The Role of the Vocational Rehabilitation Counselor in Life Care Planning

The Dictionary of Occupational Titles (DOT), 4th edition (U.S. DOL, 1991a, p. 52), defines a (or program), and aiding clients in outlining and obtaining appropriate medical and social ser­vices. The DOT further states that ocational rehabilitation counselors may specialize in a type of disability (e.g., spinal cord injury, traumatic brain injury, amputation, burn, visual impairment, hearing impairment, chronic pain, etc.). The role of the vocational rehabilitation counselor in life care planning expands this definition and is specific to persons who are catastrophically impaired or have complex medical needs and limited access to the labor market.

This role has become more defined since the early 1980s, when life care planning was first introduced into the litera­ture (Deutsch & Raffa, 1981). In today’s climate, vocational rehabilitation counselors serve as an instrumental member of the rehabilitation team to coordinate assessments in an effort to mea­sure a person’s aptitude, achievement levels, and transferable work skills. These assessments help determine one’s potential for future work activity, such as full- or part-time employment, sheltered or supported employment, or, in cases where work activity is not a realistic goal, achieving their highest level of productivity or independent living. The essential premise underlying vocational rehabilitation is that involvement in work or some productive, meaningful activity is the goal of one’s rehabilitation program (Marme & Skord, 1993; Weed & Field, 1994, 2001). And if return to work or productive activity is appropriate, then the needs and steps to achieve that goal must be included in the life care plan (Weed, 2007).

Vocational rehabilitation counselors who work within the life care planning arena generally are rehabilitation professionals who have a minimum of a master’s degree in rehabilitation counseling, hold one or more national certifications in the field of rehabilitation, and have extensive training and experience in the areas of evaluation and assessment, catastrophic case management, transferable work skills, earnings capacity analysis, and job placement (Weed & Field, 1994, 2001). Vocational rehabilitation counselors can be credentialed in a number of areas, most notably CRC (certified rehabilitation counselor), CDMS (certified disability management specialist), CCM (certified case manager), CVE (certified vocational evaluator), and ABVE (American Board of Vocational Experts). Credentials can also be obtained from other organizations that, on the surface, appear to be based more on profit making than on advancing the role and function of the rehabilitation professional. While some of these credentials may be valuable, the authors strongly encourage those professionals interested in pursuing further credentials to thoroughly research the history of the organization, assure the credential is founded upon role and function research, and scrutinize the validity of the offer.

Vocational rehabilitation counselors with advanced degrees and appropriate credentials are properly trained, qualified, and fully prepared to complete life care plans. They can be found working in a variety of fields, including workers’ compensation, personal injury, health or disability insurance/managed care, federal Office of Workers’ Compensation Programs, and state vocational rehabilitation agencies. Additionally, many facilities (e.g., specialty centers of excellence such as Shepherd Center in Atlanta, Georgia) employ rehabilitation counselors to assist in the evaluation and, when appropriate, transition of a client into other services for return-to-work assistance or to achieve productivity.

Vocational rehabilitation counselors must be knowledgeable and stay within the accepted stan­dards and guidelines of the particular jurisdiction for which they are preparing the life care plan. For instance, in the workers’ compensation arena, the vocational counselor must work within the estab­lished definitions of disability and return-to-work hierarchy.

This also includes the “odd lot” doctrine that has been defined by case law as “any work that the client may be able to perform which would be of limited quantity, dependability or quality, and for which there is no reasonably stable market for their labor activities” (Gil Crease v. J.A. Jones Construction Company, 1982; Clark v. Aqua Air Industries, 1983). In comparison, vocational reha­bilitation counselors within the disability insurance arena, such as long-term disability/short-term disability (LTD/STD), will be expected to provide information on the status of the client’s “any/own occupation,” as well as the client’s vocational potential and the cost of future vocational/educational needs. Similarly, vocational rehabilitation counselors within the personal injury arena will need to determine if the client has vocational potential and to what degree. They will also need to provide information on the cost of the client’s expected future vocational/educational needs in an effort to identify vocational damages associated with the injury or disability.

Regardless of the specific jurisdiction, vocational rehabilitation counselors in life care plan­ning must be able to determine first if a client can work and, if so, what work the client can perform. This determination would include providing information on not only the types of vocational activity a client can be expected to perform, but also the cost, frequency, and duration or replacement of any training or assistance (such as job coach, vocational counseling, rehabili­tation technology, modified or custom-designed workstation, supported employment, tuition/ books, or other specialized education programs) that may be required to reach the goal (Weed & Riddick, 1992). Depending on the type of disability, the vocational rehabilitation counselor will work with a variety of medical and allied health professionals in determining one’s vocational potential and providing information for the life care plan.

Professionals such as physicians and medical specialists, physical therapists, occupational thera­pists, speech/language pathologists, recreation therapists, nurses, psychologists, neuropsychologists, audiologists, counselors or other mental health professionals, and, in the case of school-age clients, school personnel, all work with the vocational rehabilitation counselor to provide information for the life care plan. Generally, team members whose primary responsibilities are for cognitive and psychosocial remediation interact more with vocational counselors than do other team members, and interactions are more effective when focused on adaptive work behaviors such as the ability to relate with coworkers and supervisors (Sbordone & Long, 1996). In some cases, the nurse case manager for a client with a catastrophic injury will be the primary author of the life care plan, and the vocational rehabilitation counselor must work in conjunction with the nurse to gather and disseminate vocationally relevant information. It is common for the vocational rehabilitation counselor to rely on the client’s primary physician (if available to the expert based on legal protocol), typically a physiatrist, also known as a specialist in physical medicine and rehabilitation (PM&R), in determining a client’s functional level and potential to perform vocational activity. In appropriate cases, the vocational counselor may request a functional capacity evaluation (FCE), which may also be known as a physical capacity evaluation or functional capacity assessment, to objectively delineate a client’s physical functioning. Although there are arguments about the validity of FCEs, in the authors’ opinion, an appropriately trained examiner can provide objective data regarding the client’s ability to perform various physical demands (lifting, standing, walking, sitting, pushing/pulling, etc.), which are usually performed in a facility that specializes in occupational health information. The FCE provides a snapshot view of a client’s functional abilities on one particular day (although evaluation may be conducted over 2 days), and given the outcome of the testing, the client’s work capacity from a physical standpoint is determined. Additional factors that the vocational rehabilitation counselor must take into consideration in assessing a client’s physical capacities are the client’s ability to perform work activity over time (endurance), the client’s subjective complaints, test validity/reliability (often associated with the examiner as well as the tests), and secondary gain issues (Matheson et al., 2002). In summary, the FCE is just one of many pieces of information used by the vocational rehabilitation counselor in assessing a client’s vocational potential.

It is the responsibility of the vocational rehabilitation counselor to maintain a vocational focus on issues related to the life care plan. Most important, the counselor needs to work with the team to establish a medical or psychological foundation to support a client’s work potential opinion. A case in which the authors consulted illustrates the need to establish a medical foundation. The case involved a 50-year-old iron-metal construction worker who fell 70 to 90 feet from scaffolding and received multiple orthopedic injuries. The nurse case manager assigned to the case referred the client for a vocational evaluation to determine his work potential. Results from the vocational evaluation coupled with the client’s reported high motivation to return to work seemed to suggest that he had the capacity to return to work in some area related to his previous work experience. The vocational rehabilitation counselor then proceeded to conduct a labor market survey to identify actual jobs in his area. Although on the surface it appeared that the case was progressing appropriately (at least from the case manager’s perspec­tive), it was learned through contacts with the client’s treating physician that it was his opinion the client was permanently and totally disabled from work. Indeed, the client applied for and was approved for Social Security Disability Insurance (SSDI) benefits, which supported the doctor’s opinion that the client was disabled from work activity. The physician furthermore indicated that his recommendations with regard to the client’s vocational potential had not been solicited by the vocational counselor. In fact, the physician was unaware that a vocational rehabilitation plan had been developed to return the client to work, and he obviously did not support the plan. This is a clear example of the importance of interacting with a client’s medical care providers (when able) to establish a foundation to support the vocational plan.

The terms vocational assessment and vocational evaluation have been used over the years in reha­bilitation literature to generally describe the process of gathering data and determining a person’s potential for work activity. Botterbusch (1987) defines vocational assessment as “more limited in scope” than vocational evaluation and cites the Vocational Evaluation and Work Adjustment Association (1983) definition of vocational evaluation, which “incorporates medical, psychological, social, vocational, educational, cultural, and economic data” (p. 191). In Siefker (1992), it is noted that the two phrases “do not describe a significantly different process and can be considered synon­ymous” (p. 1). For purposes of this post, the phrases will be used interchangeably to describe the comprehensive evaluation of a client’s biographical and social history, education and work history, medical and other pertinent records (employment/personnel records, school records, parents’ school records in pediatric cases, etc.), psychological/neuropsychological records, and actual vocational test results in determining vocational potential.

In compiling data for the life care plan, it is within the role of the vocational counselor to recommend and obtain a formal vocational assessment/evaluation, particularly in the case of a client who:

¦     Is of working age (generally age 16 to 67)

¦     Has no or an unclear vocational goal

¦     Has no work history or a series of short, sporadic jobs

¦    Has not been determined permanently and totally disabled (i.e., is thought to have some vocational potential)

It may be interesting to note that there has been an increase in the Social Security Administration’s (SSA) determination of full or normal retirement age. The age in which SSA full retirement benefits may begin is now considered to be 67 years old for people born in or after 1960. For individuals born in 1937 or earlier, the full retirement age is 65 and increases incrementally to age 67 for individu­als born between 1937 and 1960. Individuals may still begin taking retirement at age 62; however, their SSA retirement benefits will be reduced by an amount greater than for individuals retiring at age 62 today (see www.ssa.gov). Obviously, rules apply to normal SSA retirement benefits, which are different from Social Security Disability Insurance (SSDI) benefits and Supplemental Security Income (SSI) benefits that may be received by some clients with a disability.

For clients who are catastrophically injured, it is important for the vocational evaluation to be as specific as possible and to take into account the client’s personality traits, interests, aptitudes, and physical capabilities so as to adequately identify appropriate vocational options (Weed & Field, 1994, 2001). In their book, Counseling the Able Disabled, Deneen and Hessellund (1986) describe some of the most common reasons for vocational testing. Below is a modified version of the list that is felt to be most relevant to life care planning:

Provide information about a person’s interests, mental and physical abilities, and temperament with respect to work.Support, clarify, and document impressions gained during interviews.Discover job interests and potential vocational objectives. Objectively and accurately describe the client’s likes, dislikes, needs, and abilities rather than rely solely on verbal interview information.Observe and evaluate the client’s physical stamina, endurance, agility, and ability as related to work performance.Evaluate the degree to which a particular impairment is a physical disability or handicap.

Vocational assessments can vary depending on the particular jurisdiction in which the case is involved. For example, vocational evaluations performed for workers’ compensation cases typically do not include personality testing in determining suitable employment (Weed & Field, 2001). These evaluations generally focus on aptitudes and physical capacities (and sometimes interests) as well as the client’s demonstrated work history. It is the authors’ opinion that vocational evalua­tions that do not address personality factors or testing should be closely scrutinized as to why such assessment tools are not included. Is it an oversight on the part of the evaluator? Is the evaluator not qualified to administer personality tests? Is the evaluator relying upon government data associated with the job history as published in the DOT and the Transitional Classification of Jobs (Field & Field, 2004)? Or is there a deliberate attempt not to define personality traits, which may have a positive or negative effect on the client’s vocational potential? Even in workers’ compensation cases, at least one court ruled on appeal that a client’s vocational interests were relevant and necessary (Weed & Field, 1994, 2001).

When referring for a vocational evaluation, the vocational rehabilitation counselor must review the evaluator’s credentials and specify which areas to assess. (Also see the section on referring for neuropsychological testing later in this post.) The vocational rehabilitation counselor should be concerned not only with the expertise and experience of the evaluator, but also with the techni­cal or scientific aspects of a particular assessment tool and the way in which the test results will be used (Kapes & Mastie, 1988; Siefker, 1992). In developing a life care plan, the vocational rehabili­tation counselor must be able to translate results from the vocational evaluation into requirements for the life care plan (Weed & Field, 1994, 2001; Weed, 2007). Such requirements may include
cost for training, transportation, tuition, specialized or adaptive equipment, and maintenance and replacement schedules of needed equipment (Siefker, 1992; Weed, 2007). For example, the authors were involved in identifying the costs associated with completing a master’s degree and pursuing a PhD for a triple amputee who was a teacher at the time of his electrical injury. Not only were costs included in the life care plan for education requirements, but also costs of transportation, prosthetic devices, maintenance and replacement, clothing allowance (due to increased wear and tear on garments as result of prosthetic use), and computer and other assistive technology needed to assist the client in attaining his vocational goal of education administrator. This case example also demonstrates that a client’s ability to achieve a vocational goal is closely related to other life care plan issues such as ability to perform activities of daily living (ADLs), accessible housing and transportation, psychological adjustment to disability, home/attendant care, wheelchair or mobility needs, and others. This case also provides an example of the inclusive approach the vocational rehabilitation counselor must use in conducting a comprehensive assessment of the client and interrelating realistic occupational goals with all other aspects of the client’s care.

In addition to having a comprehensive evaluation performed, the vocational rehabilitation counselor must be sensitive to how the specific tests are administered. For example, group vs. indi­vidual; time, speeded, or untimed; paper and pencil vs. computer administered vs. work sample; short vs. long form; normed vs. nonnormed; and objective vs. subjective, to name a few (see Table 4.1). In general, group tests are not as specific as individual tests (Anastasi, 1982; Siefker, 1992), and speeded or timed tests are usually biased against catastrophically impaired persons. In clients who are motorically or cognitively impaired, tests that are timed may reveal a lower score than is intellectually indicated given that the score is based on speed more so than ability. Additionally, situational or job specific tests that evaluate a person’s ability for work activity in an actual work environment typically are more favorable and yield more accurate results than a work sample assessment in which job tasks are simulated. Some authors suggest that a client’s vocational poten­tial can be most effectively determined when the workplace is used as the primary site of all reha­bilitation activity. They further indicate that no other location can be compared to the workplace for face validity and actual job activities (Sbordone & Long, 1996).

Much has been written on the various vocational assessment tools given to persons with a disability (see Vocational Assessment & Evaluation Systems: A Comparison, 1987; A Counselor’s Guide to Career Assessment Instruments, 1988; Vocational Evaluation in the Private Sector, 1992; and A Guide to Vocational Assessment, 2006). The following list is provided to give an overview of some of the more common or well-known tools used in the vocational assessment/evaluation of persons who are catastrophically impaired. The reader is referred to the publications referenced previously for a description of each test and information regarding its usefulness for specific populations of persons with a disability. Intelligence:

¦    Wechsler Intelligence Scales (preschool, child, and adult versions; the standard of the industry)

¦     Stanford—Binet Scales (child and adult)

¦     Slosson Intelligence Test (brief and very general)

¦     Raven Progressive Matrices (emphasis on reasoning ability)

Personality:

¦     Minnesota Multiphasic Personality Inventory (MMPI) (also in Spanish)

¦     16 Personality Factors (16 PF)

Speeded, timed, and               Speeded and timed tests may be biased against physically

untimed tests                         impaired clients. Untimed tests may not reveal how

competitive a client may be.

Individual vs. group tests        Usually the group test is offered for economic reasons and is more general. Individually administered tests allow for examiner comment regarding effort and behavioral observation.

Vocational evaluators often use short tests for achievement, intelligence, aptitude, and interest screening. Tests such as the Wide Range Achievement Test and current revision (WRAT), Self-Directed Search, General Aptitude Test Battery (GATB), Slosson Intelligence Test, and others are not as precise as more detailed tests (e.g., Wechsler). Many evaluators are not qualified to administer more precise tests.

In order of general priority for best assessment:

• On the job with an employer On the job based on general standard by professional evaluator• Work sampleIndividually administered test Leaving out personality           It is common in workers’ compensation to leave out interest

factors                                  and personality factors when developing an opinion. Basic

information with regard to interests, work values, and personality as it relates to work is recommended.

¦     Myers-Briggs Type Indicator (MBTI)

¦     Personality Assessment Inventory (PAI)

¦     Rorschach Inkblot Test

Interest:

¦     Strong-Campbell Interest Inventory

¦     Career Assessment Inventory (CAI)

¦     Self-Directed Search (SDS)

¦     Kuder Occupational Interest Inventory

Aptitude:

¦     General Aptitude Test Battery (GATB)

¦    Apticom

¦    Armed Services Vocational Aptitude Battery (ASVAB)

¦     Differential Aptitude Tests (DAT)

¦     McCarron Dial System

¦     Crawford Small Parts Dexterity

¦     Hester Evaluation System

¦     Purdue Pegboard

Achievement:

¦     Wide Range Achievement Test (WRAT as revised)

¦     Woodcock-Johnson Psychoeducational Battery (as revised)

¦     Peabody Individual Achievement Test

¦     Basic Occupational Literacy Test (BOLT)

Work Sample:

¦    VALPAR

¦    Jewish Employment and Vocational Service (JEVS)

Assessment of Physical Functioning:

¦    Vineland Social Maturity Scale

¦     PULSES (physical condition, upper limb, lower limb, sensory, excretory, support factors)

¦     Barthel Inventory of Self-Care Skills

In conjunction with objective test results, the vocational rehabilitation counselor should consider the client’s behavior during the interview and test session. Behavioral observation is an integral part of the vocational assessment process and should always be interpreted with the actual test results and client’s history, assuming the test was one that lends itself to such observation (Siefker, 1992). The qualified vocational evaluator is attuned to behavioral issues that may affect test results (e.g., pain behaviors, visual/hearing difficulties, need for medication or rest breaks, fatigue, cul­tural issues and language barriers, and environmental issues, such as: Is the room too hot or cold? Is it early or late in the day?). Likewise, the client’s behavior may reveal areas of concern or discrep­ancy that may warrant further investigation (e.g., Was the client late for the testing session? What are the nonverbal behaviors? Are the client’s appearance and grooming appropriate?). Behavior is a valid indication of how one will respond in certain situations, whether it is in a work environment or social/community setting.

In addition to behavioral observations, information about a client’s abilities and skills obtained through educational and work experience may be more valid than test results (Siefker, 1992; Weed & Field, 1994, 2001). For this reason, a transferable skills analysis may be an essential component of the vocational evaluation and for determining a client’s vocational potential. Simply described, a transferable skills analysis is based upon a profile of the worker traits required of a specific occupation. It is used primarily for clients with a documented work history and takes into consideration one’s work experience and residual functional capacities to determine appropriate vocational options. The DOT and Transitional Classification of Jobs (COJ) are necessary to compile a transferable skills analysis, and some experts utilize various computer programs to assist with managing large amounts of data (Truthan, 1997; McCroskey, 2001; Weed & Field, 2001; Gibson,

2003). Also, the Occupational Information Network (O*Net) has been designed to replace the DOT eventually; however, the O*Net does not yet offer a way to conduct a transferability analysis that can be reliably used in formulating opinions for Social Security disability determinations and personal injury cases, and the DOT continues to be the vocational resource of choice at the present time. See the vocational resources section later in this post for a description of these and other relevant vocational publications.

Neuropsychological evaluations are performed on clients following a brain injury or neurological disease and are essential in identifying the relationships that exist between one’s brain and behavior or, more specifically, between one’s actions and abilities and higher-level cognitive processes (Gabel et al., 1986; Evans, 2004). It is within the role of the vocational rehabilitation counselor to refer a client for a neuropsychological evaluation in cases where there is documented or suspected brain injury/impairment. According to Gabel et al. (1986), referral to a neuropsychologist is appropriate to assess problems of a more long-standing nature and includes areas such as visual, auditory, or tactile processing difficulties; constructional apraxia (copying designs or free drawing); abstract reasoning or concept formation; receptive or expressive language deficits; attention/concentration deficits; and short- or long-term memory problems. Neuropsychological testing is valuable not only to assess a client’s current behavioral and learning problems (i.e., to establish a functional baseline), but also to establish prognosis, monitor and document changes over time, and assist in the planning of the rehabilitation program (Evans, 1999).

Historically, the focus of neuropsychological testing has been on the determination of brain damage and its location. Over the past decade, there is a growing interest within neuropsychology to focus on the client’s capacity to function in everyday life. The prediction of work behavior is the second most frequent reason for referral to neuropsychological evaluations. However, such evaluations are somewhat limited by a lack of norms based on specific job types and specific client population, and more work is needed in this area (Sbordone & Long, 1996).

Neuropsychologists and vocational rehabilitation counselors generally share the goal of facilitat­ing the client’s transition to an active and productive life. Vocationally speaking, neuropsychological evaluations should assist the vocational counselor in identifying the client’s vocational capabilities and behaviors and in planning for a successful entrance into an appropriate work environment or, at minimum, to achieve the highest level of functioning/productivity (Sbordone & Long, 1996). For this reason, neuropsychological evaluations are helpful for both adult and pediatric clients and, as with vocational evaluations, must be as specific as possible.

For purposes of life care planning, results from neuropsychological evaluations must relate specifically to the client’s function and ability and also provide recommendations for future care needs. Problems in thinking and reasoning, information-processing speed, attention/ concentration, and long- or short-term memory are vocational barriers that need to be accurately assessed (Sbordone & Long, 1996). Additionally, psychosocial and interpersonal relationship skills need to be assessed such that there is an obvious need for strong communication and collaboration between vocational rehabilitation counselors and neuropsychologists in the interest of maximizing return to work and identifying life care planning recommendations.

Neuropsychological testing helps determine how much assistance is needed in the home, on the job, at school, and within the community. When referring for a neuropsychological evalua­tion, it is prudent for the vocational rehabilitation counselor to know to whom a referral is being made and the credentials of the neuropsychologist. Experience has shown that the most qualified
neuropsychologist not only has a PhD in clinical psychology and is board certified as a neuropsy­chologist, but also has experience in evaluating persons across all levels of severity of brain injury and has demonstrated a commonsense approach to evaluation and test interpretation.

Once a referral is made to a neuropsychologist, it is recommended that the vocational counselor provide specific questions to the neuropsychologist, which, when answered, would provide information needed specifically for the life care plan. The effects of brain trauma can be found in any or all aspects of one’s life, including interpersonal, vocational, educational, recreational, and activities of daily living. It is the role of the neuropsychologist to evaluate the long-term or lifelong effects of brain injury on the client’s ability to function (Weed, 1994; Evans, 2004). Suggested questions specifically pertinent for the life care planning process are listed in Table 4.2.

In addition to the standard evaluation report, add the following as appropriate.

Please describe, in layman terms, the damage to the brain.Please describe the effects of the accident on the client’s ability to function.Please provide an opinion on the following topics:Intelligence level? (include pre- vs. post-incident if able)Personality style with regard to the workplace and home?Stamina level?Functional limitations and assets?Ability for education/training?Vocational implications on style of learning?Level of insight into present functioning?Ability to compensate for deficits?

i. Ability to initiate action?

j. Memory impairments (short-term, long-term, auditory, visual, etc.)?

k. Ability to identify and correct errors?

Recommendations for compensation strategies? m. Need for companion or attendant care?What is the proposed treatment plan?Counseling? (individual and family)Cognitive therapy?Reevaluations?Referral to others (e.g., physicians)?Other?How much and how long? (Include the cost per session or hour and reevaluations.)

Source: Roger O. Weed, partially adapted by R. Frazier.

Rehabilitation counselors should ask neuropsychologists to answer the questions as part of their evaluation for life care planning.

As stated previously, neuropsychological evaluations are useful in both adult and pediatric cases. The interested reader is referred to Neuropsychological Assessment (Lezak, 1995) for detailed information on neuropsychological evaluations. According to Lezak (1976), the basic neuropsychological battery contains both individually administered tests and paper-and-pencil tests that are self-administered. The individually administered tests can take up to three hours, and the paper-and-pencil tests can take from three to six hours, depending on the extent of the client’s impairment(s). The paper-and-pencil tests typically are not timed; however, the individually administered tests are usually timed. Especially in the case of pediatric clients, neuropsychological evaluations are often given over two sittings in order to avoid fatigue factors. Again, the vocational rehabilitation counselor is cautioned to be sure the neuropsychologist provides a comprehensive evaluation that is sensitive to the client’s particular needs and provides information that is relevant for life care planning. Similar to vocational evaluations, neuropsychological evaluations are not done with a single test but instead are a compilation of data based on test results and interpretation and behavioral observations. It is recommended, and good practice, for the vocational counselor to establish a mechanism to meet or speak directly with the neuropsychologist to discuss test results and solicit input for life care planning.

For purposes of this post, a brief overview of some of the more common evaluation tools for each age group is given.

Pediatric cases present many unique challenges for the life care planner (Weed, 2000). One challenge is that there is little, if any, history on which to rely, and practitioners are often hesitant to offer future care recommendations. For this reason, neuropsychological evaluations are particularly helpful with children to qualify and quantify the impact of a child’s brain injury on functioning and behavior (Weed, 1996). Although there are many assessment tools to evaluate pediatric clients, the Halstead—Reitan and Luria—Nebraska batteries are the most frequently used in the neuropsychological assessment of children (Gabel et al., 1986).

According to Gabel et al. (1986), perhaps the greatest usefulness of the Halstead—Reitan batteries is the establishment of objective baseline data that can clarify a child’s strengths and weaknesses and be helpful in outlining educational strategies and programs to enhance capabilities. In comparison, the Luria—Nebraska Children’s Neuropsychological Test Battery can be administered to children ages 8 to 12 years and focuses on functional systems involved in brain—behavior relationships. A third common assessment battery for children is the Kaufman Assessment Battery for Children (K-ABC) (1983 and revisions), which is individually administered to children ages 2 to 12 years old and measures intelligence and achievement. Also, for academic assessment, it is common for the Woodcock—Johnson Tests of Achievement or Cognitive Abilities test to be administered. Last, a useful tool to assess infants who have experienced brain trauma from age 2 months to 30 months is the Bayley Scales of Infant Development (1969 and revisions). The scales are considered to be the best measure of infant development and provide valuable data regarding early mental and motor development and developmental delay. Other scales of infant developmental attainment are the Cattelle Scales of Infant Development and the Vineland Adaptive Behavior Scales (1984 and revisions).

Whereas there are numerous neuropsychological assessment tools from which to choose when evaluating children for life care planning, there are significantly more tests for adult assessments. Below is a brief list of some of the more common neuropsychological tools for adults and areas they evaluate. For more information and descriptions on the listed tests, refer to Lees-Haley’s Last Minute Guide to Psychological and Neuropsychological Testing (1993).

¦    Wechsler Adult Intelligence Scale, 3rd edition (WAIS-III) (intelligence)

¦    Wisconsin Card Sorting Test (executive or higher-order functions)

¦     Boston Naming Test (language)

¦     Rey Auditory Verbal Learning (memory)

¦    Wechsler Memory Scale-Revised (WMS-III) (memory)

¦     Stroop Color Test (mental control)

¦     Serial 7s or Serial 3s (attention)

¦     Benton Visual Retention Test (visual memory)

¦     Gates-MacGinitie Reading Tests (reading academic skills)

¦     Hooper Visual Organization Test (visual perception)

¦    Woodcock-Johnson (academic and cognitive assessment)

¦     Haptic Intelligence Test (intelligence); used for clients with visual impairment

¦     Leiter Intelligence Test (intelligence); used for clients with hearing impairment

¦     Hisky-Nebraska Aptitude Test (aptitude); used for clients with hearing impairment

In summary, neuropsychological evaluations for clients with brain impairment are usually essen­tial in the field of life care planning to assess both the near- and long-term effects of brain damage on one’s functioning and developmental levels. Information obtained through neuropsychological testing can be crucial in developing the appropriate future care planning of a client with a trau­matic brain injury. Inasmuch as neuropsychological evaluations are vital to life care planning, test results for young children are very variable. Generally, IQ test results are not considered of sub­stantial value until the child reaches school age. Additionally, it is generally more preferable to rely on schoolchildren’s standardized achievement test scores than on actual grades as a true measure of their achievement. In referring a client for neuropsychological testing, the vocational counselor should ensure that the evaluator reviews all available medical and academic records and that the evaluation includes developmental assessments in addition to the standardized test batteries. It is common to include in the life care plan provisions for neuropsychological reevaluations at specific life stages in the client’s development or at specific time intervals throughout one’s life expectancy in order to assess and monitor the client’s functioning abilities. This also applies to the assessment of aging on brain injury or neurological impairment (Weed, 1998).

In addition to contributing information relevant to a client’s vocational and educational outlook with regard to life care planning, the vocational counselor also may be asked to assess the client’s loss of earnings capacity. According to one source, future medical care and loss of earnings capacity are directly related to the education and experience of most vocational counselors. The vocational counselor can offer valuable input in three critical areas: lost capacity to earn an income, loss of opportunity to be employed (loss of access to the labor market), and cost of future medical care (Weed & Field, 1994, 2001; Weed, 2000; Weed, 2002). The first and second areas will be described in this post. The third area, establishing the cost of future medical care will not be covered specifically in this section. Refer to this post tables for a summary of the relevant factors to consider in establishing a foundation for earnings capacity for both pediatric and adult clients.

With regard to lost earnings capacity, it is first necessary to establish the client’s wages at the time of injury. This can be fairly simple for a client who was working at the time of injury in a job that is considered representative of his or her earnings potential. In pediatric cases or for young clients who may have been working but had not yet established a clear vocational identity, the process can be more challenging. The issue of identifying earnings capacity can be divided into four client populations (Weed, 1996; Weed & Field, 2001):

Clients injured at birth or in the neonatal period Clients injured before they reach school age (and have no academic grades or standardized test scores)Clients injured before establishing a career identity Clients injured after having an established work history representative of their vocational potential

Clearly, there are differences in the way the vocational rehabilitation counselor considers informa­tion based on the age of the client at the time of injury.

The listed factors can be a good predictor or give a reasonable approximation of what the client could have done prior to the injury (preinjury earnings or capacity). Obviously, the more history and documentation there is, the better and more accurate a foundation can be established with regard to earnings capacity.

Establishing a Foundation for Earnings Capacity

The vocational rehabilitation counselor must determine the level of the client’s functioning both before the injury (preinjury) and after the injury (postinjury) as it relates to the types of jobs the client could hold now or in the future. In general, wage loss refers to the amount of money (wages) lost by the client as a result of the injury and is based on his or her actual past work history. Earnings capacity, on the other hand, refers to the loss of future earnings related to what would be considered a reasonable estimation of the client’s work potential (capacity) (Weed & Field, 1994, 2001; Weed, 2000).

In some cases, it may be possible to determine that a client is permanently and totally disabled from the workforce based on work history and type of injury. Such an example includes the case of a 58-year-old career truck driver who was involved in a motor vehicle accident and has tetraplegia resulting from a spinal cord injury at C4 level. Although it may be arguable that the client could possibly be employed as a dispatcher or in some other related job in the trucking industry, it is not likely given his advanced age and the fact that he would require extensive job modification and rehabilitation technology, as well as an employer willing to make the modifications and employ the client. In such cases, the actual earnings of the client would be the basis on which to project wage loss (Blackwell et al., 1992).

In other cases, it may be more appropriate to identify a client’s pre- vs. postinjury earnings capacity in categories of jobs rather than specific job titles (Weed, 2000). For example, in cases where the client is a child or young adult with no clearly established work history, the vocational expert can identify categories of jobs that are representative of types of workers (such as skilled or unskilled) and can then identify certain jobs that fall under those categories (such as lawyer or laborer) to determine the client’s earnings capacity. Another alternative is to estimate the client’s pre- vs. postinjury educational capacity. For example, if the client is expected to have the educational capacity of a high school graduate, average earnings representative of a high school graduate can be used. Similarly, average earnings of individuals with a 4-year degree, master’s degree, and doctorate or professional-level degree can be determined based on education level.

To determine wage loss or loss of earnings capacity, the vocational expert essentially evalu­ates the client’s preinjury and postinjury employability (defined in Weed & Field, 1994, 2001, as possessing the skills, abilities, and traits necessary to perform a job) and compares the two. Once the counselor has evaluated the difference in pre- and postinjury earnings capacity, the economist then calculates the total amount of lost earnings capacity over the client’s work life expectancy (Siefker, 1992).

There are many factors and approaches to consider when determining future wage loss and earnings capacity analysis. Of the many approaches, the RAPEL method considers most of the factors (Weed & Field, 1994, 2001). The RAPEL method, developed by Weed (1994), offers a comprehensive approach to determining earnings capacity analysis, particularly in forensic cases. The approach incorporates a rehabili­tation plan (or life care plan for the client who is more catastrophically impaired), information with regard to the client’s access to the labor market (employability), information with regard to the client’s placeability (defined as the likelihood that the client could successfully be placed in a job), earnings capacity, and labor force participation or work life expectancy. Generally, if there is a reduction in the client’s life expectancy as a result of his or her injury, there also will be a reduction in the work life expectancy. The experienced vocational counselor would express this
reduction in a percentage of loss or number of years lost in the labor market. For more informa­tion on the topic of wage loss/earnings capacity analysis, refer to Dillman (1987) and the post on the role of the economist on this website. The reader is also referred to Neulicht and Berens (2005) for a description of PEEDS-RAPEL, a method for determining wage loss/earnings capacity for pediatric clients.

The labor market survey is designed to reveal current information about a specific job market (Weed & Field, 1994, 2001). Questions include:

Part of the opinion regarding an adult client’s earnings capacity may be related to the current labor market. Obviously, a pediatric case would not include a specific employer-by-employer analysis; however, data that are collected by the government with regard to the future outlook of an occu­pation may be included. See Table 4.4 for common topics included in the labor market survey (summarized from Weed & Field, 1994, 2001).

Method(s) used (What methods were used to obtain the information? Suggest starting with residual employability profile by VDARE for worker traits.)

City Directory or Haynes Directory Chamber of Commerce Professional and trade associations Job service

Vocational rehabilitation

Other

Publications

Wage rates for selected occupations (state)

Occupational supply and demand (state Department of Industry and Trade or Labor) State career information systems (or similar)

Manufacturing directory (SIC codes)

Bureau of Labor Statistics; e.g., Area Wage Survey (federal)

Census Bureau (federal)

Job Service microfiche/posted jobs (state)

Classified ads or job flyers

Identified discreet jobs related to client’s experience

Labor Market Access Analysis

Other

Results

Employer/s contacted — approximately 10 Job(s) available

Wages and benefits (holidays, vacation, sick, medical, dental, personal leave, etc.)

Training/education needed

Willingness to work with disabled

Accessibility/architectural barriers

Other

Conclusions (the professional’s opinion)

Placeability Expected income Other related comments

It should be noted that the way in which the consultant asks questions could skew the results toward a desired direction. In an example case, a plaintiff’s expert revealed that a client who had chronic pain was unemployable and used as partial justification the results of a labor market survey. She reported that the survey revealed that the client would not be an acceptable candidate for sedentary jobs that were directly in line with her work history. Following the deposition, the defense expert contacted the same employers and distinctly different information was provided. It was hypothesized that the consultant asked questions in a way that solicited support for her conclusions. Ethics, on the part of some consultants, can also be suspect. In another case, contact with the employers listed in another consultant’s notes revealed that no employer on the list recalled
being contacted with regard to a labor market survey, therefore raising the question of whether a survey had actually been performed.

Once a prospective job is located, it may be appropriate to conduct a job analysis (Weed et al., 1991; Blackwell et al., 1992; Weed & Field, 1994, 2001). The analysis is designed to determine if job traits match the worker’s traits and therefore represent a reasonable probability of employ­ment. There are specific guidelines that consultants must follow in order to make sure that they are conducting the analysis according to published standards. Indeed, one successful malpractice law­suit resulted when a nurse completed a “job analysis” that consisted of less than one page (Drury v. Corvel, as cited by Oakes, 1994). The topics covered in the analysis did not follow published standards. In fact, it appeared as if the nurse was unaware that the government and others have published on this topic.

It is important that the life care planner, who may not be a vocational expert, be aware that when working with the vocational aspects of the plan, the vocational expert must provide a proper foundation for an opinion. For more information, the reader is encouraged to review these topics in the Rehabilitation Consultant’s Handbook (Weed & Field, 1994, 2001), the Revised Handbook for Analyzing Jobs (U.S. DOL, 1991c) and Methods and Protocols: Meeting the Criteria of General Acceptance and Peer Review under Daubert and Kumho (Field, Johnson, Schmidt, & Van de Bittner, 2006).

The vocational rehabilitation counselor has many resources available to assist in assessing a cli­ent’s vocational potential and making appropriate recommendations for the life care plan. The following lists a few of the more valuable reference materials used by the vocational rehabilitation counselor:

¦    Dictionary of Occupational Titles (DOT), 4th edition (1991). Contains definitions of 12,741 job titles and descriptions of jobs found in the national economy. Data compiled by the U.S. Department of Labor. Now available in revised format on CD-ROM (Field & Field, 1995). This publication is expected to be eliminated when the O*Net (see below) is activated on the World Wide Web.

¦    Transitional Classification of Jobs (COJ) (2004). Contains worker trait profiles of the 72 U.S. Department of Labor worker traits for each of the 12,741 DOT job titles. The worker traits are assigned a code and rated. Also includes information on the O*Net database.

¦    Occupational Outlook Handbook (OOH) (2003). Clusters jobs by occupation and gives information with regard to employment potential, labor market trends, salary, require­ments, and training needed to enter the occupation. Updated versions available at www. bls.gov/oco/.

¦    The Enhanced Guide for Occupational Exploration (GOE) (1991). Provides descriptions of all jobs organized within related job clusters and includes information pertaining to academic and physical requirements, work environment, salary and outlook, typical duties, skills and abilities required, and where to obtain additional information.

¦    The Revised Handbook for Analyzing Jobs (RHAJ) (1991). Gives descriptions on how to examine individual jobs to determine suitability for a client.

¦    Job Analysis and the ADA: A Step-by-Step Guide (1992). This is another option for a compre­hensive guide for determining the suitability of a job for clients with disabilities.

¦     O*NET, the Occupational Information Network. A comprehensive database of worker attributes and job characteristics. Contains hundreds of occupational units (OUs) and is intended as the replacement for the Dictionary of Occupational Titles. O*NET will be the nation’s primary source of occupational information. However, it is not usable in its present form for transferability of skill analysis (manual or computerized). Available at http://online. onetcenter.org.

The previously listed resources use data compiled by the federal government, with many published by the government. In addition to the ones listed, there are other state, regional, and local publica­tions specific to occupations found in certain geographic areas. For various approaches to transfer­able skills analysis, see Weed (2002) and the associated special-issue journal on this subject.

For additional print and computer resources available to the vocational rehabilitation counselor, the following may be useful:

¦     SkillTRAN (Truthan, 1997). An online and telephonic system of ordering job search and transferable skills information. Also other resources for purchase; (800) 827—2182 or www. skilltran.com.

¦     Vertek, Inc. (Gibson, 2003). Developed the OASYS computerized job-matching program; (800) 220-4409 or www.Vertekinc .com.

¦     McCroskey Vocational Quotient System (MVQS) (McCroskey, 2001, updated 2005). Job—person matching, transferable skills analysis, values, needs, vocational interest and per­sonality reinforcer (VIPR) type indicator, and earning capacity estimation system; (612) 569—0680 or www.vocationology .com.

¦     Job Accommodation Network (JAN), Office of Disability Employment Policy, U.S. Department of Labor (1984). Offers free consulting service that provides information about job accommodations, the Americans with Disabilities Act (ADA), and the employability of people with disabilities; (800) 526—7234 or www.jan .wvu .edu.

This post outlines some of the vocational factors that a life care planner may encounter if a client is expected to have the capability for work activity. If the life care planner does not have the expertise to develop opinions in this specialized area, it may be reasonable to obtain services of a vocational expert and ensure that the vocational expert includes the relevant areas, as described in this post, and has sufficient expertise to develop reasonable opinions. Some of the topics included in this post are designed to assist the nonvocational expert with an overview so that appropriate questions can be asked in order to enhance the life care plan, reduce overlap or dupli­cation in services, and facilitate the client’s return to employment and achievement of a highest level of functioning. Table 4.5 summarizes some issues, topics, and questions that a life care plan­ner who is not a vocational expert can ask the professional on whom the life care planner is relying for a vocational opinion and recommendations.

First determine if vocational aspects have been considered or are already underway (e.g., already initiated by insurance company or attorney).• What interview information have you obtained from the client (e.g., work skills, leisure activities, education, work, functional ability)? Have you obtained copies of relevant medical records?Have you obtained work-related information (such as tax returns, job evaluations, school and test records, training history, and treating MD comments)?Does the client need testing before determining vocational potential (e.g., vocational evaluation, psychological, neuropsychological or physical capacities testing)? Also, is the evaluation a quality and valid appraisal?If there is work potential, is there a need for justifying a plan by performing a labor market survey? (If LMS, what method is used? e.g., direct contact with employers vs. statistics or publications.)• What is the client’s expected income, including benefits? (If personal injury litigation, then pre- vs. postinjury capacity.)If there is an apparent market for the client’s labor, is there a need for a job analysis? (And if an analysis was completed, was it done according to the Americans with Disabilities Act guidelines?) • What are the estimated costs of the vocational plan?• Counseling, career guidance? (When does it start/stop, and what are the frequency and cost? e.g., 30 hrs. over 6 months at $65/hr.) • Job placement, job coaching, or supported employment costs?• Tuition or training, books, supplies? (Include dates for expected costs, e.g., technical training 2 years @ $400/yr. for 1997-1999.)Rehabilitation or assistive technology, accommodations or aides, costs for work, education, and/or training (e.g., computer, printer, workstation, tools, tape recorder, attendant care, transportation — include costs and replacement schedules)?• What effect, if any, does the injury have on worklife expectancy (e.g., delayed entry into workforce, less than full-time, earlier retirement, expected increased turnover, or time off for medical follow-up or treatment)?Anastasi, A. (1982). Psychological Testing (5th ed.). New York: Macmillan.

Blackwell, T., Conrad, D., & Weed, R. (1992). Job Analysis and the ADA: A Step-by-Step Guide. Athens, GA: E & F Vocational Services.

Botterbusch, K. F. (1987). Vocational Assessment and Evaluation Systems: A Comparison. Menomonie, WI: University of Wisconsin Materials Development Center.

Clark v. Aqua Air Industries, 435 So. 2d 492 (1983).

Crease, G. v. J. A. Jones Construction Company, 425 So. 2d 274 (LA App. 1982).

Deneen, L., & Hessellund, T. (1986). Counseling the Able Disabled. San Francisco: Rehab Publications.

Deutsch, P, & Raffa, F. (1981). Damages in Tort Actions (Vol. 8). New York: Matthew Bender.

Dillman, E. (1987). The necessary economic and vocational interface in personal injury cases. Journal of Private Sector Rehabilitation, 2, 121—142.

Evans, R. (2004). The role of the neuropsychologist in life care planning. In R. Weed (Ed.), Life Care Planning and Case Management Handbook (pp. 77—87). Boca Raton, FL: CRC Press.

Field, J. E., & Field, T. F. (1995). Passport to Data. Athens, GA: Elliott & Fitzpatrick (computer program).

Field, J. E., & Field, T. F. (2004). Transitional Classification of Jobs. Athens, GA: Elliott & Fitzpatrick.

Field, T., Johnson, C., Schmidt, R., & Van de Bittner, E. (2006). Methods and Protocols: Meeting the Criteria of General Acceptance and Peer Review under Daubert and Kumho. Athens, GA: Elliott & Fitzpatrick.

Gabel, S., Oster, G., & Butnik, S. (1986). Understanding Psychological Testing in Children. New York: Plenum Publishing.

Gibson, G. (2003). Oasys. Bellevue, WA: Vertek, Inc. (computer program).

Kapes, J., & Mastie, M. (Eds.). (1988). A Counselor’s Guide to Career Assessment Instruments (2nd ed.). Alexandria, VA: National Career Development Association.

Lees-Haley, P. (1993). The Last Minute Guide to Psychological and Neuropsychological Testing: A Quick Reference for Attorneys and Claims Professionals. Athens, GA: Elliott & Fitzpatrick.

Lezak, M. D. (1995). Neuropsychological Assessment (3rd ed.). New York: Oxford University Press.

Marme, M., & Skord, K. (1993). Counseling strategies to enhance the vocational rehabilitation of persons after traumatic brain injury. Journal of Applied Rehabilitation Counseling, 24, 19—25.

Matheson, L., Rogers, L., Kaskutas, V., & Dakos, M. (2002). Reliability and reactivity of three new func­tional assessment measures. Work, 18, 41—50.

McCroskey, B. (2001, updated 2005). The McCroskey Vocational Quotient System 2005, version 2005.03. Brooklyn Park, MN: Vocationology, Inc. (computer program).

Neulicht, A. T., & Berens, D. E. (2005). PEEDS-RAPEL©: A case conceptualization model for evaluating pediatric cases. Journal of Life Care Planning, 4(1), 27—36.

Oakes, M. (1994). Drury v. Corvel. Retrieved June 20, 2003, from www.oakes .org/webdoc14.htm.

Power, P (2006). A Guide to Vocational Assessment (4th ed.). Austin, TX: Pro-Ed.

Sbordone, R. J., & Long, C. J. (Eds.). (1996). Ecological Validity of Neuropsychological Testing. Delray Beach, FL: St. Lucie Press.

Siefker, J. M. (Ed.). (1992). Vocational Evaluation in Private Sector Rehabilitation. Menomonie, WI: University of Wisconsin Materials Development Center.

Truthan, J. (1997). SkillTRAN, LLC. Spokane, WA: SkillTRAN, LLC (computer program).

U.S. Department of Labor (U.S. DOL). (1984). Job Accommodation Network. Washington, DC (computer program).

U.S. Department of Labor (U.S. DOL). (1991a). Dictionary of Occupational Titles. Washington, DC.

U.S. Department of Labor (U.S. DOL). (1991b). Enhanced Guide for Occupational Exploration. Washington, DC.

U.S. Department of Labor (U.S. DOL). (1991c). Revised Handbook for Analyzing Jobs. Washington, DC.

U.S. Department of Labor (U.S. DOL). (2002—2003). Occupational Outlook Handbook. Washington, DC.

Weed, R. (1994). Evaluating the earnings capacity of clients with mild to moderate acquired brain injury. In C. Simkins (Ed.), Guide to Understanding, Evaluating and Presenting Cases Involving Traumatic Brain Injury for Plaintiff Lawyers, Defense Lawyers and Insurance Representatives. Washington, DC: National Head Injury Foundation.

Weed, R. (1996). Life care planning and earnings capacity analysis for brain injured clients involved in per­sonal injury litigation utilizing the RAPEL method. Journal of Neurorehabilitation, 7, 119—135.

Weed, R. (1998). Aging with a brain injury: The effects on life care plans and vocational opinions. The Rehabilitation Professional, 6, 30—34.

Weed, R. (2000). The worth of a child: Earnings capacity and rehabilitation planning for pediatric personal injury litigation cases. The Rehabilitation Professional, 8, 29—43.

Weed, R. (2000). The worth of a child: Earnings capacity and rehabilitation planning for pediatric personal injury litigation cases. The Rehabilitation Professional, 8, 29—43.

Weed, R. (2002). The assessment of transferable work skills in forensic settings. Journal of Forensic Vocational Analysis, 5, 1—4 (special issue editorial).

Weed, R. (2007). Life Care Planning: A Step-by-Step Guide. Athens, GA: E & F Vocational Services.

Weed, R., & Field, T. (1994). Rehabilitation Consultant’s Handbook (2nd ed.). Athens, GA: Elliott & Fitzpatrick.

Weed, R., & Field, T. (2001). Rehabilitation Consultant’s Handbook (3rd ed.). Athens, GA: Elliott & Fitzpatrick.

Weed, R., & Riddick, S. (1992). Life care plans as a case management tool. The Individual Case Manager Journal, 3, 26—35.

Weed, R., Taylor, C., & Blackwell, T. (1991). Job analysis for the private sector. NARPPS Journal and News, 6, 153-158.