low incidence disabilities: severe/multiple disabilities, deaf-blindness, and traumatic brain injury

Title, EditionISBN

© 2009 Pearson Education, Inc.All rights reserved.

Exceptional Children: An Introduction to Special Education, 9th EditionISBN 013514454X

© 2009 Pearson Education, Inc.All rights reserved.

Chapter 12Low Incidence Disabilities:

Severe/Multiple Disabilities, Deaf-Blindness, and

Traumatic Brain Injury

© 2009 Pearson Education, Inc.All Rights Reserved.2

Exceptional Children: An Introduction to Special Education, 9th EditionHewardISBN 013514454X


Focus QuestionsWhy is a curriculum based on typical developmental stages and milestones inappropriate for students with severe and multiple disabilities?How can a teacher assist a child who has been hospitalized with a traumatic brain injury return to school?Why are functional and age-appropriate curriculum so critical for students with severe and multiple disabilities?How does access to the general academic curriculum benefit students with severe disabilities?What are the most important skills for a teacher of students with severe and multiple disabilities? Why?How much time should a student with severe and multiple disabilities spend in the general education classroom?

KEY TERMS AND CONCEPTSDefinitions: PECS, Brain Dysgenesis (and causes), Functional Assessment, Functional Analysis, Naturalistic Teaching, Profound disabilities, Multiple Disabllities,Positive Behavioral Support (PBS) – what it is, how used, componentsSevere disabilities:

Definition Characteristics, When identified Curriculum (functional/daily living) Use of AAC Methods. Instructional programs Communication issues Advantages of placement in neighborhood school. Reasons why

they do not attend neighborhood schools. Recreational and leisure skills

Closed/open head injury and examplesTraumatic Brain Injury:

What is it? Educational modifications Causes




Severe DisabilitiesSevere Disability Significant disabilities/impairments in intellectual,

physical(motor), and/or social functioning Significantly below the norm Below age and grade level expectations Identified shortly after birth Compare how child performs on tests, developmental

functioning/progress compared to others their age IQ scores of 35 to 40 or 40 to 55 Functions as a typical 2 to 6 year old




The organization TASH ( formerly The Association for Persons with Severe Handicaps) describes the people for whom it advocates as “ people with significant disabilities and support needs who are most at risk for being excluded from society; perceived by traditional service systems as most challenging; most likely to have their rights abridged; most likely to be at risk for living, working, playing and learning in segregated environments; least likely to have the tools and opportunities necessary to advocate on their behalf; and are most likely to need ongoing, individualized supports to participate in inclusive communities and enjoy a quality of life similar to that available to all people” ( TASH, 2011).




Profound Disabilities Profound developmental disabilities in all five of the

following areas: cognition communication social skills development motor-mobility activities of daily living

Requires a service structure of continuous monitoring and observation

Functioning is below the level of a two year old in all five areas

IQ scores of 20 to 25 and below




Multiple Disabilities Multiple disabilities means concomitant

impairments, the combination of which causes such severe educational needs that they cannot be accommodated in special education programs solely for one of the impairments

Ex.- intellectual disability and blindness; intellectual disability and orthopedic impairment




NJAC 6A:14 Definition "Multiply disabled" corresponds to "multiply

handicapped" and “multiple disabilities,” and means the presence of two or more disabling conditions, the combination of which causes such severe educational needs that they cannot be accommodated in a program designed solely to address one of the impairments. Multiple disabilities includes cognitively impaired-blindness, cognitively impaired-orthopedic impairment, etc. The existence of two disabling conditions alone shall not serve as a basis for a classification of multiply disabled. Eligibility for speech-language services as defined in this section shall not be one of the disabling conditions for classification based on the definition of "multiply disabled." Multiply disabled does not include deaf-blindness.




Deaf-BlindnessDeaf-blindness means concomitant hearing and visual impairments, the combination of which causes such severe communication and other developmental and educational needs that they cannot be accommodated in special education programs solely for children with deafness or children with blindness

Ex. A program for children who are deaf would not be appropriate for a child who has vision loss.

Ex. A program for children who are blind, would not be appropriate for a child who has hearing loss.




Deaf-BlindnessThe majority have some functional hearing and/or vision

More than 90% have one or more additional disabilities

57% also have physical disabilities 66% have cognitive impairments 38% have complex health care

needs




Characteristics Most students with severe disabilities

Exhibit significant deficits in intellectual functioning

Possess more than one disability Need special services and supports because of

motor impediments; communication, visual and auditory impairments; and seizure disorders

Treatment of medical conditions and health problems results in frequent and often extended absences from school

Exhibit significant and obvious deficits in multiple life-skill or developmental areas




Characteristics and PrevalenceCharacteristics

Slow acquisition rates for learning new skills Poor generalization and maintenance of newly learned skills Limited communication skills Impaired physical and motor development Deficits in self-help skills Infrequent constructive behavior and interaction Stereotypic and challenging behavior

Prevalence Estimates range from 0.1% to 1% of the population Can include students under the following

categories: ID, MD, OHI, Autism, TBI, DB




CharacteristicsSlow acquisition rates for learning new skills

Compared with students with disabilities, learn at a slower rate, need more instructional trials to learn a given skill, learn fewer number of skills, have extreme difficulty learning abstract concepts.

Poor generalization and maintenance of newly learned skills

Generalization- performance of a skill in settings or under conditions different from those in which the skill was learned initially

Maintenance- continues use of a skill after instruction has been terminated

Instruction must be specifically planned in order for generalization and maintenance to take place




CharacteristicsLimited communication skills

Limited in ability to express themselves and understand others

Some cannot talk or gesture meaningfully and might not respond when communication is attempted

Impaired physical and motor development Have limited mobility Many cannot walk, cannot stand or sit up with

support Slow to perform basic tasks such as rolling over,

grasping objects, holding their heads May worsen without consistent PT and medical

treatment




CharacteristicsDeficits in self-help skills

Cannot independently care for their basic needs(dressing, eating, exercising, bowel movements, exercising, bladder control, personal hygiene)

Infrequent constructive behavior and interaction Some do not seek out interaction with other

children/adults May appear to be completely out of touch

with reality May not show normal emotions Difficulty to capture their attention




CharacteristicsStereotypic and challenging behavior

Engage in ritualistic behavior Rocking back and forth, waving fingers in front of

face, twirling the body Self-stimulatory behavior

Grinding teeth, patting the body Self-injurious behavior

Head banging, hair pulling, eye poking, hitting or scratching or biting one-self

Aggressive behavior Hitting or biting others

These behavior may interfere with learning adaptive behaviors with acceptance and functioning; safety concern




Characteristics Exhibit warmth, persistence,

determination cheerfulness, a sense of humor, sociability, various other desirable traits

Teachers find great satisfaction in working with students who have severe disabilities and in observing their progress




CausesSevere intellectual disabilities can be caused by biological conditions, that may occur before birth (prenatal), during (perinatal),or after birth (postnatal)

In almost every case, a brain disorder is involved

Brain disorders are the result of either Brain dysgenesis (abnormal brain development) Brain damage (caused by influences that alter the

structure or function of a brain that had been developing normally up to that point)




Brain Dysgenesis & Damage Brain Dysgenesis- abnormal brain development

Prenatal accounts for most cases of severe cognitive limitations

Ex. Mother’s substance abuse (alcohol, drugs, poor nourishment) during pregnancy

Brain Damage- cause by influences that alter the structure or function of the brain that had been developing normally up to that point

Automobile/bike accidents, head trauma, falls, assaults, abuse Malnutrition, neglect, ingestion of poisonous substances Diseases that effect the brain (meningitis, encephalitis)




Causes Continued•A significant percentage of children with severe disabilities are born with chromosomal disorders

Genetic or metabolic disorders can cause serious problems in physical or intellectual development

Complications of pregnancy can cause severe disabilities

Severe disabilities may develop later in life from head trauma

Factors such as malnutrition, neglect, ingestion of poisonous substances, and certain diseases that affect the brain also can cause severe disabilities

In many cases, the cause cannot be clearly determined




Traumatic Brain Injury (TBI)

Definition•An acquired injury to the brain caused by an external force, resulting in total or partial functional disability or psychosocial impairment, or both that adversely affects a child’s educational performance

• Applies to open or closed head injuries

•TBI is the most common acquired disability in childhood and the leading cause of death in children




NJAC 6A:14 Definition "Traumatic brain injury" corresponds to

"neurologically impaired" and means an acquired injury to the brain caused by an external physical force or insult to the brain, resulting in total or partial functional disability or psychosocial impairment, or both. The term applies to open or closed head injuries resulting in impairments in one or more areas, such as cognition; language; memory; attention; reasoning; abstract thinking; judgment; problem-solving; sensory, perceptual and motor abilities; psychosocial behavior; physical functions; information processing; and speech.




Types and Causes of TBI Head injuries are classified by the type of injury, by the kind of damage sustained by the brain, and by the location of the injuryOpen Head Injury- result of penetration of the skull, such as that caused by a bullet or a forceful blow to the head with a hard or sharp object Closed Head Injury- head hits a stationary object with such force that the brain slams against the inside of the cranium

Shaken baby syndrome Bicycle injury Car accident




Traumatic Brain Injury (TBI)Concussion, a mild brain injury, is a brief loss

of consciousnessContusions usually accompany a moderate

brain injury and consists of bruising, swelling, and bleeding

Hematoma occurs when blood vessels in the brain rupture

Coma is a severe head traumaAnoxia is the loss of oxygen to the brain for a

period of time during a severe brain injury




Effects and Educational Implications of TBI p 428

TBI is complex with symptoms varying depending on severity, extent and site, age of the child at the time of the injury, and time passed since the injury

Three categories of impairments from brain injuriesPhysical and sensory changesCognitive impairmentSocial, behavioral, and emotional problems

Recovery is a long and unpredictable process




Effects and Educational Implications of TBI continued

Impairments may be temporary or lasting Physical and sensory changes

Headaches, dizziness, nausea Coordination, spasticity of muscles Reduced speed and motor performance and precision of

movement Cognitive impairments

Short and long term memory deficits, difficulty maintaining attention and concentration

Difficulty keeping up with discussions, note taking Social, behavioral and emotional problems

Mood swings, self-centeredness, lack of motivation Chronically agitated, irritable, restless or anxious




Teaching Students with TBI Modifications similar to those required by

students with other disabilities Special counseling – similar to that for students with

emotional or behavioral disorders Extra time – similar to what is required by students

with LD Linking auditory instruction to visual cues – similar to

that is required by students with hearing impairment Shorter school day Peer aide Textbooks at home Tape-recording lectures




Curriculum: What Should Be Taught?Students with Severe and Multiple Disabilities

Functional skills - activities of daily living skills (ADLs) needed now and in the future

Age-appropriate skills-activities that are appropriate for same age peers with disabilities

Communication skills -an essential quality of human life Literacy -provides access to information and further learning Recreation and leisure skills-the ability to play and later to

occupy themselves constructively and pleasurably during free time Recreation and leisure skills – must be taught, don’t come naturally. Without being taught, people sit by the television or only

socialize with other people who have disabilities. Making choices-opportunities to make choices and the ability to

make choices Access to general education curriculum-integrating academic

standards into lessons on functional skills




FunctionalityFunctional skills- immediately useful to a student, frequently required in school and non-school environments, results in less dependence on othersAllows student to participate in less restrictive environments Ex. Dressing oneself, prepare a snack, ride a public bus, purchase items from coin-operated vending machine, recognize common sight words in community setting (man, woman, stop, walk)Should employ authentic materials

Make purchases with real money




Age-Appropriateness Should participate in activities that are age appropriate

for their same aged peers without disabilities Ex. Adolescents should not use the same

materials/activities as younger children without disabilities (clap your hand games, cutting a pasting snowmen)

Ex. Teach recreation and leisure activities iPod operation, bowling

IEP goals should be functional and age appropriate- more likely to be reinforced in the natural environment- more likely to be maintained




Making Choices Making choices is a way of making

activities meaningful. Improves quality of life Help students express their

preferences and make decisions about matters that will affect them Ex. Picture Activity Schedule-Prompt

student with a picture of two activities, and have them choose what they want to do




Communication Skills Communication occurs when

communication partners establish shared meanings. More skilled communicator follows the lead of the less skilled speaker

Balances turns between conversation partners

Responds with interest and affect




Communication Skills Communication is independent of the

specific form or mode that is used as a channel for communication. If can communicate verbally- more likely

to have more education, employment, residential opportunities

Augmentative and Alternate Communication may be appropriate

Use of gestures, sign language, communication boards, picture exchange communication systems (PECS), electronic communication boards

PECS-Picture Exchange Communication System




Communication Skills Communication must “work”; that is be functional

for the child by influencing the behavior or others. Communication Functions:

Name objects, people, activities Tell people what to do Secure help Convey social pleasantries (“Hi”; “Bye”) Convey interest in an activity Protest Convey emotional or physical state Make a choice Request and/or report information




Literacy Provides increased access to

information and further learning Benefit from learning early literacy

skills




Recreational & Leisure Activities Must be taught explicitly Helps students:

interact socially Maintain physical health and motor skills Become more involved in community activities

If not taught, may spend excessive time: sitting wandering looking at television

Should be age appropriate




Access to General Education Curriculum

Mandated by NCLB that students with disabilities participate in state wide assessments

Ways to Access Gen. Ed.: Embed core academic content into

functional activities Adding functional applications to

instructional objectives based on core content standards




Selecting and Prioritizing Instructional Targets

Important component of IEP Goals and Objectives

Functional Skills vs Academic Skills? Skills need to be meaningful for the

learner and family Use person centered planning methods

with students and family to help prioritize relevant skills and learning activities




How Should Students be Taught? P 432-433

Select and prioritize instructional targets that are meaningful for students and their families

Instruction must be carefully planned, systematically executed, continuously monitored for effectiveness




Components of an Instructional Program Precisely assess the student’s current level of

performance-determine what needs to be taught Ex. Can student hold head up? How long? Under what

conditions? In response to what verbal or physical signals? Clearly define the skill to be taught

Ex. When applesauce is applied to student’s finger, he/she will put the finger in his/her mouth within 5 seconds.

Break down skills into smaller steps (task analysis) Assess student at each step to determine where to begin

instruction Determine how the learner can actively participate

Active engagement, repeated practice Alternative response methods




Components of an Instructional Program Provide a clear response prompt or cue to the child

Verbal, physical Eventually fade prompts

Gradually withdraw response prompt Contrived prompts must be withdrawn so that a

student’s correct responses come under control of naturally occurring stimuli




Components of an Instructional Program Provide immediate feedback

Reinforce correct responses Corrective feedback for errors and nonresponses Take data

Use strategies that promote maintenance and generalization Have student perform skills in different settings,

with different instructors in naturalistic setting

Directly and frequently assess the student’s performance Collect data on student performance




Naturalistic Teaching “teachable moment”- when a student demonstrates and

interest in something, great time to teach them a related skill

Components Environmental conditions that capture student attention

and interest Ex. Naturally occurring conditions or conditions

teacher can manipulate (ex. Recess, Lunch, putting something out of reach)

Teacher must be able to control those condition Ex. Blocking access to water fountain, not allowing

student access to what he/she wants Provide a natural reinforcement

Prompt student to communicate what he wants, then allow him to get a drink of water




Naturalistic Teaching Strategies: Mand- verbal instruction that cues students to perform a

behavior that they may know how to perform, but do not do Ex. Teacher blocks access to water, teacher obtains

attention then says (mand) “Tell me what you want”, student complies, then gets water and praise

Mand-Prompt- teacher mands, as stated above, but also prompts student

Ex. Teacher blocks water access, teacher obtains students attention and mands, student does not comply teacher provides prompt by saying “Water” or “I want water”, gain attention and repeat man-prompt-wait sequence no more than three times, then give access to water(reinforce) so student is not discouraged from asking for water again (another teachable moment)

Model- student can perform a behavior but hesitates to do so, teacher may dispense with mands and just model the correct behavior for students to imitate (peer buddy)




Naturalistic Teaching ImplementationAttend to students

Observe student preferences, anticipate needs, search for communicative intent in behavior

Teach functional skills at opportune moments Teach at lunchtime, free time, transition time, before/after class, on bus

Establish a stimulating environment Provide situations where student will be motivated to produce

communicative and social behaviorsRefrain from providing too much assistance

Require students to use functional behaviors to make requests or protests, provide only assistance that is successful for responding

Reinforce appropriate communicative and social behaviors Begin with frequent reinforcement and fade to less frequent

reinforcement and natural consequencesAssess results

Collect data to determine if student has learned spontaneous communication and social skills




Naturalistic Teaching http://www.youtube.com/watch?v=

0juQbMrJggY http://www.youtube.com/watch?v=

qUqqxoTfMEE




Partial Participation Even though some individuals with severe disabilities cannot

independently perform all steps of a given task or activity, they often can be taught to perform selected components or an adapted version of the task

Suggestions for avoiding misuse of partial participation: Passive participation

Learner is present but not active Myopic participation

Participation is limited to only some parts of the activity which are chosen for the convenience of others

Piecemeal participation Partial participation is only used part of the time

Missed participation Miss it all together in trying to help the student be

independent




Small Group Instruction Benefits

Instruction may be more likely to generalize to group situations or settings

Opportunities for social interactions and reinforcement from peers

Opportunities for incidental or observation learning from other students

May be a more cost-effective use of a teacher’s time




Small Group Instruction Teacher Strategies

Make sure all students have prerequisite skills Encourage students to listen and watch other

group members, praise them for doing so Make instruction interesting by keeping individual

turns short, give all members turns Active student response- choral responding,

response cards Teach at a lively pace with brief intertrial intervals Involve all members by using multilevel instruction Use partial participation/material adaptations Keeping waiting time to a minimum Promote cooperation




Positive Behavior Support Use of functional assessment methodologies to

support student’s placement and guide the development of positive behavior support plans

Scientifically based Components Understanding the meaning that a behavior has for a

student Teaching the student a positive alternative behavior Using environmental restructuring to make the

undesired behavior less likely Using strategies that are socially acceptable and

intended for use in integrated school and community setting




Positive Behavior Support Begins with a functional assessment of

problem behavior Functional Assessment- determines

environmental variables that cue and maintain undesirable behavior (ABC’s)

Functional Analysis- an experimental manipulation of variables to verify their function in triggering problem behaviors

Put interventions in place to produce a more socially acceptable behavior




Positive Behavior Support Interventions:

Provide students with choice of tasks or task sequence

Intersperse easy or high-probability tasks or requests with more difficult items or low probability requests

Maintain a rapid pace of instruction Use a response-prompting procedure that results in

fewer errors Modify task difficulty Deliver reinforcement non-contingently on a fixed

time schedule Provide free access to leisure items and activities

Positive does not mean punishments or aversives.




Where Should Students with Severe and Multiple Disabilities be Taught?

Benefits of the neighborhood school and inclusion More likely to function responsibly as adults in a pluralistic

society Integrated schools are more meaningful instructional

environments (segregation now promotes segregation in the future)

Parents and families have greater access to school activities (family convenience)

Helps develop range of relationships with non-disabled peers. Peers without disabilities are more likely to function

responsibly as adults in a pluralistic society Students with severe disabilities are more likely to develop social

relationships with students without disabilities if they are included at least part of the time in the regular classroom (increased social contacts)




Social Relationships Desired outcome in inclusive education Placement in general education allows for

more opportunities for positive social contact, and developing friendships

Examples of Social Relationships Peer tutor/buddy (p 446-447: Creating peer buddy

program) Eating companion Friend Art, Home Economics, Industrial Arts, Music,

Physical Education companionBenefits of inclusion on social skills and relationships

have the most extensive empirical support




Teaching Students with Severe and Multiple Disabilities

Teaching students with severe disabilities is difficult and demanding. It requires teachers to: be well organized, firm, and consistentbe knowledgeable about one-to-one and small group instructional formatsbe able to work cooperatively with other teachers and related service professionalsmaintain accurate records and constant planning for future needs of studentsbe sensitive to small changes in behaviorbe consistent and persistent in evaluating and changing instruction to improve learning and behaviorWorking with students who require instruction at its very best can be highly rewarding to teachers:The effective teacher is consistent and persistent in evaluating and changing instruction to improve learning and behaviorWorking with students who require instruction at its very best can be highly rewarding to teachers