Multiple Disabilities

Introduction
Individuals with multiple disabilities used to be easily defined: they were those children excluded from school on the basis of extensive mental, physical, and/or behavioral impairments that were permanent in nature. Today, the definitions and classifications of severe handicaps, severe/profound impairments, or multiple disabilities are less than precise. Children so labeled present a complex picture: they might include those with diagnoses of mental retardation, schizophrenia, autism, or cerebral palsy. Further behavioral, sensory, or orthopedic problems may also be involved. Depending on the type and severity of the disabilities, a student with multiple disabilities will most likely require ongoing support in more than one major life skill area. A team of educators and therapists should work closely with the student and his/her family to plan a successful educational program. The individualized program should include a variety of supports to meet the student's educational, language, social, vocational, and functional skill development. Accommodations for medication schedules, special diets and adaptive equipment should be included. Early intervention programs, preschool and educational programs with the appropriate support services are important to children with multiple disabilities. Educators, physical therapists, occupational therapists, and speech-language pathologists are all members of the team that may provide services, along with others, as needed for each individual. Assistive technology, such as computers and augmentative/alternative communication devices and techniques, may provide valuable instructional assistance in the educational programs for students with severe/multiple disabilities. Teachers can play a vital role in helping students with multiple disabilities learn to negotiate the world around them. Because students with multiple disabilities are frequently unable to express their fears and anxieties, it is up to significant adults to make it worthwhile for them to leave their safe lives for the uncertainties of the external world. Professionals who work with students with multiple disabilities in schools must provide the external structure, organization, and stability that they lack. Using creative teaching strategies for students with multiple disabilities is critical, not only to facilitate academic success, but also to help them feel less alienated from other human beings and less overwhelmed by the ordinary demands of everyday life. The individual with multiple disabilities can engage in a wide variety of useful and satisfying activities that will be beneficial in school, the community and workplace. Community-based instruction should be an important component of the older student's plan and include transition planning for post-school work and living arrangements.

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Incidence
In the 1997-98 school year, states reported to the U.S. Department of Education that they were providing services to 106,758 students with multiple disabilities (TwentyFirst Annual Report to Congress, 1999).

Description
The IDEA definition of multiple disabilities is "simultaneous impairments (such as mental retardation/blindness, mental retardation/orthopedic impairment, etc.), the combination of which causes such severe educational problems that the child cannot be accommodated in a special education program solely for one of the impairments. The term does not include children with deaf-blindness." Known causes of multiple disabilities are due to prenatal biomedical factors, which include chromosomal abnormalities, genetic metabolic disorders, disorders of brain formation, and environmental influences. In addition, complications during and after birth can account for multiple disabilities. People with severe disabilities are those who traditionally have been labelled as having severe to profound mental retardation. These individuals require ongoing, extensive support in more than one major life activity in order to participate in integrated community settings and enjoy the quality of life available to people with fewer or no disabilities. Intellectual functions of students with sever and multiple disabilities include limited academic skills, limited levels of awareness, deficits in self-care skills, a lack of typical social interactions, and challenging behaviors. Teachers will work with students who may not walk or talk. Students with multiple disabilities may not reach out and interact with their environment. Many children with multiple disabilities do not volunteer information, answer questions or perform tasks upon request. Very often, these students will work with familiar people, whom they know and trust, but not with strangers. The new instructor may form the wrong impression that the student is not capable of performing certain skills at all. (See also description for students with visual impairment, hearing impairment, orthopedic impairment, autism, and speech/language impairment.)

Characteristics
Students with multiple disabilities may exhibit a wide range of characteristics, depending on the combination and severity of disabilities and the person's age.

Personal/Motivational
May display an immature behavior inconsistent with chronological age May exhibit an impulsive behavior and low frustration level 53
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Characteristics Social/Behavioral
Students with multiple disabilities may become fearful, angry, and upset in the face of forced or unexpected changes. May lack social skills May have difficulty forming interpersonal relationships

Learning
May experience fine-motor deficits that can cause penmanship problems May have slow clerical speed. May have limited speech or communication May tend to forget skills through disuse May have trouble generalizing skills from one situation to another May lack high level thinking and comprehension skills May have poor problem-solving skills Ability to engage in abstract thinking is limited May be poor test taker due to limiting factors of the disabilities May withdraw from group activities May have difficulty locating the direction of sound May have speech that is characterized by substitution, omissions May have difficulty learning about objects and object relationships May lack maturity in establishing career goals

Physical/Health
A variety of medical problems may accompany severe disabilities. Examples include seizures, sensory loss, hydrocephalus, and scoliosis. May be physically clumsy and awkward May be unsuccessful in games involving motor skills (See also characteristics for students with visual impairment, hearing impairment, orthopedic impairment, autism, and speech/language impairment.)

General Considerations
In order to effectively address the considerable needs of individuals with severe and/or multiple disabilities, educational programs need to incorporate a variety of components, including language development, social skill development, functional skill development (i.e., self-help skills), and vocational skill development. Related services are of great importance, and the appropriate therapists (such as speech and language, occupational, physical, behavioral and recreational therapists) need to work closely with classroom teachers and parents.
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General Considerations
Best practices indicate that related services are best offered during the natural routine of the school and community, rather than by removing the student from class for isolated therapy. Community-based instruction should be an important characteristic of educational programming, particularly as students grow older and increased time is spent in the community. School to work transition planning and working toward job placement in integrated, competitive settings are important to a student's success and the longrange quality of his/her life. Students with multiple disabilities do not learn as easily by incidental learning as do less disabled and nondisabled persons. Therefore, instruction in even the most basic skills must be carefully structured and planned. (See also general considerations for students with visual impairment, hearing impairment, orthopedic impairment, autism, and speech/language impairment.)

Orientation & Mobility

Traditional orientation and mobility techniques and strategies often have little success with students who have multiple disabilities. The challenge is not choosing the most appropriate mobility technique, but being able to encourage any type of purposeful movement or effectively communicate with the student. Orientation and mobility, conventionally defined as a series of techniques and strategies to teach independent travel seems to have little to offer to these students, who may not be able to travel independently. Students with multiple disabilities very often rely on others for most of their travel needs. They "miraculously" arrive where they need to be with little or no participation or understanding of the process that took place. Active involvement by answering questions and making decisions not only promotes participation and attention, but also allows them to make mistakes. They can feel responsible for successfully arriving to their destination or, on the contrary, experience the consequences of getting lost. Maintaining physical contact with the environment not only helps in concept-building and orientation, but it also provides a necessary sense of security. One of the basic orientation and mobility skills, trailing, can be adapted to allow children to touch their surroundings as they move about. Children with balance difficulties, for example, can trail as they walk with a modified sighted guide technique for extra support, or even from their wheelchair. They need to be close enough to walls and objects to be able to reach them with their hands or arms. If they cannot trail with
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Orientation & Mobility

their body directly, then an intermediary object can be used such as a favorite toy so that students get a feel for doors, openings, corners and other environmental features and landmarks. This strategy may work especially well with those students who are tactile defensive and refuse to use their hands for exploration. There is no recipe for providing effective orientation and mobility to children with multiple disabilities. Educators can plan new and creative activities as long as the basic needs of safety, communication, control, contact with the environment, independent movement, consistency, and functionality are being carefully addressed.

Classroom Strategies
A certain amount of regimented external structure must be provided if the student with multiple disabilities is to be productive in the classroom. Assignments should be broken down into small units, and frequent teacher feedback and redirection should be offered Children with severe concentration problems benefit from timed work sessions. This helps them organize themselves. When assigning timed units of work, take it into account the student's slower writing speed. Students with multiple disabilities can sometimes be stubborn; they need firm expectations and a structured program that teaches them that compliance with rules leads to positive reinforcement. Slow clerical speed and severe disorganization may make it necessary to lessen the homework/classwork load and/or provide time in a resource room where a special education teacher can provide the additional structure the student with multiple disabilities needs to complete the work. Seat the student with multiple disabilities at the front of the class (if possible) and direct frequent questions to him/her to help maintain attention to the lesson. Work out a nonverbal signal with the student with multiple disabilities (e.g., a gentle pat on the shoulder) for times when he/she is not paying attention. Provide a highly individualized academic program engineered to offer consistent successes. The student with multiple disabilities needs great motivation. Learning must be rewarding and not anxiety-provoking. Teachers must be alert to changes in behavior that may indicate depression, such as even greater levels of disorganization, inattentiveness, and isolation; decreased stress threshold; chronic fatigue; crying; suicidal remark. Do not accept the student's assessment in these cases that he/she is "okay."
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Classroom Strategies
It is important to allow enough time for the student with multiple disabilities to respond, since it may take longer to interpret your request, organize a response and produce it. If a response is produced, it may not be in the form of speech. The teacher may need to learn how to read gestures, slight changes in muscle tone or posture and different types of body language. Classroom arrangements must take into consideration students' needs for medications, special diets, or special equipment. The use of computers, augmentative/alternative communication systems, communication boards, head sticks, and adaptive switches are some of the technological advances which enable students with severe disabilities to participate more fully in integrated settings. A student with multiple disabilities needs a curriculum grounded in preliminary sensory motor stimulation and subsequent stress on five major areas: motor, selfhelp, communication, social/interpersonal, and cognitive skills. (See also classroom strategies for students with visual impairment, hearing impairment, orthopedic impairment, autism, and speech/language impairment.)

Field Experiences
Always communicate with the student with multiple disabilities before taking him/ her anywhere. Let the student know exactly where he/she is going. Discussing the activities to come facilitates anticipation or transition to a new activity. Exploring the unknown can be very frightening and threatening for many students with multiple disabilities. Only trust and confidence in their environment will allow them to reach out and interact with it. It is important to begin instruction in familiar places, paying attention to environmental factors such as lighting, level of noise, temperature, etc. If necessary, act as a bridge between the child and objects in the environment. (See also field experiences for students with visual impairment, hearing impairment, orthopedic impairment, autism, and speech/language impairment.)

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Organizations
TASH (formerly Association for Persons with Severe Handicaps) 29 W. Susquehanna Ave., Ste. 210 Baltimore, MD 21204 (410) 828-8274; (410) 828-1306 (TTY) E-mail: [email protected] Web: www.tash.org National Rehabilitation Information Center (NARIC) 1010 Wayne Ave., Ste. 800 Silver Spring, MD 20910-5632 (301) 562-2400; (800) 346-2742 (toll free) Web: www.naric.com The Arc (formerly the Association for Retarded Citizens of the United States) 1010 Wayne Ave., Ste. 650 Silver Spring, MD 20910 (301) 562-3842 E-mail: [email protected] for publications: www.TheArcPub.com United Cerebral Palsy Associations, Inc. 1660 L Street NW, Ste. 700 Washington, DC 20005 (202) 776-0406; (800) 872-5827 (toll free); (202) 973-7197 (TTY) E-mail: [email protected] Web: www.ucpa.org (See also organizations for students with visual impairment, hearing impairment, orthopedic impairment, autism, and speech/language impairment.)

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