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Employment concerns of people with head injuries.

The primary purpose of this study is to examine the employment-related strengths and problems that people with head injuries have encountered in their rehabilitation programs. In addition, the study describes the demographics and service histories of a large sample of people with head injuries. Implications of the findings are discussed in terms of modifications needed in policies that affect the availability of vocational rehabilitation services.

The need for the study is clearly demonstrated in the increased number of people with head injuries who require employment-related assistance. While the incidence of head injury has remained constant over the past four decades (about 700,000 people a year), the survival rate has changed dramatically. According to McMahon and Growick (1988, p.274), improvements in "accident evacuation procedures, emergency medical care, and neurosurgery" have led to a four-fold increase in the head injury survival rate over the past 20 years. Data indicate that approximately 70% of people with head injuries receives their injury before they were 30 years old (Fraser, McMahon, & Vogenthaler, i 988). Two-thirds of the group are under the age of 35, and men outnumber women by a 2 to 1 ratio (Dixon, Goll, & Stanton, 1988; Umoto & Mclean, 1989). Blunt head injuries resulting from vehicle or transportation accidents predominate with smaller percentages of injuries attributed to assaults or falls.

The level of the coma and the length of time unconscious are important predictors of eventual neurological and employment outcomes (Fraser, Dikmen, Mclean, Miller, & Temkin 1988; Umoto & McLean, 1989). Described as a "constellation of syptoms," neurological outcomes of head tratuna include "memory impairment, personality disturbance, decreased motor control and fatigue, speech and language difficulty, attention and concentration deficits, and lack of initiative" (Brain & Spellacy, 1989, p.47). While neurological rehabilitation efforts have predominated, increasing attention is being given to post-acute vocational rehabilitation interventions (Fraser, McMahon, & Vogenthaler, 1988; Haffey & Lewis, 1989).

Unemployment statistics underscore the life altering impact of a severe head injury. Depending on the gravity of the head injury, post-injury tmemployment rates range from 52% to 97%, a distinct contrast to preinjury unemployment rates of 1 4% in some groups (Blain & Spellacy, 1989; Wehman, Wood, Morton, & Sherron 1988). Even in studies reporting higher employment rates, approximately one-third of the people were working in less demanding jobs or sheltered workshop settings (We@unan et al., 1988).

Follow-up research over periods of four and five years provides similar results. In a review of long-term outcome studies, Haffey and Lewis (1988) concluded that the baseline for return to work following head injury ranges from 23% to 30%. They also pointed out that neurological rehabilitation yields outcomes only slightly better than the baseline. Further, the expectation that most survivors will have a normal life span presages the need for life-long services for people with head injuries (Fraser, Dikmen, Mclean, Miller, & Temkin, 1988). Unfortunately, services have not kept pace with the need. In 1982, the National Head Injury Foundation estimated that between 1 and 1.8 million people with head injuries had not received any rehabilitation services (McMahon & Fraser, 1988).

For the most part, priorities in head injury vocational rehabilitation have been set by professionals. Advocating the supported employment model. McMahon and Fraser (1988, p. 201) stressed the "place and train" approach with "precriptive training for specific jobs." They recommended comprehensive vocational services during job development, ongoing assessment, work hardening, and job coaching.

While the recommendations of professionals are valuable, the survivor's point of view is also important. Modifications in programs should not be made independent of consumer input. Hence, this study reports the perceptions held by a large number of people with head injuries regarding their employment concerns. These individual participated in a project endorsed by the National Head Injury Foundation and its network of state chapters. Respondents completed a questionare in which they evaluated both the importance of a wide range of employment services and their personal satisfaction with the availability and quality of those services.


The Concerns Report Method

The Concerns Report Method was used to collect data regarding the employment concerns of people with head injuries. Operationalizing a citizen participation philosophy, the Concerns Report Method enables consumers both to specify the issues to be considered and how those issues should be judged (Schriner & Fawcett, 1988a, 1988b). Previous research demonstrate that the Concerns Report Method is a reliable and valid measure for identifying strengths and problems from the perspective of consumers. The approach has been used successfully with residents of low-income neighborhoods (Schriner & Fawcett, 1988b), clients of htunan service agencies 1Seekins @ Fawcett, 1 987), Patients and staff in psychiatric institutions (Fawcett, Muiu Seekins, Whang, Fletcher, & Hannah, 1982); and persons with disabilities (Roessler, Schriner, & Troxell, 1990; Schriner & Roessler, 1990).

In this study of employment needs of people with head injuries, the Concerns Report Method consisted of the following (a) an Employment Concerns Index (item pool) used by a disability organization and consumers to develop a tmique questionnaire, (b) an Employment Concerns Questionnaire created by consumers that includes items formatted for importance and ratings, and (c) an Employment Concerns Report identifying strengths and problems of respondents. The Employment Concerns Index consists of 100 items which integrate core human values such as security, justice, self-esteem, and freedom in statements related to employment. One item, for example, "You can get help for initial on-the-job problems following the injury," relates the notion of security to Postemployment services.

The second element, the Employment Concerns Questionnaire, results from the activities of a working group. In this study, the working group consisted of four survivors, ten family members (parents, spouses, siblings), and two head injury professionals who attended a preconference workshop at the National Head Injury Association National Meeting (Washington, DC, June, 1988). During the workshop, the working group reviewed the item pool (100 items) and selected 30 items to include in the Employment Concerns Questionnaire. Some items were selected directly from the item pool; others were rewritten by the working group to better represent the concerns of people with head injuries.

Funding swere sununarized in an Employment Concerns Report that provided consumer perspective on employment issues in terms of importance and satisfaction. Group importance and satisfaction ratings were calculated for each questionnaire item using the following formula: 100 X [n1(O)+n2(1)]/N=% where n1 is the number of respondents answering "no,"n2 is the number of respondents answering "yes," and N is the total number of respondents. Employment strengths (item with high importance and high satisfaction ratingsi and employment problems were presented (items with high importance and low satisfaction ratings; see Tables 3 and 4 for formulas). Because the ratings are binary, the strengths rating represents the percentage of respondents who answered "yes"on importance and "yes" on satisfaction. The problem rating represents the percentage of respondents who answered "yes" on importance and "no" on satisfaction.


People completing the Concerns Report Questinnaire (N = 1052) were head injury survivors on the mailing lists of 10 state chapters of the National Head Injury Foundation. After receiving the questionnaire in the mail, respondents voluntarily completed the ratings and returned the questionnaire to the Research and Training Center. In some states, the questionnaire was distributed with the support of the state vocational rehabilitation agency. Survivors in eight states provided the bulk of the sample, e.g., Colorado (n = 50), Florida (n=198), Georgia (n = 80), Massachusetts (n = 90), Maine (n = 85), Minnesota (n = 222), Mississipi (n = 59), and Washington (n = 174). The reader is reminded that the results and conclusions are based on data from a voluntary or "convenience" sample, a factor that limits the external validity of the research.


Most of the respondents were white (n = 1000; 95%) and had completed high school (n = 773, 73%). Approximately half of the group (n = 517,49%) had some college experience with 23% (n = 239) reporting a college degree anUor post-graduate education. Respondents typically lived at home with family (n = 474; 450%) or in their own home or apartment (n = 360; 34%). A majority of the group (n = 571, 55%) completed the survey on their own, while 43% (n = 447) received help from a spouse, parent, friend, guardian, or other family member. The average amount of time since injury was 7.3 years (SD = 7.4 years). Additional background characteristics are discussed in relation to exceptions for a representative sample of people with head injuries.

Young Adults

Consistent with past research, respondents were yotmg adults, 34 years old on the average (SD = 12.31), who had obviously been injured at an early age as well. Fifty-nine percent (59%, n = 625) of the sample incurred a head injury be@Neen the ages of 10 and 29. Eighty-four percent (84%, n = 859) of the group were injured before age 39. Average age at injury was 27 (SD = 12.46).

Male/Female Ratio

Incidence data indicate that most cases of head injury involve males, usually at a two-to-one ratio. The sex of respondents in this study conformed to that pattern. Men comprised 66% of the sample (n = 692), and women, 34%, of the sample (n = 359).

Types of Injury

The literature review revealed that the preponderance of head injuries are blunt or closed head injuries resulting from automobile or transportation related accidents. In this sample, 84% (n = 844) of the group had suffered a closed head injury. Open head injuries were reported by 8% (n = 78) of the group.

Constellation of Symptoms

Head injury is associated with a constellation of symptoms which seriously affects the individual's social and vocational functioning. Data from respondents in Table 1 support the cluster description of head injury symptoms. The majority of the respondents indicated problems with motor functioning, physical capabilities (strength, endurance, medical stability), and cognitive abilities. A large group (49%) also reported adaptive behavior problems, e.g., problems relating to others and controlling one's temper. Vision was affected for one-third of the group, and hearing for only 12% of the sample. The data in Table 1 indicate that people with head injuries are coping with a variety of factors subsequent to head injury that influence their social and vacational functioning.
Table 1
Constellation of Symptoms
Does your head injury affect your
Capability Yes No
 n % n %
Cognitive Ability 782 74 270 26
Motor Function 593 56 459 44
Physical Capability 577 55 475 45
Adaptive Behavior 513 49 539 51
Vision 359 34 693 66
Hearing 127 12 925 88

Employment Status

In the literature, unemployment rates for people with head injuries ranges from approximately 50% to 97%, depending on the severity of the injury. The majority of respondents in this study was unemployed; 70% of the group (n = 711) were not working at the time they completed the questionnaire. Only 14% were working full-time, with 12% working part-time. A small percentage of the group stated that they were self-employed (4%), either full-time or part-time. Availability and Importance of Vocational Services.

Two sources of information on the availability and importance of vocational services for people with head injuries exist in this report. First, respondents described the services they have received and are receiving (see Table 2). Data in Table 2 indicate that the majority of respondents had received medical and postacute rehabilitation care. Indicative of the amount of time that has elapsed since injury, most of the people were not receiving these services at the time that they completed the questionnaire. Unfortunately, they were not involved in other services either. Although significant percentages of the group reported receiving vocational counseling (41%) and personal counselling (49%) in the past, no more than 14% to 26% respectively were doing so when the data were collected.
Table 2
Services Received or Currently Receiving Since Injury
Service Yes No
 n % n %
Inpatient Medical 762 (74) 72 (7) 290 (978) 28 (93)
Outpatient/Postacute 683 (233) 65 (22) 369 (819) 35 (78)
Vocational Counseling 427 (148) 41 (14) 625 (904) 59 (86)
Personal Counseling 512 (268) 49 (26) 540 (784) 51 (74)
Job Training 209 (84) 20 (8) 843 (968) 80 (92)
Job Placement 141 (67) 13 (6) 911 (985) 87 (94)
Benefits Counselling 347 (107) 33 (10) 705 (945) 67 (90)
Note. Entries in parentheses indicate services the respondents
are currently receiving.

While presenting somewhat indirect evidence, Table 2 supports the assertion that people with head injuries do not have adequate vocational services. Less than one-fifth of the group had ever received either job training or job placement assistance. Even fewer people reported receiving those services at the time they completed the questionnaire. Only 8% of the sample was receiving job training, and 6%, job placement help, at the time of the study. Thus, results in Table 2 documents the dearth of vocational services for people with head injuries.

More direct evidence is, however, available regarding the importance of employment related issues. In Table 3 the employment concern items are ranked in order of importance; item satisfaction scores are also reported. On a scale of 0 to 100, the range of importance scores is from 48 to 90. Indicative of the importance attached to the employment items, 30 of the 3 1 items received a score of 56 or higher. More importantly, 23 of 31 items were rated between 72 and 90, indicating that nearly three-quarters or more of the respondents considered the item important.

The satisfaction scores contrast sharply with the importance ratings. Initially the range of scores is lower, 30 to 64. However, the most significant difference between the distribution is that 25 items have satisfaction ratings of less than 50. The majority of participants, therefore, expressed dissatisfaction with 80% of the questionnaire items.

Data in Table 3 support the hypotheses that people with head injuries attach great importance to employment concerns and that they are dissatisfied with their access to vocational training, placement, and postemployment services. The nature of their concerns is discussed in the next section on employment strengths and problems. [TABULAR DATA 3 OMITTED]

The Need for Comprehensive Employment Services

Tables 4 and 5 present the employment strengths and problems from the perspective of 1052 people with head injuries. As previosly indicated, respondents considered most of the items important to them. They were satisfied with only a few of the items. [TABULAR DATA 4 AND 5 OMITTED]

Employment Strengths.

Only three items received sufficient endorsement to be termed employment strengths; they were (a) You are treated with respect by service providers, (b) You have access to transportation, and (c) You are encouraged to develop all of your abilities. Two of the items, treated with respect and encouraged to develop abilities, are complimentary of the individual who provides services to people with head injuries. Because most of the sample had not received vocational services, the services providers referred to would primarily be those who work in acute and post-acute care facilities (see Table 2), i.e., physicians, physical therapists, occupational therapist, and social workers.

Respondents identified acclss to transportation as a strength. Given the fact that 70% of the sample is unemployed, the resources mentioned may pertain more to transportation for medical services and other occasional demands. The larger question of adequate transportation on a daily basis for employment would, therefore, not be directly addressed in the data. Practical experience of prof'essionals who work with people with head injuries indicated that access to reliable transportation to and from a job is a major problem.

Consistent with previous findings, no vocational services were singled out for conunendation. In fact, the only mention of specific vocational preparation and placement services is found in the list of employment problems.

Employment problems.

The number of employment problems mentioned by respondents far exceeds the number of strengths. While as many as nineteen items could be considered significant problems, the seven highest rated problems have been selected for discussion. They are as follows: (a) You have access to appropriate placement assistance by a professional knowledgeable about head injuries, (b) You have access to appropriate career counseling by a professional knowledgeable about head injuries, (c) Your needs are considered in the design of job training programs, (d) Your vocational preparation needs are met, (e) You are recognized for your vocational potential, (f) You have access to job training related to local opportunities, and (g) You receive long-term follow-up services needed to maintain employment.

Top priority problems cited by people with head injuries fell into three categories: preparation, placement, and postemployment. In the preparation area, respondents stated that they are not recognized for their vocational potential and that their vocational preparation needs are not met. Specific service gaps pertain to career couseling and job training. Problems with job training included failure to develop training programs that meet the needs of people with head injuries and lack of access to job training related t local job opportunities.

The most important employment problem concernced inadequate access to placement assistance by a professional knowledgeable about head injuries. While this concern addresses the job acquisition phase of employment, it may also reflect discontent with the preparation and postemployment stages as well. In terms of postemployment concerns, participants expressed the need for long-term follow-up services which enhance the probability of job retention.

Summary and Discussion

The Employment Concerns Report data from 1052 people with head injuries reinforce findings and recommendations in the head injury literature. People with head injuries are, for the most part, young adults who were injured in their teens or twenties. Males exceed female in the group by approximately a two-to-one ratio. Most of the injuries are closed head injuries, which result in a constellation of sequelae that seriously affects the person's social and vocational functioning. High unemployment rates (70% of this group) document the serious effects of the injury on the individual's daily functioning.

The frequency of vehicular accidents in the case histories of people with head injuries underscores the need for improved prevention efforts. Installation of air bags in automobiles, continued education regarding seat belt use, development of reinforced passenger compartments in automobiles, and promulgation of motorcycle helmet laws are of prime importance.

Another factor apparent in the demographic data of people with head injuries is the long period of time over which services will be needed. Most of the respondent (72%) were under the age of 39. Expected to live a normal life span, these individuals will need social and rehabilitation services for 30 to 40 years. Public and private services must prepare to meet the need for long-term support in the home, community, and workplace. Given the lifespan implications of head injury, it is no wonder that respondents attribute great importance to vocational issues. Unfortunately, they also report high level of dissatisfaction with the quality and availability of those services. Participants in this study were not currently receiving employment-related services such as vocational couseling, job training, and job placement; and most had not received those services since being injured. Furthermore, they cited the need for appropriate placement assistance and long-term follow-up support.

Together with evidence from other sources, this study suggests that there are two basic issued facing people with traumatic brain injury and their families with respect to employment. The first concerns the insufficiency of the knowledge base from which to develop and implement appropriate vocational rehabilitation strategies. As has been noted by other researchers, very little evidence exists regarding effective vocational rehabilitation approaches, although neurological rehabilitation coupled with work trials and supported employment models appear promising (Haffey & Lewis, 1989; Noble, 1990; Wehman et al., 1988). According to Haffey and Lewis (1989), successful vocational placements are often preceded by observable gains during work trials, e.g., improved self-awareness, realistic expectations, control of emotions, enhanced information processing abilities, and avoidance of substance abuse. Supported employment models provide on-the-job services such as job modification and job retention counselling helpful to people with head injuries.

The second basic issue addresses the way society organizes and finances services to people with disabilities. Traditionally, categorical program have been established to serve people with particular types of disabilites (Berkowitz, 1987). More recently, some states have moved toward what Noble and Conley (n.d.) call a "generic strategy" based on functional deficits, regardless of the condition creating those deficits. The generic strategy has the potential benefit of enhancing equity and efficiency in service delivery by directing the most resources toward individuals with the most severe disabilities.

Improved allocation of services may contribute to more efficient use of public resources, thereby allowing more services to be delivered to more individuals with severe disabilities, including survivors of brain injury. It appears unlikely, though, that more efficiency alone will result in sufficient support to offset the "lifetime costs for rehabilitation and care" associated with head injuries (Dixon, Goll, & Stanton, 1988) and to achieve the service goals set by the National Head Injury Foundation in 1985 which include (a) expand the array and coordination of services, (b) increase access to and awareness of those services, (c) increase the vocational opportunities for people with head injuries, and (d) create a "fixed point" for the planning and delivery of head injury services (McMahon & Fraser, 1988, p. 198).

In conclusion, this study presents a valuable insight into the perspective of a large number of survivors of head injury. Their cor@unents underscore not only the importance of vocational rehabilitation to the group but also the dissatisfaction that many survivors have with those services and policies. People with head injuries need acces to a life span continum of services provided by professionals who are knowledgeable about head injury and its effects.


The National Head Injury Foundation of America, its state chapters, the Employment Preparation Committee of the President's Committee of Employment of People with Disabilities, and the Arkansas Research and Training Center in Vocational Rehabilitation (University of Arkansas) co-sponsored this report. The preparation of the report was supported in part by a research and training center grant (G0083C0010/5) from the National Institute on Disability and Rehabilitation Research, Office of Special Education and Rehabilitive Service, Department of Education.


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Author:Price, Patricia
Publication:The Journal of Rehabilitation
Date:Jan 1, 1992
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