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Education for Multi-Handicapped Children:

"Working with a PLAN OF ACTION"

At schools or in programs for multi-handicapped children, we try to develop and maintain a clear, concise, and explicit strategy of education. The usual educational methods do not meet the needs of our children. We strive to create a basic climate in which safety, structure, and trust are emphasized. The plan of action for each child is the key with which we develop a specific program of needs and goals for that individual.

(Sheet 1)
The rationale for our plan of action for each multi-handicapped child is:
- to plan a strategy to stimulate the development of the child;
- to create target goals for the child;
- to evaluate the success of our strategy; and
- to administer the plan of action more effectively.
Our purpose here is to demonstrate our method for creating a plan of action. The process begins with the referral and screening of children who our program might help. When we are certain that we can benefit a child, we develop a strategy with specific goals.

(Sheet 2)
When a multi-handicapped child is referred to us, information concerning the child is formally requested and gathered. Most of this information is obtained through a "Research Commission." This commission consists of an ophthalmologist, a physical doctor, a psychologist, a social worker, and the school director, who serves as chairman of the commission. The child is evaluated by the ophthalmologist to determine the presence and nature of any visual impairment. When the certainty of a visual impairment is established, the child is interviewed by the psychologist and the school director. If possible, this interview is conducted in a location known and trusted by the child.

This interview seeks to answer several questions:
- Will the child benefit by placement in our school?
- Is our school able to provide an educational program in which the child will be successful?
- Are there serious problems that might indicate the child should not be placed in our school?

We use four criteria to answer these questions:
- the social-emotional skills of the child;
- the sensorial skills of the child;
- the motor (muscular) skills of the child; and
- the cognitive skills of the child. Social-emotional skills evoke the following questions:
- Will the child react or respond to an adult?
- Can the behavior of the child be influenced?
- Can the child participate within a group setting or circle of children?
- How does the child interact with other children within the group?
- Are there serious behavioral problems?
- Does the child display unique or peculiar behavior?

Sensorial skills are demonstrated by the way the child orients visually to the environment and by his or her perception of details. Attention is also paid to the visual-motor skills in handling different materials. With blind children, attention is paid to their sense of touch and to their recognition of sounds and language.

Motor skills can be separated into gross motor skills and fine motor skills. Attention is paid to the child's hand-hand coordination, hand-eye coordination, and to the child's movement within the environment. With serious physical impairments, we must decide which handicap takes precedence and which school or program is most appropriate.

Cognitive skills are as important as social-emotional skills in determining which program is most appropriate. Much attention must be paid to language development. Does the child understand spoken language? Does the child communicate through language? What is the child's level? Does the child use language to communicate or simply to repeat words or phrases like a parrot? The child must be observed performing tasks. Can the child play? Are there variations in playing? Can the child tolerate interruptions? Can the child play with groups? From these questions, an impression of the child's cognitive level is formed.

After observing the child and evaluating the criteria, we are able to accept the child unless there are serious problems that we cannot manage. These problems might include very serious physical handicaps, anti-social behavior, or the need for complicated medical or nursing care.

Once the child is accepted, the information from the Research Commission is used to determine which program is appropriate for the child. The child's strengths and weaknesses are considered, and a classroom strategy is formulated. As a base for teaching a multi-handicapped child, we try to create a positive classroom atmosphere in which safety and routine offer a clear structure.

The first eight weeks in the classroom are used to orient the child into the new situation. This process is observed and recorded with as much detail and description as possible. This information is necessary to develop a plan of action for the child.

(Sheet 3)
During the orientation process, other specialists begin their processes of observation and screening. We refer to this as a multiple discipline screening. Besides teachers and their assistants, there are physical therapists, ergo or work therapists, and logopedists (speech therapists). They each play an important role during the screening period. Each specialist reports his or her observations to add to the information already gathered.

The teacher has the most contact with the child during the orientation period. The report of the teacher's observation is used to make a file recording the level of the child's social-emotional, sensorial, motor, and cognitive skills. This report is usually made from interactive observations. If necessary, other instruments, such as the SRZ, are used. Tests can also be adapted from formal instruments or constructed by the teacher.

Through classroom observations, the School-Psychologist aids the teacher in providing a more objective picture of the child. The information from the teacher's report of the four skill areas is extended to become the basis of the first meeting at which the teacher formulates proposals for the plan of action.

The Technical-Ophthalmologist-Assistant (TOA) monitors the child's visual functions during the orientation period. After examining the child in a clinical situation, the TOA observes the child in a classroom situation. Is the information consistent? The teacher and the TOA try to get a picture of how the child uses his or her visual abilities in the classroom. A number of questions are asked during this observation:
- how long is the child's visual attention;
- how is the child's vision in group activities;
- spacial orientation in the environment;
- does the child use vision when handling materials;
- does the child pay attention to visual signals; and
- what is the quality of the child's perception of details?
A report of these observations is added to the file of information used to develop the plan of action.

(Sheet 5)
During the screening process, the Ergotherapist observes motor skills. Special attention is paid to the relationship between gross/fine motor skills and the ability to handle materials. The goal is to find ways to allow a child with physical impairments to drink, eat, play, and take care of personal needs as efficiently as possible. In the classroom, measurements are made to insure that furniture meets ergonomic standards for each child. Advice concerning adaption of wheelchairs, clothing tables, and eating tools is given to group leaders in the dormitories. If necessary, the Ergotherapist visits the child's home to observe and give advice.

(Sheet 6)
Of course, the Physical Therapist is also concerned with motor skills. But unlike the ergotherapist, the Physical Therapist is more interested in the quality of the motor skills (motoscopie) which includes muscular tone and joint movability. To measure the quantity (or range) of motor skills (motometrie), special scales, such as Bailey's Developmental Scales, are used to determine the developmental age of the child. During the screening process, the Physical Therapist determines whether treatment is necessary or not and formulates short and long term goals.

(Sheet 7)
Finally, after screening, the Speech Therapist's report concerns the mouth-motor skills which include eating and drinking behavior as well as speech and articulation. Language comprehension and production indicate how well the child is able to understand instructions and explanations. Does the child speak in one word sentences? The Speech Therapist determines if instruction in communication is necessary.

At the beginning of the screening process, it is very important to restrict the number of experts a child sees. The attachment of the child to technical specialists can be harmful to the development of the child. Therefore, at the beginning of the screening process strict appointments are made. "Who is doing what with the child?" One specialist observes while another takes measurements. Priorities must be established during consultation with the child's parents. Of course, the parental role is crucial, and the parents may help decide which therapy or treatment will take precedence. Finally, a total picture of the child's developmental abilities emerges.

Today, great emphasis is placed on the "total child," and a combination of treatments is often chosen. In young multi-handicapped children, many developmental areas are linked together. The following disciplines can be emphasize in a combination treatment approach:
- speech training;
- physical therapy;
- ergo therapy;
- music therapy; and
- visual stimulation. A combination treatment approach has many advantages:

(Sheet 8)
A. The multiple discipline team can work toward many goals at the same time. For example, a stimulating orientation period can make the child more open to physical therapy and speech training;

B. The therapy and classroom conditions are more functional for the child;

C. More variation between the requirements of each therapy is possible allowing time (half hour appointments) to be used more effectively;

D. Continuity is guaranteed (if one therapist is ill, the treatments continue);

E. The child is less often out of the classroom; and

F. There is more mutual transfer of practical knowledge between therapists.
(end of Sheet 8)

After eight weeks, the screening period is completed. Finally all the information has been gathered, and a meeting involving all the professionals and the parents is scheduled. The main purpose of this meeting is to formulate a general goal or perspective. This can be very difficult because many teachers and therapists feel it is too risky to predict the future. It is also threatening to make promises to the parents which are not certain. Nevertheless, it is important to dare to give direction to a child's development. While it is easier to follow a child's development than to give it direction, formulating a perspective is absolutely necessary to develop a plan of action. In fact, the perspective is the first step in developing a plan of action. All the information has now been collected and recorded, and finally, the child can regain the lead in the process.

Following the perspective, we formulate short term goals.

Allow me to give you an example:
(Sheet 9)
This plan of action concerns an actual boy, Peter, who we will see later on in a video recording. Peter is following a course of "Orientation and Mobility" in Breda. The perspective or general goal for Peter is to be as independent as possible within his home. The problem is that Peter cannot find his working table or group table in the classroom. In the hallway, it is difficult for him to find the toilet. A typical short term goal could be to get Peter to walk from his seat to his work table. Of course, it is not possible in the classroom to work with each child's plan of action at the same time. It is inherit in the multi-handicapped classroom that some children are more impaired than other children. The teacher has to make choices and consider the wishes of the parents.

Therefore, it is important to form a picture of the central activities of the group. For each child, the goals are briefly listed. As described by my colleague, the goals are defined in terms of:
- social-emotional development;
- sensorial development;
- motor development; and
- cognitive development.

Schematically, it looks like this:

(Sheet 10)

In this overview of group activities, items are chosen which are worked out in plans of action. Different disciplines work with a plan of action. When treating a child, therapist make a plan of therapy.

Our experience is that developing and working with a plan of action for multi-handicapped children produces good results:
- the effects are measurable;
- treatment is more efficient;
- the results and treatments are transferable to other situations;
- new therapists can more easily join the team;
- and a lot more.

Developing a plan of action requires time and energy. But, it is our honest conviction that the investment pays off.

We are ending with the video tape about Peter which we mentioned earlier: "Working with a Plan of Action."

Thank you for your attention. Biographical Information

Ton Metselaar

is a Location Director at a school for multi-handicapped children in Breda, The Netherlands. This school uses the system of a Plan of Action. Ton Metselaar has worked at special schools for children with learning disabilities since 1978. Among other positions, he has served as Director. Since 1991 he has worked with multi (visual-retarded-motor) handicapped children within a multi-disciplinary team.

Johan Berghuis

is the Director for the Multi-Handicapped division of the Bartiméus Education Association located in Doorn and Zeist, The Netherlands. He has worked with multi-visual handicapped children since 1978. After serving for several years as a classroom teacher, he now holds a position in management within the Bartiméus Association. He interest continues in the development of curricula for multi-handicapped children.

Sheet 1

The rationale for our plan of action for each multi-handicapped child is:

- to plan a strategy to stimulate the development of the child;

- to create target goals for the child;

- to evaluate the success of our strategy; and

- to administer the plan of action more effectively.

Sheet 2

REFERRAL
 
 

INTAKE SOCIAL WORKER ASSIGNMENT

FORMAL REQUEST OF HISTORICAL RECORDS
 
 

INTAKE RESEARCH RESEARCH COMMISSION

- social-emotional skills

- sensorial skills

- motor skills

- cognitive skills
 

ACCEPTING THE CHILD

- which program or class

- first counselling advice

- strengths and weaknesses
Sheet 3

MULTIPLE DISCIPLINE SCREENING

TECHNICAL OPHTHALMOLOGIST SOCIAL-EMOTIONAL SKILLS
ASSISTANT TEACHER
SENSORIAL SKILLS
PHYSICAL THERAPIST
MOTOR SKILLS
ERGO THERAPIST SCHOOL PSYCHOLOGIST
COGNITIVE SKILLS
SPEECH THERAPIST

FORMULATION OF PERSPECTIVE (GENERAL GOALS)

FORMULATION OF SPECIFIC SHORT TERM GOALS FEEDBACK

PLAN OF ACTION FOR INDIVIDUAL CHILD

Sheet 4

Screening Technical Ophthalmologist Assistant

Client: TOA:

Birth date: Date:

Clinical Research Data:

- Visual activity:

- Field of vision:

- Peculiarities:

Observation Data:

- Visual attention:

- Vision use in group activities:

- Spacial orientation:

- Reaction to visual signals:

- Visual use when handling materials:

- Perception of details:

Advice:

Sheet 5

Screening Ergo Therapy

Client: Therapist:

Birth date: Date:

Present Situation:

General Impression:

- Motor skills (gross/fine):

- Sensorial skills:

- Cognitive skills:

- Play:

- Self care in daily life:

- Physical adaption aids:

Advice:

Questions:

Sheet 6

Screening Physical Therapy

Client: Therapist:

Birth date: Date:

Present Situation:

General Impression:

- Motoscopie (quality):

- gross:

- fine:

- Muscular tone:

- Mobility:

- Motometrie (quantity):

Definition of Problem:

Advice:

Questions:

Sheet 7

Screening Speech Therapy

Client: Therapist:

Birth date: Date:

Present Situation:

General Impression:

- Speech:

- Language comprehension:

- Language production:

Definition of Problem:

Advice:

Questions:

Sheet 8

Advantages of a Combination Treatment:

A. The multiple discipline team can work toward many goals at the same time. For example, a stimulating orientation period can make the child more open to physical therapy and speech training;

B. The therapy and classroom conditions are more functional for the child;

C. More variation between the requirements of each therapy is possible allowing time (half hour appointments) to be used more effectively;

D. Continuity is guaranteed (if one therapist is ill, the treatments continue);

E. The child is less often out of the classroom; and

F. There is more mutual transfer of practical knowledge between therapists.
Sheet 9

Plan of Action

Name: Peter S.
Group: De Tamboerijn
Leader: Helma
Start Date: 24 March
End Date: 29 April Perspective: Peter will expand his daily self care and independently learn to orient and find his way within and outside a building.
Problem: Peter cannot walk from his seat to his working table or group table in the classroom.
Goal: Peter will learn to walk:
1. from his seat to his working table;
2. from his working table to his group table; and
3. from his group table to the classroom door.
Planning: March-April Who: Group leader When: Each day Where: Classroom
Date: Method: Material: Pupil response:
9:15 seat to working table

10:00 working table to group table

10:15 group table to class door

We start with part 1 each day at 10:00
1. Crossing/distance is short.
2. Guided from the back, so he can use his hands.
3. Starting from a straight position.
4. Short, verbal instructions. Hesitation with first trials; not always successful.

With a teacher's verbal instruction from a distance, he correctly completes the tasks.
 

Sheet 10

Group Plan of Action: group.../period...
George Danny Jane Ringo Naomi Richard
Social-
Emotional
Skills

Sensorial
Skills
 

Motor
Skills
 

Cognitive
Skills

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