Physical Disabilities, Health Impairments and ADHD

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 11Physical Disabilities,

Health Impairments, and ADHD

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

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


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

Physical disabilities: Academic achievement(why below grade level) Self-image Positioning, transferring, lifting. Why proper positioning is

importantCurriculum – what is includedPT, OT: What they do, differences in their jobsAsthma: Causes, impact on education




Components of IDEA DefinitionsSevere Orthopedic Impairment (OI)

Congenital abnormality - club foot, absence of a limb

Impairments caused by disease - poliomyelitis, bone tuberculosis

Impairments by other causes - cerebral palsy, fractures, burns

Adversely affecting educational performance




Components of IDEA Definitionscontinued

Other Health Impairment (OHI) Limited strength, vitality, or alertness due

to chronic or acute health problems Asthma, attention deficit/hyperactivity

disorder, diabetes, epilepsy, a heart condition, hemophilia, leukemia, sickle cell anemia





Severe Orthopedic ImpairmentSevere Orthopedic Impairment (OI)

Orthopedic Impairment- involves the skeletal system- bones, joints, limbs, associated muscles

Neuromotor Impairment- involves the central nervous system, affects ability to move, use, feel or control certain parts of the body

Both may cause similar limitations in movement





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.




IDEA Definitions Chronic Conditions- long-lasting, most often permanent conditions (cerebral palsy)

Acute Conditions- may produce severe and debilitating symptoms, is of limited duration ( a child who acquires a pneumonia)

Many children with OI and OHI receive services under other categories

Some do not require specialized educational services- just accommodations in the classroom (extended time, preferential seating)

This is typically done through a 504 Plan (Section 504 of the Rehabilitation Act




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




Orthopedic ImpairmentsCerebral Palsy

A disorder of voluntary movement and posture

Most prevalent physical disability in school age children

No clear relationship between the degree of motor impairment and degree of intellectual impairment (if any)

Classified according to muscle tone and motor movement

Spastic, Athetosis, Ataxia, Rigidity, Tremor, Mixed

Cerebal Palsy




Orthopedic Impairments

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

tissues surrounding the brain

Spina Bifida

Hydrocephalus




Orthopedic ImpairmentsMuscular Dystrophy

Progressive weakening and degeneration of the muscles No known treatment exists to stop or reverse any

form of muscular dystrophy Little relation between impairment and intellectual

development

Spinal Cord Injuries Caused by penetrating injury, fracture, stretching, or

compression of spinal cord Car accidents, sports injuries, and violence most

common causes Results in paralysis below affected vertebra Males represent 80% of traumatic spinal cord injuries




Review

Match the disability with its descriptor

Disability Descriptor

Hydrocephalus Vertebrae not enclosed in spine

Spina Bifida Disorder of movement and posture

Cerebral Palsy Fluid around the brain




Other Health Impairment

Other Health Impairment (OHI)

Limited strength, vitality, or alertness due to chronic or acute health problems

Attention deficit/hyperactivity disorder, diabetes, epilepsy, a heart condition, hemophilia, leukemia, sickle cell anemia





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

pz7g&index=6&feature=plcp




Other Health ImpairmentsAsthma

Chronic lung disease resulting in a narrowing of airways

Leading cause of absenteeism in school Causes are unknown but considered an

interaction of heredity and environment Triggers:

Emotional stress Exercise Exposure to allergens




Other Health ImpairmentsCystic Fibrosis

Body’s endocrine glands excrete thick mucus that can block the lungs and parts of the digestive system

No reliable cure has yet been found Child typically undergoes daily therapy where chest is

vigorously thumped (pounded)




Other Health ImpairmentsHIV and AIDS

Breakdown in the immune system prevents the body from fighting infections

No known cure or vaccine exists Children afforded legal protection under Section

504 http://www.youtube.com/watch?v=cxPq0CRssRs&list=PL

484D30B3D61C8D33&index=10&feature=plpp_video




Attention-Deficit/Hyperactivity Disorder – Overview

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

time




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

http://www.youtube.com/watch?v=z2hLa5kDRCAhttp://www.youtube.com/watch?v=NTnVYGWWiWUhttp://www.youtube.com/watch?v=Dktbd32B6aY




Causes ADHD Not well understood Evidence indicates that genetic factors

may place individuals at a greater than normal risk of an ADHD diagnosis

Research using neuroimaging technologies has shown that some individuals with ADHD have structural or biochemical differences in their brains




Drug TreatmentsPrescription Stimulant Medication

Most common intervention of students with ADHD Examples: Ritalin (most common), Adderall, Dexedrine,

Desoxyn, Cylert Many show marked improvements in adverse behaviors Parents and teachers reported appreciation for symptom

reduction No clear evidence indicates that stimulant

medications lead to improved academic achievement

Must be careful with side effects: insomnia, decreased appetite, headaches, weight loss, decrease in positive affect, irritability




Behavioral TreatmentsBehavioral Intervention

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




Behavioral Treatments Teacher-Administered Interventions

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.




Characteristics continuedVisibility - the visibility of impairment may cause some to underestimate the child’s abilities and limit opportunities

Visibility of condition effects how children view themselves and the degree to which others accept them.

Ex. Use of braces, wheelchairs, crutches, adaptive tables, special van/bus, helmet, assistance using toilet at school

Severity with which the condition affects different areas of functioning




Educational Approaches Accommodations

Minimal, in general education classroom Specialized instructions Coordination of services Parallel Curriculum

Coping with disabilities. Self-advocacy Mobility (orientation only for students with visual

impairments) Using adaptive methods and assistive technologies

for mobility, communication and daily living tasks increasing independence by self-administering

special health care routines; and learning self-determination and self-advocacy skills




Teaming Transdisciplinary Team Approach (physical and

occupational therapists, speech therapists, health care aides, and other specialists who frequently provide services to these students)

Beneficial for students with physical disabilities and health impairments

Typically receive many types of related services

Educational Needs Therapeutic Needs Vocational Needs Social Needs

Educational and health care personnel must openly communicate and cooperate with one another




Physical Therapists (PTs) Involved in the development and maintenance of

motor skills, movement and posture Encourage children to be as motorically independent

as possible, help develop muscular function, reduce pain, discomger and long term physical damage

May suggest sitting positions and activities in the classroom and may devise exercise or play programs

Ex. Prescribe exercises to help child increase control of muscles and use specialized equipment

Therapies Swimming, heat treatment, special positioning for feeding

and toileting http://www.youtube.com/watch?v=RBn_udj-MV0




Occupational Therapists (OTs)

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

http://www.youtube.com/watch?v=02JlnqUhXeU&feature=related

http://www.youtube.com/watch?v=A_u1tmXvcyg




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

to disabilities




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




Animal Assistance Providing personal care attendants Enhancing independence Providing social values as companionsHelp/service dogs

Trained to carry books and other objects, pick up telephone receivers, turn light switches on or of, open doors

Balance and support- get up from a seated position Contact a family member in case of emergency

Monkeys Trained to serve as personal care attendants for people

with disabilities

Can be used as a social “ice breaker” in starting a conversation with people in the community




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




Special Health Care Routines

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




Lifting and Transferring Students Teacher must know how to move and

transfer students with physical disabilities Teachers should follow an individualized

routine that addresses: Making contact with the child Communicating what is going to happen in a manner

that the child can understand Preparing the child physically for the transfer Require the child to participate in the routine as much

as possible Can post photos/charts of the positions and

procedures http://www.youtube.com/watch?v=soiLXx93B-4




Independence and Self-Esteem Need to develop respect for themselves and feel

that they have a rightful place in their families, schools and communities

Should be encouraged to develop as much independence as possible

Teach students how to explain their disability/health condition and respond to questions, expressing concerns or requesting help from others

Self-help groups- help provide information and support to children affected by similar disabilities

Students gain confidence and skills as their learn to manage their own health care needs.




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




Related Services in the Classroom

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




Inclusive Attitudes Classroom is a useful place to

discuss disabilities and encourage understanding and acceptance of a child with a physical disability or health impairment

Ex. Role play, simulations, opportunities to use crutches, braces, wheelchairs




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

Note: CHADD.org has many helpful articles




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?