanent injuries when a North Carolina Hospital failed to diagnose and properly treat bacterial meningitis that left the child with severe neurological damage. Then, just a month later, Scarlett secured an $11 million settlement for a 28-year-old Iraq War veteran who was struck by a vehicle in a crosswalk, rendering her brain damaged.