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Summary of Review Articles and Factors Associated with Employment Outcomes Following TBI

Citation Review Focus Key Factor Associated with Employment Outcomes Relevance to Work Evaluations Holtzberg Narrative review Factors relevant to gaining employment included: Processes relevant to gaining employment (2001) that asked the  Motor skills/ ambulation requiring consideration: question: What are  Social (family functioning, availability of  identifying whether individual has job best practices for supports, substance abuse, workplace readiness skills gaining and integration)  exploring career options maintaining  Psychiatric (PTSD, anxiety/depression,  exploring job placement options employment interpersonal, self-awareness, affect control, Process relevant to maintaining following TBI? adjustment) employment requiring consideration:  Cognitive (learning, perception, memory,  ensuring on-going support and generalization in novel situations) provision of physical rehab services to Factors relevant to maintaining employment included: keep individual medically stable  Client (self-awareness, affect regulation,  provision of workplace supports such creativity, substance use, work habits) as monetary compensation and  Workplace(workplace integration, benefits, integrated work environments natural supports)  interventions focused on decreasing  Social Supports (caregivers, rehab services) substance abuse  provision of satisfying jobs and career advancement and counseling  involvement of families  understanding of disability rights and income replacement benefits Yasuda et Narrative review Although inconclusive, the literature does suggest that Establishment of rapport by gaining an al. (2001) that synthesized the the following factors may be predictive of rtw understand of individuals’ strengths, literature re: RTW outcomes: abilities, support needs, preferences and in relation to:  injury severity (mixed evidence) interests  resulting impairments (e.g. physical, cognitive, *Return to work social behaviour, alcohol abuse, personality Analysis of whether a job worth keeping 2

outcomes changes (some evidence)  age 40 and above (mixed evidence) Exploration and identification of *Factors  marital status (married individuals lower rtw rates) individuals’ personal and employment influencing rtw  gender – women more likely to return to work goal (mixed evidence) *Vocational  race- lower rtw rates for individuals from minority Review of prior work history and reasons programs that groups (mixed evidence) for separation enhance  education – lower levels of attainment associated employment with lower rtw (mixed evidence) History of seizures, medications and including  pre-injury occupation -persons in structured identified medical restrictions supportive occupations such as building and trades more likely employment to return to work) Identification of situations that can trigger inappropriate responses in the client  post-injury occupation- those hired by pre-injury employer more likely to be successful and have Assessment of the individual’s abilities higher hourly wages e.g. vision, energy patterns and fatigue,  social support and psychosocial adjustment attention and concentration, under what important to successful rehab and rtw circumstances does the individual not  level of functional independence (some evidence) attend, become distracted or experience  fear of losing benefits and lack of transportation sensory overload, memory, forgetfulness,  work culture e.g. friendliness, ‘natural supports recall of events and learning new info, with co-workers problem-solving and relying on management of memory problems one another to complete tasks, processes to facilitate job performance Assessment of individual’s social needs  work benefits e.g. fringe benefits, opportunities for wage raises and advancement, formal & informal Job analysis : but this can only provide a supports, opportunities for socialization with co- “best guess” about potential future workers performance  attitudes re: accommodations & modifications amongst vocational rehab counselors and Identification of whether job considering employers would capitalize on persons strengths or 3

potential barriers that may need to be overcome

Assessment of available supports, attitudes and perceptions about accommodations

Identification of individualized compensatory strategies and evidence that client can successfully use strategies to improve job performance

Identification of problem behaviours and prevention or suppression of unacceptable behaviours Sherer et A systematic Key factors relevant to employment outcomes as Results from early neuropsych assessment al. (2002) review which indentified from studies included: (i.e. those obtained at resolution of PTA or investigated the  pre-injury educational level within 1 months post-injury) can provide ecological and  pre-injury employment an additional dimension to predicting predictive validity  accuracy of self-awareness future vocational outcomes of  pre-injury alcohol use neuropsychological Under studied factors include: assessment in  family support relation to  access to public transportation vocational  access to post-acute rehab services outcomes after TBI.  general economic conditions

Strong support for the use of early neuropsych assessments for predicting employment outcomes even when accounting for other medical indicators such as 4

severity of injury

Insufficient or inconclusive evidence for the use of late or concurrent neuropsych assessments to predict employment outcomes. However this may be because no studies have investigated this relationship as it’s primary goal & late neuropsych assessment may assist with treatment planning Ownsworth A systematic Pre-injury and demographic characteristics are not Assessment of client’s general cognitive, & review which modifiable – knowledge of these may be more relevant visuo-perceptual, executive functions and McKenna examined factors to early identification of those individuals most emotional status are all relevant to a (2004) related to vulnerable to poor employment outcomes therapist’s understanding of potential employment vocational success outcomes following Factors that have demonstrated the strongest TBI, with a focus association with employment outcomes and may Knowledge of individuals’ functional on meta-cognitive provide the most beneficial information for prediction abilities provides evaluator with greater skills (e.g. self- include: predictive information than just injury awareness & and  pre-injury occupational status severity indices self-regulation)  functional status at discharge  general intellectual or global cognitive functioning Collection of data on pre-injury  perceptual or visuo-spatial ability occupation and occupational experience  executive functions relevant  emotional status Understanding availability of vocational  access to rehabilitation and vocational support services also relevant services Wehman et A selective Individual factors relevant to employment outcomes Need to look beyond acute prognostic al. (2005) narrative review include: indicators, to consider pre-injury which targeted  self-awareness & acceptance of disability productivity, education, rehabilitation studies that  age at injury (i.e. over 40 = greater likelihood of services received in evaluation process addressed the negative outcomes) 5

relationship  individuals’ career goals and preferences Need to consider support factors and between work re-  individuals’ interpersonal relationships, mental relevance to employment outcomes entry and: health Support factors relevant to employment outcomes Needs to consider follow-up services *self-awareness include: available and role they may play in job  workplace supports e.g. socially inclusive work retention *predictors environments, health care benefits, opportunities for advancements, socialization *supported with co-workers, decision-making latitude employment  provision of vocational rehabilitation services and long-term follow up *use of supports  labour market issues/layoffs  policies that support work re-integration and vocational services for individuals with disabilities  financial incentives to engage in work and systems to protect income replacement benefits + benefits counseling Giaquinto Editorial describing  sensory, physical, neuropsychological deficits RTW only in part dependent on client’s & Ring the needs of relevant to rtw following brain injury impairments and disability, with (2007) individuals with  TBI survivors higher probability of finding work if environments also requiring assessment disabilities (e.g. below age 35 TBI, stroke, spinal  the provision of adaptations/modifications such as cord injuries, low additional time to complete duties, step-by-step back pain, procedures & directions, memory and meta- amputations) in cognitive strategies returning to work Shames et Narrative review Pre-morbid & injury factors: Availability of funding & skilled al. (2007) that highlights:  severity of injury/ impairment level as professionals determined by LOC, PTA, GCS, GOC, length 6

*factors that can of stay, status at discharge from rehabilitation Provision of services in line with influence RTW  levels of serum S-100B, marker of structural principles of supported employment brain damage related to failure to return to work *treatment and  requirement for tracheotomy and presence of rehabilitation issues aphasia Development of a good “working authors consider  abnormalities on diagnostic tests (e.g. alliance” between patients, staff and relevant for diencephalic damage, abnormalities in visual families rehabilitation evoked potentials) professionals  age at time of injury with age over 40 indicative of negative outcomes  pre-injury occupational and educational background (e.g. managerial or professional 3x more likely to return to work than skilled workers, such as technicians, sales and services and 1.5 x more likely than manual labourers)  pre-injury employment status – if employed pre-injury, 3-5 x more likely to return to work  presence of pre-injury psychiatric history, substance abuse and behavioural problems  mechanism of injury Cognitive factors:  self-awareness  inattention  impaired memory  learning  impaired processing speed  decreased verbal power  executive functions (e.g. initiation, organizing, prioritizing, decision-making, coping with novelty & risk, creative problem-solving) 7

Psychosocial factors:  psychological distress related to dizziness, pain, depression  psychosocial adjustment  opportunities for social interactions, decision- making latitude  access to transportation

Vocational training opportunities:  availability of voc services  rural/urban opportunities  economic & cultural factors influencing expectations re: re-employment  types of compensation systems Kirsh et al. An integrative Personal factors relevant (for brain injury) To facilitate work integration, person, job (2009) literature review  Age, education & occupation and work environment factors must all be that examined the  Attention, processing speed and working memory, assessed principles and self-awareness inter-personal skills, adjustment & practices guiding affect control Need to identify if there is a fit between work integration Environmental factors person, environment and occupation within the fields of  Availability of long-term support (personal) and intellectual rehabilitation services (professional) Need to match individuals’ preferences disability (ID),  Availability of supported employment, supportive and abilities to work demands brain injury and employers and colleagues mental health,  Availability of accommodations Need to identify potential barriers to work Aimed to identify  Availability of funding integration e.g. attitudinal, stigma, labour best practices for market forces and benefits systems that do  Payment of disability benefits supporting not support work integration transitions into mainstream 8

occupations across these three populations