d. activities of daily living...–applying toothpaste –tying shoes –spreading with a knife...

d. Activities of Daily Living

If the child is not doing an age-appropriate task efficiently, is the difficulty…

Physical strength or coordination? Then work on physical capacity in related skills.

• Exposure and experience? Then arrange for child to observe others doing the task.

• Lack of awareness of visual information? Then describe visual aspects and problem solve options.

• Lack of motivation ? Then build in external or internal reinforcers.

• Inefficiency in time? Then work on speed building and adapting key steps of task.

In a study of DLS by Lewis and Iselin (2002), students with VI were significantly different than sighted peers

Based on parent report,

notable differences were…

– use of hair dryer, alarm clock

– washing hair

– applying toothpaste

– tying shoes

– spreading with a knife

– preparing sandwiches

– wash and dry dishes

– empty wastebasket

Traditionally, assessment is through task analysis or discrepancy analysis

Assess and teach in natural settings with real

materials at appropriate times.

• A. Identify the steps in a typical task

• B. Compare how your student completes the activity

• C. Make needed adaptations

• D. Teach steps at which the student is not proficient

Tips for teaching DLS…

• 1. Do the task yourself with a

simulated visual impairment

• 2. Ask blind/VI adults how they do it

• 3. Make sure student has observed the entire task being done by someone else several times

• 4. After teaching, try it with different people in different settings.

Importance of routines

-Use memory cues (photos or objects)

– Follow nonpreferred activity (brushing teeth) with preferred one, or add preferred qualities to activity

– Before leaving home, check on a picture list in the bathroom

• Hair combing

• Tooth brushing

• Clothing buttoned and zipped

Itinerant/consultant teacher role

–Recommend uses of visual cues (color, lighting, contrast)

– Interpret and recommend anticipatory cues and motivators

–Recommend tactile or auditory adaptations

Adaptations may include…

• Stabilizers (rubber mats, materials taped to surface)

• Substitutions for visual information (Liquid level indicator, differently textured cups, money reader)

• Labeling system (Puff paint, rubber bands on cans, tactile symbols on drawers)

(From TSBVI)

• Organizing containers (bowls, trays, baskets)

For children who do not understand or value social approval, many DLS are

not motivating. • Why do I have to wear shoes when my feet

feel better without them?

• Why do I have to use utensils when it is easier to pick things up with my hands?

• Why do I have to brush my teeth when it irritates the inside of my mouth and I don’t like the taste of the toothpaste?

• Why do I have to eat vegetables when I would rather just eat french fries and drink soda?

Teamwork

• Maria, a four-year-old who refuses solid food although there is no medical difficulty.

• Henry, a 10-year-old with low vision who resists having his teeth brushed and hair combed.

e. Orientation and Mobility Does eligibility require potential for locomotion?

Variations in O&M needs

• Different functional needs • Different modes of communication • Need for adaptive equipment • Adaptations of standard techniques (e.g., trailing) • Different reinforcers • Greater emphasis on concrete experience • Difference in specialist role

Be realistic….learners with cognitive impairments may reach these levels of independence (Joffee and Ehresman, 1997)

• Rote travel: Mastery of familiar routes but needs initial instruction for new and altered routes

• Limited rote travel: Mastery of familiar indoor routes and a few outdoor routes

• Supervised travel: Use of tactile cues or physical assistance to travel

Adaptations in structure and sequence

1. Teach route in shorter increments.

2. Use a different sequence of instruction (e.g., backward chaining).

Use of communication and memory strategies

• Show pictures or symbols of destinations.

• Provide lists, pictures, or cards in sequence.

• Give directions one step at a time and repeat.

• Use students’ own communication system (e.g., sign language).

Adapted equipment is determined by the educational team, including physical or

occupational therapists and O&M specialists.

Know what is fastest, what is preferred, and what works best in public settings.

Considerations for Students using Adaptive Devices

• Teamwork

– Physical and Occupational Therapist

• Environmental Assessment

– Drop-offs (stairs, curbs)

– Doors, ramps

– Accessibility

• Teach student to have control of the travel situation

Control environments

Teach in distraction free situations.

Reduce visual clutter and confusion.

Add tangible or visible symbols that are easily identified.

Provide additional practice

Overlearn routes and skills.

Slowly build in opportunities for generalization.

Maintain consistency.

Provide different motivators

• Emphasize student interests.

• Make reinforcers more concrete.

• Make reinforcers more immediate.

Travelers with deafblindness

• Orientation depends on kinesthetic rather than auditory feedback.

• Vibrations, moving air, and odors are more important (but less reliable).

• Communication with the public is more complex.

Communication options for deafblind travelers

• Print on palm

• Speech with written response

• Prepared cards or recorded loops that state – Assistance needed

– How to assist (tap, guide)

– Fact of vision and hearing impairment

With students who use wheelchairs

• Provide choices in routes.

• Use a touch signal before moving if child is nonverbal.

• If guiding, provide verbal directions.

• If moving chair, provide preview information.

• Electronic Travel Aids or adapted canes may be useful for some.

When moving a person in a wheelchair…

Always set brakes if you leave chair.

Tell student before

moving him or her. Go up and down curb

with back of chair lower than front.

Role of personnel in VI may include…

O&M specialist

Identifying and practicing common routes and classroom spaces

Teaching and reinforcing use of AMD, cane, Miniguide

Using signs or symbols to choose route direction

TVI and classroom staff

Identifying appropriate symbols for points and destinations

With class staff, identify touch signals to use before moving child

Use verbal cues with touch for body parts, directional terms

Select visual/tactile/auditory cues to identify classroom areas

Teamwork

• Lee, a 9-year-old boy who wants to travel independently but receives too much help from others.

f. Recreation and Leisure

To be recreational, an activity must be preferred and selected.

For some students, determining selection is complex.

• 1. Choice from representative objects (begin with one preferred and one not preferred)

• 2. Daily schedule or calendar should include a symbol for FREE TIME or ACTIVITY CHOICE

• 3. Initiative may need to be prompted and reinforced.

Provide feedback to classroom staff and family about child’s preferences and abilities

Adapt materials (family activities) visually or tactilely Use mutual tactile attention (Chen & Downing, 2006) to encourage exploration and manipulation of materials

Identify activities that appeal to preferred senses…when a child enjoys light, choose age appropriate toys with lighting.

Cool Glow

What’s new? RESEARCH and INSTRUCTIONAL PROGRAMS

• Lieberman and MacVicar (2003) explored

– Recreational habits of deaf-blind children

– Main recreational partners

– Barriers

– Assistive devices

Questionnaire completed by families of 51 deafblind students

(Mean age 12.5)

• Results:

–On a scale of 1-5, families’ rated satisfaction with current recreation and phys ed at 3

–Most common assistive devices were electronic switches, walkers, bicycles, swings, communication boards, bowling ramps, standers

Most common partners were…

• 1. Parents

• 2. Siblings

• 3. Relatives

• 4. Sitters

• 5. Neighbors

• 6. Peers

Most common recreational activities for these students were…

• Swimming 57%

• Swinging or rocking 33%

• Walking 31%

• Climbing equipment 24%

• Biking 24%

• Video games 20%

• Watching TV 20%

• Listening to music 16%

• Watching movies 14%

Young people with cognitive disabilities were less active after graduation…

• Bowling (41%)

• Exercising at home or going for a walk (35%)

• Playing catch (24%)

• Swimming, biking, basketball (24%)

Non-physical activities included…

• CDs and TV (65%)

• Washing the car (59%)

• Videos and radio (53%)

• Feeding the dog

• Visiting family, shopping, eating out, movies (47%)

Families reported that motivators were…

Special Olympics! Activity level of family Sibling participation Strategies that facilitated post-secondary participation Community mentors Social activities with preferred people

Importance of community, structure, and social support….

One parent described the value of her son’s school experiences…“It has been a process. It's really been fine tuned since he graduated. But even those activities, required or not, it's just that wonderful exposure that he has had so that he can say with assurance; I do or don't want to do that.”

Teamwork • Tim’s preferred recreational

activity is listening to music, and his family allows him to do this for most of his unstructured time.

Anna wants to be on the track team at her school, but the coach will not accept her.

6. Planning for adulthood….not just job planning!

• Vocational

• Domestic

• Recreational and leisure

• Community (Nietupski & Nietupski, 1987)

Role of TVI/O&M specialists

– Assures VI is considered in planning

– Participates on

transition team – Assesses and supports

adaptations in new settings

– Supporting use of

known skills in new settings

Establish an expectation of work

Students may not know adults who are doing jobs that they can do.

They may know teachers work in schools, but

do they know there are custodians and dishwashers?

They may know salespeople sell things in

stores, but do they know there are stockers?

They may know that truck drivers transport

materials, but do they know who washes and maintains the trucks?

Secondary school: community-based instruction

Traveling/being transported to a site Following a routine that is different from school routine Interacting with people other than school personnel Supplementary to regular school routines

Sample schedule for Rick (Downing, 1996)

Age 16,low vision and hearing loss. Walks. Likes to laugh and tease. Indicates preferences using objects and gestures

• First period: Uses rhythm instruments to participate in band.

• Second period: Home economics. Helps with food preparation. When teacher is lecturing Rick gathers used towels and washes/dries them

• Third period: Art class, using tactual materials.

• Fourth period: Woodshop, uses wood and some painting with assistance from peers.

• Lunch: Eats with one or two classmates . Makes choices, responds to peer prompts.

• Fifth/sixth periods: Community based instruction (3 days) and study hall (listens to preferred music) and goes home early for PT

Think and talk

• Rick’s goals are To greet others by smiling, waving, and saying hello To place several items in a tote bag and carry them for several blocks To follow a familiar route from school to the CBI site.

In your neighborhood, describe one site where Rick might go for community based instruction. As the VI teacher, what might your role be?

Preparation for living with others in Post-Secondary Settings

• Making choices about where and with whom to live

• Balancing the needs of all residents

• Describing and referring to visual impairment

• Requesting and declining assistance

Photo by L. Penny Rosenblum

Residential options

• Home with own family (separate or joined units)

• Foster home • Group home • Supported living with purchased services • Fully staffed care facility

Being an adult member of a family is an option…

Best practices: Preparation for employment

Successful employment depends on

• Work experience

• Knowledge of employment options

• Realistic assessment of skills

• Ability to discuss adaptations related to visual impairment

Models for supported employment

• Enclave: A group of people who need support within a larger employment context.

• Supported employment: Use of a job coach to accomplish a task collaboratively.

Recent literature has shifted to include the perspective of employers

Employers reported these experiences with visually impaired employees (Wolffe and Candela, 2002)

• Technology was important, but so was pairing for some tasks.

• There was high satisfaction, and anticipated challenges were not realized.

• They followed the same process as in hiring all employees

Major challenges included…

• Incompatible equipment

• Educating staff members

• Adjustments related to transportation

• Dealing with unhappy employees when the visually impaired person got rid of his dog!

– Wolffe and Candela, 2002

Resources… School to Work: Developing Transitional Portfolios for Students with Significant Disabilities (Bridgeo, Gicklhorn, Zatta, Perkins School for the Blind)

Basic Skills for Community Living

Levack, Hauser, Newton, & Stephenson, TSBVI.

Good news from the National Longitudinal Transition Study

Group 1 (1991) and Group 2 (2005) (Ferrell, K. , www.afb.org)

• In Group 2, 19% more young adults with visual and/or multiple disabilities lived with their parents (58% to 77%)

• 25% fewer lived in institutions or facilities (31% to 6%)

• 3% more lived independently (1% to 4%)

Educational improvements

Students with multiple disabilities/deafblindness more often graduated from high school.

–Cohort 1 26% graduated, 74% dropped out

–Cohort 2 51% graduated, 49% dropped out

Social and employment experiences of students with MD/DB in the NLTS (AFB)

• In Group 1, almost no students participated in community groups or activities

• In Group 2, 13% participated in community groups or activities and 37% volunteered in work activities or community service

• 10% of students in cohort 1 had held a job, compared with 36% in Cohort 2.

Post-secondary educational experiences of students with MD/DB

in the NLTS (AFB)

• “Whereas there were too few students in cohort 1 to show involvement in any kind of postsecondary education, in cohort 2, 40% of youth with multiple impairments/deafblindness participated.”

• This included 30% increase in those who attended a technical school.

• http://www.afb.org/=3178

Work experiences

• Cohort 1 10% had a job in high school

• Cohort 2 36% had a job in high school

Cohort 1 14% worked for pay as young adults

Cohort 2 26% worked for pay

Working… MD/DB students in cohort 2 …

increased the rate at which they engaged in postsecondary education, paid employment, or job training from 26.1% in the mid-1980s to 58.6% in 2003.

The largest proportion of growth… was in paid employment with a 19.9 percentage-point increase in participation between cohorts, from 9.3% to 29.2% in cohort 2.

http://www.afb.org/=3178

Education: Project FOCUS

• A model demonstration program designed to support access to University of Arizona’s academic offerings and campus life

• Includes students from Tucson Unified School who have intellectual disabilities

• Students attend at least 2 courses a semester for 2 years

• They have instructional supports related to campus life, employment, and overall self-reliance

What’s New? Person centered planning

“Person-centered planning is a process-oriented approach to empowering people with disability labels. It focuses on the people and their needs by putting them in charge of defining the direction for their lives, not on the systems that may or may not be available to serve them. This ultimately leads to greater inclusion as valued members of both community and society.”

Cornell University, Employment and Disability Institute

http://www.ilr.cornell.edu/ped/tsal/pcp/

Residence: Learning to live with others in post-secondary settings

• Making choices about where and with whom to live

• Balancing the needs of all residents

• Describing and referring to visual impairment

• Requesting and declining assistance

• Requesting privacy and knowing when others want privacy

Photo by L. Penny Rosenblum

A successful instructional program with Mandy

• 31 year old woman who is blind and has moderate cognitive disabilities

• She could not do multi-step tasks without supervision

• Staff thought that food preparation tasks would be most motivating and reinforcing

Continued learning: 31-year-old Many activated a microswitch system

and Mp3 player to hear step-by-step directions.

She mastered six tasks of 44-54 steps each through step-by-step instructions delivered by the devices.

(Preparation of drinks, sandwiches, cold pasta dishes, blended drinks) (Lancioni, Singh, O’Reilly, Sigafoss, and Olivia, 2011).

What if competitive employment is not an option?

• Independent jobs

• Jobs with guidance by job coach

• Volunteer work

• Structured day activities

• Post secondary education (college attendance and participation)

• Homemaker and family member

• Enclave work with supervision

Think and Talk…*

• DESCRIBE what discussions you have had with your student’s family and educational team about future options.

• DISCUSS what helped group members to participate in successful discussion and planning for their student’s adulthood.

The common goal: A better quality of life in adulthood

For a visually impaired individual, quality of life depends on skills that may not be taught in the regular classroom.

Expanded core skills enhance • Independence

• Initiative

• Options

• Opportunities

Most of the work in assessment of Q o L is from medical literature

Quality of Life Profile for Adults (University of Toronto, www.utoronto.ca/qol/profile/adultVersion.html)

BEING: Physical, Psychological, Spiritual BELONGING: Living space; People; Access to resources BECOMING: Daily activities, Leisure, Growth

Beyond the basics….

An acceptable quality of life includes

Preferred activities

Social contacts or friends

Identity (Possessions, a place to keep things, connections)

Choices

Challenges

Adult occupational: Money may NOT be the main goal.

• Independent jobs

• Jobs with guidance by job coach

• Volunteer work

• Structured day activities

• Post secondary education (college attendance and participation)

• Homemaker and family member

• Enclave work with supervision

Team Work: What will a good quality of life be for your student?

• Where will she or he live?

• What will s/he do during the day?

• What s/he give to others?

• What will s/he do for fun?

• What do you think this student’s family envisions?

Braille Monitor

Decision Activity III: Preparing Dominic for the future

Lives in a group home for past three years

Attended specialized school for school years

Semi-independent in most

basic skills (travel, dressing, eating)

What are his strengths and abilities?

Lifting and physical activities

Opening doors for others

Smiles, laughs, and enjoys favorite people

• How will you help Dominic makes the most of the next three years?

• As the TVI, what will your role be with Dominic?