Robert T. Fraser

Moderating factors in return to work and job stability after traumatic brain injury

Objective:To examine job stability moderating variables and develop a postinjury work stability prediction model. Design:Multicenter analysis of individuals with traumatic brain injury (TBI) who returned for follow-up at 1, 2, and 3, or 4 years postinjury, were of working age (between 18 and 62 years of age at injury), and were working preinjury. Setting:Six National Institute on Disability and Rehabilitation Research TBI Model System centers for coordinated acute and rehabilitation care. Participants:A total of 186 adults with TBI were included in the study. Main outcome measures:Job stability was categorized as stably employed (employed at all 3 follow-up intervals); unstably employed (employed at one or two of all three follow-up intervals); and unemployed (unemployed at all three follow-up intervals). Results:After injury, 34% were stably employed, 27% were unstably employed, and 39% were unemployed at all three follow-up intervals. Minority group members, people who did not complete high school, and unmarried people were more likely to be unemployed. Driving independence was highly influential and significantly related to employment stability. A discriminant function analysis, which included age, length of unconsciousness and Disability Rating Scale scores at 1 year postinjury, accurately predicted job stability groupings. ConclusionData analysis provided evidence that employment stability is predictable with a combination of functional, demographic, and injury severity variables. Identification of people at risk for poor employment outcomes early on can facilitate rehabilitation planning and intervention.

The effect of telephone counselling on reducing post-traumatic symptoms after mild traumatic brain injury: A randomised trial

Background: Mild traumatic brain injury (MTBI) is a significant public health problem affecting approximately 1 million people annually in the USA. A total of 10–15% of individuals are estimated to have persistent post-traumatic symptoms. This study aimed to determine whether focused, scheduled telephone counselling during the first 3 months after MTBI decreases symptoms and improves functioning at 6 months. Methods: This was a two-group, parallel, randomised clinical trial with the outcome assessed by blinded examiner at 6 months after injury. 366 of 389 eligible subjects aged 16 years or older with MTBI were enrolled in the emergency department, with an 85% follow-up completion rate. Five telephone calls were completed, individualised for patient concerns and scripted to address education, reassurance and reactivation. Two composites were analysed, one relating to post-traumatic symptoms that developed or worsened after injury and their impact on functioning, the other related to general health status. Results: The telephone counselling group had a significantly better outcome for symptoms (6.6 difference in adjusted mean symptom score, 95% confidence interval (CI) 1.2 to 12.0), but no difference in general health outcome (1.5 difference in adjusted mean functional score, 95% CI 2.2 to 5.2). A smaller proportion of the treatment group had each individual symptom (except anxiety) at assessment. Similarly, fewer of the treatment group had daily functioning negatively impacted by symptoms with the largest differences in work, leisure activities, memory and concentration and financial independence. Conclusions: Telephone counselling, focusing on symptom management, was successful in reducing chronic symptoms after MTBI. Trial registration number: ClinicalTrials.gov, #NCT00483444

PEARLS depression treatment for individuals with epilepsy: A randomized controlled trial

OBJECTIVE Depression is associated with higher rates of suicide and lower levels of functioning and quality of life in individuals with epilepsy. The objective of this randomized controlled trial was to determine the effectiveness of PEARLS, a home-based program for managing depression in adult individuals with epilepsy and clinically significant acute and chronic depression. METHODS Delivered by masters-level counselors, PEARLS is a collaborative care intervention consisting of problem solving treatment, behavioral activation, and psychiatric consultation. Patients were randomly assigned to the PEARLS intervention (N = 40) or usual care (N = 40), and assessed at baseline, 6 months, and 12 months. RESULTS Compared with patients who received usual care, patients assigned to the PEARLS intervention achieved lower depression severity (P<0.005) (Hopkins Symptoms Checklist-20) and lower suicidal ideation (P = 0.025) over 12 months. CONCLUSIONS The PEARLS program, a community-integrated, home-based treatment for depression, effectively reduces depressive symptoms in adults with epilepsy and comorbid depression.

Workers' risk of unemployment after traumatic brain injury: A normed comparison

We examined, among those persons working preinjury, the risk of unemployment 1 year after traumatic brain injury (TBI) relative to expected risk of unemployment for the sample under a validated risk-adjusted econometric model of employment in the U.S. population. Results indicate that 42% of TBI cases were unemployed versus 9% expected, relative risk (RR) = 4.5, 95% confidence interval (CI) (4.12, 4.95). The relative risk for unemployment was higher among males, those with higher education, persons with more severe injuries, and more impaired early neuropsychological or functional status. Difference in unemployment rates gave similar results for gender, severity of injury, and early neuropsychological and functional status. However, for education, the excess was smaller among those more highly educated, but the unemployment rate in the more highly educated in the general population was sufficiently small to yield a larger relative risk. In conclusion, after accounting for underlying risk of unemployment in the general population, unemployment is substantially higher after TBI for people who were employed when they were injured. The differential employment status varies depending on demographics, severity of brain injury, early functional outcome, and neurobehavioral indicators. For characteristics such as education, associated with rates of unemployment in the general population, different methods used to compare the rates may yield different results.

Stability of employment after traumatic brain injury

Although substantial information exists about factors related to who returns to work and time taken to return to work after traumatic brain injury (TBI), less is known about the stability of the work experience after the injury. One hundred sixty-five workers with complicated mild to severe traumatic brain injury were followed for 3 to 5 years postinjury. Work stability definitions included amount of time worked (amount of time worked divided by time observed postinjury) and maintenance of uninterrupted employment once a person returned to work. Amount of time worked was significantly and systematically related to brain injury severity, neuropsychological functioning at l-month postinjury, and preinjury characteristics such as prior work stability and earnings. However, once persons returned to work, the ability to maintain uninterrupted employment was largely related to premorbid characteristics such as being older, higher income before the injury, or a preinjury job with benefits. It was also related to higher neuropsychological functioning at 1-month postinjury (reflecting the combined effects of premorbid functioning and traumatic brain injury severity), but not related to neurologic indices of severity.

Understanding Employers’ Hiring Intentions in Relation to Qualified Workers with Disabilities: Preliminary Findings

Introduction As part of the planning process for a larger survey study to examine factors affecting employers’ intention to hire and hiring of people with disabilities, a series of three semi-structured focus groups were held with key hiring decision makers, such as Human Resources directors, Chief Operating Officers (COOs), or Chief Executive Officers (CEOs) of small, medium, and large Seattle area companies. Aim The chief goals of the focus groups were to elicit and refine the participants’ beliefs, normative influences, and perceived control relative to hiring workers with disabilities. Method Narrative data obtained from the focus group discussion were examined using the Theory of Planned Behavior (TPB) to identify themes expressed by the focus group participants within the context of company size. Results Themes did vary by company size, but a prevailing concern across all companies related to questions about the efficiency/effectiveness of contact with vocational rehabilitation agencies. For both small- and mid-sized companies, there was a belief that people with disabilities could not do the work or were somehow less qualified. For large companies, convincing departmental and team managers that outreaching workers with disabilities would be a worthwhile hiring practice remained a challenge. Conclusion The themes derived from this study can be used to help occupational rehabilitation professionals develop educational and marketing interventions to improve employers’ attitudes toward hiring and retaining individuals with disabilities.

Long-term outcomes from the PEARLS randomized trial for the treatment of depression in patients with epilepsy

Depression is associated with higher rates of suicide and lower quality of life in individuals with epilepsy. We previously published the 12-month outcome from our randomized clinical trial of PEARLS (Ciechanowski P, Chaytor N, Miller J, et al. Epilepsy Behav. Epub 5 July 2010). The purpose of this study was to determine the long-term effectiveness of PEARLS, a home-based collaborative care intervention consisting of problem-solving treatment, behavioral activation, and psychiatric consultation, in individuals with epilepsy. Patients were randomly assigned to PEARLS (N=40) or usual care (N=40), and assessed at baseline and 6, 12, and 18 months. Patients assigned to PEARLS achieved lower depression severity (P<0.05) (Hopkins Symptoms Checklist-20), lower suicidal ideation (P<0.02), and better emotional well being (QOLIE-31) (P<0.02) over 18 months, compared with patients given the usual care. The PEARLS program significantly reduces depressive symptoms in adults with epilepsy, and this effect is maintained for 18 months after baseline and for more than 1 year after completion of home visits.

Further Validation of the WPSI Vocational Scale: Comparisons with Other Correlates of Employment in Epilepsy

Summary: The present study evaluates the relationships between employment status and five types of variables: years of education, intelligence, emotional adjustment, neuropsychological impairment, and psychosocial adjustment. The latter two areas were evaluated by procedures specifically developed for work with seizure patients and include use of the Neuropsychological Battery for Epilepsy and the Washington Psychosocial Seizure Inventory. Fifty‐eight patients were divided into groups based on their employment histories and classified as unemployed, underemployed, and employed. Results indicated that the two types of procedures developed specifically for work with clients having seizures demonstrated the most potent and consistent relationships with employment status. The study suggests that the use of these procedures in the evaluation of employability may be more effective than using only those variables which traditionally have been applied.

Program Evaluation in Epilepsy Rehabilitation

Summary: The Vocational Services Program of the University of Washington Regional Epilepsy Center is described, and data relating to the first 106 clients who entered the program are examined. A major emphasis of the study was characteristic differences between those clients later competitively employed and program dropouts. Other study purposes related to examining client satisfaction ratings of different aspects of services and establishing whether a relationship existed between seizure occurrences and job loss. Stepwise discriminant function analysis indicated that “months employed in the last 24” appeared to be the stable discriminator between the employed and dropout groups. The group later employed averaged 12 of the prior 24 months in employment, whereas dropouts approximated 7. Associated psychiatric/addictions treatment was initially a key outcome discriminator, but it did not hold up on cross‐validation. Subjects were more satisfied with individualized client services (e.g., counseling sessions) than with group activities (e.g., Job Club). As opposed to seizures, emotional/attitudinal difficulties with this rehabilitation population appeared to be the primary reason for job loss. A work adjustment or job station program can be critical for these individuals and others with neurological impairments. The importance of counselor follow‐up after the initial job placement is also underscored. This program, with about half of its clients entering unsubsidized jobs, basically replicated the results of other community‐oriented epilepsy rehabilitation programs.

Understanding employers' hiring intention in relation to qualified workers with disabilities

The present study focused on the intentions of employers to reach out toward qualified workers with disabilities as part of their hiring pool recruitment activity. An employer survey was developed in accord with the theory of planned behavior (Ajzen, 2005). According to the tenets of the model, it was hypothesized that through multiple regression, it would be demonstrated that employer attitudes, subjective norms, and perceived control variables predict the intention to engage in hiring behavior toward qualified workers with disabilities in the next six months. Overall, the model accounted for 67% of the variance in the survey of Northwest employers (n = 92) in relation to hiring intentions with normative influences (CEOs, CFOs, etc.) accounting for the greater proportion of the variance, beta coefficient 0.48, p < 0.01. Attitudes toward the hiring behavior and perceived control had lesser beta weights, 0.24 and 0.22, p < 0.05. Implications of these findings and those from the focus groups used to develop the survey are reviewed in detail relative to more effective vocational rehabilitation marketing efforts.