Vocational Rehabilitation Services and Outcomes for ...

J Head Trauma Rehabil c 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright

Vocational Rehabilitation Services and Outcomes for Transition-Age Youth With Traumatic Brain Injuries Phillip Rumrill, PhD; Paul Wehman, PhD; Robert Cimera, PhD; Cahit Kaya, PhD; Chad Dillard, MD; Fong Chan, PhD Objective: This study examined data provided by the US Department of Education’s Rehabilitation Services Administration (RSA) in an effort to evaluate the relationship between (a) demographic variables and vocational rehabilitation (VR) services and (b) the employment outcomes of transition-age youth with traumatic brain injuries. Setting: Not applicable. Participants: Data for 1546 transition-age youth (ie, 16-25 years of age) with traumatic brain injuries were examined. Design: Purposeful selection of multivariate logistic regression was employed to analyze the data. Main Measures: Not applicable. Results: Receipt of more VR services at higher expenditure levels over shorter periods of time was related to case closure in successful competitive employment status. Also, higher levels of education at the time of enrollment in the VR program (ie, bachelor’s degrees or higher); nonreceipt of social security disability benefits at the time of enrollment in the VR program; and receipt of VR services such as occupational/vocational training, job search, job placement, on-the-job support, maintenance, and information/referral were associated with competitive employment outcomes. Conclusion: Client demographic and VR service–related variables significantly predict competitive employment outcomes for transition-age youth with traumatic brain injuries. Vocational rehabilitation services should focus on the specific interventions that are most closely associated with successful rehabilitation. Key words: transition-age youth, traumatic brain injuries, vocational rehabilitation

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RAUMATIC BRAIN INJURY (TBI) is the leading cause of death and lifelong cognitive disability among Americans younger than 45 years.1 It is estimated that 1.7 million people in the United States are currently living with TBIs.2 Unfortunately, the prevalence of TBI is increasing among transition-age youth (ie, people between the ages of 16 and 25 years).3 In 2009, 248 418 children were treated in the United States for TBIs caused by sports- and recreation-related

Author Affiliations: Center for Disability Studies, Kent State University, Kent, Ohio (Drs Rumrill and Cimera); Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond (Drs Wehman and Dillard); and Department of Rehabilitation Psychology and Special Education, University of Wisconsin-Madison, Madison (Drs Kaya and Chan). The contents of this article were developed under 2 grants from the United States Department of Education, NIDRR grant #H133A130066 and NIDRR grant #H133A100007. However, those contents do not necessarily represent the policy of the Department of Education, and readers should not assume endorsement by the Federal Government. Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal’s Web site (www.headtraumarehab.com). The authors declare no conflicts of interest. Corresponding Author: Phillip Rumrill, PhD, Department of Rehabilitation Counseling, Kent State University, 413 White Hall, 150 Terrace Dr, Kent, OH 44242 ([email protected]). DOI: 10.1097/HTR.0000000000000186

activities; this represents a 57% increase since 2001.4 This increased incidence of TBIs among young people is occurring in addition to the high incidence of TBIs that are sustained as a result of military combat.5 Indeed, as many as 10% of American soldiers who have served in the Iraq and Afghanistan military theatres have sustained TBIs.6 For these individuals, the multisystemic effects of TBI can dramatically influence their career aspirations,7,8 prospects for higher education,7,8 and community living choices during this critically important developmental period.9 Employment outcomes for people with TBI lag far behind those of the general population. Whether the brain injury is mild or more severe, many obstacles related to the physical, emotional, and cognitive symptoms of TBI prevent people from successfully finding and keeping jobs. Looking for job leads, keeping track of appointments, and going on interviews are frequently overwhelming. On the job, adapting to change and interacting with coworkers may become problematic. Forgetting a meeting, giving a customer the wrong change, or not understanding a coworker’s joke may affect the person’s performance and job satisfaction.10,11 Indeed, it has been reported that 75% of persons with TBI who return to work lose their jobs within 90 days if they do not have adequate job retention supports, such as assistive technology and other reasonable accommodations.3 1

Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

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JOURNAL OF HEAD TRAUMA REHABILITATION

Even when a person with TBI is successfully employed, he or she may subsequently need help when adapting to changes in job or life situations.12 Toriello et al5 cited the loss of social supports that often accompanies TBI, changes in one’s cognitive abilities as a result of injury, and employers’ lack of understanding of how to accommodate workers with TBI as 3 major reasons for the difficulties that people with TBI have in maintaining their careers postinjury. Postsecondary students with TBI, many of whom are young adults in the midst of other life transitions, face numerous academic and career preparatory challenges related to their cognitive, emotional, and psychosocial problems.13 These challenges may be evident in students with all types of TBI, including concussions and other injuries that have traditionally been considered “mild” in their impact and intrusiveness.14 Although about 80% of college and university students with TBI report problems performing in their academic settings, less than half report using campus disability services and only 20% report being aware of support services in the community.14 The state-federal vocational rehabilitation (VR) program provides services to individuals with actual or potential work disabilities,15 spending more than $2.5 billion per year for services ranging from assessment, diagnosis, medical services, and counseling to training, job placement, and job retention services.16 People with TBI tend to underutilize VR services; only one-third of Americans with TBI have ever heard of the state-federal VR program, and 5% to 6% receive state VR services.17 This is especially problematic for transition-age youth with TBI, whose lack of experience in the world of work and other adult life roles makes them particularly vulnerable to the cycle of joblessness and poverty that is an all-too-frequent accompaniment of the disability experience in contemporary American society.18 The relationship between VR services and employment outcomes for this vulnerable and often disenfranchised population is not well understood, but, if it were, rehabilitation professionals could tailor VR interventions that have the greatest likelihood of success for transition-age youth with TBI. The present study retrieved data from the US Department of Education, Rehabilitation Services Administration’s (RSA) Case Service Report (RSA-911) database, which documents demographic variables, VR services, and employment outcome information on all individuals who receive services from the state-federal VR program. The purpose of the present study was to analyze the RSA-911 data to evaluate the relationship between (a) certain demographic variables and VR services and (b) the employment outcomes of transition-age (16-25 years) people with TBI who participated in VR services.

The following research questions were posed for this study: 1. Controlling for demographic and disability benefits covariates, are the types of VR services received related to successful competitive employment outcomes among transition-age youth with TBI? 2. What specific VR services are associated with successful competitive employment outcomes for transition-age youth with TBI? METHODS Participants The sample in this study consisted of 1546 youth with TBI between the ages of 16 and 25 years at the time of application whose VR cases were closed as either successful (ie, competitively employed in integrated community work settings) or not successful (ie, all other case closures) in federal fiscal year 2011. These VR clients had a mean age of 20.11 years (SD = 2.69). Thirtythree percent of the participants were women and 67% were men. Participants’ racial and ethnic backgrounds were predominantly white (72.6%), followed by 13.1% African American, 9.6% Hispanic/Latino, 2.5% Asian, and 2.1% American Indian. Six percent of the participants had coexisting depression or other mood disorders as a secondary disability. About 63% of the participants were social security beneficiaries at the time of application for VR services. A full representation of the demographic characteristics of the participants is presented in Table 1. Variables Predictor variables Two sets of predictor variables were used in this study, the first of which consisted of demographic covariates, including age, gender, race/ethnicity, education level at the time of enrollment in VR services, coexisting depression or other mood disorders, and receipt of disability benefits (supplemental security income [SSI]/social security disability insurance [SSDI]). The second set of predictor variables consisted of VR services provided to transition-age youth with TBI. Vocational rehabilitation services include diagnostic and evaluation, training, educational, medical restoration, job placement, employment maintenance, and other services. A list of VR services is available as Supplemental Digital Content, available at http://links.lww.com/JHTR/A152. Outcome variable The outcome variable for this study was competitive employment. Rehabilitation Services Administration


Traumatic Brain Injury and Vocational Rehabilitation TABLE 1

Characteristics of the study

sample Characteristic Age, y 16-18 19-22 23-25 Gender Female Male Race White Black or African American Hispanic or Latino Asian or Pacific Islander American Indian or Alaska Native Education Special education Less than high school High school Associate degree Bachelor’s degree or higher SSI/SSDI at application Yes No Secondary impairments at application No secondary impairments Sensory and communicative impairments Physical impairments Mental impairments Medical insurance at application Yes No Significant disability Yes No Case service variables Eligibility to closure (in months) = Mean (SD) Number of services = Mean (SD) Case expenditures = Median

Total N (%) 579 (37.5) 597 (38.6) 370 (23.9) 507 (32.8) 1039 (67.2) 1123 (72.6) 203 (13.1) 148 (9.6) 39 (2.5) 33 (2.1) 168 (10.9) 609 (39.4) 484 (31.3) 262 (16.9) 23 (1.5) 974 (63.0) 572 (37.0) 694 (44.9) 93 (6.0) 311 (20.1) 448 (29.0) 1147 (74.2) 399 (25.8) 1529 (98.9) 17 (1.1) 39.06 (31.45) 4.74 (2.54) US $3168

Abbreviations: SSDI, social security disability insurance; SSI, supplemental security income.

defines competitive employment as working either fulltime or part-time in an integrated setting, as selfemployed, or in a state-managed Business Enterprise Program for a payment of minimum or above-minimum wage. Minimum wage is the state or federal minimum wage, whichever is higher. Placement in postsecondary education or vocational training is not considered competitive employment. Competitive employment was considered a successful outcome of the VR process. Vocational rehabilitation clients who did not obtain competitive employment after completing the program were considered to have unsuccessful outcomes.

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Statistical analysis Multivariate logistic regression analysis was used to investigate the relationship between predictor variables and the criterion variable of competitive employment for transition-age youth with TBI. The purposeful selection approach, as suggested by Hosmer et al,19 was utilized to build the logistic regression model. Purposeful selection ensures that researchers build the most parsimonious and “best-fit” model that can be adopted. The research team followed the 7 steps of purposeful selection recommended by Hosmer et al19 : 1. Examining one-on-one relationships between predictor variables and outcome variable using an α level of .20 or .25 to recruit every important predictor variable. 2. Entering all significant variables determined at step 1 into a logistic regression using the “enter” method. 3. Retaining variables that were significant and removing variables that were not significant if removal of them did not change the β coefficients of the significant variables by more than 20%. 4. Entering variables that were not significant at step 1 into the regression model one at a time and retaining significant variables. 5. Examining the variables and changes in them more closely. 6. Checking for interaction among variables. 7. Assessing the model’s adequacy and checking its fit.19 RESULTS Descriptive statistics and between-group analyses After receiving VR services, 49.7% of participating clients (N = 768) obtained competitive employment. On average, clients spent 39 months (SD = 31.45) in VR and received 4.74 (SD = 2.54) VR services. The median case expenditure for all participants was US $3168. Results indicated that time spent in rehabilitation was significantly lower for the successfully employed group (M = 35.56 months, SD = 30.25) than for the unemployed group (M = 42.50 months, SD = 32.24; t(1544) = 4.36, P < .001; d = −0.22). The number of services received was significantly higher for the successfully employed group (M = 5.39, SD = 2.49) than for the unemployed group (M = 4.11, SD = 2.43; t (1544) = −10.20, P < .001; d = 0.52). Median case expenditure was significantly higher for the successfully employed group (US $4799) than for the unemployed group (US $2137; P < .001). Results also indicated that assessment (70.6%), VR counseling and guidance (65.7%), and job placement (40.7%) were the most frequently provided VR services. Supported employment (SE) was provided www.headtraumarehab.com


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for only 18% of participating clients. Reader, interpreter, and personal attendant services were provided for less than 1% of clients. Reader, interpreter, and personal attendant services were not included in the logistic regression analysis because of clients’ low rate of receipt of those services. Logistic regression analysis Age (16-18, 19-22, and 23-25 years; 23-25 years of age was the reference category), gender (male, female; male was the reference category); race/ethnicity (white, black or African American, Hispanic or Latino, Asian or Pacific Islander, American Indian or Alaska Native; white was the reference category); education level at the time of enrollment (less than high school, special education, high school graduate, associate’s degree, bachelor’s degree or higher; bachelor’s degree or higher was the reference category); receiving SSI or SSDI (SSI, SSDI, no SSI/SSDI; no SSI/SSDI was the reference category); depression and other mood disorders as a secondary disability; and VR services were used to predict competitive employment for transition-age youth with TBI. As a first step, one-to-one relationships between the predictor variables and the competitive employment outcome variable were examined. The results indicated that gender; education level; receiving SSI or SSDI; coexisting depression or other mood disorders; and assessment, VR counseling and guidance, occupational/vocational training, on-the-job training, job readiness training, job search, job placement, on-the-job supports, maintenance, rehabilitation technology, information/referral, and other VR services were significantly associated with competitive employment at the P value of less than .20 level. It is worth noting that SE was not significantly associated with competitive employment outcomes. All of the significant predictor variables from the first step were then put into a logistic regression model using the “enter” method. In the presence of other variables, education level, receiving SSI or SSDI, job search, job placement, on-the-job support, and maintenance services were significantly associated with competitive employment at the P value of less than .05 level. The insignificant predictor variables were removed from the model a few at a time. When VR rehabilitation counseling and guidance was removed, information/referral services became significant. Removal of occupational/VR training and on-thejob training services changed the β coefficient of job search services more than 20% (from B = 0.33 to B = 0.40). Therefore, those services were put back into the model. Next, the variables that were set aside in the first step were put back into the model one at a time. None of those variables were significantly associated with competitive employment. The final model included educa-

tion level, receipt of SSI or SSDI benefits, job search, job placement, on-the-job support, employment maintenance, information/referral, on-the-job training, and occupational/vocational training as predictors of competitive employment for transition-age youth with TBI (see Table 2). The omnibus test for the final model was significant (χ 2 [12, N = 1546] = 250.98; P < .001), indicating that the predictors were collectively and significantly associated with competitive employment. The Nagelkerke R2 of 0.20 indicated that predictors had a moderate effect size in predicting competitive employment. The model accurately classified 66.2% of the participants into competitively employed and unemployed groups. Specifically, results indicated that clients with special education, less than high school education, high school diplomas, and associate’s degrees were less likely (odds ratio [OR] = 0.47, 0.44, 0.44, 0.71; 95% confidence interval [CI], 0.17-1.26, 0.17-1.15, 0.17-1.15, and 0.271.88, respectively) to obtain competitive employment than clients with bachelor’s degrees or higher. Clients who received SSI/SSDI had a 49% reduction in the odds of obtaining competitive employment (OR = 0.51; 95% CI, 0.40-0.64) compared with clients who did not receive SSI or SSDI benefits. Odds ratios for the VR service predictors were as follows: The odds of participants receiving job placement services having their cases closed in successful competitive employment status were 2.55 times (OR = 2.55; 95% CI, 1.99-3.27) greater than the odds of those who did not receive job placement services. The odds of participants receiving on-the-job support services having their cases closed in successful competitive employment status were 2.25 times (OR = 2.25; 95% CI, 1.71-2.96) greater than the odds of those who did not receive on-the-job support services. The odds of participants receiving maintenance services (eg, cash payments to facilitate everyday living including transportation, clothing, motor vehicle and/or home modifications, and services to family members) having their cases closed in successful competitive employment status were 1.59 times (OR = 1.59; 95% CI, 1.16-2.16) greater than the odds of those who did not receive maintenance services. The odds of participants receiving job search services having their cases closed in successful competitive employment status were 1.45 times (OR = 1.45; 95% CI, 1.10-1.91) greater than the odds of those who did not receive job search services. The odds of participants receiving occupational/ vocational training services having their cases closed in successful competitive employment status were 1.39 times (OR = 1.39; 95% CI, 1.00-1.93)


Traumatic Brain Injury and Vocational Rehabilitation TABLE 2

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Logistic regression results

Variables Education level Bachelor’s degree or higher Special education Less than high school High school graduate Associate’s degree Receiving SSI or SSDI Job placement On-the-job support Maintenance Job search Occupational/vocational training Information/referral

β

SE

Wald

df

Significance

12.09

4

0.01

Exp(B)

95% CI

− .75 − .80 − .81 − .33 − .67 .93 .81 .46 .37 .33

0.50 0.48 0.48 0.49 0.11 0.12 0.13 0.15 0.13 0.16

2.21 2.75 2.79 0.46 33.02 55.06 34.16 8.67 7.18 3.98

1 1 1 1 1 1 1 1 1 1

0.13 0.09 0.09 0.49 0.00 0.00 0.00 0.00 0.00 0.04

0.47 0.44 0.44 0.71 0.51 2.55 2.25 1.59 1.45 1.39

0.17-1.26 0.17-1.15 0.17-1.15 0.27-1.88 0.40-0.64 1.99-3.27 1.71-2.96 1.16-2.16 1.10-1.91 1.00-1.93

.32

0.14

4.85

1

0.02

1.38

1.03-1.84

Abbreviations: SSDI, social security disability insurance; SSI, supplemental security income.

greater than the odds of those who did not receive occupational/vocational training services. The odds of participants receiving information/referral services having their cases closed in successful competitive employment status were 1.38 times (OR = 1.38; 95% CI, 1.03-1.84) greater than the odds of those who did not receive information referral services. DISCUSSION The present study had several limitations that must be kept in mind when interpreting its results. First and foremost, this study examined data throughout the United States and did not investigate differences that may occur within and between states. Such information is critical if individual states and agencies are to improve the quality of their services and the outcomes that clients realize. Also, the present study examined data from only 1 year, 2011. Consequently, it is unclear whether findings in this investigation change over time for transition-age VR clients with TBI. Multiyear investigations of the predictors of employment outcomes for VR clients with TBI would enable researchers to place VR services within important (and often dynamic) historical, political, and economic contexts. Also, the ex post facto nature of this research made it impossible to systematically manipulate the independent variables, which is a requirement for studies seeking to draw causal inferences.19 Therefore, the present findings do not imply cause-andeffect relationships among study variables. Other acknowledged limitations of the present study included the dichotomous coding of the outcome variable, competitive employment, which must be viewed as a partial but incomplete proxy for successful rehabilitation; the

unavailability of information regarding the severity of client’s TBI and extent of functional limitations, both of which are documented predictors of employment outcomes for people with TBI; and possible self-selection biases regarding the characteristics of people with TBI who enroll in VR services vis-`a-vis the characteristics of people with TBI who do not. Even with these limitations, the present study reveals potentially important findings regarding the relationships among client characteristics, VR services, and employment outcomes for youth with TBI, findings that may have implications for the planning and delivery of VR services to this population. These data may take on special significance in light of the increasing number of youth with concussions or mild TBI, most of whom are not aware of VR services but could benefit from many of the time-limited VR interventions that predict successful employment (C. Dillard, N. Ditchman, K. Nersessova, N. Foster, P. Wehman, and M. West, unpublished data, 2012.). Although the majority of people who sustain mild TBIs recover within 7 to 10 days of their injuries, a small but substantial group continues to exhibit physical, cognitive, and/or emotional symptoms for weeks to several months postinjury. The maturation and development of adolescents can be interrupted by even a mild TBI, resulting in the person’s existence in a perpetual state of “limbo” due to prolonged symptoms. This can have a negative impact on academic performance and ultimately affect whether a person is able to develop and maintain a career path. Consistent with the present findings, VR services geared toward job placement, onthe-job support, employment maintenance, job search, vocational training, and information/referral are vitally important interventions for youth with TBI who sustain their injuries during the critical exploration stage of www.headtraumarehab.com


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career development.9,20 The finding that job placement services were the strongest predictors of competitive employment outcomes indicates that youth with TBI benefit significantly from assistance from rehabilitation professionals in identifying job leads, cultivating contacts with prospective employers, and posting their credentials on electronic job search boards. In addition, the new Workforce Innovation and Opportunity Act (PL 113-128), which was signed into law by President Obama in July 2014, calls for a substantially greater emphasis on transition-age interventions and closes access to sheltered workshops by 2016. This law sets the standard for all young people with disabilities to enter competitive employment, including those with TBI. The Workforce Innovation and Opportunity Act may have a uniquely positive impact on people with TBI given the recent study by Wehman et al7 who analyzed the employment outcomes of youth with TBI through the National Longitudinal Transition Study (NLTS-2). These findings troublingly indicated that sheltered workshop placements were more common than competitive employment for this group. This is a discouraging finding in light of the increasing emphasis that is being placed on competitive employment in the community for people with significant disabilities,9 and it behooves rehabilitation professionals to consider the factors, such as those identified in the present study, that contribute to successful competitive employment outcomes for youth with TBI. It is not surprising that participants in this study who received more VR services had better outcomes, and the cost differential for these services for successful rehabilitants ($4300) versus services for unsuccessful VR clients ($2,700) seems like a sound investment that may increase the likelihood of competitive employment. We make this point cautiously, however, given the correlational, noncausal nature of the association between cost of services and competitive employment outcomes in this study. However, what is quite surprising is that only 18% of transition-age youth with TBI receive SE services from the state-federal VR program. Supported employment has been identified as a highly viable intervention for people with TBI who need significant employment supports. Recently, Graham and West21 completed a Campbell Cochrane-approved systematic literature review of return to work research for individuals with TBI and found SE to be an efficacious intervention. This supports a number of studies that document the effectiveness of SE with people with TBI.12,22 As SE has historically been viewed as an intervention primarily for people with intellectual or developmental disabilities, it is possible that participants in the present study did not receive SE services because VR counselors were not

aware of its appropriateness or efficacy for transition-age youth with TBI.9 Vocational rehabilitation counselors may not know where or how to access SE programs specializing in youth with TBI. Access to SE is often very limited for people with certain disabling conditions such as TBI, severe intellectual disability, cerebral palsy, epilepsy, mental illness, and physical disability.23 Furthermore, providing SE services is expensive.23 It may be that many, if not most, of the participants in this study did not have long-term follow-along dollars from state or local sources to augment VR sponsorship of SE services. In addition, most states do not have specifically written Medicaid waivers that would allow for long-term SE for individuals with TBI. Previous research has shown that, when financially supported, SE services for individuals with TBI are cost-effective and costs typically decrease over time.24 Supported employment would seem to be a potentially important but currently underutilized VR service that clients, disability advocates, and rehabilitation professionals should continue to advance as a policy goal. To that end, preservice training and continuing education for rehabilitation counselors regarding (a) the efficacy of SE services for use with TBI, (b) the importance of natural supports and reasonable accommodations in the workplace as job retention strategies for workers with TBI, and (c) the medical and psychosocial sequelae of TBI could increase the likelihood that youth with TBI receive SE services through the statefederal VR program. This study suggests 2 major implications beyond the specific VR services rendered to successful and unsuccessful rehabilitants. First, as Cimera et al25 noted, those youth with disabilities in states where transition services are provided to individuals at younger ages experience better employment outcomes than those who live in states where transition services are initiated at older ages. Findings from the present study reinforce the importance of VR services delivered between ages 16 and 25 years, especially certain types of services, with approximately half of participants having their VR cases closed in successful competitive employment status. Todis and Glang26 presented longitudinal findings indicating that people with TBI who received employment interventions during high school were more likely to gain employment as young adults than were people with TBI who did not receive employment interventions during high school. Second, one has to ask whether the 50% VR success rate observed in this study of transition-age youth with TBI is an acceptable figure. The answer is: probably not. According to the report by Graham and West,21 there were a number of studies that showed better competitive employment outcomes, some of which involved people with moderate and severe TBI (the present study


Traumatic Brain Injury and Vocational Rehabilitation included people with all levels of severity). It should be noted, however, that not all of the studies reviewed by Graham and West21 focused exclusively on people with TBI who received state VR services. The lower rate of competitive employment observed among participants in the present study may be attributed to unique characteristics of youth with TBI who enroll in VR services. Given that participants in this study who held bachelor’s degrees were significantly more likely to emerge from the VR program in competitive employment than were participants with lower levels of educational attainment, it would seem that support for college tuition should be a case planning priority for transition-age youth with TBI who have the academic skills to succeed in college. Here again, the correlational nature of the study does not permit one to infer a causal relationship between educational attainment and competitive employment outcomes. Of course, college tuition assistance must be accompanied by academic supports such as tutoring, training in cognitive support technology, and consultation regarding classroom accommodations if students with TBI are to succeed in postsecondary education.7 Moreover, it is imperative that transition-age youth with TBI who are enrolled in high school or college programs gain hands-on work experience in integrated community settings. A number of recent studies bear witness to the high positive correlation between paid employment during high school or college and competitive employment outcomes after graduation among young people with TBI and other disabling conditions.27–30 No discussion of labor force participation among people with disabilities is complete without due consideration of disability benefits. It should come as no surprise that participants in this study who were receiving social security benefits were 49% less likely to be successfully rehabilitated in competitive employment status than their counterparts who were not receiving benefits. This underscores the powerful systemic disincentive to seek, secure, and maintain gainful employment that exists within social security programs.31 Indeed, the benefits paid by the social security administration’s 2 disability programs (ie, SSDI and SSI) are

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predicated on the beneficiary being too disabled to work.32 When this determination is made during the critically important career developmental stages of exploration and establishment,20 young people with TBI, and other disabilities, for that matter, often integrate the external confirmation of their disabled status into their self-concepts—self-concepts that do not necessarily include the role of worker.18 Unemployment and receipt of disability benefits then conjoin in a long-term self-fulfilling prophecy that is very difficult to change. To successfully change this pattern, young people with TBI need assistance in understanding disability benefits, especially the implications of paid employment to those benefits. It should be noted here that individuals with disabilities who receive SSI or SSDI benefits are generally considered to have greater functional limitations than people with disabilities who do not receive benefits.32 Because information on the severity of clients’ functional limitations was not available for the present study, it is not possible to determine whether differential employment outcomes are attributable to systemic disincentives in social security programs or to the severity of clients’ functional impairments. CONCLUSION Findings from this investigation clearly indicate that youth with TBI can obtain and maintain competitive employment when provided with appropriate VR services to meet their individual needs. More VR services provided in a more intensive time frame and including greater case expenditures predict more positive employment outcomes for youth with TBI, as do higher levels of education and nonreceipt of social security benefits. With regard to the types of VR services that predict employment outcomes, job placement, on-the-job support, maintenance, job search, vocational training, and information/referral services are most prominent. By understanding the demographic and VR service-related predictors of rehabilitation success among transition-age youth with TBI, rehabilitation professionals and other stakeholders can continue their progress in helping this population realize its full adult potential.

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