Effects of postsecondary education on employment outcomes and earnings of young adults with traumatic brain injuries

1.1 Adults with traumatic brain injuries

In the United States, about 1.7 million Americans sustain traumatic brain injuries (TBI) each year, with approximately two-thirds of these injuries affecting people between the ages of 15 and 24 years (Centers for Disease Control and Prevention [CDC], 2016; MacLennan & MacLennan, 2008). Employment outcomes for individuals with TBI lag far behind those of the general population. Specific to young adults with TBI, they may face a variety of complications, including cognitive impairments, behavioral concerns, and social difficulties, which can negatively impact their educational and vocational pursuits (Strauser et al., in press; Todis et al., 2011; Wehman et al., 2014). Cuthbert et al. (2015) analysed patient data from the Traumatic Brain Injury Model Systems National Data and Statistical Center (TBIMS-NDSC) to estimate the prevalence of unemployment and part-time employment in the United States for working-age individuals with TBI who received services from TBIMS between 2001 and 2010. The results indicated that the prevalence of unemployment at two-year post-injury (2003–2012) for adults with TBI was 60.4%, whereas the average unemployment rate for the U. S. population during the same period was 9.0%. In another study, young adults with TBI were found to be 2.3 times less likely to obtain a college degree and were 1.7 times more likely to be unemployed or have an unskilled career compared to the general population (Anderson et al., 2009). There is emerging research evidence to support college and university training as an effective employment intervention for young adults with disabilities (O’Neill et al., 2015). For students with TBI who have academic potential, attending and graduating from college could improve their likelihood of finding gainful employment by helping them cope with their physical, emotional, and cognitive symptoms (Strauser et al., in press), thereby paving the way for a meaningful career leading to a middle-class life.

1.2 Purpose of the study

Although the positive effect of college and university training on employment outcomes and lifetime earnings is well documented in the business and labor economics literature, there is a paucity of research studies investigating the effectiveness of education as an employment intervention for young adults with TBI. Accordingly, the purpose of this study was to examine the effect of college and university training on employment outcomes in a sample of young adults with TBI who were served by state VR agencies. The RSA-911 dataset provides a rich source of demographic, VR-service, and employment outcome information about people with disabilities served by state VR agencies (Ditchman et al., 2013). Using this dataset, we conducted a matched case-control study using propensity score matching to adjust for non-random assignment to evaluate the effect of college and university training on employment outcomes and earnings among young adults with TBI served by state VR agencies. Specifically, this study was designed to answer two key research questions:

Is college and university training an effective intervention for increasing the rate of competitive, integrated employment among young adults with TBI who receive services from the state-federal VR program?

2.1 Study cohort

Data for this study were extracted from the RSA-911 data base, which contains detailed information about demographics, disability, types of services, and employment outcomes for all clients receiving state VR services in the United States. The data are furnished annually to RSA by state VR agencies. Data from the RSA-911 for fiscal year 2014 were used for the present analyses because that year represents a more typical economy than the full employment era preceding COVID-19 and the economic crisis that has accompanied the pandemic in 2020 (Smialek & Collins, 2019). The inclusion criteria for the present study were: (a) young adults between the ages of 18 and 35, (b) a primary diagnosis of TBI, and (c) a high school diploma or less education at intake.

Participants in this study included 1,574 young adults with TBI who met the inclusion criteria and whose cases were closed in fiscal year 2014. The sample included 1162 (73.8%) males and 412 (26.2%) females. Racial and ethnic backgrounds were dominated primarily by European Americans (n = 1080, 68.6%), followed by African Americans (n = 252, 16.0%), Hispanics/Latinos (n = 173, 11.0%), Native Americans (n = 37, 2.4%), Asian Americans (n = 29, 1.8%), and Native Hawaiians and/or other Pacific Islander Americans (n = 3, 0.2%). The mean age of the participants at intake was 24.17 years (SD = 5.34). Seven hundred eighty-eight participants (50.1%) were Social Security beneficiaries receiving Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI). Six hundred eighty-two participants (43.1%) were Medicaid recipients.

2.2 Variables

Four demographic variables (i.e., age, gender, race, receipt of Medicaid insurance) and one VR service variable (i.e., receipt of assessment services) were used for the propensity score matching analysis. These covariates were used to adjust the selection bias between the treatment and control groups. The outcome variables included employment outcome (employed vs not employed in a competitive, integrated setting), average number of hours worked per week, and average weekly earnings at VR case closure.

2.3 Statistical analysis

Propensity score matching methods for non-experimental causal comparative studies (Austin, 2011) were used to create a matched group of young adults with TBI who did not receive college and university training as part of their VR services (the control group) that was compatible with the group of young adults with TBI who received college and university training (the treatment group). Next, the matched group (no college or university training) and the treatment group (received college or university training) were compared to examine the effect of college and university training on employment outcomes. Chi-square analysis and t-tests for independent sample analysis were used to analyze the differences between the treatment and control groups on employment outcomes.

3.1 Descriptive statistics

To maximize the sample size for the treatment group, participants with a high school education or less at application and some college, associate’s degree, or bachelor’s degree and higher at closure were classified as the college and university training group (treatment group). Participants with a high school education or less at application and also at closure were defined as the no college and university training group (control group). Five prominent covariates (age, gender, race, receipt/non-receipt of Medicaid, and receipt/non-receipt of assessment services were used for the propensity score matching analysis. Assessment services were used as a proxy for lower levels of TBI severity. Prior to propensity score matching, there were 278 participants in the treatment group and 1,296 participants in the control group. Information regarding the demographic characteristics of the treatment and control groups, the t-test results, and the chi-square results is presented in Table 1.

As can be observed in Table 1, young adults with TBI in the treatment group were younger than participants in the control group, t(1574) = –4.971, p < 0.0001. The percentage of European American participants was higher in the treatment group than in the control group, χ ² (1, N = 1574) = 14.112 p < 0.0001. There were proportionally more participants who received Medicaid in the control group than in the treatment group, χ ² (1, N = 1574) = 38.395, p < 0.0001. There were fewer participants receiving assessment services in the control group than in the treatment group, χ ² (1, N = 1574) = 5.991, p < 0.05. These results show that the treatment and control groups differed significantly on four of the five prominent covariates.

Propensity score matching using logistic regression analysis and the nearest neighbour method was conducted to equalize the treatment and control groups on the five prominent covariates. As can be observed from Table 1, propensity score matching using the five prominent covariates was able to identify 278 young adults with TBI from the control group that match the prominent characteristics of the 278 participants in the treatment group. Chi-square and t-test results indicated that there were no statistically significant differences between the treatment and control groups on four of the five prominent covariates. However, the percentage of participants who were Medicaid recipients in the treatment group was lower than in the control group, χ ² (1, N = 556) = 5.25, p < .05.

3.3 Employment-related outcome analysis

We conducted one chi-square test of independence and two t-tests for independent samples to evaluate the effects of college and university training on employment outcomes, hours work per week, and weekly earnings.

4.1 Clinical implications

Gainful employment has many benefits. Work is a large part of people’s personal identity; it grants social legitimacy to people’s lives, helps people to live with dignity, and enables them to view themselves as productive members of society (Freyers, 2006). This is particularly relevant to youth with TBI, because the condition can lead to individuals experiencing a loss of personal sense of identity, contracted view of self and the future, and lower quality of life (Muenchberger et al., 2008). College and university training increases the probability that an individual will find a meaningful job that can lead to a successful career. In the present study, we demonstrated the effectiveness of college and university training on improving the employment outcomes and earning capacity of young adults with TBI who received services from state VR agencies. Tucker and Degeneffe (2017) also highlighted the importance of VR supports including college or university training and personal adjustment counseling because youth with TBI may encounter many disability-related and psychosocial challenges as they transition to employment. In state VR agencies, rehabilitation counselors play an important role in helping persons with disabilities achieve their independent living and employment goals. For example, when working with clients with TBI, rehabilitation counselors can promote their adjustment to TBI and improve access to resources and services (Dillahunt-Aspillaga et al., 2014). Rehabilitation counselors can provide tuition support for young adults with TBI to attend college and pre-employment transition services (e.g., self-advocacy training, social skills training, and job interviewing and job seeking skills training) to help students develop character strengths and emotional efficacy to cope with the demands and challenges of college life and prepare for finding employment. These VR services can augment services (e.g., study skills training, time management training, and accommodation services) provided by disability service providers to maximize the probability that students with TBI will persist with their career goals, graduate from college, and find gainful employment. However, currently, there is a gap among neuro-rehabilitation providers, VR counselors, and disability service providers in college settings. Neuro-rehabilitation and health professionals need to become familiar with state VR agencies in their geographic area and develop a working relationship with rehabilitation counselors in order to refer their clients with TBI deemed to have academic potential to state VR agencies for employment related services. This can be done by professionals taking a more proactive approach in familiarizing themselves with the resources offered in the community, and personally connecting with rehabilitation counselors in these communities to network and develop alliances. Findings of the present study also indicate that college and university training for youth with TBI is a good investment. However, according to the Bureau of Labor Statistics (2015), people with disabilities are less likely to complete a bachelor’s degree in comparison to people without disabilities. College students with TBI may have difficulty navigating the academic rigors of their training (owing largely to cognitive impairments in addition to physical, societal, and systemic barriers; Rumrill et al., 2016). It can also be difficult for students with TBI to self-advocate and seek appropriate services; therefore, rehabilitation counselors need to work closely with neuro-rehabilitation providers and disability service providers as a team to develop treatment plans and provide evidence-based disability and rehabilitation services that will improve college life adjustment, goal persistence, and career self-efficacy and outcome expectancy of students with TBI.

4.2 Limitations

This study has several limitations. First, we used observational data to create treatment and control groups instead of using a randomized controlled trial design, and we cannot make conclusive statements about causality. Additionally, this study was limited by only demographic and vocational rehabilitation service variables available in the RSA-911 database. It is possible that a comprehensive set of demographic variables could provide more accurate propensity scores for matching youth with TBI who received college or university training with those who did not receive such services as a VR intervention. These factors limit the generalizability of findings of the current study. To increase the sample size, we used a loosely described definition of college or university training as youth with TBI who completed some college, associate’s degree, or bachelor’s degree and higher. It may be better to combine multiple years of RSA-911 data and retrieve participants who have a college degree or higher at closure.