The relation between VR services and employment outcomes of individuals with traumatic brain injury. (VR Services and TBI).

There is a substantial incidence of traumatic brain injury in the United States (Brantner, 1992; Taylor, Forbes, & Goodwin, 1998). It is estimated that between 500,000 and 1.5 million individuals sustain a traumatic brain injury each year (Brantner, 1992; Chandler, Czerlinsky, Moore, Rutman, & Schumacher, 1993; Taylor, Forbes, & Goodwin, 1998), with males under 35 years of age representing the majority of these individuals (Bullard & Cutshaw, 1991; Garske & Thomas, 1992). A traumatic brain injury (TBI) is a non-degenerative, non-developmental injury or disease of the brain caused by trauma, infectious processes, anoxia, or vascular abnormalities (Brantner, 1992; Preston, Ulicny, & Evans, 1992).

The impact of TBI is unique (Taylor, Forbes, & Goodwin, 1998). It has wide-ranging affects on physical, cognitive, psychological, and behavioral capacities (Taylor, Forbes, & Goodwin, 1998), and loss of function in a combination of these areas is not uncommon (Brantner, 1992; Kosciulek, 1991). These deficits are often displayed as persons with TBI attempt to return to work (Wehman et al., 1989) as they are likely to encounter environmental and attitudinal barriers, outdated or limited vocational assistance, and social separation (West, 1996). As a result of these multifaceted challenges, the rates of successful return to employment are low and decline more over time (Michaels & Risucci, 1992). In fact, few individuals with TBI "return to work at the same level, for the same pay, and at the same number of hours per week as before the injury" (Uomoto, 2000, p. 1).

An important indicator of recovery after TBI is return to work (Krankowski, 1993), and vocational outcome has therefore been a central focus of TBI research (Chandler et al., 1993). For the past 20 years, studies investigating employment outcomes of persons with severe TBI have produced disappointing results (Ben-Yishay, Silver, Piasetsky, & Rattock, 1987; Brooks, McKinlay, Symington, Beattie, & Campsie, 1987; Ellerd & Moore, 1992; Jellinek, Torkelson, & Harvey, 1982; Lam, Priddy, & Johnson, 1991; Peck, Fulton, Cohen, Warren, & Antonello, 1984; Rappaport, Herrero-Backe, Rappaport, & Winterfield, 1989; Weddell, Oddy, & Jenkins, 1980). Post-injury employment rates for these individuals have ranged from 22% to 55% (Wehman, Bricout, & Targett, 2000), and wage levels for those who returned to work post-injury have also been low (Groswasser, Melamed, Agranov, & Keren, 1999).

As a result of the low employment rates and earnings reported for persons with TBI, numerous studies have examined predictors of employment outcomes for these individuals. For instance, favorable employment outcomes were reported for individuals with TBI following participation in supported employment (Groswasser, Melamed, Agranov, & Keren, 1999; Preston, Ulicny, & Evans, 1992; Target, Wehman, Gorton, & Petersen, 1998; Wehman et al., 1990; Wehman et al., 1989). Other studies examined the effects of neuropsychological functioning (Fabiano, 1991; Lam et al., 1991; Morris, Ryan, & Peterson, 1982; Newnam, Heaton, & Lehman, 1978), severity of injury (Chandler, 1993; Fabiano, 1991), demographic characteristics (Chandler, 1993), length of time between injury and return to work (Brooks et al., 1987; Ip, Dornan, & Schentag, 1995; Oddy, Coughlan, Tyerman, & Jenkins, 1985), and assistive technology (Gamble & Satcher, 2002) on the rehabilitation outcomes of persons with TBI. Conversely, no studies were found which examined conventional vocational rehabilitation (VR) service correlates of employment outcomes for these individuals.

The purpose of this study was to identify the number of consumers with TBI that received six distinct VR services and investigate the relationship between the provision of these services and rehabilitation outcomes. Specifically, this study answered the following research questions: (1) How many of the participants received assessment, college, counseling/guidance, job placement, restoration, and work adjustment services? (2) Are assessment, college, counseling/guidance, job placement, restoration, and work adjustment services significantly related to closure status? (3) Are there significant differences in weekly earnings based on the provision of assessment, college, counseling/guidance, job placement, restoration, and work adjustment services?

Method

Data Collection

The data were obtained from client closure reports found on the RSA-911 database from the participating public rehabilitation agency and included (a) demographic characteristics, (b) VR services provided, and (c) outcomes achieved. Two measures of employment success were used-closure status and weekly earnings. The Rehabilitation Services Administration developed a standard for closure status on its database that includes rehabilitated (Status 26) and non-rehabilitated (Status 28) closures. An individual must maintain employment for a minimum of 90 days in order for the case to be closed as rehabilitated. However, a rehabilitated closure does not necessarily indicate that the person is working in competitive employment (Gilmore, Schuster, Timmons, & Butterworth, 2000). Consumers closed as rehabilitated are further categorized into (a) competitive employment, (b) sheltered employment, (c) self-employment, (d) business enterprise program, (e) homemaker, and (f) unpaid family worker statuses. In contrast, a non-rehabilitated closure indicates that the client was unemployed and not in one of the preceding groups following VR intervention.

It was felt that combining all rehabilitated closures might confound the effects of the VR services on closure status and weekly earnings. Therefore, closure status was divided into two categories-competitive employment and not working. The overwhelming majority (87.9%) of rehabilitated closures were in competitive employment. Clients closed in sheltered, self, homemaker, and unpaid family worker statuses respectively accounted for just 34 (5.7%), 12 (2.0%), 17 (2.9%), and 9 (1.5%) of the rehabilitated closures and were excluded from the analyses. No business enterprise program closures were reported. The weekly earnings measure is unambiguous. Higher weekly earnings denoted greater success.

Sample

The sample consisted of all 1,073 public rehabilitation clients with a major disabling condition of TBI whose cases were closed in competitive employment and non-rehabilitated statuses from October 1992 through September 2000 in a southeastern state. Of these individuals, 521 (48.6%) were competitively employed at closure and 552 (51.4%) were not working at closure. Nine hundred and fifty three (88.8%) were classified as having a severe disability and 120 (11.2%) were classified as not having a severe disability. Two hundred and thirteen (19.9%) were African American, 836 (77.9%) were Caucasian, 14 (1.3%) were Hispanic American, 3 (.3%) were Asian American, and 7 (.7%) were Native American. Eight hundred (69.9%) were male and 345 (30.1%) were female. The marital status varied: 224 (20.9%) were married and 849 (79.1%) were single. Ages ranged from 16 to 71 (M = 35.40, SD = 9.68). The mean education grade-level achievement was 11.52 (SD = 2.31). Upon application for services, 93 (8.7%) reported having prior employment experience and 980 (91.3%) did not report having previous work experience.

Data Analysis

A combination descriptive and correlative research design (Pedhazur & Schmelkin, 1991) was used to examine the distributions of VR services and their relationship to employment outcomes. Descriptive, chi-square, logistic regression, and analysis of variance [i.e., one-way ANOVA and factorial ANOVA (i.e., six-way)] procedures were used to analyze the data and answer the research questions. Chi-square analysis is appropriate for evaluating the relationship between a dichotomous independent and dependent variable (Huck & Cormier, 1996). Logistic regression analysis was used to analyze the relationship between VR services and a dichotomous dependent variable [i.e., closure status] (Cohen & Cohen, 1983). A one-way ANOVA can be utilized for evaluating the relationship between one independent variable and a continuous dependent variable (Huck & Cormier, 1996). According to Huck and Cormier (1996), a factorial ANOVA is appropriate for evaluating the relationship between several independent variables (i.e., VR services) and a continuous variable (i.e., weekly earnings). The Statistical Package for the Social Sciences (SPSS, 1995) was employed in these calculations. Only those consumers closed in competitive employment (n = 521) were selected to evaluate differences in weekly earnings. A significance level was set at .05.

Results

Table 1 presents the distributions of the six VR services received by the sample. A limited number of clients received college services (9.3%). Larger percentages of consumers received assessment, counseling/guidance, job placement, restoration, and work adjustment services. Counseling/guidance was the most frequently provided service (88.8%).

The distributions of the service (e.g., predictor) variables were then carefully examined. For analytic purposes, these variables would ideally display a 50%-50% distribution (Moore, 2001a). Distributions of 80%-20% are appropriate for logistic regression analysis (Moore, 2001a). Distributions significantly greater than this (e.g., 95%-5%) should be excluded from the process (Cohen & Cohen, 1983; Moore, Flowers, & Taylor, 2000) due to lack of experimental variation within predictor variables which may result in Type II errors (Huck & Cormier, 1996). Similar to procedures used in studies conducted by Bullis, Davis, Bull, and Johnson (1995), Moore (2001a), Moore et al. (2000), and Moore, Feist-Price, and Alston (2002a, 2002b), predictor variables with distributions greater than 95%-5% would in fact be excluded from the analysis. No predictor variables were excluded based on this criterion. The predictor variables were largely independent, with phi correlation coefficients ranging from--.01 to .22. These low values provided no evidence of multicollinearity.

Closure Status

Results of the logistic regression analysis are described in Table 2. Overall, the classification model correctly categorized 78.2% of the cases. The following VR services were positive predictors of closure status: college (p < .001, OR = 5.21, 95% CI = 2.95-9.19), counseling/guidance (p < .001, QR = 3.03, 95% CI = 1.74-5.28), and job placement services (p < .001, OR = 20.77, 95% CI = 13.89-31.07). The odds ratio (OR) provides the estimated coefficients that predict competitive jobs. The coefficients are the log of the odds of the event occurring (i.e., change in the log odds associated with one unit change in the independent variable). The odds of obtaining competitive employment for those receiving college services were 5.21 times the odds of obtaining competitive employment for those not receiving college services. The odds of obtaining competitive employment for clients receiving counseling services were 3.03 times the odds of obtaining competitive employment for clients not receiving counseling services. The odds of obtaining competitive employment for consumers receiving job placement services were 20.77 times the odds of obtaining competitive employment for consumers not receiving job placement services. Conversely, work adjustment was a significant negative predictor of closure status, although its odds ratio was quite low. That is, the odds of obtaining competitive employment for those not receiving work adjustment services were .61 times the odds of obtaining competitive employment for those receiving work adjustment services.

Weekly Earnings

A factorial ANOVA was conducted with weekly earnings for competitively employed clients as the dependent variable and the six VR services as factors. Because certain combinations of services were received by none of the participants, only 29 of the 64 cells in the six-way ANOVA were filled. Type IV sum of squares was specified to fit the model as this is the appropriate option for situations in which there are empty cells (Shannon & Davenport, 2001). The model accounted for 16% of the variance in weekly earnings, F(28, 492) = 3.32, g < .001. A significant main effect emerged for work adjustment services. Weekly earnings were significantly less for consumers who received work adjustment services (M = $196.52) than for their counterparts who did not receive such services (M = $282.83), F(I, 492) = 6.88, p < .01.

More important, however, was the significant three-factor interaction noted for assessment, college, and job placement services on mean weekly earnings for competitively employed clients, F(1,492) = 7.05, p < .009. The finding for the interaction of college with assessment when job placement was not provided is different from the finding for the association between college and assessment when job placement was provided (see Figures 1 and 2). Simple effect results in Figure I indicate that when job placement services were not provided, mean weekly earnings were dependent upon a combination of assessment and college services. Specifically, consumers who did not receive either service (i.e., assessment or college) had higher earnings (M = $308.40, 95% CI = $233.53-$383.27) than consumers who received college services alone (M = $255.60, 95% CI = $93.61-$417.59). Results also indicate that consumers who were provided with college and assessment had higher earnings (M = $276.58, 95% CI = $171.27-$381.90) than consumers who received assessment alone (M = $206.77, 95% CI = $167.50-$246.04). In short, when job placement services were not provided, the effect of college training on mean weekly earnings was different at each level of assessment. Results from Figure 2 indicate that when job placement services were provided, consumers who received college training had higher mean weekly earnings than consumers who did not receive college training for each level of assessment.

[FIGURE 1-2 OMITTED]

Table 3 displays summary statistics on weekly earnings for competitively employed clients by each level of the six factors. At $274, median weekly earnings were highest for clients who received college services. In contrast, median weekly earnings were lowest ($173) for clients who received work adjustment services.

Discussion

College, counseling, and job placement were significantly and positively related to closure status. With an odds ratio of 20.77, the job placement variable contributed most to the prediction of competitive employment for consumers with TBI. Several other studies also identified job placement as a significant predictor of successful closure for con sumers with other types of disabilities (Bolton, Bellini, & Brookings, 2000; Moore, 2001a; Moore et al., 2000; Moore et al., 2002b; Wheaton, Wilson, & Brown, 1996).

Counseling and college services were also significant predictors of competitive closure, although these service variables had lower odds ratios of 3.03 and 5.21 respectively. In a cross-disability study of VR consumers, those closed successfully were more likely to have received counseling (Wheaton et al., 1996). In addition, Moore (2001b) found counseling and guidance to be significantly associated with closure success for VR consumers with hearing loss. The collective findings of this and previous studies provide evidence that the provision of counseling and guidance services is related to positive employment outcomes. This study's findings for college services on closure status are consistent with results from previous research. For instance, Moore (2001a) found that college training was a significant predictor of successful work status at closure for VR consumers who were deaf, late-deafened, and hard-of-hearing.

In order to control for possible confounding effects of disability severity on employment status, we examined the relationship between college services and employment status for only those consumers reporting a severe primary disability. Chi-square analysis revealed that college services were significantly related to employment status, [chi square] (1, n = 953) = 42.22, [PHI] = .21, 11 < .001. That is, consumers with severe TBI who were provided with college services were significantly more likely to be closed into competitive jobs (74 of 90 or 82.2%) when compared to those individuals with severe TBI who were not provided with such services (399 of 863 or 46.2%). This suggests significant variation in functioning of persons classified as having severe TBI.

The significant inverse relationship between work adjustment services and closure status in this study is of particular interest. The low odds ratio (i.e., .61) indicated a possible spurious association. Therefore, we analyzed the relationship between work adjustment training and employment status while controlling for disability severity. In short, we excluded those cases from the analysis representing consumers with non-severe TBI. Chi-square analysis refuted the previous finding: work adjustment training was not significantly or inversely related to employment status, [chi square] (1, n = 953) = 1.21, [theta] = .04, p = .27. This finding suggests that severity of disability could have contributed to differences found on employment status along with work adjustment services. Deficits in behavioral functioning are common following TBI (Cicerone & Fraser, 2000). Perhaps clients who received adjustment services had greater difficulty inhibiting impulsive or inappropriate interpersonal responses than clients who did not. Interpersonal skills are critical to vocational success (Kosciulek, 1991). It is conceivable that clients with pronounced deficits in this area were more likely to have their cases closed unsuccessfully. Alternatively, counselors may have either referred clients with greater deficits to this program or expected less from clients who received these services (i.e., Pygmalion effect). As such, we urge readers to refrain from perceiving or interpreting the inverse relationship between work adjustment training and closure status as valid.

Competitively employed consumers who received work adjustment services made an average of $86.31 less per week than competitively employed consumers who did not receive work adjustment services. The descriptive statistics presented in Table 3 reflect this main effect. In a study of consumers with mental retardation, Moore et al. (2000) likewise found a significant inverse relationship between work adjustment training and weekly earnings. Due to concern for accepting a false treatment effect (Type I error), we conducted a one-way ANOVA to evaluate the relationship between work adjustment services and level of income while controlling for severity of disability. Specifically, only those consumers with severe TBI who were closed into competitive jobs were included in this analysis. The one-way ANOVA result refuted our concern: consumers with severe TBI who were provided work adjustment services (n = 127) possessed a significantly lower level of income (M = $193.32) when compared to those who were not provided work adjustment services (n = 346; M = $254.41), F (1,471) = 14.91, p < .001.

Mean weekly earnings were higher for competitively employed consumers who did not receive assessment, college, and job placement services than for their counterparts who received college services alone (see Figure 1). Reasons for this are unclear. It could be hypothesized that competitively employed clients who did not receive these services had the functional capacities, experience, skills, and training necessary to secure higher paying jobs at the onset of VR intervention. Alternatively, other variables could have influenced this interaction. For example, demographic and global VR service variables (i.e., time in rehabilitation, service costs, etc.) may be important.

In the absence of job placement, competitively employed consumers who received assessment and college services had higher weekly earnings than competitively employed consumers who received assessment services alone (see Figure 1). In the presence of job placement, competitively consumers who received college services had higher mean weekly earnings than their counterparts who did not receive college services at each level of assessment (see Figure 2). These findings along with the summary information in Table 3 affirm the important relationship of college services to the earnings capacities of consumers with TBI.

To further investigate the relationship of college on earnings for competitively employed participants, we conducted a one-way ANOVA while controlling for disability severity. Consumers with severe TBI who received college services (n = 74) had significantly higher weekly earnings (M = $306.62) than consumers with severe TBI who did not receive college services (n = 399; M = $225.28), F(1,471) = 17.87, p < .001.

College services therefore were related to closure status and weekly earnings both before and after controlling for disability severity. However, a limited percentage of the sample (9.3%) received this service. It is possible that VR professionals over-estimated the functional deficits of the participants. This premise is strengthened by an earlier study which found that clinicians tended to overestimate pathology in their clients with TBI (Faust et al., 1998).

The results of this research support an argument for increased access to postsecondary education services for VR clients with TBI. Several other authors have established a reasoned, positive relationship between the provision of college services to VR consumers and vocational outcomes as measured by employment rates and earnings (Moore, 2001a; Price-Ellingstad & Berry, 1999; Schmidt-Davis, Hayward, & Kay, 1999). The findings of this and prior studies suggest that enhanced access is necessary not only to increase rates of competitive employment for VR consumers, but also to improve their quality of employment (i.e., wages). It should be noted, however, that assignment to services was not random and may represent the practice of counselors recommending postsecondary training for higher functioning consumers.

Implications for Practice

There are two primary implications for current practices. First, the findings reveal that the provision of college, counseling and job placement services are positively related to competitive jobs for clients with TBI. The current and previous studies support these services, especially the provision of job placement services, as invaluable resources in the vocational rehabilitation process. Two-way simple interaction effects also revealed that in the absence of job placement services, the combination of assessment and college services are significantly related to consumers with TBI achieving higher levels of weekly earnings. Rehabilitation practitioners should be educated on the importance of providing such services as this may lead to greater numbers of consumers with TBI achieving competitive jobs and higher levels of income.

Second, in light of the positive relationship of college, counseling, and job placement on competitive jobs and the combination of assessment and college, in the absence of job placement, on income, one might recommend that more consumers with TBI be provided with such services. Specifically, counselors should consider identifying additional consumers with TBI who might benefit from the provision of college, counseling, job placement and the combination of assessment and college in the absence of job placement services.

Implications for Future Research

From a research perspective, this study was limited in several ways. The findings have limited generalizability because the study was conducted using consumer records of general practices from only one state. Other researchers may wish to replicate this study to determine if the findings are consistent throughout the state-federal rehabilitation system. This study also did not account for differences in all employment outcome measures. Future authors are encouraged to describe occupational placements for competitively employed consumers who received these services and compare the groups on hours worked each week.

In addition, researchers who conducted prior longitudinal studies have found that employment was not durable for persons with TBI (Ashley, Persel, Clark, & Krych, 1997; Ellerd & Moore, 1992; Hillier, Sharpe, & Metzer, 1997; Kaitaro, Koskinen, & Kaipio, 1995; Olver, Ponsford, & Curran, 1996). Thus, the relatively short (i.e., 90 day) employment maintenance requirement for competitive closures in this study may have limited the findings. Future researchers are encouraged to implement an extension to the 90 day measure of maintenance of competitive jobs. Such an approach may provide more valid data to evaluate work status at closure. Last, there is potential for error in any RSA-911 database. VR counselors typically complete the service information to be included in this database upon case closure (Wheaton et al., 1996). Some counselors may rely exclusively on memory for this information (Wheaton et al., 1996). Information recorded by counselors may also be inaccurately typed into the database (Wheaton et al., 1996). Consequently, an unknown number of miscalculations may exist. It is assumed, however, that these unknown errors are indiscriminate and result in no methodical bias in the data (Wheaton et al., 1996).

Conclusions

In summary, this investigation of the relation between VR services and employment outcomes of persons with TBI supports three conclusions: (a) College, counseling/guidance, and job placement services were significant positive predictors of closure status for the sample; (b) work adjustment services were inversely related to weekly earnings for competitively employed consumers in this study; and (c) assessment, college, and job placement services interacted significantly on weekly earnings for competitively employed consumers in this study. It was also found that job placement was the most important positive predictor of closure status for the sample. Thus, job placement should receive greater emphasis in rehabilitation education and training. Finally, college training benefited the sample considerably, yet it was observed that a limited number of consumers received this service.

As a broad generalization, these conclusions may be helpful to VR professionals and their clients with TBI. These findings, however, should be considered within the context of the limitations of the study. Additional research is undoubtedly needed to assess the relationship between VR services and employment outcomes of individuals with TBI.

Table 1
Services Received by the Sample

Service Received      Frequency   Percent

Assessment
No                       138        12.9
Yes                      935        87.1

College
No                       973        90.7
Yes                      100         9.3

Counseling/Guidance
No                       120        11.2
Yes                      953        88.8

Job Placement
No                       730        68
Yes                      343        32

Restoration
No                       700        65.2
Yes                      373        34.8

Work Adjustment
No                       824        76.8
Yes                      249        23.2

N = 1,073

Table 2

Logistic Regression Analysis for Service Variables on Closure Status
for Individuals with Traumatic Brain Injury

Service                                                      95%
Variable                     Odds Ratio                  Confidence
                        B       (OR)      df     p      Interval (OR)

Assessment            -.22       .81      1    .341        .52-1.26
College               1.65      5.21      1    .000 *     2.95-9.19
Counseling/Guidance   1.11      3.03      1    .000 *     1.74-5.28
Job Placement         3.03     20.77      1    .000 *    13.89-31.07
Restoration           -.15       .86      1    .388        .62-1.21
Work Adjustment       -.50       .61      1    .015 *      .41-.91

N = 1,073

* p < .05

Table 3

Summary Statistics on Weekly Earnings for Competitively Employed
Clients by VR Services

Service                                Low   High   Mdn
Variable              Category    n    ($)    ($)   ($)      SD ($)

Assessment               No       65    87    999   250      217.27
                         Yes     456    12    999   200      146.09

College                  No      440    12    999   200      157.20
                         Yes      81    30    999   274      160.08

Counseling/Guidance      No       19    16    368   200       94.73
                         Yes     502    12    999   210      161.27

Job Placement            No      216    16    999   225.50   181.72
                         Yes     305    12    999   200      139.41

Restoration              No      330    15    999   210      164.65
                         Yes     191    12    999   204      150.43

Work Adjustment          No      390    12    999   230      166.39
                         Yes     131    21    696   173      124.62

n= 521

* Note: Code 999 was entered into the weekly earnings record position
if a customer had earnings of $999 or more.

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David Gamble The Compass School

Corey L. Moore Langston University

David Gamble, M,A,, CRC; CSESS, Teacher, The Compass School, 6001 12th Avenue East, Tuscaloosa, AL 35405.