Severe multiple impairment

Historically, individuals with severe and/or multiple disabilities who survived childbirth where subjected to poor treatment. The presence of these abnormalities at birth was considered to be shameful and carried significant stigma. Between the 1700s and the late 1800s, there was a period of optimism based in part on new educational methods originating in France based on the work of Jean Marc-Gaspard Itard, and Edouard Sequin. After this period and up into the 1960s, children with severe and/or multiple disabilities were institutionalized due to the non-uniform outcomes of these educational practices. In the 1970s, governmental policies in part results in lower admissions. Many former residents now are placed in community-based settings or in their own homes with supports provided by their families with assistance. Those individuals who are currently still in state institutions are generally over forty, and have profound mental retardation and multiple disabilities.

Traditionally, students with multiple disabilities were excluded from public education. This assumption was based on the belief that these individuals were unable to learn at all. This assumption started changing in the mid twentieth century. In 1970, the Developmental Disabilities Services and Construction Act of 1970 sought to make support available to individuals with severe disabilities such as mental retardation, cerebral palsy and epilepsy and improve conditions in institutions. This created framework which was used to create Education of the Handicapped Act in 1975 (Public Law 94-142), now called Individuals with Disabilities Education Act (IDEA). This legislature made it possible for students with severe and/or multiple disabilities (then called multi-handicapped) to be education in segregated school environments. Since this time, public schools have been increasingly serving students with severe and/or multiple disabilities even as early as infancy. The reauthorization of IDEA in 1990 placed emphasis on inclusion in classrooms of all students with disabilities, and since this time, the delivery of special education services has shifted from total separation to more inclusive classrooms.

Currently there is no category that separates students with Severe or profound disabilities from students with multiple disabilities. Students with profound disabilities are grouped with students with multiple disabilities due to similarities in their characteristics. These characteristics are;
 * Limited use of speech and/or communication
 * Difficult in basic physical mobility
 * Tendency to forget skills through disuse
 * Trouble generalized skills from one situation
 * A need for support in major life activities such as domestic care, leisure, community participation and vocation.

Diagnostic & Eligibility Criteria
In order for a student to be diagnosed with Severe and/or Multiple Disabilities, it must first be determined that the student the lack of success is not due to For students who have a combination of two or more disabilities including but not limited to Cognitive Disability (Intellectually Impaired), Deafness, Hearing Impairment, Orthopeadic Impairment, Speech/Language Impairment, and Other Health Impairment. This combination results in significant needs in the areas of development and academics that cannot be served by special education services in one area alone. The number of students served under this category in 2006 was 0.3% of all students.
 * Lack of scientific and empirically based teaching practices and programs for reading
 * Lack of high quality empirically based techniques for math
 * Limited English proficiency
 * Environmental, cultural or economic disadvantage.
 * Eligibility for deaf-blindness.
 * Traumatic Brain Injury
 * High levels of absenteeism not related to health.

Measurements
Multiple disabilities is considered a low incidence disability. Since the 1980’s, students who have been served has steadily increased from 68,000 students, to 142,000 in 2006-2007 which is about 0.3% of all students served.

Due to the nature of this category, there is no common screening or medical procedure to place individuals into severe and/or multiple disabilities. There are various forms of assessment for various conditions including universal screening (in the case of vision, and hearing), observation of behavior patterns, comparison of motor or developmental milestones, or overt physiological problems (like cleft-palette or club foot).

Disorders may be detected at birth, or in infancy with programs such as Child Find, or in preschool.

Models
There may be several reasons for Severe and/or Multiple Disabilities. Although some are caused by hereditary, injury or disease, others are produced by unknown factors. It has been noted in literature that fetal alcohol exposure increases the risk of multiple disabilities, however the exact cause is not known. Additionally due to the many different possibilities of combinations, it may not be one specific or common cause.

Treatment and intervention may involve medical treatment, behavioral management or education. Medical treatment of disorders may include using medical techniques and procedures to correct or alleviate challenging aspects of the disabilities. Behavioral management involves using behavioral techniques such as reinforcement and conditioning. Behavioral techniques have been shown to be beneficial with working with children with autism. Educational techniques focus on explicitly teaching these individuals life skills required to be as independent as possible.

Additionally, the presence of severe and/or multiple disabilities can cause several medical issues including seizures, sensory loss, hydrocephalus, and scoliosis.

Current Research Literature
Current research literature is focused in the areas of attitudes towards the disabilities in addition to aspects of severe and/or multiple disabilities on various life activities and future development.

Carter & Hughes, (2006) researched attitidues of various educational professionals on inclusion of students with severe disabilities in the classroom and found that while educational professions agreed on the benefits of including students with severe disabilities in the general education classroom, there was disagreement over the most effective way of attaining this goal. Cook, Cameron, & Tankersley, (2007) found that teachers who perceived a lack in their own abiliy to educate children with disabilities were more indifferent to the disabilities present in their classrooms. This is two examples of research regarding attitudes towards inclusion of students with severe and/or multiple disabilities.

Other research areas currently being investigated involve what interventions and teaching practices are most effective with students with severe and multiple disabilities.

Issues
Due to new prenatal techniques of screening it is possible identify profound and multiple disabilities. This brings forward several ethical and moral issues in addition to how much education. These include:

Should doctors treat all newborns despite the extent of their disabilities?
In a case involving a child with severe multiple disabilities that made the child incompatible with continued life, the parent opted to not operate to correct the defect which resulted in the child’s death. This issue strongly involves questions regarding quality-of-life.

===Should parents/medical professionals terminate the Lives of severely disabled infants/non-persons. Should medical treatment be used to limit biological development to make it easy for families to care for individuals with severe and multiple impairments?=== Should ‘defective’ or children with severely disabilities be terminated before birth? Should treatment be withheld from infants with severe disabilities? These questions are related to quality of life and human worth.

In an unusual case, a young girl was surgically altered and sterilized to limit growth on the request of the parents so this girl would not experience puberty and it’s associated issues of sexuality and problems with care.

Do all students have the right or ability to participate in Universal Educability? Should education need to be given to all students regardless of the severity of the disability?
Proponents for and against Universal Educability differ on whether or not there are some individuals who are unable to learn or be educated. Proponents for Universal Educability suggest that no matter the level of performance and ability, education can significantly benefit the life of individuals with disabilities. Proponents against suggest behavioral methods of conditions does not equate to education and benefit.

Questions related to if education should be given to students who are severely and profoundly impaired. Students like Ashley X who are unable to move on their own and others who are in vegetative states are eligible for free and appropriate education. These questions are focused on if resources used to educate this individual could be better used providing better education for less impaired students who may achieve more. It has been proven that despite these profound cases, education does have an effect; the debate is whether the effect is significant enough for the public expenditure.

Definitions
Severe and multiple disabilities is a label that has traditionally been given to individuals with severe to profound cognitive impairments and/or mental retardation and another confounding disability. There is growing understanding that minimal or mild disabilities do exist such as a mild learning disability with mild or severe autism. The greater the impact on the person’s life, the more likely there will be a need for support.

Often, individuals with severe and/or multiple disabilities require extensive supports which have long durations which may even involve lifespan in at least one major life activity (such as domestic care, leisure, community participation and vocation.) Types of disabilities include; restriction of movement – this includes disorders where movement of limbs or the bible is limited such as cerebral palsy. Skeletal and/or structure abnormalities – This includes disorders where skeletal formation is abnormal such as scoliosis (curvature of the spine). Sensory disorders – This includes loss of vision or hearing. IDEA requires that students with the combination of hearing and vision loss be included under the deaf-blindness category.

Students with severe and/or multiple disabilities can include; a teenage boy who is paraplegic with severe hearing loss with hearing aids, a young girl who has cerebral palsy and a cognitive impairment. Each of these students has different needs that will need to be addressed.

Terminology
Terms found consistently in special education of students with severe and/or multiple disabilities"

Mental retardation(obsolete but still used by IDEA): Mental retardation means significantly sub-average general intellectual functioning, existing concurrently with deficits in adaptive behavior and manifested during the developmental period, that adversely affects a child's educational performance also called Intellectual and Developmental Delay or Cognitive Impairment.

Adaptive behavior: Behavior that is considered everyday life skills (like money concepts, self-help, etc) which is expected of average adult functioning.

Autism: A developmental disability significantly affecting verbal and nonverbal communication and social interaction, generally evident before age three, that adversely affects a child's educational performance. Other characteristics often associated with autism are engagement in repetitive activities and stereotyped movements, resistance to environmental change or change in daily routines, and unusual responses to sensory experiences.

Brain Damage/Traumatic Brain Injury: An acquired injury to the brain caused by an external physical force, resulting in total or partial functional disability or psychosocial impairment, or both, that adversely affects a child's educational performance.

Cerebral Palsy (CP): This refers to nondegenerative neurological disorders that appear in infancy or early childhood caused by abnormalities in parts of the brain that control muscle movements which permanently affect body movement and muscle coordination.

Congenital: Refers to defects and/or damage experience by a fetus during development. Spina bifida is a congenital disorder.

Child Find: a component of Individuals with Disabilities Education Act (IDEA) that requires states to identify, locate, and evaluate all children in order to identify those students who are in need of early intervention or special education services.

Chronological Age: This refers to the period of time between the date of birth and the present date.

Mental Age (obsolete): A term once used to describe the functional level

Continuum of services: This describes the spectrum of special education services that are available to students with disabilities ranging from most restrictive to least restrictive

Deaf/blind or Deafblindness: Combination of both hearing and visual impairments, the combination of which causes such severe communication and other developmental and educational needs that they cannot be accommodated in special education programs solely for children with deafness or children with blindness. severe communication and other developmental problems.

Developmental Delay: This refers to when a child functions (physically, cognitively, social and emotional) at a level that is lower than would be expected for their chronological age.

Due Process: Safeguards provided by legislation to protect individuals from constitutional right violations. These are also considered procedural safeguards.

Epilepsy: A neurological disorder where neurons in the brain signal abnormally which disturb the normal pattern of neuronal activity causing strange sensations, emotions, and behavior or sometimes convulsions, muscle spasms, and loss of consciousness.

Exceptional children: Term given to children who deviate from the average to such a degree they require some form of special instruction so they can obtain an appropriate and meaningful education. This term refers to students who deviate on both sides of average (gifted and disabled).

Aphasia: An impairment related to the ability to use or understand words in speech, writing or gesture. Most commonly caused by damage or injury to brain centers for speech processing. Failure-to-thrive: This term is given to young children fail to develop and grow normally without any apparent organic problems.

Fragile X chromosome: The most common form of genetic disorder that results in Intellectual impairment. Males generally have the impairment, however females show less intellectual impairment however they carry the gene.

Free and Appropriate Education (FAPE): This refers to special education and related services that are provided by public schools at no cost to the family. What is an appropriate education differs for each child with a disability, and a IEP must be created to determine what is appropriate based on the needs of the child.

Hospital and/or Homebound instruction: This refers to instruction that takes place by a certified instructor in a home or hospital situation for students who are unable to attend school. This is usually short-term.

Individualized Education Program (IEP): This is a educational plan required by IDEA, that is developed by a multidisciplinary team and implemented. This document must include a statement of current performance, annual goals, what special education services will be provided to the student, the dates for start and duration of services and objectives.

Informed consent: This refers to the legal terminology regarding the individual’s right to know what their rights and consequences are in relation to a test or treatment program.

Intelligence: A psychological term that refers to an individual’s ability to perceive and understand relationships in their environment and recall associated meaning. Usually given in terms of an IQ score.

Least restrictive environment (LRE): A principle in which students with disabilities should be educated with their non-disabled peers to the maximum extent possible. This does not mean that all students with disabilities must be placed in classrooms with students without disabilities, because it also needs to be appropriate to the student’s needs. See FAPE

Mainstreaming: See LRE

Neonatal: The time period in a child’s life relating to the first month of life.

Occupational therapy: A related special education service that focuses on the development and maintenance of functions and fine motor skills for appropriate life skills.

Physical therapy: A related special education service that focuses on mobility and posture related to movement and gross motor skills.

Postnatal: The period of time just after birth and the first few months of life.

Prenatal: The period of time before birth experienced by a fetus/baby

Pull-out program: this refers to special education programs which pull the student out of the general education classroom to provide more intensive interventions or other

Pull-in program: This refers to special education programs that pull services into the classroom to provide more intensive interventions and services within the general education classroom.

Abbreviations

 * ADA : Americans with Disabilities Act
 * IDEA : Individuals with Disabilities Education Act.
 * SEA : State Education Agency
 * LEA : Local Education Agency
 * AAMR: American Association of Mental Retardation
 * AAIDD: American Association of Intellectual and Developmental Delays, The new name for AAMR
 * FAPE: Free and Appropriate Education.
 * DSM-VI-TR (Diagnostic and Statistical Manual. 4th Edition, Text Revision, of the American Psychiatric Association): An industry manual that provides a diagnostic system for classifying disorders in mental health.
 * ILS: Independent living skills – Basic skills required to function independently as much as possible in an appropriate environment. This consists of domestic skills (like cleaning and dressing), community living, self-help and others.
 * IFSP: Individualized Family Service Plan

Early Intervention
Students and Families with severe and multiple impairments when identified early, can be provided with an Individualized Family Service Plan (IFSP) which provides supports from birth to the age of three. These services include access to specialized instruction, speech and language services, physical therapy, occupational therapy, family training and counseling, assistive technology devices and services, audiological services and others. This also provides health services that may be necessary so as to benefit from these early intervention services. The aim of early intervention is to provide links between the family and community to meet the developmental needs a child with disabilities.

Preventive
Severe and/or multiple disabilities caused by developmental can be prevented by good health practices. This includes reduction and elimination of alcohol or drug use while pregnant, availability of prenatal and postnatal care, good nutrition, immunization and public awareness. Causes are not known for many types of disabilities and preventing these ‘random’ disabilities is not possible at this time.

Academic Interventions
Within the classroom there are several forms of interventions that can be utilized to assist with education as much as possible. Here are some examples of academic interventions.
 * Have students listen to/watch information on tapes or video
 * Provide significantly abbreviated stories made with pictures and simple sentences
 * Adapt worksheets for various subjects so as to provide access for the student with severe and multiple disabilities. For example, while teaching math concepts like addition and subtraction, providing student with tactile toys so they can interact with the object helps make the concepts more concrete.
 * Increase peer interaction by using peer helpers and collaborative teaching.
 * Plan daily schedules and provide pictorial and tactile ways for the student to have access to schedules. Students will know what to expect and reduce any behaviors during task transition.

Assistive Technology
There is several types of assistive technology available to students with severe and/or multiple disabilities. These include technology for increasing access to the environment for students with disabilities. Assistive Technology is defined by IDEA (1997) "any item, piece of equipment, or product system, whether acquired commercially off the shelf, modified, or customized, that is used to increase, maintain, or improve the functional capabilities of a child with a disability" (IDEA, 1997, 20, USC, Ch. 33, Sec. 1401 [25] US). There is no specific Assistive Technology for severe and/or multiple disabilities however; depending on the needs of the child, there is technology which can be utilized. Assistive Technology can be divided into two categories, ‘High’ Tech and ‘Low Tech’. High technology requires usually costly, high maintenance computerized or electronic systems. Low technology systems are generally readily available and do not require electronic or costly equipment. There are several types of Assistive technology to serve various forms of disability and these can be either high or low technology. According to ABLEDATA, an online database of assistive technology and rehabilitation products and services, there are thousands of solutions. Here is a sampling of a few that may be beneficial to students with severe and/or multiple disabilities.

Assistive Technology for Communication
Some combinations of disorders and/or profound disabilities may find oral communication difficult or even impossible. Alternative and Augmentative Communication (AAC) devices are used and can be either high or low tech. A high technology example would be a computer with a touchscreen or keyboard that when text and/or pictorial symbols are vocalized using a text-to-speech program so the student with the disability will be able to ‘vocalize’ and communicate. A low technology example is a communication board, which consists of a board with pictograms on it or the words yes and no, which the student points to using either their hand, a mouth-stick or other gesture to indicate what they want or need.

Assistive Technology for Education
Some disabilities reduce access to instructional presentations and text. A high technology example would be a digital presentation recorder. A digital camera records the presentation/flipchart and plays it for the student in a way that the information can be magnified or contrast increased for students with visual impairments. A low-tech device would be a magnifier, a student desk which allows a student with a wheelchair to be able to work at, or a book holder for students who are unable to hold books or turn pages.

Assistive Technology for Daily living
Some profoundly and multiple disabled individuals are limited in their ability to do daily living functions. These include areas of mobility, positioning, clothing, eating and drinking, transferring (moving from wheelchair to toilet or bed.) and toiletry. Some examples of assistive technology include equipment to hold individuals in position, and modified eating utensils.

Criticisms
Due to how IDEA defines multiple disabilities and the requirement that the impairment must be significantly severe so that it cannot be accommodated solely by one of the impairments limit the impact of students who have multiple impairments. It has been found in research, that several students have co-morbid conditions, for example, ADHD and Emotional and Behavioral disorders. These students are general listed under a primary condition with the hope that the other condition will improve. Another example is visually impaired students who have a learning disability. This definition limits the number of students who can be served under multiple disabilities; despite it is likely that many other students require accommodations for not just their primary disability. Other criticisms include
 * There is no limit to the severity of the impairment that equates that even children who may be a permanent vegetative state (children incapable of responding to stimuli and do not benefit from any clinical treatment other than keeping them alive) are eligible for free and appropriate education. This increases the amount of funding required from taxpayers.
 * Schools may not have the ability to provide services to meet the needs of these students in addition to including them in general education classrooms. Teachers may not have qualifications to allow this.

Adaptability
For many individuals with severe and multiple disabilities, adaptive skill acquisition is a major component of the educational program. For several individuals, skills such as eating, toileting, dressing, orientation and mobilization require training. For students with disorders relating to muscle tone, control and abnormal reflexes, modification may be required for the aforementioned areas.

Examples of modifications for eating include, modifying the utensils used to eat to allow the individual to feed his or herself if possible. For toileting, bladder management training may be required for students who may have disorders which result in reduced bladder control.

As the student ages, transition training is included to help increase these students. This usually takes the form of community-based instruction. Community-based instruction involves providing experience to students with disabilities in using public and community resources and facilities in the effort to make the transition between school and general life activities. This includes experiences like shopping in a market, using public transportation and leisure activities. Community-based instruction helps generalize literacy skills learned within schools into the general community.

For students with impairments so severe, that an independent life is unlikely (like vegetative students), adaptability would include assistive technology to increase communication and other life skills.

Government Policies/Support
Severe and multiple disabilities has been addressed by federal legislature since 1970 with the passage of the Developmental Disabilities Services and Facilities Construction Act of 1970. Called developmental disabilities, the Center for Disease Control defines this as; “developmental disabilities are a diverse group of severe chronic conditions that are due to mental and/or physical impairments. People with developmental disabilities have problems with major life activities such as language, mobility, learning, self-help, and independent living. Developmental disabilities begin anytime during development up to 22 years of age and usually last throughout a person’s lifetime.” According to the CDC website, about 17% of all children under the age of 18 fit this definition. The high percentage given by the CDC may be due to the fact that the CDC definition does not include educational functioning that is part of the IDEA definition.

With the passage of the Education for All Handicapped Children Act (EHA) in 1975, a category has existed for severe and multiple impairments (then called multihandicapped). This required that schools provide free and appropriate education for all students including special education and related services at no cost to the child or guardians. This was initially aimed at providing adequate education for individuals with severe impairments who received no instruction as well as individuals who were receiving inadequate education. This legislature requires placement of these individuals in the least restrictive environment, which attempts to include students with severe and multiple impairments with peers as much as possible.

EHA also required that schools to provide appropriate individualized services and periodically revaluating and monitoring the effectiveness of these services. A written plan called an Individualized Education Program (IEP) needs to be written for each student and include what will be provided to meet the requirements of the law. After several amendments, this is now called Individuals with Disabilities Education Act (IDEA).

Under IDEA (2004), Multiple Disabilities is defined as “Multiple disabilities means concomitant impairments (such as mental retardation-blindness or mental retardation-orthopedic 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. Multiple disabilities does not include deaf-blindness.”

Provision Of Individualized Services
Due to the large variety of conditions involved in this disorder, the personal that are involved in providing individualized services are multidisciplinary in nature. Related services include but not limited to, the school nurse, speech language pathologist, occupational therapist, physical therapists, communication therapist, social workers, audiologists, pediatricians, orientation and mobility experts, and school administrators. Depending on the individual needs of the student, the team members would reflect areas that will but utilized.

Benefits
It is generally considered to be beneficial to include students with severe and/or multiple disabilities in general education classrooms. As the study by Carter & Hughes (2006) showed, most educators believe that inclusion in benifitial, however the implementation methods where not as universally agreed upon. Benefits are for both the student with and those without disabilities. For students with disabilities, it’s found that inclusion increases social competence and academic involvementFor students without disabilities, an appreciation of difficulties facing individuals with severe and multiple disabilities as well as acceptance. It has also been found that these students build better leadership skills and gain self-esteem. Inclusion is therefore considered very benefitial.

Problems with Inclusion
Currently there is a lack of general education teachers who are specifically trained to support inclusion for students with severe and multiple impairments. Skills required of general education teachers working with these individuals include adapting the environment and educational curriculum for these learners and facilitating peer interactions, whether it is collaborative learning or in class peer particiption. Additionally these students may require assistance in manipulating objects, communication, learning classroom behaviors such as sitting, standing or walking if possible.

Settings
Historically, students with multiple disabilities, and severe/profound disabilities were typically served in more restrictive settings than other students with disabilities. Separate class and separate day school placements were most common for students with multiple disabilities, autism, and traumatic brain injury.

Increasingly students with severe and multiple disabilities are being served in a variety of settings. In 2006, most students where included in general education classrooms with and served with pull-out programs. They spent the majority of their time outside of the classroom, however there was inclusion. The second highest area of placement was in separate schools.

Discrimination
Individuals with severe and multiple impairments require supports to help them succeed. These individuals meet similar forms of discrimination based on their impairment as other disabilities see. These include lower expectations, low peer interaction and susceptibility to abuse.

After school employment prospects are not good and many do not have employment. The employment rate for individuals with all disabilities is 36%, while the employment rate for individuals with self-care disabilities (as individuals with severe and multiple impairment would experience) is 16% suggesting that 84% of these individuals do not work.

Limitations
These students are profoundly impaired and have several barriers to their education and life skills. These include barriers to communication, have difficulty generalizing learning from one context to another, requirement of significant supports in several life skills area. This lack of communication makes parental bounding very difficult for families.

Having sensory impairments in addition to cognitive impairments creates challenges in instruction, mobility and self-care. Fortunately many types assistive technology are now available to aid in mobility and self-care. The cognitive impairment limits these individuals ability to think abstractly and require very concrete instruction as well as assistance in generalizing skills from situation to situation. Community instruction helps this generalizing/transferring of skills.