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BACKGROUND: Employment has long been an area of concern for people with disabilities. National samples in the United States are needed to understand the experiences of people with disabilities related to employment. OBJECTIVES: (1) Describe and evaluate associations between personal and health-related factors with employment after disability, and (2) describe and evaluate associations between facilitators, barriers, and work-related external factors with maintaining a longest held job after disability. METHODS: We recruited a national sample of people with physical disabilities from panels assembled by a United States market research organization; by selection, 1309 were working and 491 were not. We evaluated the likelihood of employment and maintaining employment after disability onset using Poisson regression. Model 1 evaluated factors associated with employment; Model 2 evaluated factors associated with maintained employment. RESULTS: Model 1: Older age, decreased ability to pay bills on time, and assistive device use were associated with decreased likelihood of employment after disability onset. Non-Black minority identification, fatigue, and higher physical function were associated with increased likelihood of employment. For Model 2, the likelihood of maintaining a longest held job was associated with acquiring a disability at work, receipt of job accommodations, valuing opportunities for advancement and health benefits, having a helpful living situation, and helpful human resource attitudes. Decreased likelihood of maintaining a longest held job after disability onset was associated with job dissatisfaction and supervisors' attitudes. CONCLUSIONS: This work highlights opportunities for employers to focus efforts on job accommodations and support in the maintenance of employment after disability.

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BACKGROUND: There is increasing evidence that employment, or the lack thereof, affects an individual's health. Consequently, employment provides people with physical disabilities (PWPD) with financial independence, enhances their well-being and self-worth, and facilitates a sense of purpose. People with physical disabilities often retain job skills and motivation to return to work after acquiring a disability. Their vocational rehabilitation and job accommodation needs likely differ from people with disabilities resulting from developmental, sensory, cognitive, and mental health conditions. To better target the needs of PWPD and improve vocational rehabilitation services, it is crucial to identify the modifiable factors that influence their employment outcomes. OBJECTIVE: This research aimed to examine systematically the client-, employer-, and context-related facilitators and barriers to employment experienced by PWPD. METHODS: We recruited to this cross-sectional study, PWPD from the Midwestern United States who returned to work after injury or illness. An online survey collected data on demographic characteristics and educational history; disability and functional status; supports, facilitators and barriers to employment; and job information and accommodations. RESULTS: 347 working-age PWPD completed the survey; at the time of survey completion, 270 were working and 77 were not. People with physical disabilities who reported social support and encouragement at work were more likely to be working than respondents who did not. Negative attitudes of supervisors and colleagues, inaccessible work environments, and inflexible work schedules were barriers to employment. Important reasons for working included financial needs, a sense of purpose, and self-worth. CONCLUSIONS: Results provide insights into the importance of social supports in the work environment. Novel approaches are needed to develop supportive relationships with supervisors and coworkers.

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IMPORTANCE: Autistic youth who graduate with a high school diploma may experience challenges in acquiring functional skills for everyday independence. Few studies have focused on how their functional and self-management skills change during the transition to adulthood. OBJECTIVE: To examine cross-sectional differences and longitudinal changes in the functional and self-management skills of transition-age autistic youth. DESIGN: Exploratory longitudinal study (18-mo follow-up). SETTING: Community. PARTICIPANTS: Autistic high school students who graduated with a high school diploma and their parents (N = 50). OUTCOMES AND MEASURES: Pediatric Evaluation of Disability Inventory-Computer Adaptive Test (ASD). RESULTS: Older youth (ages 18-20 yr) had significantly lower normative Social/Cognitive and Responsibility domain scores (i.e., self-management) than youth ages 14-17 yr. Approximately 2 yr later, youth in both age groups significantly improved in scaled scores on the Daily Activities and Responsibility domains. CONCLUSIONS AND RELEVANCE: Autistic youth's functional and self-management skills fell below those of nonautistic peers; however, these skills do change over time and are therefore appropriate targets for intervention. Plain-Language Summary: The findings of this study highlight the importance of focusing on the functional and self-management skills of autistic youth as part of their transition to adulthood. Occupational therapists can play a valuable role in helping autistic youth to achieve independence as adults by assessing their functional needs and strengths and by providing client-centered interventions.

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Employment intervention is essential for supporting people with Parkinson's disease (PwPD), who leave the workforce on average 5 years earlier than those without Parkinson's disease (PD). We developed a framework for occupational therapists (OTs) to address employment for PwPD. Our qualitative analysis employed data source triangulation of environmental scan of resources and publications, electronic medical records data, and focus groups with clinicians and PwPD. The framework underwent expert panel review by OTs and researchers who are knowledgeable of current evidence-based practices for PD. The framework is based on the Person-Environment-Occupation-Performance (PEOP) Model and PEOP Occupational Therapy Process and comprised of four parts: PEOP features of PD relevant to employment, performance changes experienced by PwPD, a process to evaluate and address employment, and intervention ideas. This framework serves as an impetus to explore evidence-based, scalable, proactive intervention approaches to address employment in PwPD.

Creating a framework to help occupational therapists support people with Parkinson's Disease to maintain employmentThis study aims to support people with Parkinson's disease (PwPD) in maintaining employment by developing a framework for occupational therapists (OTs). PwPD often leave their jobs 5 years earlier than others because they lack early employment support. OTs are well suited to address this need due to their expertise in task analysis, client-centered interventions, and enabling participation in meaningful activities.The researchers created a framework through an iterative process. They analyzed various sources, including occupational therapy resources and medical records, and reviewed data from focus groups with clinicians and PwPD. The framework aligns with the Person-Environment-Occupation-Performance (PEOP) Model and PEOP Occupational Therapy Process and consists of four main parts:Understanding how Parkinson's disease affects individuals, their work environment, and job-related aspects.Identifying the changes in employment performance experienced by PwPD.Outlining a process for OTs to evaluate and intervene in employment-related issues.Providing various intervention ideas categorized by therapeutic domain.The study also acknowledges the challenges clinicians face when addressing employment needs in PwPD. In conclusion, this framework serves as a foundation for clinicians and researchers to explore evidence-based, proactive intervention strategies for assisting PwPD in maintaining their employment.

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PURPOSE: Research documents poor outcomes for autistic adults in the domains of employment, independent living, and social relationships. Measurement and sample limitations in prior studies may have amplified past estimates of poor outcomes. The goal of the current study was to improve upon past approaches and to create and describe a measurement approach to capture adult outcomes that reflected the context of young adulthood and the perspectives of autistic individuals, pairing objective outcome indicators with subjective satisfaction indicators. METHODS: Thirty-six autistic young adults (mean age 19.8 years) and a parent completed self-report surveys. Using these data, we defined an objective and subjective (i.e., satisfaction) outcome indicator in each of three domains: productivity (employment or post-secondary education), social well-being (frequency of contact with friends), and living situation (autonomy). RESULTS: Three-quarters of young adults experienced at least 5 out of 6 positive outcomes. Over 90% were engaged in school, work, or a structured transition program, and an equal percentage were satisfied with their productivity activity. Over three-quarters of adults had a good amount of contact with friends and were satisfied with their social life. Most young adults had a moderate level of autonomy in their daily lives, and all were satisfied with their living situation. CONCLUSION: Tailoring outcome measurement approaches specifically for autistic young adults provided a more optimistic portrayal of outcomes than previously noted in the literature. The approach used better reflects a neurodiversity approach and may be useful for evaluating the effectiveness of transition services or interventions.

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INTRODUCTION: Ecological momentary assessment (EMA) is a methodological approach to studying intraindividual variation over time. This study aimed to use EMA to determine the variability of cognition in individuals with chronic stroke, identify the latent classes of cognitive variability, and examine any differences in daily activities, social functioning, and neuropsychological performance between these latent classes. METHODS: Participants (N = 202) with mild-to-moderate stroke and over 3-month post-stroke completed a study protocol, including smartphone-based EMA and two lab visits. Participants responded to five EMA surveys daily for 14 days to assess cognition. They completed patient-reported measures and neuropsychological assessments during lab visits. Using latent class analysis, we derived four indicators to quantify cognitive variability and identified latent classes among participants. We used ANOVA and Chi-square to test differences between these latent classes in daily activities, social functioning, and neuropsychological performance. RESULTS: The latent class analysis converged on a three-class model. The moderate and high variability classes demonstrated significantly greater problems in daily activities and social functioning than the low class. They had significantly higher proportions of participants with problems in daily activities and social functioning than the low class. Neuropsychological performance was not statistically different between the three classes, although a trend approaching statistically significant difference was observed in working memory and executive function domains. DISCUSSION: EMA could capture intraindividual cognitive variability in stroke survivors. It offers a new approach to understanding the impact and mechanism of post-stroke cognitive problems in daily life and identifying individuals benefiting from self-regulation interventions.

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IMPORTANCE: Throughout childhood, youth learn the skills they need to carry out their daily life tasks. Despite the importance of being able to manage these tasks to succeed in adulthood, limited research has examined the process through which youth learn to do so. OBJECTIVE: To investigate adolescents' perspectives of parental approaches that help them learn to manage daily responsibilities. DESIGN: Qualitative pilot study. SETTING: Community. PARTICIPANTS: Eight adolescents with and without disabilities. RESULTS: Semistructured interviews with adolescents were analyzed using recursive, conventional content analysis. Interviews asked about how adolescents viewed the process of developing the skills needed to manage daily responsibilities independently. Parent approaches identified by the adolescents fit into three overarching themes: Parents teach them how to carry out and manage responsibilities, monitor them as they become more responsible for tasks, and provide varied levels of independence. The approaches described by the adolescents explain an implicit and transactional process of shifting responsibility for daily life tasks from parents to youth. CONCLUSIONS AND RELEVANCE: Further investigation of the transfer of responsibility for daily life tasks is necessary to build our understanding of this complex process and support successful transition to adulthood. What This Article Adds: Adolescents described several approaches parents used to help them to learn to manage tasks, which may provide direction for occupational therapy clinicians working with youth who are transitioning to adulthood.

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BACKGROUND: Digital therapeutics, such as interventions provided via smartphones or the internet, have been proposed as promising solutions to support self-management in persons with chronic conditions. However, the evidence supporting self-management interventions through technology in stroke is scarce, and the intervention development processes are often not well described, creating challenges in explaining why and how the intervention would work. OBJECTIVE: This study describes a specific use case of using intervention mapping (IM) and the taxonomy of behavior change techniques (BCTs) in designing a digital intervention to manage chronic symptoms and support daily life participation in people after stroke. IM is an implementation science framework used to bridge the gap between theories and practice to ensure that the intervention can be implemented in real-world settings. The taxonomy of BCTs consists of a set of active ingredients designed to change self-management behaviors. METHODS: We used the first 4 steps of the IM process to develop a technology-supported self-management intervention, interactive Self-Management Augmented by Rehabilitation Technologies (iSMART), adapted from a face-to-face stroke-focused psychoeducation program. Planning group members were involved in adapting the intervention. They also completed 3 implementation measures to assess the acceptability, appropriateness, and feasibility of iSMART. RESULTS: In step 1, we completed a needs assessment consisting of assembling a planning group to codevelop the intervention, conducting telephone surveys of people after stroke (n=125) to identify service needs, and performing a systematic review of randomized controlled trials to examine evidence of the effectiveness of digital self-management interventions to improve patient outcomes. We identified activity scheduling, symptom management, stroke prevention, access to care resources, and cognitive enhancement training as key service needs after a stroke. The review suggested that digital self-management interventions, especially those using cognitive behavioral theory, effectively reduce depression, anxiety, and fatigue and enhance self-efficacy in neurological disorders. Step 2 identified key determinants, objectives, and strategies for self-management in iSMART, including knowledge, behavioral regulation, skills, self-efficacy, motivation, negative and positive affect, and social and environmental support. In step 3, we generated the intervention components underpinned by appropriate BCTs. In step 4, we developed iSMART with the planning group members. Especially, iSMART simplified the original psychoeducation program and added 2 new components: SMS text messaging and behavioral coaching, intending to increase the uptake by people after stroke. iSMART was found to be acceptable (mean score 4.63, SD 0.38 out of 5), appropriate (mean score 4.63, SD 0.38 out of 5), and feasible (mean score 4.58, SD 0.34 out of 5). CONCLUSIONS: We describe a detailed example of using IM and the taxonomy of BCTs for designing and developing a digital intervention to support people after stroke in managing chronic symptoms and maintaining active participation in daily life.

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Purpose People with disabilities (PWD) are less likely to be employed than those without disabilities. Reasonable job accommodations are an essential factor for ensuring equal access to jobs for PWD. However, use of job accommodation is less than optimal among PWD with various types of disabilities. Sometimes, PWD have co-occurring impairments, which might affect accommodation use. This research aimed to explore disability phenotypes, frequently used accommodations, and employee- and job-related factors associated with the extent of job accommodation use. Methods A cross-sectional online survey of PWD was conducted in the Midwest region of the United States. Latent class analyses were used to identify disability phenotypes. Descriptive analysis and stepwise Poisson regression were used to identify factors associated with job accommodation use. Results A total of 326 PWD with work experience after acquiring a disability were included in this analysis. We identified three disability phenotypes: (1) Severe disability in cognitive, physical, emotional, communication and visual domains (32%), (2) Moderate cognitive and low physical disability (48%), and (3) High physical disability phenotypes (20%). 80% of PWD received at least one accommodation. Flexible working schedules, telework, and access to a support person in the workplace were the most common accommodations. Employee- (age, disability phenotypes, motor function) and job-related factors (job preparation, self-employment) are associated dependently with accommodation use. Conclusion This analysis identifies three disability phenotypes and highlights both employee- and job-related factors associated with accommodations used. It may be beneficial to consider multiple contextual factors, including co-occurring disability, employee- and job-related factors, when assisting people with job accommodations.

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Autistic young adults experience challenges participating in the workforce, post-secondary schooling, and living in the community. We examined how participation outcomes have been measured in autistic young adults. Articles (n = 113) were identified through database searches and citation tracking. Guided by current models in the literature, data were extracted for each measure of participation. Results include a description of the studies in the review, the extent to which participation across life situations has been addressed, and a critical analysis of the measures used to describe participation. While there is some breadth in the investigation of participation across diverse life situations, there is limited depth in what the measures capture and many measures used lack psychometric support.

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INTRODUCTION: The impact of depressed mood in daily life is difficult to investigate using traditional retrospective assessments, given daily or even within-day mood fluctuations in various contexts. This study aimed to use a smartphone-based ambulatory assessment to examine real-time relationships between depressed mood and functional behaviors among individuals with stroke. METHODS: A total of 202 participants with mild-to-moderate stroke (90% ischemic, 45% female, 44% Black) completed an ecological momentary assessment five times per day for 2 weeks by reporting their depressed mood and functional behaviors regarding where, with whom, and what activity was spent. RESULTS: Participants spent 28% of their wake-up time participating in passive leisure activities but spent the least time in physical (4%) and vocational (9%) activities. Depressed mood was concurrently lower when participants engaged in social activities (ß = -0.023 ± 0.011) and instrumental activities of daily living (ß = -0.061 ± 0.013); spent time with family members (ß = -0.061 ± 0.014), spouses (ß = -0.043, ± 0.016), friends (ß = -0.094, ± 0.021), and coworkers (ß = -0.050 ± 0.021); and were located in restaurants (ß = -0.068 ± 0.029), and homes of family members (ß = -0.039 ± 0.020) or friends (ß = -0.069 ± 0.031). Greater depressed mood was associated with worse ratings in satisfaction, performance, and engagement of activities in concurrent (ßs = -0.036 ± 0.003, -0.053 ± 0.003, -0.044 ± 0.003) and time-lagged models (ßs = -0.011 ± 0.004, -0.012 ± 0.004, -0.013 ± 0.004). DISCUSSION: Smartphone-based ambulatory assessment can elucidate functional behaviors and associated mood after stroke. Findings support behavioral activation treatments to schedule social and instrumental activities for stroke survivors to reduce their depressed mood.

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Social communication and executive functioning challenges as well as co-occurring anxiety/depression may make acquiring the skills needed to manage daily life tasks difficult for diploma-track autistic youth, thus limiting their participation in adult roles. This study describes the associations between executive function, social communication skills, and internalizing behaviors on task management in academically capable autistic adolescents (n = 46) using multiple regression with mediator analysis. The three predictors and youth age explained a moderate amount of variance in task management. Metacognition mediated the effect of social communication skills and internalizing behaviors on task management. Relations between underlying factors that influence self-management of daily life tasks are complex, supporting the need for multifaceted assessment and intervention approaches for academically capable autistic youth.

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PURPOSE: Youth with disabilities who graduate with a regular high school diploma often continue to have difficulties in their daily functioning that ultimately impact adulthood outcomes. To better understand these functional difficulties and determine how best to address them, it is important to distinguish deficits in discrete skills from difficulty organizing skills to self-manage complex tasks associated with adult roles. The purpose of this study was to explore the extent to which challenges in social, executive function and behavior management factors relate to these two aspects of daily functioning. METHODS: This is a secondary analysis of the National Longitudinal Transition Study 2 funded by the United States Department of Education. The direct and indirect associations between youth underlying factors and self-management of daily life tasks (SMDLT) versus discrete functional skills were modelled using structural equation modelling. RESULTS: A model incorporating social skills, communication, and behavior regulation explained 55% of the variance in SMDLT. In contrast, the model predicting discrete functional skills had fewer significant associations and described less variance (37%) in the outcome. CONCLUSIONS: Findings suggest that using measures of SMDLT and designing targeted interventions for SMDLT might help improve participation in independent living and productivity for diploma-track youth with disabilities.Implications for rehabilitationSuccessful transition from high school to adult roles requires the ability to self-manage the daily life tasks required for those roles, such as employment, post-secondary education, and independent living.The ability to self-manage daily tasks is distinct from mastery of discrete functional skills and should be assessed with measures that uniquely examine this domain.Social and communication skills, executive functioning, and behavioral regulation, are important contributors to the ability to self-manage life tasks for diploma-track youth with disabilities and should be incorporated into multifaceted interventions.Interventions to improve self-management of tasks should include teaching strategies and practice coordinating underlying skills in flexible ways that meet the varying demands of tasks and diverse environments.

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BACKGROUND: People with disabilities and chronic health conditions rely on a range of services and supports to complete daily tasks, maintain health, and participate in the community. Preliminary research suggests the COVID-19 pandemic greatly disrupted these services and this population may be particularly susceptible to unemployment. OBJECTIVE: Describe employment and service disruptions for individuals with disabilities and chronic health conditions during the onset of community-based spread of COVID-19 in the United States. METHODS: Adults with disabilities and chronic health conditions completed online surveys to report employment and service changes via multiple choice and open-ended questions. Multiple choice questions were analyzed using descriptive statistics; open-ended responses were coded using content analysis. RESULTS: Participants (n = 109): 79.8% female, 88.1% white, 77.121% completed a 4-year college degree or greater, 61.4% had annual income ≥$45,000. Only 14.9% of survey respondents reported disruptions in employment. On average, 54.0% of service changes were due to discontinuation, including loss of physical therapy, job coaching, community organizations, transportation, and peer supports. Other changes included a shift to virtual service delivery and family members taking the role of service providers. CONCLUSIONS: Individuals with chronic health conditions and disabilities experienced service disruptions, even in a sample with considerably more economic, social, and educational privilege than the general population of people with chronic health conditions and disabilities in the United States.

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BACKGROUND: Most research examining birth history (i.e. related birth complications) and developmental milestone achievement follow outcomes for infants at-risk with very specific birth weight categories and gestational age classifications. The purpose of this study was to examine how birth weight relates to infants' birth histories and developmental milestone achievement when they fall into a variety of birth weight and gestational age categories. METHODS: In the current study, we examined birth histories and onset ages for developmental milestones by analyzing a convenience sample of anonymous existing data from 663 developmental histories completed by parents at the time of an initial evaluation at a pediatric outpatient occupational therapy clinic. Infants fell into 3 birth weight categories; low birth weight (LBW), normal birth weight (NBW), and high birth weight (HBW) and 3 gestational age classifications considered with birth weight; small for gestational age (SGA), appropriate for gestational age (AGA), and large for gestational age (LGA). RESULTS: NBW, AGA, and SGA infants with related birth complications had lower birth weights than infants without birth complications. Larger birth weights were associated with earlier ages for independent sitting for HBW infants, earlier ages for eating solids for NBW infants, and earlier walking onsets for LBW and NBW infants. Higher birth weights were also linked with rolling at a younger age for LGA infants, earlier walking and speaking words for AGA infants, and sooner independent sitting for SGA and AGA infants. CONCLUSIONS: Our findings suggest that birth weight and gestational age categories provide unique insights into infants' birth history and developmental milestone achievement.

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