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Focus QuestionsHow might the effects of an acute health condition on a student’s classroom participation and educational progress differ from those of a chronic condition?Why is the prevalence of chronic medical conditions in children much higher than the number of students receiving special education under the disability categories of orthopedic impairments and other health impairments?What does a classroom teacher need to know about physical disabilities and health impairments in children?Why do you think attention-deficit/hyperactivity disorder (ADHD) is not included as a separate disability category in IDEA?How might the visibility of a physical disability or health impairment affect a child’s self-perception, social development, and level of independence across different environments?
Focus QuestionsWhat are some of the problems that members of transdisciplinary teams for students with physical disabilities and multiple health needs must guard against?
Of the many ways that the physical environment, social environment, and instruction can be modified to support the inclusion of students with physical disabilities, health impairments, and ADHD, which are most important?
KEY TERMS AND CONCEPTSIDEA definition of physical and health impairmentsWhat is Assistive Technology? Give examplesDefinitions: Hydrocephalus, Cystic Fibrosis, Spina Bifida, Muscular Dystrophy, etcComorbidity (definition, ADHD and comorbidity)Legislation and ADHD (504 and IDEA)ADHD
What is it Stimulant use (why significant increase) ABA (methods to treat). Self- monitoring
NJAC 6A:14 Definition OI "Orthopedically impaired" corresponds
to "orthopedically handicapped" and means a disability characterized by a severe orthopedic impairment that adversely affects a student's educational performance. The term includes malformation, malfunction or loss of bones, muscle or tissue. A medical assessment documenting the orthopedic condition is required.
PrevalenceStudies of the number of children with physical disabilities and health impairments have produced hugely diverse findings1% of children receiving special education services are orthopedically impaired (OI)11.6 % of children receiving special education services are otherwise health impaired (OHI)Two factors make the actual number of children with physical disabilities and health conditions much higher than the number receiving special education services under IDEA
Many children with OI and OHI receive services under other categories
Some do not require specialized educational services
Spina Bifida Vertebrae do not enclose the spinal cord Congenital malformations of the brain, spinal cord, or
vertebra Can result in paralysis below affected vertebra Hydrocephalic condition common; treated with a shunt Hydrocephalus-cerebrospinal fluid accumulates in
NJAC 6A:14 Definition OHI "Other health impaired" corresponds to "chronically
ill" and means a disability characterized by having limited strength, vitality or alertness, including a heightened alertness with respect to the educational environment, due to chronic or acute health problems, such as attention deficit disorder or attention deficit hyperactivity disorder, a heart condition, tuberculosis, rheumatic fever, nephritis, asthma, sickle cell anemia, hemophilia, epilepsy, lead poisoning, leukemia, diabetes or any other medical condition, such as Tourette Syndrome, that adversely affects a student's educational performance. A medical assessment documenting the health problem is required.
Other Health ImpairmentsSeizure disorder (epilepsy)
Caused by abnormal electrical activity in the brain Three different categories based on severity Seizures can be controlled with medicine
Diabetes Chronic disorder of metabolism Body unable to obtain and retain adequate energy
from food Type 2 diabetes the most common form Obesity increases the likelihood of Type 2 diabetes Treated with insulin, diet, and exercise http://www.youtube.com/watch?v=ISSo2RfCcmA&list=UUg0sL-UssDXE2Ohk3Df
The essential feature is a persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequent and severe than is typically observedThree ADHD subtypes: combined, predominantly inattention, and hyperactive-impulsiveMost students with ADHD have the combined typeChildren with ADHD can be served under the “other health impairments” category of IDEA or under Section 504 of the Rehabilitation ActEstimates of prevalence of ADHD range from 3% to 7% of all school-age childrenMost children with ADHD struggle in the classroomThere is comorbidity with other disabilities
ADHD DefinitionDiagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) definition:Essential features: A. Persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequently displayed and is more severe than is typically observed in individuals at comparable level of development.
B. Some hyperactive-impulsive or inattentive symptoms must have been present before seven years of age.
C. Some impairment from the symptoms must be present in at least two settings.
D. There must be clear evidence of interference with developmentally appropriate social, academic or occupational functioning.
E. The disturbance does not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorders and is not better accounted for by another mental disorder.
ADHD Definition ContinuedThree Subtypes:Attention-Deficit/Hyperactivity Disorder Predominantly Inattentive Type: This subtype is used if six (or more) symptoms of inattention (but fewer than six symptoms of hyperactivity-impulsivity) have persisted for at least six months.Attention-Deficit/Hyperactivity Disorder Predominantly Hyperactive-Impulsive Type: This subtype should be used if six (or more) symptoms of hyperactivity-impulsivity (but fewer than six of inattention) have persisted for at least six months.Attention-Deficit/Hyperactivity Disorder Combined Type: This subtype should be used if six (or more) symptoms of inattention and six (or more) symptoms of hyperactivity-impulsivity have persisted for at least six months.
ADHD Definition Continued A. “Persistent pattern of inattention and/or hyperactivity-impulsivity that is more
frequently displayed and is more severe than is typically observed in individuals at comparable level of development.” Individual must meet criteria for either (1) or (2):
(1) Six (or more) of the following symptoms of inattention have persisted for at least six months to a degree that is maladaptive and inconsistent with developmental level:
Inattention (a) often fails to give close attention to details or makes careless mistakes in schoolwork, work or other activities(b) often has difficulty sustaining attention in tasks or play activity(c) often does not seem to listen when spoken to directly(d) often does not follow through on instructions and fails to finish schoolwork, chores or duties in the workplace (not due to oppositional behavior or failure to understand instructions)(e) often has difficulty organizing tasks and activities(f) often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)(g) often looses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books or tools)(h) is often easily distracted by extraneous stimuli(i) is often forgetful in daily activities
ADHD Definition Continued (2) Six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at
least six months to a degree that is maladaptive and inconsistent with developmental level: Hyperactivity
(a) often fidgets with hands or feet or squirms in seat(b) often leaves seat in classroom or in other situations in which remaining seated is expected(c) often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)(d) often has difficulty playing or engaging in leisure activities quietly(e) is often “on the go” or often acts as if “driven by a motor”(f) often talks excessivelyImpulsivity(g) often blurts out answers before questions have been completed(h) often has difficulty awaiting turn(i) often interrupts or intrudes on others (e.g., butts into conversations or games)
B. Some hyperactive-impulsive or inattentive symptoms must have been present before age 7 years.C. Some impairment from the symptoms is present in at least two settings (e.g., at school [or work] and at home).D. There must be clear evidence of interference with developmentally appropriate social, academic or occupational functioning.E. The disturbance does not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorders and is not better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).
ADHD Co-morbidity Most children with ADHD struggle in the classroom Score lower on IQ and achievement tests More than half require remedial tutoring for basic skills 30% repeat one or more grades 20% of students with Learning Disabilities and
Intellectual Disabilities were also diagnosed with ADHD Not unusual for students with Asperger and Tourette
syndromes to also be identified with ADHD 58% with ADHD experience emotional and behavioral
problems *Co-morbidity – two or more conditions existing at the same
Attention-Deficit/Hyperactivity Disorder40-50% of children with ADHD can be served under the “other health impairments” category of IDEASome are serviced under learning disability, behavioral disability or emotional disturbanceOthers are serviced through Section 504 of the Rehabilitation ActPrevalence- estimates of prevalence of ADHD range from 3% to 7% of all school-age children
Applied Behavioral Analysis (ABA) Positive reinforcement for on task behavior
Contingency plan (if you do…. then you can do….) Token economy system
Modifying assignments and instructional activities to promote success Systematically gradually teaching self-control
Self monitor Checklists
Methods include positive reinforcement for on-task behavior, modifying assignments and instructional activities to promote success, and systematically teaching self-control
A deficit of executive functioning is a primary characteristic of children with ADHD
Students should be taught to monitor their behavior
Seating child close to the teacher Give clear directions Make consistent reinforcement Breaking assignments into smaller pieces Provide opportunities to actively respond within ongoing
instruction Providing differential consequences for behavior
Positive reinforcement for appropriate behavior- praise, tokens
Ignoring inappropriate behavior Time out or response cost for inappropriate behavior
Conduct a functional behavior assessment if interventions are not working
Self-Monitoring (p 398-399)Implementation1.Specify the target behavior and performance goals2.Select or create materials that make self-monitoring easy3.Provide supplementary cues to self-monitor 4.Provide explicit instruction5.Reinforce accurate self-monitoring6.Reward improvements in the target behavior7.Encourage self-evaluation8.Evaluate the program
Behavioral Treatments Teach self control if impulsivity impacts learning
Deficits in executive functioning- ability to verbally think through and control one’s action
Http://www.ncld.org/ld-basics/ld-aamp-executive-functioning“Executive functioning describes a set of mental processes that helps
people to connect past experience with present action. Learn how executive function governs your child’s ability to manage time, make plans, and keep track of more than one thing at once.”
Children must learn to self regulate their behavior and reduce impulsiveness
Ex. Correspondence training- procedure in which children are reinforced for “do-say” verbal statements about what they had done previously and “say-do” statements describing what they plan to do
Characteristics – Physical Disabilities and OHI As a group, students with physical disabilities or health impairments function well below grade level academically
Daily health care routines and medications have negative side effects on academic achievement
Educational progress is often hampered by frequent and sometimes prolonged absences from school for medical treatment when flare-ups or relapses require hospitalization
As a group, students with physical disabilities and health impairments perform below average on measures of social-behavioral skills
Concerns about physical appearance are frequently identified as reasons for emotional difficulties and feelings of depression
Characteristics continuedImportant factors that affect educational needs: Age of Onset, Visibility, and Severity
Age of onset - children with congenital or acquired impairments have different needs
Important for teacher to know Ex. Child may not have the use of their legs since
birth, missed out on some developmental experiences, especially if there were no early intervention services
Ex. A teenager loses the use of her legs in an accident may need support from parents, teachers, specialists and peers in adapting to life with this newly acquired disability.
Concerned with child’s participation in activities, especially those that will be useful in self-help, employment, recreation, communication and aspects of daily living (dressing, buttoning, drinking from a cup)
Conduct assessments and make recommendations to parents and teachers regarding the effectiveness of appliances, materials, and activities at home and school
Help with vocational programs - opportunities for work and independent living after completing an educational program
Other Specialists Speech Language Pathologists- speech therapy, language
interventions, oral motor coordination (chewing & swallowing), augmentative and alternative communication (AAC) services
Adapted Physical Educators- provide physical education activities designed to meet the individual needs of students with disabilities
Recreating Therapists- provide instruction in leisure activities and therapeutic recreation
School Nurses- provide certain health care services to students, monitor students’ health and inform IEP teams about the effects of medical conditions on students’ educational programs
Prosthetists- make and fit artificial limbs Orthotists- design and fit braces and other assistive devices Orientation and Mobility specialists- teach students to
navigate their environment effectively and safely Health Aides- carry out medical procedures and health-care
services in the classroom Counselors/Social Workers- help students and families adjust
Environmental ModificationsNecessary to enable a student with physical and health impairments to participate more fully and independently in schoolAdaptations to provide increased access to a task or an activityChanging the way in which instruction is deliveredChanging the manner in which the task is doneProvide increased access to a task or an activity; may change the way instruction is deliveredEx.
Install paper cup dispensers near water fountains so students in wheelchairs can use them
Move a class/activity to an accessible part of the school building so that a student with a physical impairment can participate
Provide soft tip pens that require less pressure for writing Adjust desk and tabletop heights for student in a wheelchair Modify written/oral responses on tests Wheelchair accessible classroom
Assistive Technology IDEA defines assistive technology as assistive
technology devices and the services needed to help a child obtain and effectively use devices
Assistive technology device- any item, piece of equipment or product system whether acquired commercially off the shelf, modified, or customized, that is used to increase, maintain or improve the functional capabilities of a child with a disability. Does not include a medical device that is surgically implanted or the replacement of such device.
Assistive technology service- any service that directly assists a child with a disability in the selection, acquisition, or use of an assistive technology device
Examples: Low Tech- flexible drinking straw, adapted eating utensils, wheelchair, glasses, a “grabber” or “reacher”
High Tech- computerized synthetic speech device, electronic switch activated by eye movement
Special Health Care Routines Individualized Health Care Plan (IHCP)-
identifies special health related needs, included as part of the students IEP
Identifies history, diagnosis and assessment data relevant to the condition
Includes information on how to handle routine healthcare procedures, physical management techniques and medical emergencies that may arise while child is in school
Positioning, Seating and Movement Encourage development of muscles and bones
and help maintain healthy skin Promotes safety Can influence how a child with physical disabilities
is perceived and accepted by others Simple adjustments can contribute to improved
appearance and greater comfort and increased health for the child
Good positioning results in alignment and proximal support of the body, distributes pressure evenly and provides comfort for seating, reduces deformity
Stability positively affects use of the upper body, feelings of physical security and safety
Educational PlacementsFor no other group of exceptional learner is the continuum
of educational services and placement options more relevant
During the 2008-2009 school year: 52% of students who received special education
services under the category of orthopedic impairment were educated in general education classrooms; 17% in resource rooms; and 24% in separate classrooms
60% of students with health impairments were educated in general education classrooms; 24% in resource rooms; and 11% in separate classrooms
Technology-dependent students need both a medical device and ongoing nursing care to avoid death or further disability
Controversial issues concerning including students with physical impairments and special health care needs in general education classroomsThe extent of responsibility properly assumed by teachers and schools
Irving Independent School District v. Tatro
Catheterization is a related service Cedar Rapids Community School District
v. Garret F Nursing services are related services
Acceptance is the most basic need of children with physical disabilities and health impairments
Resources ADHDNational Institute of Mental Health: http://www.nimh.nih.gov/health/publications/attention-deficit-hyperactivity-disorder/complete-index.shtml
US Library of Medicine: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002518/
CHADD: School and ADHD: Kindergarten through 12th Grade http://www.chadd.org/Content/CHADD/AboutCHADD/CHADDPublicPolicy/Education/default.htm#Return
Helpguide.org: ADD/ADHD Parenting Tips: Helping Children with Attention Deficit Disorderhttp://www.helpguide.org/mental/adhd_add_parenting_strategies.htm
Resources continued50 Tips on the Classroom Management of Attention Deficit Disorder. Hallowell and Ratey. http://www.sacramentopsychology.com/index.php/articleslayout/56-attention-deficithyperactivity-disorder/110-50-tips-on-the-classroom-management-of-attention-deficit-disorder-.html
LDonline: Strategies for Teaching Youth with ADD and ADHD: http://www.ldonline.org/article/13701/
ED.gov: Teaching Children With Attention Deficit Hyperactivity Disorder: Instructional Strategies and Practices http://www2.ed.gov/rschstat/research/pubs/adhd/adhd-teaching.html
Resources continuedExecutive Functioning Http://www.ncld.org/ld-basics/ld-aamp-executive-functioning“Executive functioning describes a set of mental processes that helps people to connect past experience with present action. Learn how executive function governs your child’s ability to manage time, make plans, and keep track of more than one thing at once.” More information:http://www.ncld.org/ld-basics/ld-aamp-executive-functioning/basic-ef-facts Executive Functioning and Learning DisabilitiesExecutive Skills and Your Child with Learning DisabilitiesHow to Help a Child with Weak Working MemoryWhat is Executive Function?What Is Working Memory and Why Does It Matter?