A vocational rehabilitation partnership to provide transition services to young adults with neurodevelopmental disabilities: The cognitive skills enhancement program

2.1.1 Community-academic partnership

CSEP is a clinical rehabilitation program designed for transition-age adults with NCD. It is funded by a community-academic partnership between an academic institution and the state VR program. The partnership was established when the state VR program identified that customers with NCD were less likely to graduate from vocational training programs than customers without NCD and therefore sought to support customers with NCD via cognitive rehabilitation transition services. Through this partnership, the academic institution faculty and staff are contracted to develop, implement, and operate a clinical transition program that is located within a state VR pre-vocational training facility, referenced hereafter as ‘state VR training facility’. This ongoing contract allows the state VR program to provide unique and comprehensive clinical rehabilitation services to young adults with NCD transitioning to postsecondary education. Academic faculty and staff with expertise and experience in NCDs conceive the program (based on prior work), maintain the contract, develop, and implement the program.

Thus, CSEP is neither a research grant nor a traditional fee-for-service model. This offers a major advantage in service delivery, as participants are offered comprehensive rehabilitation services on site while pursuing postsecondary education. The considerable access and service delivery barriers that are often present for young adults with NCD who are enrolled in postsecondary education are minimized. Further, this partnership supports flexible responses to rapidly changing needs, barriers, and priorities from all stakeholders (e.g., institutions, state VR training facility leadership, clinicians, participants).

2.1.2 Participants

Participants with NCD are referred by state VR counselors. Participants are typically diagnosed with ASD, specific learning disabilities, ADHD, and/or other acquired cognitive disorders (e.g., TBI). When CSEP began in 2004, there was heterogeneity across diagnoses within the program. Over time, ASD emerged as the most common diagnosis, perhaps due to increased diagnosis and referrals for adults on the spectrum. Participants are often referred to CSEP due to limited self-awareness and understanding of the impact of disability, difficulty establishing and maintaining reciprocal social relationships, poor emotional regulation and impulse control, and/or other executive functioning impairments. Most participants experience cognitive inflexibility, intolerance of uncertainty and change, and have difficulty generalizing learning across environments.

Participants are screened for CSEP eligibility via a review of records and an individual screening interview. Individuals who meet criteria for CSEP demonstrate: (1) evidence that cognitive impairments are contributing to functional limitations; (2) adequate verbal functioning and abstract reasoning to allow participation in group treatment, typically demonstrated by a Wechsler Adult Intelligence Scale (WAIS-IV) (Wechsler Adult Intelligence Scale–Fourth Edition - PsycNET, n.d.) Full Scale IQ >  70, Verbal Comprehension Index >  70, and Similarity Subtest >  6; and (3) expression of understanding of and willingness to participate in the program.

This program evaluation was approved by the University of Pittsburgh’s Office of Research Protections, IRB# 2204005. This project has been characterized as being an activity that does not meet the formal definition of research, according to the federal regulations at 45 CFR 46.102(l). Participants are fully informed and provide written consent to participate before enrolling in this transition program.

2.1.3 Evolution of CSEP from 2004–2018

The overarching goal of CSEP is to improve employment outcomes for transition-aged individuals with NCD by increasing awareness of strengths, limitations, and impact of disability, all through the development of social-emotional and executive functioning skills. Although the goal has remained consistent since inception in 2004, CSEP has evolved in terms of treatment targets, interventions, and staff structure.

2.1.3.1 Program and staff structure CSEP participants are enrolled in the program full time (i.e. Monday through Friday, 8:00am-3:30pm) for 15 weeks. The program cycles coincide with the semester ‘term’ schedule at the training facility. From 2004 through 2018, CSEP employees primarily consisted of academic faculty and staff. Specifically, the staff team included one Program Coordinator: a masters or doctoral-level clinician with relevant certifications (e.g., Certified Brain Injury Specialist, Certified Rehabilitation Counselor); one state VR counselor; and two to four part-time rehabilitation counseling graduate student trainees. The graduate student trainees were the interventionists responsible for the bulk of provision of clinical services. Interventionists were supervised by a team of experienced clinicians that included masters and doctoral level Licensed Professional Counselors and a Licensed Psychologist specializing in neuropsychology during weekly group supervision meetings. Graduate student trainees also received individual supervision.

2.1.3.2 Treatment targets and interventions CSEP was initially developed as a comprehensive clinical rehabilitation transition program modeled after programs with preliminary efficacy in TBI populations (Ben-Yishay & Daniels-Zide, 2000, p.; Cicerone et al., 2011; Dahlberg et al., 2007; Gehring et al., 2011; Prigatano, 2005; Prigatano et al., 1984). CSEP initially targeted self-awareness, cognitive rehabilitation, and executive functioning skill building. As the program evolved, a variety of specific cognitive skills (e.g., memory, attention, problem solving), social skills (e.g., communication, self-advocacy, assertive behavior), and vocational skills (e.g., resume building, mock-interviews, appropriate workplace behavior), as well as an introduction to assistive technology, were identified as treatment targets. In essence, a broad range of developmental and cognitive challenges (e.g., awareness, problem solving, memory, social skills) were targeted simultaneously and in sequence in the context of a supportive therapeutic environment.

Individual counseling was eventually embedded into a program built on psychoeducation groups. Participants were assigned a primary interventionist with whom they established one to three individualized goals designed to increase employability. These goals were tracked for program evaluation purposes and fell into the following domains: social skills, personal hygiene, emotion regulation, impulsivity, self-esteem and advocacy, problem solving, planning, cognitive flexibility, and organization. Interventionists developed individualized treatment plans with SMART (i.e., specific, measurable, attainable, relevant, time sensitive) goals and methods for goal attainment (Bovend’Eerdt et al., 2009). Participants met with their interventionist twice a week for 30 minutes to work on goals.

Vocational mentorships have been a core component of CSEP since its inception. Participants are matched with a mentorship site based on their interests and skills. They work at a local business or organization for seven weeks, approximately six hours per week. This exposes participants to workplace settings, often for the first time. Mentorship provides the opportunity for participants to practice newly learned social skills and regulation strategies. These placements also increase participants’ awareness of the impact of their disabilities in the workplace. Community-based assessments are completed at the conclusion of the mentorship.

Leadership of the state VR training facility emphasized two new needs, 1) enhance the facility-community relationship, and 2) provide mental health counseling to an increasing number of students presenting with mental health challenges. The need to improve the facility-community relationship grew out of a desire to advocate for individuals with disabilities in the local community. We determined we could meet this need while simultaneously enhancing opportunities for skill generalization by designing programming that engaged CSEP participants in meaningful community volunteering.

The second need related to the increasing number of students with NCD presenting with co-occurring symptoms of anxiety, depression, post-traumatic stress disorder, etc. Given the expertise of our staff in NCD disabilities, we expanded the scope of our program to also address co-occurring mental health symptoms. Whereas CSEP was originally designed to narrowly address the impact of cognitive deficits, providing mental health interventions reduced the burden on the in-house therapists, increased the number of students who could receive mental health services, and potentially enhanced vocational outcomes by addressing symptoms that were constraining the impact of vocational rehabilitation efforts.

As part of this increased emphasis on addressing mental health challenges, CSEP leadership, based upon ongoing clinical research being conducted by members of the CSEP team (Beck et al., 2020; White et al., 2021), decided to place particular emphasis on addressing emotion regulation. There is increasing evidence that emotion regulation is a transdiagnostic mechanism underlying many mental health disorders and symptoms (Mazefsky & White, 2014). Further, emotion regulation impairment likely underlies co-occurring mental health diagnoses, aggression, meltdowns, avoidance, self-harm, crisis services, and suicidality in individuals with NCD (Conner et al., 2020, 2021). Ineffective emotion regulation exacerbates social functioning impairment and continues to be largely unaddressed in many traditional VR programs (Mazefsky et al., 2013).

3.1.2 Skill generalization

During the early years of the program, CSEP clinicians consistently reported that participants were not generalizing learned strategies and skills in novel environments. These outcomes occurred despite participants seemingly mastering content in group and individual sessions, as evidenced by restating material in their own words, independently generating individualized examples, and planning to use newly learned skills. For example, clinician observations made through community-based assessments during mentorship indicated participants were not using newly learned strategies and accommodations on site. During CSEP exit interviews, participants had difficulty recalling or describing the material learned in CSEP. Many had difficulty identifying the individual goals they worked on all term. Vocational training program instructors also indicated that many participants were not implementing strategies in their academic training programs. We concluded that program targets needed to be narrowed to focus on two to three targets with repetition and depth rather than breadth, and that additional supports be provided to generalize strategies and skills into new settings.

3.1.3 Implementation-related barriers

We experienced two interrelated implementation challenges. First, we noted low fidelity in delivering the intervention. Second, it was challenging to meet and sustain the intensive training and supervision needs of the clinical staff. To that point in the project, CSEP had primarily been delivered by graduate student trainees who worked for one to two years before graduating. This model inevitably produced a high turn-over rate, and training students in a short amount of time was challenging. Further, student trainees required months of training prior to being able to effectively deliver evidence-based mental health treatments, thereby exacerbating the turnover issue.

To resolve these issues, we recruited and hired full-time staff as the primary interventionists. Graduate student trainees remain involved in CSEP but are now given a small caseload for training purposes and are not the primary interventionists. Interventionists consist of four Master’s-level clinicians, one Bachelor’s-level clinical support staff, and one or two graduate student interns. Interventionists are still supervised by a team of experienced clinicians that included three Licensed Professional Counselors and a Licensed Psychologist/Neuropsychologist.

3.2.1 EASE

The Emotional Awareness and Skills Enhancement (EASE) program is a 16-week individual mindfulness-based intervention designed to target emotion dysregulation among adolescents and young adults diagnosed with ASD (Conner et al., 2019). EASE incorporates meditation practices and cognitive strategies, drawn from Mindfulness-Based Stress Reduction and Mindfulness-Based Cognitive Therapy, to teach individuals with ASD to cultivate awareness of emotional intensity and strategies to calm during states of heightened emotional intensity. EASE consists of four modules and incorporates four generalization sessions to practice skills learned in sessions. Participants are taught to notice physical and behavioral cues of emotional arousal intensity, rather than emotion labeling or processing. Participants develop a personalized scale for rating emotional intensity and strategy plan for managing emotions by the end of treatment. EASE has established feasibility, acceptability, and preliminary efficacy among youth and young adults on the autism spectrum (ages 7–25) with and without intellectual disability (Beck et al., 2021; Conner et al., 2019).

EASE was optimized for implementation with the CSEP context and population. The 16-week intervention was collapsed into 14 weekly individual therapy sessions with a trained EASE clinician. The EASE manual was edited for college-age participants and caregiver involvement was removed from the treatment. Group meditation practices were integrated into CSEP at the beginning and end of each programming day. All CSEP clinicians were trained to prompt participants to use EASE strategies at any sign of heightened reactivity for in vivo practice. CSEP clinicians completed an EASE training and engage in regular weekly supervision with one of the EASE developers.

3.2.2 PEERS®

The Program for the Education and Enrichment of Relational Skills (PEERS®) for Young Adults is an evidence-based social skills training program designed for neurodiverse young adults with social skills deficits (Laugeson et al., 2015). The intervention consists of 16 weekly 90-minute groups, with groups for young adults and caregivers being run simultaneously. Group leaders use the Socratic method to teach social skills, primarily in the form of concrete rules and steps of social etiquette and forming and maintaining relationships. Participants practice social skills in-session and are assigned homework to practice in natural social settings. PEERS® was developed for neurodiverse individuals with average intellectual ability, and, as a result, is a fast paced and complex treatment. PEERS® has been successfully adapted for inclusive residential postsecondary college programs (Rose et al., 2021).

All CSEP interventionists are PEERS® for Young Adults Certified Providers and engage in weekly supervision. PEERS® was tailored to fit within the CSEP context while retaining the intervention content. Adjustments were made to the number of sessions (i.e. 14 total sessions), the pace of the intervention (i.e. one session was delivered in four 50-minute groups), and the social coaching format. Participants were assigned to work with a CSEP interventionist who served as a social coach instead of the caregiver model. Social coaches met with participants weekly and provided 1) social coaching in natural settings (e.g., the cafeteria), 2) assistance with weekly social skills homework assignments (e.g., planning, pre-coaching, and post-coaching), and 3) assistance with finding a source of friends (Laugeson, 2017).

3.2.3 Work readiness

Work readiness has remained a priority for the state VR program. CSEP work readiness programming incorporates aspects of pre-vocational training that stakeholders have identified as necessary to improve employment outcomes (Hedley et al., 2017), including soft skills (e.g., punctuality, hygiene); professional behavior (e.g., professional introductions, teamwork); and identifying, securing, and using reasonable accommodations through self-advocacy. Psychoeducational work readiness groups are offered three days per week, three to four 45-minute groups per day.

Vocational mentorship placements remain a cornerstone of CSEP work readiness programming. In addition to promoting self-awareness, placements are designed to facilitate applied learning of work readiness domains (e.g. soft skills, professional behavior, and reasonable accommodations). Mentorships also serve as an excellent opportunity to practice generalization of emotional regulation and social skills.

3.2.4 Community participation

Community-based activities have been found to predict positive employment outcomes in students with disabilities (Test et al., 2009). In addition to facilitating positive relationships in the local community (a stakeholder goal), community participation activities are excellent opportunities to generalize skills learned to real world settings (Test et al., 2009). This is particularly important for young adults with NCD given their challenges with skill generalization.

CSEP community participation programming includes community-based activities in non-school and natural environments. Community participation activities are facilitated one day per week (Fridays). CSEP staff work with local businesses and organizations to identify opportunities to volunteer (e.g., adopt a highway, local soup kitchen), tour community resources and meet community leaders (e.g. visiting the County Courthouse, interviewing the Deputy Coroner), and fundraise (e.g. food drive, raising money for charity). These activities require navigating public transportation, introductions and conversing with new people, working as a team, and navigating novel situations, which all provide ample opportunity for skill practice and generalization. Prior to community participation, participants plan with clinicians the emotion regulation and social skills they would practice during the activities. Interventionists provide in vivo skills coaching and evaluation, which facilitates the consolidation and generalization of new skills and promotes insight and awareness.