Bonga University Department of SNIE

INSTRUCTOR:- HABTAMU D. Febru 1, 2022

Hand book for the course of education of persons with multiple disabilities

Chapter one:-introduction to multiple disabilities

History of multiple disability

Multiple Disabilities Trends and Controversies Several important trends, some

considered controversial because they advocate the inclusion of these students in
general education with the necessary supports, reflect improvements in the lives
of these students.
First, through advancements in medicine and technology these individuals not
only experience longer lives, but also have better options in mobility,
communication, sensory augmentation, and other areas.
Multiple Disabilities Second, starting in the 1960s, there has been gradual
improvement in societal attitudes toward people with significant disabilities. This
has led to legal protections, special education, community living alternatives,
supported employment, and an increase in relevant supports.
Multiple Disabilities Third, with the Timothy W. decision (Timothy W. v.
Rochester, New Hampshire, School District, 1989), "free and appropriate education
for all" was reaffirmed, schools were required to keep current with best practices
for educating those with significant disabilities, and the procedure of selecting
who can and cannot learn was declared illegal.
Multiple Disabilities the current trend to include individuals with severe or
multiple disabilities in classrooms and community activities with their nondisabled
peers has been particularly controversial. Special education placement data show
gradual growth of students with disabilities who are placed in a general education
setting, but much slower growth for students with severe and multiple disabilities.
Schools have complained that they are not able to include these students or
provide the necessary supports and services to achieve a meaningful education for
all involved.
Multiple Disabilities Some general education teachers have communicated an
unwillingness to have these students in their classrooms, even with support, and
they also may lack the required skills necessary to teach these children in a
general education classroom. However, there are numerous examples of schools
meaningfully including these students in ways that promote social and educational
participation, as well as evidence to support the benefits of inclusion for both
students with severe disabilities and typical classmates. More research, the
dissemination of information on inclusion, and improvements in teacher training
are needed.

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Definition under IDEA of Multiple Disabilities

When a child has several different disabilities we say, that he/she has multiple
disabilities. For example, a child may have difficulties in learning, along with
controlling her movements and/or with hearing and vision. The effect of multiple
disability can be more than the combination of two individual disabilities.
A child who is multiple disabled should receive help as early as possible so that
she can be helped to achieve her potential, and so that her disabilities will not
become worse.
The child will be slow to make progress and will have difficulty in generalizing.
It is important that we are patient and that we set realistic goals that are small
and achievable, as the child can learn only in small steps with a lot of practice
and repetition.
Because children with multiple disabilities have problems with all muscle
movement, with understanding and often with seeing and hearing as well,
communication is very difficult for them.
Often we may not know how much a multiple disabled child is understanding,
and her attempts to communicate may be unfamiliar to us and may pass
unnoticed. For these reasons we may wrongly label a child as being mentally
handicapped when she is not. We must try our best to assess a child's
understanding and expression to ensure that she is not wrongly labelled.
Some examples of multiple disabilities are:
 Deafblind (Visual Impairment + Hearing Impairment)
 Visual Impairment + Hearing Impairment + Mental Retardation
 Visual Impairment + Mental Retardation
 Cerebral Palsy + Mental Retardation/ Hearing/ Speech/ Visual problems
The greater the severity or impact on an individual, there is
a greater likelihood for increased need for supports. Often, individuals with a
severe disability require ongoing, extensive support in more than one major life
activity in order to enjoy the quality of life available to people with fewer or no
disabilities and to participate in integrated community settings. They may also
have additional significant disabilities, including movement difficulties, sensory
losses, and/or behavior problems.

Multiple disabilities is a term for a person with a combination of disabilities, for

instance, someone with both a sensory disability and a motor disability.
Additionally, in the United States, it is a special education classification under
which students are eligible for services through the Individuals with Disabilities
Education Act, or IDEA. Not every governmental education entity uses the
classification, however. In some states, legislation indicates that in order to be

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classified as having "multiple disabilities", at least one of a student's documented
disabilities must include intellectual disability. Individuals classified as having
multiple disabilities usually have more than one significant disability, such as
orthopaedic impairment, sensory impairment, and/or behavioral or emotional
issues. Under the IDEA, students are labelled with multiple disabilities when their
educational disabilities require more than the services that are available for just
one of their disabilities. For instance, if a student has a developmental
disability, emotional disabilities, and a visual impairment, they may be classified
as having multiple disabilities. However, not every student who has more than
one disability receives this classification.
Multiple disabilities is a term for a person with a combination of disabilities, for
instance, someone with both a sensory disability and a motor disability. ...
However, not every student who has more than one disability receives this
classification.
Multiple disabilities is defined as simultaneous impairments that result in severe
educational needs (mental retardation and blindness, mental retardation and
physical impairment)
"Multiple Disabilities" is a broad umbrella term meaning, simply, that the
student has more than one disability. The specifics of this diagnosis are almost
endlessly variable, and great care needs to be taken to adjust individual
educational support to the child's particular needs.

Children with multiple disabilities have a combination of more than one disability,
such as intellectual disability, mobility issues, visual or auditory deficits, language
delay, brain injury, and more. The term "multiple disabilities" does not specify
which of the many possible disabilities a student has, nor does it specify how
severe those disabilities are. The specifics vary greatly by the individual.

Multiple Disabilities The U.S. federal government definition includes those who
have more than one impairment, "the combination of which causes such severe
educational needs that they cannot be accommodated in special education
programs solely for one of the impairments“ Dual sensory impairment, or deaf-
blindness, is defined as a separate disability group. Multiple disabilities have
interactional, rather than additive, effects, making instruction and learning
complex.
What are the 4 categories of disability?

The four major types of disabilities include physical, developmental, behavioral

or emotional, and sensory impaired disorders. While many disabilities fall under
one of these four umbrellas, many can fall under two or more

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Under IDEA, Multiple Disabilities:
...means concomitant [simultaneous]
impairments (such as intellectual disability-blindness, intellectual disability-
orthopedic impairment, etc.), the combination of which causes such severe
educational needs that they cannot be accommodated in a special education
program solely for one of the impairments.

According to Deutsch-Smith, people with multiple disabilities require ongoing and

intensive supports across their school years and typically across their lives. For
some, these supports may well be in only one life activity, but for many of these
individuals, supports are needed for access and participation in mainstream
society. Supports are necessary because most individuals with multiple disabilities
require assistance in many adaptive areas.

No single definitions covers all the conditions associated with severe and multiple
disabilities. Schools usually link the 2 areas (severe disabilities and multiple
disabilities) into a single category for students who have the most significant
cognitive, physical, or communication impairments (Turnbull, Turnbull, &
Wehmeyer).

As you can see, there’s more to IDEA’s definition of multiple disabilities than
having more than one impairment or disability. A key part of the definition is
that the combination of disabilities causes the student to have severe educational
needs. In fact, those educational needs must be severe enough that they cannot
be addressed by providing special education services for only one of the
impairments.
Whatever the combination is, a child served under IDEA’s category of “multiple
disabilities” will have a special education program that is designed to address the
educational needs that arise from all of the child’s disabilities, not just one.

Note that IDEA does not include deaf-blindness as an example of multiple

disabilities. That’s because deaf-blindness is defined separately and is a disability
category of its own under IDEA.
Beyond the Federal Definition
So, what level of educational need is considered “severe enough” to make a
student with multiple disabilities eligible for special education? Each state defines
this for itself. So it’s important to know your state’s definition of multiple
disabilities. It’s also important to know:
 how each disability affects the child’s learning and functioning, and
 how the combination of disabilities does as well.

Multiple Disabilities this disability category includes those students with the most
severe physical, cognitive, and communicative impairments. Most of the students

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served under the multiple disability category do have some level of cognitive
impairment, but the specific diagnosis of this impairment can often be ambiguous
or undetermined. It should be noted however, that these students can also have
average or even above-average intelligence. The common connection between
students in this category is not just that they have two or more coexisting
impairments, but that they generally need extensive support across many skill
areas.

There are many fact sheets on disability available here at the Canter for Parent
Information and Resources. To learn more about specific disabilities,
https://www.parentcenterhub.org/specific-disabilities/
Bear in mind that it’s hard to say how a combination of specific disabilities will
affect an individual child. That will depend on the disabilities involved and their
severity.
Multiple Disabilities Aren’t All the Same
The term multiple disabilities is general and broad. From the term, you can’t tell:
 how many disabilities a child has;
 which disabilities are involved; or
 how severe each disability is.
Many combinations of disabilities are possible. For example, one child with
multiple disabilities may have an intellectual disability and deafness. Another
child may have cerebral palsy and autism. Sharon, above, had three different
disabilities. All have multiple disabilities—but oh, such different ones!
To support, parent, or educate a child with multiple disabilities, it’s important to
know:
 which individual disabilities are involved;

 how severe (or moderate or mild) each disability is; and

 how each disability can affect learning and daily living.

 The different disabilities will also have a combined impact.

Multiple disabilities have been defined as the combination of more than one
disability in a person. It includes children who have two or more of the following
condition:
Varying degrees of mental retardation, Cerebral palsy, Autism, Blindness or
low vision, Deafness or hearing loss, Physical disability as polio, paralysis,
delayed motor development, Neurological impairment, Communication disorder.
The combination of disabilities may vary from child to child and the degree of
severity may also vary.

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The age of onset of the condition can be since birth till teen years. Children may
be both with one disabling condition but may also acquire the second or the third
disabling condition in the following years.
Also a combination of disabilities may interact over time and in turn lead to
developmental arrest and secondary complication which in turn may lead to
physical or mental disorders such as deformities or contractures and psychiatric
disorders.
Multiple Disabilities refers to a combination of two or more disabling conditions
that have a combined effect on the child’s communication, mobility and
performance of day-to-day tasks. As every child is different, similarly every child
with MD is different. However there are some things that these groups of children
have in common.

 It affects the all-round development of the child

 Communication with the world around is most severely affected
 Opportunities to interact with the environment becomes very limited
 Ability to move around in the environment is restricted
 Need regular help in simple day-to-day activities such as wearing a shirt,
opening a door, finding a chair to sit down and so on.
 A highly structured educational / rehabilitation programme helps in their
training.
Prevalence of Multiple Disabilities

According to the U.S. Department of Education, Multiple Disabilities represent

approximately 2.0 percent of all students having a classification in special
education.

Approximately 0.23% of school-age-children are listed as having multiple

disabilities under IDEA.

The percentage of students having severe multiple disabilities is very low.

Approximately 0.1 to 1 percent of the general school age population and
approximately 2 percent of the total population of school age students have severe
and multiple disabilities. It is not likely that more than one student with severe
multiple disabilities would be enrolled in a general classroom at any given time.
Chapter two:-
Types and causes of multiple disability
Types of multiple disability
Children with multiple disabilities will have a combination of various disabilities
that may include: speech, physical mobility, learning, mental retardation, visual,

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hearing, brain injury and possibly others. Along with multiple disabilities, they
can also exhibit sensory losses and behaviour and or social problems. There are
many educational implications for these students.

Mental Illness:

Studies indicate that approximately 2% of children and adolescents receive

intervention for mental illness and psychosocial problems (Cohen, Cohen, & Brook,
1993). The most common types of mental illness seen in children are

1. Anxiety Disorders: Children with anxiety disorders respond to certain things

or situations with fear and dread, as well as with physical signs of anxiety
(nervousness), such as a rapid heartbeat and sweating. Separation anxiety
disorder, overanxious disorder and posttraumatic stress disorder are the
common types of anxiety disorder seen in children.

2. Disruptive Behaviour disorder: Children with these disorders tend to defy

rules and often are disruptive in structured environments, such as school.
Common types seen in children are conduct disorder, oppositional defiant
disorder and attention deficit hyperactivity disorder (ADHD).
3. Eating Disorder: Eating disorders involve intense emotions and attitudes, as
well as unusual behaviors, associated with weight and or food. Anorexia
nervosa and bulimia nervosa are the two types of eating disorders seen in
children
4. Affective disorders: These disorders involve persistent feelings of sadness
and/or rapidly changing moods. Most common types seen in children is major
depressive disorder
5. Pervasive Developmental Disorders: These children have difficulties and
abnormalities in their abilities to form reciprocal social interaction and to
verbally and nonverbally communicate.

Associated sensory impairment

Sensory disabilities are the disabilities affecting an individual’s senses, such as

hearing, sight, touch, smell, and taste. The main causes of sensory disabilities
include accidents or injury, genetic factors, illnesses, or environmental factors.
Some of the sensory disabilities can be corrected through surgery, while others
are long-life disorders. 

Sensory disabilities are the disabilities affecting an individual’s senses, such as

hearing, sight, touch, smell, and taste. The main causes of sensory disabilities

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include accidents or injury, genetic factors, illnesses, or environmental factors.
Some of the sensory disabilities can be corrected through surgery, while others
are long-life disorders. 

The main types of sensory disabilities include blindness and low vision, hearing
loss and Deafness, deaf-blindness, and sensory processing disorder.

 Blindness and Low Vision. ...

 Hearing loss and Deafness. ...
 Deaf-Blindness. ...
 Sensory Processing Disorder.

1. Blindness and Low Vision 

Blindness is defined by permanent vision loss, which cannot be corrected using

glasses and affects daily functioning. People with blindness have permanent loss
of sight sensory, hence cannot recognize any object or person when presented
with them. Such individuals have difficulties navigating through daily life; hence,
they require supportive devices and objects such as a walking cane, a walking
dog, and braille for learning.  an individual is considered blind if their field of
vision is less than 20 degrees in diameter. It can also be determined by the
distance by which one can see when looking straight ahead. Some blind
individuals can read materials written in large prints and placed near them. 
Blindness and loss of vision are caused by various factors, including accidents,
glaucoma, diabetic retinopathy, eye defects, tumors, macular degeneration,
cataracts, retinitis pigmentosa, and detached retinas. Some eye conditions leading
to blindness or low vision are present at or near birth, while others develop later
in life. As people age, they develop sight problems, which is evident in individuals
who are 70 years and older individuals.  Some of the vision loss problems can be
reversed, while some become a life-long problem.

2. Hearing loss and Deafness 

Hearing loss is the loss of the hearing sensory. Hearing loss disability can range
from mild to severe. Individuals with mild or partial hearing loss tend to hear
but under some conditions, such as loud sounds or use of hearing devices. The
severity of the hearing loss is presented by total loss of hearing where an
individual has no hearing regardless of how loud the sound is, and the problem
cannot be reversed. Hearing loss is caused by a number of factors such as injury
or infection, difficulties during birth, exposure to loud noises, genetic causes,
childhood diseases such as measles, rubella, and mumps, damaged auditory

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nerves, and build-up of fluid due to perforated eardrum caused outer ear
blockage.  Most individuals tend to develop hearing loss as they age. Hearing loss
at old age is usually diagnosed as dementia, where the individuals have problems
hearing. People with hearing loss communicate can use sign language or speech.
However, the use of speech depends on the severity of the disability and age of
onset. American Sign Language (ASL) or British Sign Language (BSL) is the
common sign language used by people with hearing loss. In case the individual
with hearing loss does not understand English, they may require an interpreter
to help during communications. When there are no language barriers, people with
hearing loss can process information by reading the speaker’s lips. 

3. Deaf-Blindness 

Deaf-blindness is also known as dual sensory loss. This type of sensory disability
is characterized by loss of both hearing and seeing. People with dual sensory loss
have difficulties navigating through day-to-day life as they require assistance to
communicate, access, and mobilize information. Unlike hearing loss and vision
loss disabilities, dual sensory loss disability is not common as only a few
percentages of people have the disability.  Dual sensory loss is mainly caused by
genetic problems, accidents or injury, congenital disabilities, infections, and
diseases such as Usher Syndrome. Some individuals develop the problem as a
result of environmental factors. For example, when an individual with low vision
is exposed to high frequencies of noise, they can develop a hearing disability.
Also, when a person with a hearing disability is not provided with adequate
assistance, they may likely get involved in accidents, which can damage their
visual senses, hence developing low vision disability.  Dual sensory loss is
prevalent among older people, which makes it misdiagnosed as dementia.
Dementia is also characterized by both hearing and vision loss. Special care is
required to care for individuals with a dual sensory loss disability as they cannot
carry out daily life activities, including simple communication is hard for them. 

4. Sensory Processing Disorder 

Sensory processing disorder is a disability where an individual has difficulties

receiving and responding to information coming in via senses. Although not
recognized as a distinct medical condition, the disorder is a disability that has
raised scientists and other health stakeholders’ concerns.  Individuals with sensory
processing disorder tend to misinterpret the sensory information where they either
overreact to the information, under-respond to information, or not react at all.
Day to day sounds can be overwhelming or painful to such people, and touch

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may chafe the skin. Other signs and symptoms of sensory processing disorder
include:

o Difficulty engaging in conversation or play when it comes to children 

o Bump into things as the brain may process the wrong information
seen by the eyes
o Incoordination or seem clumsy
o Lack of ability to feel some of their body parts
o Complain of light being too bright 
o Soft touches feel hard 
o Normal sounds are too loud or irritating 
o Clothing feels itchy or scratchy   
o Sensory processing disorder is prevalent in children, but it can also
be found in adults.

Children with sensory processing disorder start out being fussy and later grow to
become anxious adults. Individuals with sensory processing disorder do not handle
change very well as they tend to have frequent meltdowns and throw tantrums.
Since most children are fussy, parents should only become concerned if the
symptoms affect their children’s daily lives. This sensory disability is commonly
seen in other developmental conditions in children, such as autism.

Some examples of multiple disabilities are:

 Deafblind (Visual Impairment + Hearing Impairment)

 Visual Impairment + Hearing Impairment + Mental Retardation.
 Visual Impairment + Mental Retardation.
 Cerebral Palsy + Mental Retardation/ Hearing/ Speech/ Visual problems.
Associated learning difficulty
ADHD, processing deficits (visual and auditory), working and short-term memory
deficits, and dyslexia. Even more than these disabilities, I've noticed a dramatic
increase of students with anxiety, depression, and mood disorders.
Associated with cerebral palsy
Cerebral palsy is caused by damage to or malformation of the areas of the brain
that control motor function during fatal development.
“Cerebral” means brain. “Palsy” means a disorder of movement.
CP refers to a group of non-progressive neuromuscular problems of varying
severity.

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CP is damage to the brain, primarily to the part of the brain that controls motor
functions. However other parts of the brain may also be affected. In such cases
the person affected has more than one disability.

The extent of the damage varies from person to person. Mild disability might
mean fine motor skills, like using scissors or writing, are difficult. Severe disability
can mean poor movement of all four limbs, the trunk and neck. The child may
even have difficulty in swallowing.

Children with CP often have coexisting conditions, which are health conditions
that a person has in addition to cerebral palsy. These other conditions may be
the result of having cerebral palsy or an unrelated, but common co-occurrence.
Associated with CP include difficulty feeding and swallowing, poor nutrition and
respiratory issues, among others.

 Oral Motor Impairment (Problems with Feeding, Swallowing and Drooling) ...
 Speech Impairment. ...
 Intellectual Disabilities. ...
 Learning Difficulties. ...
 Visual Impairment and Blindness.

Oral Motor Impairment (Problems with Feeding, Swallowing and Drooling)

Children with cerebral palsy often have impaired oral motor control, which means
they have difficulty controlling the muscles in their mouth and throat. This can
lead to problems with feeding (sucking, chewing, etc.) and dysphagia, or difficulty
swallowing. In some cases, those with dysphagia may experience pain when
swallowing or be unable to swallow at all.

Gastroesophageal reflux disease (GERD) is common among those with cerebral

palsy. GERD is a digestive disease in which stomach acid is regurgitated into the
oesophagus.

Children who have difficulty swallowing and/or GERD are at risk for aspiration,
which is when food, liquids, saliva or vomit are inhaled into the lungs. Frequent
aspiration can lead to respiratory problems, like aspiration pneumonia, and may
be life-threatening.

Those with impaired fine motor skills may also have trouble using their hands to
transport food or drink to their mouth. These children may have to rely on a

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caretaker or assistive equipment to feed them. Feeding and swallowing problems
can lead to poor nutrition, dehydration and low weight.

Speech Impairment

Many children with cerebral palsy have dysarthria, a motor speech disorder.
People with dysarthria have difficulty controlling the muscles used for speech,
such as the:

 Lips

 Tongue

 Vocal folds

 Diaphragm

Apraxia of speech is another common motor speech disorder that affects children
with cerebral palsy. Childhood apraxia of speech, as it’s referred to in children,
is when a child has difficulty saying words, sounds and syllables. The child knows
what they want to say, but their brain is unable to plan and coordinate the
muscle movements needed to do so.

Children with cerebral palsy may also struggle with speech sound disorders. These
include problems with articulation and phonological processes, or speech patterns
used by children to simplify adult speech.

It’s estimated that more than half of children with cerebral palsy have some sort
of speech impairment. Speech disorders can usually be improved through speech
therapy.

Intellectual Disabilities

Intellectual disability, formerly known as mental retardation, is characterized by

below average intellectual functioning. A child with an intellectual disability will
have limitations in both cognitive functioning—the thinking skills that lead to
knowledge—and adaptive behavior—the ability to adapt to the environment and
function in daily life. Intellectual disabilities are categorized as mild, moderate or
severe.

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An estimated two-thirds of children with cerebral palsy have an intellectual
disability. Of those children, half have a mild diagnosis and the other half have
a moderate to severe intellectual disability.

Learning Difficulties

Children with cerebral palsy sometimes have difficulty learning due to a number
of factors. Some have learning disabilities, which are neurological processing
problems that interfere with basic learning skills, like reading and writing.
Learning disabilities can also affect higher level skills, such as organization and
abstract reasoning.

Motor planning difficulties, known as motor dyspraxia, are also common with CP.
People with motor dyspraxia have a hard time understanding tasks and planning
how to perform them, which makes executing the tasks even harder. A child who
has motor planning difficulties knows what they want to do, but they have trouble
understanding how to do it. This can make learning new skills a huge effort that
requires a lot of concentration.

Perceptual difficulties, which include both auditory (hearing) and visual (seeing)
perception, may also affect a child with CP’s ability to learn. Children with
perceptual difficulties have a hard time making sense of the information they take
in through their eyes and/or ears, which can impact many areas of learning,
especially learning to read and working with numbers.

Those with impaired fine motor and gross motor coordination, as well as language
and communication problems, may also have trouble learning.

Visual Impairment and Blindness

Visual impairment refers to any kind of vision loss not including blindness, which
is when a person is completely visually impaired and can see no light at all.

Blindness: refers to a condition where a person suffers from any of the following
conditions, namely: Total absence of sight or Visual acuity not exceeding 6/60 or
20/200 (Snellen) in the better eye even with correction lenses or limitation of the
field of vision subtending an angle of 20 degree or worse. For deciding about
blindness, the visual acuity as well as field of vision has been considered.

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Low Vision: The Persons with Disabilities Act, 1995 also recognizes low vision as
a category of disability and defines it as follows:

“Person with low vision” means a person with impairment of visual functioning
even after treatment or standard refractive correction but who uses or is
potentially capable of using vision for the planning or execution of a task with
appropriate assistive device”.

The loss of vision caused by these conditions can range from a mild impairment
to complete blindness. The children with visual impairment and brain damage
may seem to use their vision differently at different times of the day. In addition
these children have trouble with perceptual responses, such as perceiving depth,
remembering visual information, searching for objects they see and identifying
important visual information. (Punani and Rawal)

One in ten children with cerebral palsy have severe visual impairment. Nearly
half of all children with spastic cerebral palsy have strabismus, better known as
cross-eye. As many as 75 to 90 percent of children with CP have a vision
impairment, including:

 Amblyopia (lazy eye)

 Optic atrophy (deterioration of the optic nerve due to damage)

 Nystagmus (repetitive, uncontrollable eye movements in a vertical or

horizontal direction)

 Visual field defects (loss of one side of the visual field)

 Refractive errors (near and farsightedness and astigmatism or blurred vision)

Hearing Loss

Hearing impairment, also known as hearing loss, refers to any degree of

impairment of the ability to hear sound. The degree of one’s hearing loss is
measured on a scale and can be slight, mild, moderate, severe or profound.
“Hearing impairment” means loss of sixty decibels or more in the better ear in
the conversational range of frequencies.

Deafness: A hearing loss greater than 90 dB. Individuals who are deaf have
vision as their primary input and cannot understand speech through the ear.
Deafness means a hearing impairment so severe that the child is impaired in

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processing linguistic information through hearing, which adversely affects
educational performance. (Turnbull, et. al., 2004).

Different types of Hearing loss

There are three main types of hearing loss, including:

 Conductive

 Sensorineural

 Mixed

Conductive hearing loss occurs when there is a problem in the outer or middle
ear, which results in hearing only faint sounds. With this type of hearing
impairment, sound is not properly carried (conducted) through the outer ear canal
to the middle ear (the eardrum and the ossicles or the tiny bones of the middle
ear) and inner ear. Conductive hearing loss can usually be corrected by medical
or surgical intervention.

The sound is not conducted efficiently to the inner ear. All sounds heard thus
become weak and or muffled. Usually such individuals speak softly irrespective
of the surrounding environmental noise. It can generally be offset by amplification
or medical intervention. Sometime surgery can restore hearing in a conductive
hearing loss.

Sensorineural hearing loss occurs when the inner ear (cochlea) or the auditory
nerve are damaged. This type of hearing impairment reduces the ability to hear
faint sounds and speech often sounds muffled. It usually cannot be corrected
medically or surgically and is the most common type of permanent hearing loss.

Sensorineural Hearing Loss: Permanent hearing loss that is a result of damage to

the cochlea or auditory nerve. The treatment for sensorineural hearing loss is
often the use of hearing aids or cochlear implants.

A person has mixed hearing loss if they have both conductive and sensorineural
hearing loss in an ear. In this case, there is damage in the outer or middle ear
and in the inner ear. Mixed Hearing Loss: A hearing loss resulting from a
combination of a conductive hearing loss and a sensorineural hearing loss.

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Central hearing loss is a rare form of hearing impairment. With central hearing
loss, the issue is in the central nervous system, not the ear. The person may be
able to hear perfectly, but they cannot interpret or understand the language.

Central hearing loss is due to damage, malformation or infections of the neural

pathways and the hearing centers in the brain. The child may hear but has
difficulty in understanding what he hears. Some of the children classified as
learning disabled or slow learners may have this type of hearing loss.

Seizure Disorder—Epilepsy

A seizure is a sudden surge of electrical activity in the brain that can cause
involuntary movements and/or behavior changes, as well as a change in
awareness. Epilepsy, also known as seizure disorders, is not a disease. It is a
spectrum condition characterized by unpredictable, recurrent seizures.

Thirty to 50 percent of children with CP have co-occurring epilepsy. It’s more

common among children who are unable to walk or have limited mobility.

Sensory Problems

A child’s ability to process information received from the senses may also be
affected depending on the severity and extent of their brain injury. This is called
sensory processing disorder. Children with sensory processing disorder can
experience increased or decreased sensory reactions, which can lead to problems
with development and behavior.

For example, a child who has an increased sensitivity to touch (known as

hypersensitivity) may not like the feeling of certain textiles and will act out or
scream if they come in contact with one. On the other hand, a child with a
decreased sensitivity to touch (known as hyposensitivity) may play aggressively
or bump into things without showing pain.

Sensory problems are common among children with other neurodevelopmental

disorders, like autism.

ADHD

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Attention-deficit hyperactivity disorder (ADHD) is a developmental disability
characterized by inattention, distractibility and impulsivity. Children with ADHD
may have a hard time staying focused and paying attention, which can make
learning a challenge. They may also have trouble controlling their behavior and
struggle with hyperactivity—a higher than normal activity level. Children with
ADHD often have issues in school and with social skills.

Approximately three to five percent of children have ADHD and it’s more common
in children with cerebral palsy or other brain disorders.

Associated with orthopaedic impairment

According to the federal Individuals with Disabilities Education Act (IDEA),

an orthopedic impairment is defined as a bone-, joint-, or muscle-related disability
that is so severe that it negatively affects a child’s educational performance.
Causes of orthopedic impairment range from genetic abnormalities (such as those
that cause a missing arm or leg) to disorders like cerebral palsy, as well as other
issues.

Students are typically evaluated by a healthcare professional to determine if they

have an orthopedic impairment that will interfere with their academic progress.
Medical professionals may also observe the child in the classroom to get a sense
of potential problems the student will face.

Orthopedic Impairment Disability Category

Children may be born with an orthopedic impairment or they may acquire it at

some point in life.1 Hereditary, congenital, and environmental factors can play a
role in causing orthopedic impairments that affect the normal functioning of the
bones, joints, or muscles.

For example, a child may be born with joint deformities, spinal bifida, or
muscular dystrophy. Acquired causes can include disease, injury, or surgery.
(Injury or surgery may lead to the loss of a limb, muscle contractures, or bone
loss that can make movement difficult.) The orthopedic impairment disability
category, per IDEA, includes all orthopedic impairments, regardless of cause.2

Causes of Orthopedic Impairment

 Amputation
 Birth trauma

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 Burns
 Cerebral palsy
 Disease (poliomyelitis, bone tuberculosis)
 Fractures
 Genetic abnormality (e.g., the absence of a member, clubfoot)
 Injury

Autism associated impairment

Autism spectrum disorder is an umbrella term that describes a group of brain

development disorders.

All children with ASD demonstrate deficits in 1) social interaction, 2) verbal and
nonverbal communication, and 3) repetitive behaviours or interests. In addition,
they will often have unusual responses to sensory experiences, such as certain
sounds or the way objects look. Each of these symptoms runs the gamut from
mild to severe. They will present differently in each individual child. For instance,
a child may have little trouble learning to read but exhibit extremely poor social
interaction. Each child will display communication, social and behavioural patterns
that are individual but fit into the overall diagnosis of ASD. Autism is
characterized by social impairments, verbal and nonverbal communication
difficulties and repetitive patterns of behavior.

 Gastrointestinal (GI) problems:- conditions are disorders of the digestive system,

an extensive and complex system that breaks down food in order to absorb
water and extract nutrients, minerals and vitamins for the body’s use, while
then removing unabsorbed waste
 Epilepsy:- a central nervous system (neurological) disorder in which brain activity
becomes abnormal, causing seizures or periods of unusual behavior, sensations
and sometimes loss of awareness. A disorder in which nerve cell activity in the
brain is disturbed, causing seizures.
 Feeding issues:- problems occur when babies refuse food, eat small amounts of
food, eat a limited variety of food, or have problems digesting food.
 Disrupted sleep:- Disturbed sleep can have many adverse health consequences,
including fatigue, decreased cognitive focus, and altered mood
 Attention-deficit/hyperactivity disorder (ADHD):- is a brain disorder that affects
how you pay attention, sit still, and control your behavior.
 Anxiety:- is your body's natural response to stress. It's a feeling of fear or
apprehension about what's to come.

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 Depression:- A mental health disorder characterised by persistently depressed
mood or loss of interest in activities,
 Obsessive compulsive disorder (OCD):- is a common, chronic, and long-lasting
disorder in which a person has uncontrollable, reoccurring thoughts ( obsessions)
and/or behaviors (compulsions) that he or she feels the urge to repeat over and
over.
Approximately one to two percent of American children have an autism spectrum
disorder. An estimated seven percent of children with cerebral palsy have co-
occurring autism. While it seems that autism is more common among children
with cerebral palsy, the link between the two disorders is not yet known.

Cause of multiple disabilities

The cause of multiple disabilities are as varied as the diagnosis itself. The
condition may be the result of a traumatic brain injury (TBI), or a genetic disorder,
or a chromosomal abnormality, or premature birth, developmental delay, etc.

Most causes of multiple disabilities are the result something that happened while
the child was a developing fetus (malnutrition, the mother's alcohol consumption
or the mother's exposure to unsafe environmental conditions or illness, genetic
conditions, or chromosomal abnormalities). Multiple disabilities can also be caused
by infections (meningitis, rubella, herpes, etc.) or exposure to environmental
toxins.

In children, early severe impairment of the brain is generally the main cause of
multiple disabilities, affecting several areas of the neurological activity
(intelligence, motricity, sensory sensitivity). Sometimes, the cause of
a student's disability is simply unknown. Studies say that approximately three
quarters of all children who have severe intellectual impairment, there is a
biological cause which is typically a prenatal bio-medical factor. In other cases,
there are specific genetic factors that cause particular types of impairments
because of gene or chromosome abnormalities.

There are several factors that cause severe and multiple disabilities and can be
divided as follows:

Prenatal causes: It includes chromosomal abnormalities, viral infections, drug

and alcohol use during pregnancy, mother's malnutrition, and physical trauma
to the mother.
 Chromosomal abnormalities.
 Premature birth.

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 Difficulties after birth.
 Poor development of the brain or spinal cord.
 Infections.
 Genetic disorders.
 Injuries from accidents
 Developmental disorders of the brain,
 Metabolic disorders; and
 Negative prenatal environmental influences
Perinatal causes: It includes lack of oxygen supply to the baby’s brain, physical
injury to the baby’s brain at birth and contracted infections during birth.
 Preconceptional factors.
 Infections.
 Exposure to toxins.
 Maternal chronic illness.
 Maternal nutritional deficiencies.
Postnatal causes: It includes childhood infections such as meningitis and
encephalitis, traumatic brain injury from an accident or abuse, lead poisoning,
reactions to medication and exposure to toxins or other environmental conditions.
The most common causes were bacterial meningitis (31 percent), child battering (15
percent), motor-vehicle- related injuries (11 percent), and otitis media (11 percent).
As with other disabilities, the severity and complexity of the
disability depends on the genetic abnormality, the amount of damage
to the brain and the environment in which the child is raised.
Chapter three:-

Major characteristics of multiple disability

People with severe or multiple disabilities may exhibit a wide range of
characteristics, depending on the combination and severity of disabilities, and the
person's age. There are, however, some traits they may share. People with severe
or multiple disabilities may exhibit a wide range of characteristics, depending on
the combination and severity of disabilities, and the person’s age. Multiple
Disabilities Characteristics People with multiple disabilities have a combination of
various disabilities that may include: speech physical mobility learning
mental retardation visual hearing brain injury; and possibly others. They
may also have sensory losses and behavior and /or social problems. Multiple
Disabilities Perhaps the most significant characteristic of many people with
multiple disabilities is deficits in the area of communication, making it difficult

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for them to communicate their wants, needs, and pains to those around them.
This limitation can be devastating to the emotional and intellectual development
of the child, but can be addressed through the use of assistive technology and
augmentative communication systems. however, some traits they may share,
including:
 Limited speech or communication;

 Difficulty in basic physical mobility;

 Tendency to forget skills through disuse;
 Trouble generalizing skills from one situation to another; and/or
 A need for support in major life activities (e.g., domestic, leisure, community
use, vocational)
Students with multiple disabilities generally have specific characteristics related to
their Intellectual Functioning, Adaptive Skills, Motor Development, Sensory
Functioning, and Communications Skills. Most students with multiple disabilities
have many impairments in intellectual functioning. Students vary widely in their
academic abilities. Adaptive skills include conceptual, social, and practical
competencies for functioning in typical community settings in an age-
consistent way. Students with motor development impairments produce abnormal
muscle tone and may have difficulty sitting and moving. Hearing and vision
impairments are very common among children with multiple disabilities such as
Deaf-blindness.
These physical and medical problems result in the presence of two or more of
the following characteristics: restriction of movement skeletal deformities
sensory disorders seizure disorders lung and breathing control; or other
medical problems related to these characteristics, such as skin breakdown or
bladder infections.

Children with multiple disabilities show some of the following characteristics:

3.1. Vision Problems: As children grow, some of them appear to always squeeze
their eyes together to look at something closely, or keep looking at their moving
fingers / paper, bump into things while walking, complain of too much light all
the time. Their eyes may also look different from ‘normal’ eyes.

3.2. Hearing Problems: A child with a hearing problem may respond to only
particular sounds. They may take a long time and repeated training to develop
speech. And mostly they may only repeat what they hear. They may also learn
to adapt to their routine environment by ‘guessing’ the conversations going
around, but may actually face a lot of difficulty in a new place with unknown

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people. Sometimes deaf children also show difficulty in balancing their body or
walking in a straight line.

3.3. Learning Problems: Due to the combined loss of two or more disabilities, the
rate and speed of learning of the children is very slow. Learning often becomes
repetitive and meaningless, unless special care is taken to make the child feel
safe about exploring the world around him. Multi handicapped children also have
very limited ideas to play with toys or things around them.
3.4. Communication: Communication is probably the one area that is most
significantly affected in children with multiple disabilities. The children are unable
to see or hear or follow the different ways in which their brother and sister play
with each other, elders are greeted, standing in a line to get a ticket or passing
a bottle of water around a dining table.

Communication for Children with Multiple Disabilities

Communication, being able to express oneself and participating in the give-and-

take of conversation, is an important area of development for children with visual
impairments and multiple disabilities. All children are communicators from the
moment they make a face, smile, utter their first cry, or gurgle with pleasure.
It’s never too early to begin exploring ways in which you can support your child’s
development of the ability to communicate. It difficulty on:-

 Delayed Communication Development

 Alternative Methods of Communication
 Symbol Systems
 Using a Schedule with Your Child
 Routines
 Sign Language
 Limited speech or communication;

3.5. Posture and Mobility (physical characterstics): Our sight, hearing and body
movements help us to move around, without bumping into things, remember the
way to reach places or even to use our own hands to hold and look at things.
Presence of Cerebral Palsy, locomotor disabilities and balance difficulties makes
it hard for the child to manage his own body movements sometimes and so it
becomes very difficult to use his body to move from one place to another.
A variety of medical problems may accompany severe disabilities. Examples
include seizures, sensory loss, hydrocephalus, and scoliosis. Many disabilities
impact activities of daily living. Possible disabilities that can be comorbid include

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visual impairment, hearing impairment, orthopedic impairment, autism, and
speech/language impairment.
Each student's individual combination of disabilities will affect his orientation and
mobility
Students with severe disabilities, including blindness, were taught specific O&M
skills within the context of functional travel routes, despite their failure to pass
the prerequisite skills on the Peabody Mobility Scale (Gee, et al., 1987). These
skills were, in many cases, generalized to other unfamiliar environments. Also,
the students appeared to have incidentally learned landmarks, clues, and memory
tasks specific to the routes. Thus, rather than requiring certain concepts and skills
prior to being taught O&M, the students appear to have acquired some of these
concepts and skills through learning to become more independently mobile.
3.6. Behavioral characteristics: Most children with multiple disabilities show
strange behaviours that are called ‘self-stimulating’ behaviours. Some of these are
moving one’s body repeatedly, shaking head side to side, moving fingers in front
of eyes, hitting or slapping the ears, swinging in one place and so on. The
children mostly do this due to lack of anything else to do. Sometimes it is
important for them to continue doing it from time to time as it helps them get
some information about the world around them in their own special way.
Sometimes these children also show disturbed sleep patterns.

 May display an immature behavior inconsistent with chronological age

 May exhibit an impulsive behavior and low frustration level
 May have difficulty forming interpersonal relationships
 May have limited self-care skills and independent community living skills.

3.7. Medical Conditions: Most multi-handicapped children also suffer from other
medical conditions such as epilepsy, frequent eye and ear infections, respiratory
disorders, muscular degeneration frequent surgeries and so on. Such medical
conditions lead to frequent hospitalizations and the child again misses out on a
lot of exposure and learning from the environment.
3.8 Social/emotional characteristics
Students with multiple disabilities are often less accepted and may be rejected by
their peers. Social rejection can result in feelings of loneliness, which, in turn,
may lead to psychological difficulties such as anxiety and depression. Inability to
set realistic priorities and goals. Inappropriate conclusions due to deficient
reasoning ability. Illogical reasons for actions. Inability to develop meaningful
relationships with others.
3.9 Psychological/cognitive characteristics

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Difficulty in basic physical mobility; Tendency to forget skills through disuse;
Trouble generalizing skills from one situation to another; and/or.

 May Feel ostracized

 Tendency to withdraw from society
 Students with multiple disabilities may become fearful, angry, and upset in
the face of forced or unexpected changes.
 May execute self-injurious behavior
Independent Living Skills for Children with Multiple Disabilities

Learning independent living skills can be a challenge for many children who have
multiple disabilities including a visual impairment. Your child’s educational team
will have important information and suggestions for how you can work together
on specific goals, but this area should help you support your child in learning

 how to eat independently;

 how to handle toilet training;
 self-care skills, such as bathing and dressing;
 orientation and mobility skills and the use of alternative mobility devices,
including the use of strollers and wheelchairs; and
 Transportation options for non-drivers.

In general children with multiple disability has

 Difficulty in basic physical mobility

 May experience fine-motor deficits that can cause penmanship problems
 May have slow clerical speed.
 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 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
 May face problems in socializing with peers
Chapter four: -

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Identification and assessment of multiple disability

Procedures and Assessment Measures used to diagnose Multiple Disabilities

A student with multiple disabilities shall be evaluated by the procedures for each
disability; and shall meet the standards for two or more disabilities. If a student
is suspected of having Multiple Disabilities, the following evaluation should be
considered:

An observation by a team member other than the student’s general education

teacher of the student’s academic performance in a general classroom setting; or
in the case of a student less than school age or out of school,

 an observation by a team member conducted in an age-appropriate

environment
 A developmental history, if needed
 An assessment of intellectual ability

Other assessments of the characteristics of speech and language impairments if

the student exhibits impairments in any one or more of the following areas:
cognition, fine motor, perceptual motor, communication, social or emotional, and
perception or memory. These assessments shall be completed by specialists
knowledgeable in the specific characteristics being assessed: A review of
cumulative records, previous individualized education programs or individualized
family service plans and teacher collected work samples If deemed necessary,
a medical statement or health assessment statement indicating whether there are
any physical factors that may be affecting the student’s educational performance;
Assessments to determine the impact of the suspected disability:

On the student’s educational performance when the student is at the age of

eligibility for kindergarten through age 21.

Eligibility for a Diagnosis of Multiple Disabilities

In order to identify and be determined as eligible for special education services

as a student with Multiple Disabilities, the IEP Committee shall document that
the following standards have been met.

1. The IEP Committee must determine that the student shall have the following
two characteristics:

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A. meet the standards for two or more identified disabilities and

B. be unable to benefit from services and supports designed for only one of the
disabilities, as determined to be primary or secondary disabilities by the IEP
Committee.

2. The IEP Committee must determine that:

A. the student has a combination of two or more disabilities;

B. the nature of the combination of disabilities require significant developmental

and educational programming that cannot be accommodated with special
education services that primarily serve one area of the disability.

3. The IEP Committee must determine that all exclusionary factors have been
ruled out. An individual will not be considered eligible for services under Multiple
Disabilities if one or more of the following exist:

1. The adverse effects are from a lack of instruction in reading or math that
is not related to the traumatic brain injury.

2. The adverse effects are from environmental, cultural, or economic

disadvantage as a result of such factors as: Second language, limited English
proficiency, other cultural values and experiences and experiential differences.

3. The adverse effects are judged to result from absenteeism (unrelated to

health) or change in residence or schools.

4. The disability is more accurately described by another category of eligibility.

Multiple Disabilities Primary Measures Used to Diagnose Individual intelligence

tests & Tests of adaptive behaviour. Early assessment of movement limitations
muscle tone and flexibility \seizure activity breathing control sucking and
swallowing vision and hearing;

Multiple Disabilities genetic makeup are also, and prenatal assessment of genetic
material or physical identification of deformities via sonograms may be conducted.

Multiple Disabilities Accurate psychological testing of these individuals is

challenging due to their frequent limitations in controlled movement, vision,
hearing, communication, or cooperative behavior. Thus, interviews with family

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members and educators regarding the person's adaptive behavior skills (i.e.,
communication, self-care, home living, social skills, community use, self-direction,
health and safely, functional academics, leisure, and work) may be more
informative and reliable than a norm-based IQ or achievement score.

Assessment for students with severe or multiple disabilities should be done using
skills or abilities that are functional. In other words, assess life skills that will
help them in everyday tasks such as dressing, eating, toileting, communicating,
and ambulating.

Guidelines for Assessment When assessing students with severe or multiple

disabilities, keep the following guidelines in mind.

Assessment should:-

Ongoing. In order for assessment to be accurate and thorough, it must be

conducted with at least one teacher or para educator for each student and, if
possible, it must be conducted daily. This is the best way to document progress.
Chronologically age appropriate. What is assessed must be age appropriate. For
example, if a student is 5 years old, it is appropriate to assess balance; if a
student is 18 years old, then balance should be assessed within an age-appropriate
activity such as kicking a soccer ball, a 3-step approach in bowling, or while
walking around a track.

Functionally appropriate. In addition to being age appropriate, assessment must

be targeted at the student’s functional level. For example, if a student with severe
disabilities is working on volleyball with his 14-year-old peers, the functional
approach may be to put his chair right up to the net and lower the net and
determine how independent he is when dropping the deflated beach ball over the
net to a peer. The word functional means that the individual can use that skill
in everyday tasks (Dunn & Leitschuh, 2010; Kowalski & Lieberman, 2011). In this
case, if the student can hold a ball, he may also be able to hold a bottle of milk
at lunchtime or hold his gym bag on his way to the gym.

Utilize community-based activities. When working on specific community based

skills, try to get the student out into the community setting, where the skills If
a student cannot stand up on his own, the instructor can plan for the student to

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execute the skill while sitting in a wheelchair, lying over a bolster, or lying on
his back on a wedge mat or flat mat.

Document levels of independence. A true assessment also includes how much

support or assistance the student needs for each skill or activity. For example, if
a student floats in the shallow end of a pool with a life jacket for 30 seconds,
document whether or not you supported her fully at both the shoulders and the
waist, partially supported her, or supported her not at all. Improvements in
independence will become more apparent when they have been documented in
detail (Kowalski et al., in press).

Include choice-making. Students with severe or multiple disabilities will have

varying backgrounds, experiences, interests, likes, and dislikes. Offer a variety of
choices with regard to textures, colors, sounds, smells, and sizes, allowing students
to pick equipment based upon their personal preferences (Canales & Lytle, 2011;
Dunn & Leitschuh, 2010).

Work with the multidisciplinary team. The multidisciplinary team or IEP team
consists of all personnel and family members who are involved with the student’s
education. These members include parents/guardians, classroom teachers, physical
education teachers, psychologists, physical therapists, occupational therapists,
speech therapists, neurologists, physicians, nurses, para educators, counselors, and
any other person involved in the educational program.

What Should We Assess?

Assessment for students with severe or multiple disabilities should be done using
skills or abilities that are functional. In other words, assess life skills that will
help them in everyday tasks such as dressing, eating, toileting, communicating,
and ambulating. Assessment Tools A few assessments are available for
individuals with severe disabilities.
The identification of a child with multiple disabilities starts with a medical
diagnosis. Medical treatment may include medication, surgery, or physical
therapy. An educational evaluation of a student with multiple disabilities is
similar to that of a student with a traumatic brain injury.

Students with multiple disabilities may need assistance in participating in daily

activities in various environments. In order to identify these goals, ecological

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inventories and person-centered plans may be conducted.
Educational evaluations include:

 Social History
 Individual Intelligence
 Individual Achievement
 Adaptive Behavior
 Communicative Abilities (both receptive and expressive)
 Learning processes in the following areas:

a. Visual perception
b. Auditory perception
c. Perceptual-motor development

Chapter five:-

Intervention approaches of multiple disability

Early intervention programs, preschool and educational programs with the

appropriate support services are important to students with sensory and additional

disabilities (NEC Foundation of America). Children with multiple disabilities often

need intensive early intervention. Educators and parents can help such children

develop communication methods, tactile skills, and the concepts that are the

framework for further learning.

5.1 Assistive Devices:

Adaptive devices for daily living include a variety of adaptations of ordinary items

found in the home, office, or school—such as a device to aid bathing or hand

washing or walking—that make performing the tasks required for self-care and

employment easier for the person who has a physical disability. Assistive devices

are any devices that can help persons with disabilities in doing activities of daily

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living, they are items that can directly enable people with disabilities to participate

in the activities of daily life. People may take help of assistive devices on their

own or with help of other people.

5.3 Orthotics:

An orthosis is a device that enhances the partial function of a part of a person’s

body (a brace or a device that allows a person to do something). This includes

the provision of splints and appliances that improve the function and appearance

of a disabled person. An orthosis can be said to be an appliance that is added to

the patient, to enable better use of the body part to which it is fitted. The main

function and aim for which orthoses are prescribed are to prevent and correct

any deformity arising out of the disability. It also provides relief from pain as it

limits motion and weight bearing. It also leads to immobilization and protection

of weak, painful or healing muscle-skeletal segments. It also leads to improvement

in the function of the specific limb.

5.4 Prosthetics:

Prosthetics refer to any artificial substitute for lost part of the body. A prosthesis

is an artificial replacement for a missing body part (e.g., an artificial hand or

leg). They can be external or internal. External prosthesis is used for upper and

lower limbs and can also be further classified into endoskeletal limbs or convention

limbs to temporary pylon prosthesis. Rehabilitation by the use of prosthetics aims

at achieving maximum function out of the remaining stump of the lost or missing

limb. The point to keep in mind when choosing the appropriate prosthetic is to

take care of the level of amputation, type of socket, material of socket, type of

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joint to be used such as hip, knee, or elbow mechanism, ankle / foot or hand /

terminal appliances.

5.5 Cosmetics:

It is the preservation, restoring or bestowing of bodily beauty. In terms of

prosthetics it implies creation of the like limbs mimicking the real limb.

Walking aids are used to increases the mobility of a patient. This is done when

some of the weight of the body can be supported by the upper limbs. Examples

of walking aids include parallel bars, walking frames crutches and sticks etc.

Selection of the walking aid depends upon the stability of the patient, the strength

of the upper and the lower limbs and the degree of coordination of movement of

the upper and lower limbs and the degree of relief from weigh bearing equipment

that is required. Types of walking aids include crutches, frames, sticks and parallel

bars.

Rehabilitation using walking aids requires time. The patient needs to regain

strength after a prolonged illness. This can be gained by taking adequate diet and

well planned progressive course of exercise. The patient also needs to become

free of the fear of falling.

At the present time, students with severe and multiple disabilities are taught in

a variety of settings, from totally segregated to fully inclusive. The doctrine of

the least restrictive environment (LRE), as applied to students with severe and

multiple disabilities has usually resulted in placement in a special education

classroom within a general school. Now an increasing number of leaders in the

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field of severe and multiple disabilities are advocating for full inclusion for these

students. Successful collaboration is essential if students are to be fully included

in schools and community settings. Because the students' needs can be extensive,

families, educators, physical and occupational therapists, speech and language

pathologists and medical personnel need to work closely with each other to ensure

that students receive an appropriate and inclusive education. In addition, students

without disabilities and community members need to understand their roles in

the collaborative planning process (Turnbull, Turnbull, Shank & Smith).

In order to effectively address the considerable needs of individuals with sensory

and additional disabilities, educational programs need to incorporate a variety of

components, including language and/or communication development, social skill

development, functional skill development (i.e., self-help skills) and vocational

skill development.

Classroom arrangements must take into consideration students' needs for

medications, special diets, or special equipment. Adaptive aids and equipment

enable students to increase their range of functioning. The use of computers,

augmentative/alternative computer communication systems, communication

boards, head sticks and adaptive switches are some of the technological advances

which enable students with sensory and additional disabilities to participate more

fully in integrated settings.

Integration/inclusion with peers without disabilities is important for the

development of social skills and friendships for students with sensory and

additional disabilities.

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These conditions should be considered when establishing school services. A multi-

disciplinary team consisting of the student's parent/guardians, educational

specialists and medical therapeutic specialists in the areas in which the individual

demonstrates problems should work together to plan and coordinate necessary

services (National Dissemination Center for Students with Disabilities).

Summary:

In this electronic text, overview about multiple disabilities is briefly described

covering the whole panorama from the definition, causes, types and the

intervention. In the subsequent modules detailed information’s about other aspects

of disability will be explained one by one in order to develop better sight to the

learner on every aspect of disability.

This electronic text is supported with electronic tutorial that consists of multimedia

through use of innovative techniques and this intends to give the learner a quick

and easy understanding about the lesson delivered through this module. Besides

glossary of terms, web resources and bibliography relating to this e-content is

provided. Self-simulation for assessment and evaluation is also provided to support

the effective utility of this content by the learner. This helps the learner to quickly

evaluate the understanding developed by the learner regarding the contents

discussed in the module. The learner is encouraged to expand on this for achieving

comprehensive knowledge base on this content.

Strategies and Modifications for Multiple Disabilities

 Early intervention is necessary as soon as the child begins school.

 Involvement of the appropriate professionals, i.e. occupational therapists,
speech/language therapists, physiotherapists, etc.

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 A team approach at the school level involving external agency/community
liaison who meet on a regular basis is essential
 The physical arrangement of the classroom will need to best accommodate
this child. Consideration of special equipment and assistive technology is
essential.
 Integration among their peers is important to assist these students with
social development. It's important to integrate multiple disabled children as
much as is possible. Research does indicate that when these students attend
their community school and participate in the same activities as their peers,
social skills develop and are enhanced. (Sometimes these students are placed
full-time in a regular classroom with support, however in the majority of
cases these students are placed in a developmental skills type of classroom
with some integration.
 Ensuring that all students demonstrate respect for the multiply disabled
student becomes a teacher's responsibility and needs to be taken seriously
with ongoing activities that develop respect from the other students in the
class.
 An Individual Education Plan will need to be carefully planned out and
adjusted on a regular basis and will need to be aligned to the needs of the
individual child.
 Remember, these children are often completely dependent on others for
most/all of their daily needs.
 Assistive technologies may aid this child and the support team will need
to decide which assistive technologies will be most appropriate.
 A safety plan will need to be developed and is often included in the IEP.
 Care needs to be given in your expectations of this student to ensure the
child doesn't become frustrated.

How to Best Support Students with Multiple Disabilities

Students with multiple disabilities often need support in every aspect of their life,
both in the classroom and beyond. Often, there are medical implications of these
disabilities as well as educational implications. First and foremost, it is vital to
understand the nature of the child's disabilities (to the fullest extent possible),
and tailor your interventions accordingly. A student with hydrocephalus and
autism, for instance, will need a very different set of treatments than a student
with cerebral palsy and deafness.

Early intervention is crucial, and early intervention services are available in most
communities. Many schools offer pre-kindergarten child development resources to
help students with disabilities. These service centers help children with mobility,

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adaptive learning methods, and more. The earlier the intervention, the better the
outcome.

Usually, a team of professionals is necessary to adequately address the student's

needs. This team will include speech pathologists, physical and occupational
therapists, music and art therapists, and more. Communicate regularly with this
team to assess the student's progress and strategize effective teaching methods.

Communication between the school, home, and any external agencies which work
with the child, is crucial.

Inclusion in general education classrooms is very important for social and cognitive
development. Many students are able to receive instruction in a general classroom
with some assistance, but the majority of students need to be placed in a special
education classroom with limited integration into general education classrooms.
Integration into the general education classrooms is helpful not just for the
disabled student, but for the other students as well. Integration of disabled
students into general classrooms provides a valuable lesson in diversity and
respect. As a teacher, it is your responsibility to ensure that all students treat the
disabled child with respect.

Students with multiple disabilities--especially those with medical issues affecting

mobility--often need special equipment in the classroom. This equipment may
include standers, wheelchairs, gait trainers, and changing tables.

Special education teachers, working together with the team of professionals

mentioned above, need to prepare an Individual Education Plan (IEP) for students
with multiple disabilities. IEPs take into account the abilities of the student, and
map out a series of goals to work toward throughout the school year. These goals
may fall into the categories of academic performance or adaptive life skills, such
as attending, basic yes/no communication, or hygiene. The IEP is a guide for best
supporting the student's individual needs, and must be carefully designed as such.

Depending on the severity of the disabilities, these students may need help in
literally every aspect of their life. Special education teachers may need to help
the student eat, move, or use the toilet.

Students with multiple disabilities benefit greatly from adaptive technologies, such
as computerized talkers or tablets. Choice boards, which allow the student to
choose from a small number of pictures on a board, are another effective means
of communication.

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Safety is a concern for these students, especially those students with medical
issues or mobility problems. These children are apt to fall and hurt themselves,
have grand mal seizures without warning, or need some other form of urgent
attention. These issues should be carefully outlined in the student's IEP, and the
teacher should be constantly on the lookout for any warning signs, ready to call
for assistance if necessary.

When giving academic instruction, assess your student's abilities realistically, and
adjust your expectations accordingly. These students can become very frustrated
very easily, which only causes more problems. Challenge your student to learn,
and keep them motivated, but don't push them so hard as to cause them agony.

Multiple Disabilities IDEA added requirements that are especially valuable for
these individuals, including:
(1) early intervention starting at birth or whenever a disability is suspected;
(2) related services such as physical, occupation, and speech and language therapy,
including augmentative and alternative communication (AAC) methods. Multiple
Disabilities
(3) the requirement for a plan and services to facilitate transition to work and
adulthood; and
(4) a value placed on inclusion in general education with nondisabled peers. Most
states provide services to these students until age twenty-two or beyond, focusing
upon functional skill development.
Supporting the Development of Eating Skills for Children with Multiple Disabilities

Learning to eat and drink can be a challenge for many children who have multiple
disabilities including a visual impairment. The way your child responds to food
can be affected by factors such as his medical conditions, physical abilities,
or resistance to trying new foods because of the texture or taste.

Members of your child’s educational team will often have important information
and suggestions for how you can work together on specific goals that will help
your child to develop his skills in this area. It is important to consult with your
child’s medical team for specific information about what beverages and foods
your child should or should not try. In addition, occupational therapists and
speech and language therapists often have training in helping children with
multiple disabilities learn to eat and drink.

A child needs to learn many skills in order to eat and drink independently.
Expecting your child to learn all of them at once is probably not realistic. Instead,
target one or two specific skills for him to learn to perform more independently,

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such as bringing the spoon to his mouth or sipping a drink from a glass or a
“sippy” cup with a lid and a spout.

And rather than trying to teach the skill all at once, think of having him partially
participate in many of the aspects of mealtime. Partial participation means that
you do some steps in the process and he does some steps. For example, you
might put the food on his spoon, but then he has the responsibility of bringing
the spoon to his mouth. Over time, you can gradually increase his level of
participation in his mealtime skills.

Consider these additional suggestions to help your child develop eating skills and
independence at mealtime:

 Allow your child to self-feed with his fingers first, before introducing
utensils.
 Start with food or drinks that your child really likes to increase his
motivation.
 Make sure your child feels secure physically. Work with his occupational
therapist or physical therapist to explore the best seating options for him.
They will have ideas about how to position or stabilize the child in his
chair so that he is not worried about falling or having to concentrate on
sitting skills.
 Work from behind your child when assisting him or showing him how to
do something so that your hands and his are moving together in the same
direction.
 Use the hand-under-hand or hand-over-hand method when guiding your
child during mealtime.
 Place a mirror in front of you and your child so that you can more easily
see his mouth.
 Include your child in family mealtimes, even if he is not eating a full meal
at that time, to let him be part of the social interaction that occurs.

Educational team members may be able to recommend equipment that can help
your child develop his eating and drinking skills with less assistance. Such
equipment might include

 utensils with built-up handles that are easier for your child to grip;
 plates or bowls with raised sides so that food is less likely to spill;
 cups or bottles that have a special opening that is easier to drink through;
and
 nonslip placemats or trays on which to place plates, cups, and utensils so
that they are less likely to move.

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Your child’s teacher of students with visual impairments may also have
suggestions for you and other team members to help your child gain skills in
learning to eat without assistance. Use of color, contrast, touch cues, texture,
positioning, and sound may increase your child’s independence at mealtime.

Toilet Training When Your Child Has Multiple Disabilities

Toileting, or elimination, is something everyone does throughout the day, so

helping your child achieve more independence in this area is likely to be a high
priority for you and your family. If your child is consistently dry for 1-1/2 to 2
hours at a time and can wake up from a nap without being soiled, she may be
ready to learn to use the toilet.

Although your child’s needs and abilities may vary from that of other children,
what is important to consider is how to maximize her participation, privacy, and
comfort when she uses the bathroom. The more she can do for herself, the less
dependent she will be on you and others for assistance. Here are some suggestions
for helping your child to be as independent as possible in using the toilet:

 The use of a bathroom routine will give your child a framework for
understanding what is going to happen and what is expected of her. You
might begin the routine by giving her a symbol that can become associated
with using the bathroom, such as a card with a piece of soap on it that
smells like the soap she uses to wash her hands or a washcloth that feels
like the towel she uses to dry her hands.
 Use the hand-under-hand or hand-over-hand method when guiding your
child to pull clothes up and down, tear off toilet paper, or wipe herself.
Gradually over time, you will be able to decrease the amount of assistance
you give her as she learns how to perform these tasks herself. Note that
these techniques need to be used carefully and with sensitivity toward your
child’s preferences, sensitivities, and abilities. Some children may be upset
when they feel their hands are being controlled, especially if they have
conditions such as autism spectrum disorders that increase their sensitivity
to sensory contact or stimulation. If this is the case, the hand-under-hand
method may be a better choice than hand-over-hand.
 Your child will be more successful in participating in using the toilet if she
feels secure physically. Work with her occupational therapist or physical
therapist to explore the best seating options for her, how to transfer her
from her wheelchair to the toilet, or where in the bathroom handrails
might be useful.

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 Select clothing for your child that is easy to take off and put on. Pants
with an elastic waistband will be easier for her to manipulate than pants
with snaps and a zipper, for instance.
 Even if your child does not appear to recognize whether the bathroom door
is open or closed, it is important to model privacy for her. Close the door
to the bathroom when assisting her with using the toilet.

Some children with visual impairments and multiple disabilities are not able to
consistently communicate to you and others that they need to use the toilet. Using
a schedule to indicate when your child is to use the toilet can help minimize
accidents. With other members of your child’s educational team, keep track of
when your child urinates and has a bowel movement. For example, if she usually
has a bowel movement approximately 30 minutes after a meal, then at 20 minutes
after the meal take her to the toilet and have her sit there. This routine will
increase the probability that she will have the bowel movement in the toilet.

Despite the best efforts, however, accidents will inevitably happen. When they
do, involve your child as much as possible in cleaning up, including the unpleasant
parts such as removing wet clothing or wiping up the floor. This way she is more
likely to make the association that when she uses the toilet, she can avoid
participating in these unpleasant tasks.

Many children learn to use the toilet more quickly and become more independent
if they are given rewards for doing so. Before embarking on such a program, it
is important to determine whether your child is able to make the connection
between using the toilet and the reward. If you do decide to use rewards for
potty training, select rewards that are only given at this time, such as a favorite
toy, special snack, or music CD that your child is given only after she successfully
uses the toilet.

Transportation Options for Nondrivers with Multiple Disabilities

If your child is a nondriver, he might choose to use a variety of transportation

options throughout his adolescence and adulthood. The options he will use with
support and those he’ll use independently, if any, will depend on his abilities
and needs. Beginning in preschool or elementary school, you can expose him to
the options he may one day use to go to school, recreational activities, shopping,
appointments, work, or an adult day program. He may be able to use one or
more options for specific purposes, to travel from your home to his job site, or
to go from his group home to his doctor’s office. Learning fixed routes for travel
will increase his independence.

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When your child is young, consider traveling as a family using public
transportation in your community. Even if you drive a car, you can plan a
monthly outing where you and your child take the public bus or a taxi. Involve
him in these outings by having specific things for him to do, such as paying the
bus fare and handing the driver a card telling what stop he needs to be let off
at or figuring out the amount of money to give the taxi driver for the fare. Over
time you can increase the amount of responsibility your child has when the two
of you travel.

Most communities have a paratransit service that provides transportation for

people with disabilities or elderly individuals for a reduced price. Speak with the
O&M specialist to learn about paratransit in your community, or call the local
bus or train company to ask if there is a paratransit alternative. When your child
is in high school, consider registering him for your local paratransit service. This
typically will involve obtaining an application, getting a signature from your
child’s doctor to verify his disability, and possibly having your child interviewed
or evaluated to determine his eligibility for the service. Most paratransit companies
allow riders to have one person with them when they travel, so you can go with
your child on the paratransit van or car. As with other forms of transportation,
consider having a monthly outing using this method of travel so that your child
becomes familiar with it. As the service provides door-to-door transportation and
is designed for people with disabilities, it may be a very viable option for your
child to use as a teenager and into adulthood.

Chapter six
Education of students with multiple disabilities in regular and inclusive classroom
These students may exhibit weakness in auditory processing and have speech
limitations. Physical mobility will often be an area of need. These students may
have difficulty attaining and remembering skills and/or transferring these skills
from one situation to another. Support is usually needed beyond the confines of
the classroom. There are often medical implications with some of the more severe
multiple disabilities which could include students with cerebral palsy, severe
autism, and brain injuries. There are many educational implications for these
students.

Suggestions on working with students who have multiple disabilities in a regular

education classroom:

Writing
• Using different materials (large grip pencils)

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• Have a peer write for the student
• Have a student present material in another
form (orally)
Reading
• Use audio books
• Books on the computer (pages turn by
activating a switch)
• Peer can read or turns the pages of the book
Lunch
• Using adapted utensils to self-feed
• Peer helpng in getting food from lunch line
Physical Education
• Having a peer kick or hit the ball while
another peer pushes or assists student along
the bases or down the field
• Student can start and stop a stopwatch when peers
are being timed in an activity
• Using specific materials for different sports being played

Peer Buddy Supports

• Writing if the student has physical

limitations
• Assisting with academic work (reviewing a
lesson or detailing instructions if needed)
• Assisting student with mobility (pushing
wheelchair, sighted guide)
• Using student’s mode of communication
(e.g., voice output device, sign language,
symbol boards)
• Help student keep attention directed toward
the teacher
• Provide corrective feedback
• Be a positive role model
• Facilitate social interactions between
student and peers

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Classroom Environment
The physical arrangement of the classroom will need to best accommodate this
child. Consideration of special equipment and assisted technology is important.

What educational practices are effective in teaching students with multiple

disabilities?
Children with multiple disabilities are generally identified at a very young age.
Early intervention is important to enhance the quality of life of those with multiple
disabilities. Early intervention service will use a family-centered approach as well
as developmentally appropriate practices. These programs help the family support
the child and help the child to use the resources they come into contact with in
everyday life. The programs also encourage communication with adults and peers.
Once the child enrolls in school, these practices have been effective in the
classroom:

 Inclusion provides students with an environment that stimulates awareness,

learning, and communication
 Support from paraprofessionals and peers
 General curriculum that has been adapted to fit the abilities of the student
 Functional and personal skill instruction
 Opportunity for partial participation in challenging activities
 Related services for physical therapy, occupational therapy, and
speech/language acquisition
 Opportunity to make choices and voice preference
 Assistive technology
 Augmentative and alternative communication devices

Students with multiple disabilities may also need physical care during the school
day. This may include assistance with feeding, toileting, and/or medical
devices (Rosenberg, Westling, & McLeskey, 2011).

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