On The Future of Vocational Rehabilitation
Remarks of Susan H. Connors, President/CEO
Brain Injury Association of America to
Council of State Administrators of Vocational Rehabilitation
February 14, 2006
My name is Susan Connors. I am the President/CEO of the Brain Injury Association of America. I’d like to thank Carl Suter and CSAVR’s staff and members for the invitation to this meeting. We have enjoyed a long-standing and collaborative relationship with CSAVR and many state vocational rehabilitation agencies.
Background
A traumatic brain injury (TBI) is a blow or jolt to the head arising from blunt or penetrating trauma or from acceleration/deceleration forces in the skull that result in a decreased level of consciousness.
According to the CDC, 1.4 million Americans sustain a TBI each year, and 475,000 of those injuries are to children.
There are at least 5.3 million Americans living with a long-term disability as a result of TBI – that’s about 2 percent of the US population overall and about 10 percent of the disability population.
CDC estimates the cost to society at $56 billion per year.
People of every age, gender, race, religion and socioeconomic status experience brain injuries. Adolescent males are at highest risk for traumatic injuries, which are caused by falls, motor vehicle crashes, assaults, sports, and other means.
Improvised Explosive Devices (IEDs) are responsible for at least 1700 recent blast brain injuries in Iraq and Afghanistan. An unknown, untreated number of concussions, which are also brain injuries, are being sustained in this war.
Brain injury can arise not only from trauma but from a variety of other causes such as stroke, aneurysm, infection, toxic exposure, lack of oxygen to the brain and tumor. Stroke alone accounts for another 700,000 brain injuries in the U.S. per year.
Both traumatic brain injuries and acquired brain injuries can lead to physical, cognitive, and psychosocial or behavioral impairments that range from balance and coordination problems to loss of hearing, vision or speech; fatigue; memory loss; concentration difficulty; anxiety, depression, impulsivity; and impaired judgment.
Employment Rates & Predictors
Despite the complexity of deficits, return to work is possible!
Return to work rates vary from 19% to 88% based on the definition of “work,” population involved, and time post injury. One study that included multiple ages and severity levels showed 66% of individuals had returned to school or were engaged in a “work activity” at 16 ½ months after injury.
The rate of job separations ranges between 14 to 22% with two-thirds of fall offs occurring in the first six months. There’s a similar decline for non-competitive placements.
Brain injury recovery occurs over time.
There is no reliable means of determining exactly when vocational rehabilitation should be undertaken. Some studies have found that age is one predictor, with younger individuals more likely to progress to work than older persons. Yet, other studies suggest there are no age or race differences in VR outcomes.
Neither the Glasgow Coma Scale nor duration of post traumatic amnesia are predictive of return to work, particularly for individuals with so called “moderate” injuries. Pre-injury education and previous work experience are employment predictors as is access to VR services.
Barriers
Individuals with brain injury face numerous challenges in almost every aspect of life, including accessing vocational rehabilitation. In a study published 10 years ago, only 34% of individuals with TBI were aware of VR services at one year post injury. We’re doing better than that now, but there are still barriers including,
· Lack of identification – the brain injury may be unknown, even by those who’ve sustained it.
· Inadequate medical treatment – people with brain injury are being discharged sicker and quicker. Between 1990 and 1999, lengths of stay for hospitalization and rehabilitation combined were cut by 30 days.
· Lack of training and/or experience among VR counselors in working with individuals with brain injury – there is a marked failure to accommodate for cognitive and psychosocial impairments, which are no more willful than physical disabilities.
· Inadequate public and private funding – interpersonal skills and impaired cognitive functioning are cited as the most frequent cause of employment loss; yet, funding for treatment and rehabilitation in these deficit areas is insufficient, if there is funding at all.
· Financial disincentives and system flaws – my files are filled with stories about how Ticket to Work doesn’t work for people with brain injury.
Models in Brain Injury
The traditional VR approach—seeking out jobs, filling out applications, modifying a work setting, and placing the individual doesn’t work in brain injury. Neither does attempts to return individuals to their previous work environments where their performance is scrutinized by those who are most familiar with their pre-injury skills.
Inadequate treatment, rehabilitation and other return to work preparation for the individual and the employer virtually ensures that people with brain injury will be unable to succeed at their pre-injury work levels immediately upon returning to the workforce.
Early and repeated job failures add insult to injury, causing further emotional and psychological harm.
Supported employment of sufficient intensity and duration, with the use of job coaches, on-the-job compensatory strategies, and work hardening experiences, is most efficacious. Follow-up and on-going adaptation is critical for the brain injury population.
Research conducted by NIDRR’s TBI Model Systems shows VR is most beneficial to persons with the most significant impairments; that men benefit from VR services more than women; urban clients benefit more than rural clients; and telehealth services may be appropriate for VR clients with TBI.
Recommendations
CSAVR members may be familiar with my recommendations. They are:
1. Specialty Counselors – I have a crazy notion that if I keep saying it enough, some day there will be specialty counselors in every state. Where such counselors exist and where their caseloads are tailored to fit the needs of our population, we tend to see more realistic goals based on strengths, persistence in exploring options, creative approaches to funding higher education, and identification of natural supports in the workplace.
2. Flexible Services and Supports – I can’t give you a laundry list of standardized needs because brain injury is complex, needs change over time, and no two injuries are alike. One thing I can tell you is that TBI clients are likely to need a broader scope and longer duration of services and supports.
3. Accept & Accommodate Cognitive Challenges – There are two sides to this coin. While I believe deeply in individually-centered, consumer-directed services and the dignity of risk, I recognize that we’re asking individuals with cognitive impairments, many of whom don’t recognize their own deficits, to navigate a complicated, bureaucratic public system. We have a responsibility to accommodate cognitive impairments in every aspect of VR—whether it is in applying for services, participating in training programs, or selecting placement. In part, this means providing assistance in making choices when necessary.
4. Citizen Advisory Councils – In the last 10 years I’ve learned a lot about brain injury from professionals and family members, but it is the individuals with brain injury who taught me the most. Independent commissions must be representative of the diversity of consumer needs.
5. Readiness Standards – Employers are not prepared to provide all the supports and services needed to return a person to work following brain injury, particularly when the individual has not received appropriate and sufficient medical and vocational rehabilitation. It is crucial that standards be developed for determination of vocational rehabilitation readiness following medical rehabilitation.
In summary, brain injury is challenging for the individuals who are injured and for the professionals who work with them. And while competitive employment may well represent the pinnacle of achievement, it is not beyond our reach. Individuals with brain injury deserve the same opportunity for independence and life satisfaction as all other members of the disability community. Specialty counselors, individualized services, cognitive accommodations, consumer input, and readiness standards will put us on that pathway.
The Brain Injury Association of America and its nationwide network of affiliated chapters would welcome the opportunity to partner with public VR in training and technical assistance or other programs. To learn more about us or the NIDRR-funded model systems, assistive technology and self-employment initiatives, please visit www.biausa.org.
