~Working memory, on the other hand, refers to the ability to retain information while simultaneously performing another cognitive task; research suggests that working memory in students with intellectual disability is significantly poorer in comparison to their typically developing peers.

Motivation:
~Individuals with intellectual disability to exhibit an external locus of control; that is, they are likely to believe that the consequences or outcomes of their behavior are the result of circumstances and events beyond their personal control, rather than their own efforts.
~Repeated episodes of failure also give rise to a related concept, learned helplessness—the perception that no matter how much effort they put forth, failure is inevitable. 

~ Oral language difficulties

Not all students with learning disabilities will exhibit these characteristics, and many pupils who demonstrate these same behaviors are quite successful in the classroom. It is often the frequency, intensity, and duration of the behaviors that lead to problems in school and elsewhere. 

~ Chronic over time
~ Generally pervasive behaviors across situations
~ Deviant from age-based standards
~ Increased likelihood of having another difficulty such as a learning or psychiatric disorder

Inattention - Fails to pay close attention to details, often makes careless mistakes

Hyperactivity - Demonstrates inability to remain seated for periods of time/ Fidgets or squirms, cannot sit still

Impulsivity - Interrupts or intrudes on others—butts into conversations or activities/ Acts without thinking, impatient. 

Deficits in social interaction include significant impairment in the use of multiple nonverbal behaviors (eye-to-eye gaze, facial expression, body postures and gestures), failure to develop age-appropriate peer relationships, a lack of spontaneous sharing with others, and the absence of social or emotional reciprocity. 

Communication 

A lack of speech has long been considered a hallmark of autism spectrum disorders. It is estimated that as many as half of all children with ASD do not develop functional speech or useful language. In individuals with ASD who do speak, “their speech may not be functional or fluent and may lack communicative intent.” 

Encourage student to have notebook with dividers and folders for work.
•Assist student in setting short-term goals.
•Provide student with homework assignment book. 

•Do not penalize for poor handwriting if visual–motor defects are present.
•Supervise writing down of homework assignments.
•Encourage learning of keyboarding skills. 

•Send daily/weekly progress reports home.
•Allow student to tape-record assignments or homework. •Regularly check desk and notebook for neatness; encourage neatness rather than penalize sloppiness. 

Compliance 
•Praise compliant behavior.
•Supervise student closely during transition times.
•Provide immediate feedback.
•Seat student near teacher.
•Ignore minor misbehavior.
•Set up behavior contract.
•Use teacher attention to reinforce positive behavior.
•Implement classroom behavior management system.
•Use “prudent” reprimands for misbehavior (i.e., avoid lecturing or criticism).
•Instruct student in self-monitoring of behavior.
•Acknowledge positive behavior of nearby students. 

Mood
•Provide reassurance and encouragement.
•Make time to talk alone with student.
•Frequently compliment positive behavior and work product. •Encourage social interactions with classmates if student is withdrawn or excessively shy.
•Speak softly in non-threatening manner if student shows nervousness.
•Reinforce frequently when signs of frustration are noticed.
•Review instructions when giving new assignments to make sure student comprehends directions.
•Look for signs of stress buildup and provide encouragement or reduced workload to alleviate pressure and avoid temper outburst.
•Look for opportunities for student to display leadership role in class.
•Spend more time talking to students who seem pent up or display anger easily.
•Conference frequently with parents to learn about student’s interests and achievements outside of school.
•Provide brief training in anger control: Encourage student to walk away; use calming strategies; tell nearby adult if getting angry. Send positive notes home. 

Socialization 
•Praise appropriate behavior.
•Encourage cooperative learning tasks with other students.
•Monitor social interactions.
•Provide small-group social skills training.
•Set up social behavior goals with student and implement a reward program.
•Praise student frequently.
•Prompt appropriate social behavior either verbally or with private signal.
•Assign special responsibilities to student in presence of peer group so others observe student in a positive light. 

•providing praise, reprimands, and consequences when in close physical proximity to pupils.

Classroom Arrangement
Classroom arrangement includes the physical layout of the classroom as well as classroom décor. Physical layout includes student seating and grouping arrangements; location of materials, equipment, and personal items; removal of tempting or dangerous items; and location of the teacher’s desk. The following suggestions have been made regarding seating and grouping arrangements: 
•Students should be seated in locations that provide teachers with easy visual and physical access at all times (Salend, 2016).
•Savage (1999) recommends using rows for direct instruction, circular patterns for discussions, and clustered arrangements for group work. 
•Place disruptive students in the “action zone” in the classroom. The action zone consists of seats across the front of the classroom and down the center. Research reviewed by Savage (1999) suggests that students seated in the action zone attend more to tasks, participate more, have higher levels of achievement, and demonstrate more positive attitudes. 

•Disruptive students should be seated near the teacher to allow for proximity control and frequent monitoring. 

~idioms (save your breath, jump the gun, second thoughts, and so on);
 ~double meanings (most jokes have double meanings);
 ~sarcasm, such as saying, “Great!” after someone has just spilled a soft drink all over the table; and
~ nicknames. 

Break down tasks 
If a student doesn’t appear capable of learning a task, break it down into smaller steps, or present the task in several different ways (for example, visually, verbally, and physically).

Assist students with organizational skills 
Individuals with autism spectrum disorders often have difficulty with organizational skills, regardless of their intelligence and/or age. Even a “straight A” student with autism spectrum disorder who has a photographic memory can sometimes be incapable of remembering to bring a pencil to class or remembering a deadline for an assignment. In such cases, assistance should be provided in the least intrusive way possible. Strategies could include putting a picture of a pencil on the cover of the student’s notebook or reminders at the end of the day of assignments that are to be completed at home. Always praise the pupil when he or she remembers something he or she has previously forgotten. 

Prepare students for change 
It is important to prepare the student for all unexpected changes, such as an assembly, a substitute teacher, rescheduling of classes, and so forth. Use a written or visual schedule to prepare for change.

Make adjustments for auditory and visual distractions
Be aware that normal levels of auditory and visual input can be perceived by individuals with autism spectrum disorders as too much or too little. For example, the hum of fluorescent lighting is extremely distracting for some people with autism spectrum disorders. Consider environmental changes, such as removing some of the visual clutter from the room, or seating changes if the student seems distracted or upset by his or her classroom environment.

Facilitate group work
If a class activity involves pairing off or choosing partners, draw numbers or use some other arbitrary means of pairing. You could also ask a class leader whether he or she would agree to choose the individual with autism spectrum disorder as a partner. This should be arranged prior to pairing. The pupil with autism spectrum disorder is most often the individual left with no partner. This is unfortunate because this student could benefit most from having a partner.

Most importantly, be positive, be creative, and, most of all, be flexible!

People with Autism Spectrum Disorder have ranging cognitive functioning levels. Not all individuals with ASD have and intellectual impairment and others are extremely smart. These individuals do have issues with communication and social interaction but that does not take away anything they have and it doesn’t make them less than anyone else.

When students have two or more primary disabilities that are significant enough to require services from more than one special education program, they may be classified as having multiple disabilities. For example, a child who has a severe physical disability and is deaf may be classified as having a multiple disability. This pupil may require services from a teacher certified to teach students with orthopedic impairments and another teacher certified to teach students who are deaf or hard of hearing. Many possible combinations of disabilities can fall under the category of multiple disabilities; since a physical or health disability is often involved, this category is addressed in this chapter. 

Children who have acquired brain injuries as a result of external force, such as from a car accident, may be served under the category of traumatic brain injury. Traumatic brain injury may result in impairments in several different areas, including physical disabilities, sensory impairments, cognitive disabilities, speech or language impairments, and behavioral disorders. This category does not include individuals who have brain injuries that occurred before or during birth or that were acquired from a degenerative disease. 

Children capable of high performance include those with demonstrated achievement and/or potential ability in any of the following areas: (1) general intellectual ability, (2) specific academic aptitude, (3) creative or productive thinking, (4) leadership ability, (5) visual and performing arts, and (6) psychomotor ability. 

Several states have essentially adopted this definition, with the exception of psychomotor ability. Although individuals certainly demonstrate giftedness in psychomotor ability, the category has been removed because the development of athletic ability is supported and generously funded in other ways. 

The second national report on gifted education, National Excellence: A Case for Developing America’s Talent, uses the term talent rather than gifted: “Children and youth with outstanding talent perform or show the potential for performing at remarkably high levels of accomplishment when compared with others of their age, experience, or environment”. Like the Marland Report, it notes that “outstanding talent” can be evidenced in general intellectual ability, specific academic ability, creative thinking, leadership ability, and/or the visual and performing arts. At the same time, it stresses that “outstanding talents are present in children and youth from all cultural groups, across all economic strata, and in all areas of human endeavor”. The recommendations contained in National Excellence provide a blueprint for states to use in expanding their definitions of children who are gifted and talented. 

Speech is the most common and the most complex mode for expression of language. It requires coordination of the neuromusculature of the breathing and voice-producing mechanisms, as well as integrity of the mouth or oral cavity.

Simply stated, a speech impairment is present when the individual’s speech deviates to such a degree that it interferes with communication, attracts unfavorable attention, and adversely affects the listeners, the speaker, or both.

One of the most prevalent of all speech problems is articulation disorders. Articulation disorders are errors in the production of speech sounds. They include omissions (han for hand), substitutions (wabbit for rabbit), additions (footsball for football), and distortions (shlip for sip). A lisp is a good example of a distortion. Common difficulties are often associated with the mispronunciation of /ch/, /s/, /sh/, and /z/ phonemes.

Articulation errors may be related to anatomical or physiological limitations in the skeletal, muscular, or neuromuscular support for speech production, or to other factors (for example, cerebral palsy, hearing loss). A child has a severe articulation disorder if pronunciation is so poor that his or her speech is unintelligible most of the time to family members, teachers, and peers.

Fluency disorders are difficulties with the rhythm and timing of speech. A fluency disorder is basically “an interruption in the flow of speaking characterized by atypical rate, rhythm, and repetitions in sounds, syllables, words, and phrases. This may be accompanied by excessive tension, struggle behavior, and secondary mannerisms”.

Stuttering is the most familiar fluency disorder. It is marked by rapid-fire repetitions of consonant or vowel sounds especially at the beginning of words, prolongations, hesitations, interjections, and complete verbal blocks.

Individuals who stutter may also be clutterers. Cluttering is a related fluency disorder characterized by excessively fast and jerky speech. A difference between stutterers and clutterers is that the stutterer is usually very aware of his or her fluency problem, whereas the clutterer may seem oblivious to the problem.

Voice disorders are problems with the quality or use of one’s voice that result from disorders of the larynx. They are characterized by “the abnormal production and/or absences of vocal quality, pitch, loudness, resonance, and/or duration, which is inappropriate for an individual’s age and/or sex”. Speech may be excessively hoarse, or lack appropriate inflection.

The two types of voice disorders are phonation disorders and resonance disorders. The characteristics of a phonation disorder are breathiness, hoarseness, huskiness, and straining. In severe cases, the individual may not have any voice at all. A resonance disorder may be characterized by hypernasality (too many sounds coming through the air passages of the nose) or hyponasality (too little resonance of the nasal passages).

Language Disorders 

How well children understand and use language affects not only their ability to learn to read and write but also the perceptions of peers, family members, teachers, and society at large.

A phonological disorder is defined as abnormal organization of the phonologic system or a significant deficit in speech production or perception. A developmental phonological disorder is the difficulty of organizing speech sounds into patterns. A child with a phonological disorder may be described as hard to understand or as not saying the sounds right—the child is likely to have difficulty decoding spoken language and may make substitutions for sounds. 

A child has a phonological disorder (as opposed to 

an articulation disorder) if he or she has the ability to produce a given sound and does so correctly in some instances but fails to produce the sound correctly at other times. Unlike articulation disorders, a phonological disorder reveals a pattern of responses and is therefore a rule-based phenomenon. Assessment for these children focuses on determining which sounds the child can produce, the contexts of correct and incorrect sound production, and the child’s use or overuse of phonological processes.

Apraxia of speech is a neurological phonologic disorder that results from impairment of the capacity to select, program, or execute the positioning of the speech muscles to produce speech sounds.

Children with a morphological disorder have problems learning and using morphological rules. They use fewer grammatical morphemes and produce more grammatical errors than same-age peers. 

Children with syntactical deficits have difficulty acquiring the rules that govern word order and other aspects of grammar such as subject–verb agreement.

Semantic disorders are characterized by poor vocabulary development, inappropriate use of word meanings, and/or inability to comprehend word meanings. Most evident are problems with word finding, the ability to generate a specific word that is evoked by a situation, stimulus, sentence, context, or conversation.

Children with pragmatic difficulties have problems understanding and using language in different social contexts. They do not understand how to infer their listeners’ needs, so they do not know what and how much information they need to provide in an interaction. 

It is crucial that the intellectual assessment of students with hearing impairments use measures that do not rely primarily on verbal abilities as indicators of cognitive functioning. There are several nonverbal assessment options considered appropriate for individuals with hearing impairments. Two examples are the nonverbal portion of the recently revised Kaufman Assessment Battery for Children and components of the Wechsler Intelligence Scale for Children. Because of the nonverbal nature of these and similar instruments, concerns exist about the validity and reliability of these assessments when used with students who are deaf. 

The two most widely used measures of academic achievement administered to children who have a hearing loss are the Stanford Achievement Test (SAT-10)and individual state achievement tests. The Stanford Achievement Test is the only national assessment routinely used to assess the academic performance of students who are deaf or hard of hearing. Fortunately, the scoring of this instrument incorporates norms based on individuals with hearing impairments. 

Communication Assessment 

The most serious negative aspect of a hearing impairment is its effect on language and speech development. Inadequate auditory stimulation during early development almost always leads to marked problems in language acquisition and speech production. Language assessment with this population should examine both receptive and expressive communication skills, including (1) form of language, (2) content of language, and (3) use of language. However, most language assessments do not assess all these areas. Professionals typically use several different assessment tools and techniques (such as language sampling) to accurately determine the individual’s language abilities.
 

Speech assessment with this population should include a battery of tools designed to ascertain the individual’s articulation, pitch, loudness, quality, and rate. Analysis of these speech functions will provide a basis for designing speech therapy goals as part of the individualized education program (IEP) for the student with a hearing impairment. 

Personal/Social/Behavioral Assessment 

A number of measures of personal, social, and behavioral functioning are being used with individuals with hearing impairments. The assessment of personal/social characteristics with this population is very challenging given the language content of most of the measures in this area, which are designed to be completed by a rater in response to items in the domains of social adjustment, self-image, and emotional adjustment. Sattler and Hoge urge caution when inferring development in these areas. Individuals with a hearing impairment may respond atypically to a personality measure, not because they exhibit aberrant social/emotional development, but as a result of their linguistic difficulties. 

Some children may be identified at birth as having a visual impairment through routine medical examinations, but many others are not identified as visually impaired until later. Parents or caregivers may notice unusual developmental behaviors caused by a vision loss. Some children may be diagnosed with a visual impairment following an accident or childhood illness. Other children may be identified through preschool or kindergarten vision screening programs. 

A screening for visual acuity is often provided at school or in the physician’s office. The acuity chart most often used for testing and reporting vision loss is the Snellen chart. An example of a distance loss on the Snellen chart is 20/70, meaning that the person has to be 20 feet away from the chart to see what the normal eye can see from 70 feet. This chart is a 20-foot distance test; other tests are given for near vision and other vision problems. 

Any student identified with a suspected vision problem should be referred to a licensed ophthalmologist or optometrist for further evaluation, including a medical examination and report. The information in this report should include etiology, medical history and diagnosis, ocular health, visual abilities, recommended low vision devices, possible assistance with travel, and a reevaluation date. This information may be provided to the educational system through a written ocular report.

In addition to a medical examination, a clinical low vision evaluation is necessary to determine if a student could benefit from other optical or nonoptical low vision devices. The low vision examination involves acuity tests, visual field testing for peripheral or central vision loss, and an interview with the individual to determine what he or she would like to do for work, school, or leisure activities. A personal prescription for low vision devices, technology, or referrals to community agencies is part of the low vision plan. If low vision devices cannot assist the student with reading, writing, or distant viewing, then Braille or auditory access may be recommended. The student’s vision teacher can attend this evaluation and bring materials relevant to the scheduled daily activities. Examples of educational materials pertinent to the student with visual impairments are reading texts, technology adaptations, daily writing journals, workbooks, maps, and charts. 

Once a medical diagnosis confirms a physical or health disability, a determination needs to be made as to whether the disability has an adverse impact on the student’s educational performance. A comprehensive educational assessment (or, for preschool children, a developmental assessment) should be performed to determine the educational effects of the physical or health disability. The precise educational assessment instruments will vary according to the student’s age and abilities. Assessments will document deficits in areas such as pre-academic functioning, academic functioning, adaptive behavior, motor development, language and communication skills, and social/emotional development. 

First and foremost, students with physical and health disabilities will need a medical evaluation by a licensed physician who provides a diagnosis of the student’s physical or health condition. 

A psychological evaluation may be given if there is a significant deficit in academic or cognitive functioning. However, it is often very difficult to evaluate cognitive abilities when the student has severe physical disabilities and is unable to speak. This is especially the case when the student has not yet learned to use a communication device or cannot do so reliably because of severe motor constraints. Psychological and educational misdiagnosis and misplacement do occur, as they did in the case of Natalie. 

If the educational evaluations demonstrate that the student’s physical or health disability is affecting his or her educational performance, a decision will be made regarding which educational category is most appropriate: orthopedic impairment, multiple disabilities, traumatic brain injury, or other health impairment. Additional assessments will be performed based on the medical and educational evaluations. If the student has a physical disability, motor assessments may be conducted by a physical or occupational therapist. If the pupil has trouble communicating, a speech–language pathologist will conduct assessments to determine the student’s communication abilities and needs at school. If the individual has trouble accessing instructional activities, materials, or assessments, an assistive technology assessment may be performed by the special education teacher in conjunction with the educational team, or the school system may have an assistive technology specialist or team of specialists. If the student requires specialized health care procedures, such as tube feeding, an individual health care plan will be developed, and the student will be assessed to determine if he or she can be taught to perform the procedure. Depending on the student’s needs, other assessments may be performed to determine appropriate educational services for the student. 

Assessment of Students With Deaf- Blindness 

The low incidence nature of deaf-blindness coupled with the scarcity of appropriate assessment instruments presents a unique set of challenges to teachers and other professionals. A team of individuals typically is needed to accurately assess the student with deaf- blindness. Valid assessment of individuals with deaf- blindness dictates collaboration among family members and professionals. The key is to conduct multiple assessments over both time and contexts. 

Unfortunately, norm-referenced assessments are of little value when assessing students with deaf-blindness. Criterion-referenced tests, developmental scales (frequently normed on children without disabilities), and informal observations often yield useful information but may still have limitations. Experts recommend that assessments focus on what the child has learned as well as what he or she needs to learn. Teachers may use authentic assessment to gain useful information. This involves obtaining information about the child during normal activities and across environments to determine what the student knows and the types of situations and settings that assist the child with deaf- blindness to learn. Also, tools are available to assess students that focus on desired outcomes. For example, the Assessment Intervention Matrix focuses on basic daily living skills as well as housekeeping and food preparation. 

A specific example of an informal measure of giftedness is the “jot-down.” Jot-down forms can be used to help teachers focus on behaviors that in combination indicate giftedness. Teachers observe characteristics and behaviors and “jot down” the names of pupils they see demonstrating the behavior described in the box on a jot-down sheet. Using jot-down sheets enables educators to observe students in class and to gather information about them as they encounter new and challenging learning experiences. Behaviors in the boxes on the jot-down sheets may be seen in all children; when observed in clusters, however, they may indicate a child who is gifted and talented intellectually, academically, creatively, in leadership, or in the visual or performing arts. Please note that all characteristics are not seen in a positive light. 

Checklists provide another way of assessing a pupil’s gifts and talents. The Pfeiffer-Jarosewich Gifted Rating Scales for school-age children are one example of an assessment instrument that looks at the various dimensions of giftedness. Teachers evaluate students in the areas of intellectual ability, academic ability, creativity, the arts, and motivation, as well as leadership abilities. Data gleaned from this rating scale can then be used with other sources of information to assist professionals in developing a picture of the student’s strengths. 

Teachers who are knowledgeable about the characteristics of children who are gifted become talent scouts as they document behaviors that are indicative of giftedness in various categories. It is important for educators to understand that giftedness comes in many different forms, each with recognized needs. The needs of students who are gifted and talented in each category arise from strengths rather than from deficits—strengths that make them children with exceptionalities when compared with age peers. 

Obviously, the first step in addressing the needs of individuals who are gifted and talented is to have educators who are knowledgeable about their characteristics. Applying this knowledge allows teachers to recommend the pupil for additional informal and formal assessment and to make accommodations for the student in their curriculum. Parent and peer nominations are also useful in identifying students, and self-nomination is often a good predictor of leadership and creativity potential. 

Tests of intellectual ability provide a formal measure of intellectual giftedness. No child can be fully represented by a number, yet tests of intellectual ability provide important information in identifying intellectual giftedness and planning appropriate modifications and services. Individual measures of intelligence such as the Wechsler Intelligence Scale for Children or the Stanford-Binet Intelligence Scales are preferred to group measures for their ability to present a more comprehensive assessment. Another critical consideration is to look for instruments that are not biased. Up-to-date information on assessment measures is vital to planning and implementing an identification process that is defensible. Once formal measures indicate intellectual giftedness, further assessment should be made to identify areas of the curriculum that need to be differentiated to allow the student to be challenged academically and intellectually.

Formal assessment of specific academic ability can best be made with instruments that remove the learning ceiling. Off-level testing (the use of measures intended for older children) is important in assessing giftedness in a specific academic area. Grade-level achievement tests have a low ceiling and do not allow a child to demonstrate what he or she knows in the particular content area being assessed. Examples of off-level testing are using the Woodcock- Johnson IV Tests of Achievement (Schrank, Mather, & McGrew, 2014) to measure a specific area of reading or mathematics or using the SAT (originally the Scholastic Aptitude Test, and later the Scholastic Assessment Test) with middle school students to ascertain the level of reasoning and achievement in mathematics or verbal ability. Giftedness in a content area can be assessed through academic work, but students who are not challenged often will not show their best effort and produce high-level products. Students who are gifted in a specific academic area usually demonstrate their high level of work when given opportunities to take part in designing the learning experience, allowing them to pursue an aspect of the content area of great interest. Pre-assessing each unit allows the assessment of knowledge and interests in a specific content area to be ongoing and reflect the academic progress being made. 

Creativity is defined in many ways—creative personality, creative products, creative thinking. Measures to assess creativity, therefore, must be chosen to match the kind of creativity that is being identified. Educators frequently assess creativity through creative products or tests of creative thinking. To assess products for creativity, it is wise to have scoring guides or rubrics available to students as they embark on creating the products. Tests by E. Paul Torrance, Frank Williams, and Gail Ryser  are frequently used to assess creative thinking skills. A more recent assessment instrument is the Developing and Assessing Products (DAP) Tool, which uses creativity as one of four components when evaluating student work products. 

Educators often equate leadership with elected positions. Being elected to office, however, is only one possible indicator of talent in leadership. It is best to identify leadership talent by observing behaviors that are indicators of leadership potential. Students should have the opportunity to present a leadership portfolio, including evidence of leadership opportunities outside of school. Leadership may be shown in a specific academic area, one or more of the visual or performing arts, or an area of service. Self-nomination through a portfolio can be coupled with peer nomination. Identifying leadership potential is important in order to match leadership opportunities with young people ready to develop their leadership skills. 

Specialists in a specific talent area are appropriate individuals to assess talent in the visual and performing arts. As experts in the visual and performing arts, they are prepared to recognize talent that is exceptional for a young person when compared with others of the same age and/or background. Products, sometimes assembled in a portfolio, and recorded or actual performances provide the means for assessing talent in the arts. Of course, recognizing and identifying talent is important in order for schools to provide learning opportunities to develop the talent to the highest levels possible. 

School districts should establish policies that reflect best practices in screening and assessment:

~Each district should have a written plan for nominating and identifying students for gifted services.
~The nominating process for gifted education services should be ongoing. 

~Creativity A term with multiple meanings, generally referring to the production of novel or original ideas or products. 

~Screening for services can occur at any point in the school year.
~Assessment should be made in the language in which the student is fluent. 

~Nonbiased measures should be used, taking into consideration ethnicity, culture, developmental differences, gender, economic conditions, disabilities, and environmental influences. 

~Multiple measures include self-nomination, parent and teacher nomination, product and performance assessment, portfolios, and test scores.
~The school district should have written procedures on informed consent, student retention, student reassessment, student exiting, and appeals procedures. 

~Difficulty formulating questions
~Excessive repetition of information
~Incorrect grammar or syntax
~Limited vocabulary

Youngsters with receptive language problems typically have difficulty 

~Comprehending compound and complex sentences
~Following oral directions
~Responding to questions appropriately
~Understanding humor or figurative language

hinders their overall social growth. Research on social skills in adolescents who are deaf suggests distinct differences from their hearing peers in such areas as maturity, knowledge of social mores and attitudes, and social interactions.

Students may receive special education services under the IDEA category of orthopedic impairment due to a wide variety of disorders. These disorders can be divided into three main areas: neuromotor impairments, degenerative diseases, and musculoskeletal disorders. Each of these areas has unique characteristics and contains many different disabilities. It would be an impossible task to discuss all of the rare conditions that may result in physical disabilities. Teachers are encouraged to learn about specific diagnoses by searching reliable online databases such as those sponsored by the National Organization for Rare Disorders (2018b) or the National Institute of Neurological Disorders and Stroke (2018b). Following is a sample of some of the most common orthopedic impairments in the school- age population. 

A neuromotor impairment is an abnormality of, or damage to, the brain, spinal cord, or nerves that send impulses to the muscles of the body. Neuromotor impairments often result in complex motor problems that can affect several body systems (for example, limited limb movement, loss of urinary control, loss of proper alignment of the spine). Individuals with neuromotor impairments have a higher incidence of additional impairments, especially when there has been brain involvement (for example, intellectual disability, seizures, and visual impairments). Two types of neuromotor impairments that fall under the IDEA category of orthopedic impairment are cerebral palsy and spina bifida.

1. Cerebral Palsy. Cerebral palsy refers to a group of nonprogressive disorders of voluntary movement or posture that are caused by damage to a part of the brain that controls muscle movement, occurring before or during birth or within the first few years of life (National Institute of Neurological Disorders and Stroke, 2018a). Cerebral palsy is associated with many different etiologies, including prematurity, complications of pregnancy (such as lack of oxygen), teratogens (such as the TORCH infections), certain genetic syndromes, and acquired causes.

Individuals with cerebral palsy have increased or decreased muscle tone, a lack of muscle coordination when performing voluntary movements, and/or exaggerated physical reflexes (National Institute of Neurological Disorders and Stroke, 2018a). The severity can range from mild to severe. Some mild forms of cerebral palsy may be noticeable only when the person runs and appears to move in an uncoordinated fashion. At the other extreme, individuals with severe forms of cerebral palsy are unable to make the motor movements necessary to walk, sit without support, feed themselves, chew food, pick up objects, or speak.

The four most common types of cerebral palsy are spastic, athetoid, ataxic, and mixed. Spastic cerebral palsy is characterized by very tight muscles occurring in one or more muscle groups. This tightness results in stiff, uncoordinated movements. In athetoid cerebral palsy, the individual will exhibit slow, writhing movements. Persons with ataxic cerebral palsy, or ataxia, have poor balance and equilibrium in addition to uncoordinated voluntary movement. Mixed cerebral palsy refers to a combination of types, such as spastic and athetoid, as in the case of Natalie described at the beginning of this chapter.

Cerebral palsy is classified further by which limbs (arms and legs) are affected. This classification system also is used for other types of motor disorders and paralysis. Some of the major classifications are hemiplegia, in which the left or right side of the body is affected; diplegia, in which the legs are more affected than the arms; paraplegia, in which only the legs are affected; and quadriplegia, in which all four limbs are affected. Natalie’s spastic cerebral palsy is the type in which all four limbs are severely involved. Hence, she is described as having severe spastic quadriplegic cerebral palsy, in addition to the athetoid movement patterns.

Although cerebral palsy is considered nonprogressive because the brain damage does not worsen over time, further complications and additional disabilities may result because of increased or decreased muscle tone. Many individuals develop contractures (the permanent shortening of muscles that results in the inability to fully extend a joint, such as being unable to fully extend the arm at the elbow or completely straighten at the knees) that further decrease motor movement and function. Atypical muscle tone can result in conditions such as curvature of the spine (scoliosis) and hip displacement because of the constant pull of muscles due to high tone or the lack of support on the joint from muscles with low tone. Abnormal oral reflexes may decrease the ability to chew and swallow proficiently, which might result in a need for a feeding tube (a tube going into the stomach through which nutritional liquids are given) if the person is unable to eat sufficient amounts of food. Individuals with cerebral palsy have an increased incidence of other disorders, including epilepsy, visual impairments, speech–language impairments, as well as intellectual disability (Johnson, Chin, & Hoon, 2019). However, cognitive ability can range from giftedness to intellectual disability, and accurate scores can be difficult to obtain, particularly when the person’s speech is affected. At present, there is no cure for cerebral palsy. Cerebral palsy often is managed through medication (such as the muscle relaxant baclofen) and/or surgery to reduce or prevent physical deformities related to atypical muscle tone. These treatments may reduce some of the effects of cerebral palsy, but movement abnormalities will remain. Part of a student’s treatment regimen may include the use of various braces or splints, known as orthotics, to help maintain alignment and decrease the development of contractures. New, experimental treatments are under investigation in the hope of improving motor function.

2. Spina Bifida. During the first twenty-eight days of pregnancy, special embryo cells form a closed tube that will become the brain and spinal cord. When this process is interrupted and the tube does not completely close, a congenital abnormality known as a neural tube defect occurs. When it occurs in the area of the spinal cord, a condition known as spina bifida (or “split spine”) results. In the most severe form, myelomeningocele spina bifida, the baby is born with a sac protruding from an opening in the spine that contains part of the spinal cord. Because the spinal cord becomes injured while growing outside of the spinal column, it does not function properly at the point of the sac and below (Spina Bifida Association of America, 2018). Surgery will be performed to remove the sac within the first few days of life, but the damage to the spinal cord cannot be reversed. Since 1996, some babies born with myelomeningocele spina bifida have had surgery while still in their mothers’ wombs. The results of a seven-year, multicenter study demonstrated that fetal surgery has some early advantages over surgery after birth in terms of reduced rates of hydrocephalus (buildup of cerebrospinal fluid in the brain) and higher rates of independent walking by 30 months of age. Additional research is under way to determine if the long-term effects of fetal surgery are worth the risks posed to the mother during surgery and the risk of preterm delivery or infant mortality. 

The characteristics of myelomeningocele spina bifida depend on the location of the defect. As with a spinal cord injury, there will be a lack of movement and sensation below the area of injury. Although the defect can occur anywhere along the spinal column, it typically occurs in the lower part of the spinal cord. Usually, the individual will have difficulty walking, but may be able to do so with braces, crutches, or a walker. Some children will need a wheelchair for long distances, and others may only have independent mobility with use of a wheelchair. In addition, many students will need to perform a clean intermittent catheterization procedure in order to empty their bladders. Children with spina bifida have an increased frequency of latex allergies, thus requiring the use of latex-free gloves and avoidance of latex products such as latex bandages and latex balloons.

Students with spina bifida are at risk for increased buildup of fluid in the brain, or hydrocephalus. To treat hydrocephalus, a shunt (small tube) is placed under the skin from the brain and usually into the abdominal area to drain the excess fluid. It is important for teachers to know the signs and symptoms to look for should the shunt become blocked. Representative symptoms include headache, irritability, vomiting, crossed eyes, inability to look up, difficulty swallowing, lethargy, worsening arm or leg function, seizure, and worsening brain function (for example, deterioration in school performance, emotional or personality changes). Sometimes the symptoms are subtle and not easily detected. However, if a shunt blockage is suspected, the teacher will need to notify the appropriate personnel and student’s parents immediately. If the shunt is failing to drain properly, the child will need shunt repair surgery to avoid lasting effects due to increased pressure within the brain. 

Many individuals with spina bifida and hydrocephalus are at risk for executive functioning deficits that can affect their learning. This may include deficits in such areas as shifting and sustaining attention, memory, recall, organization, visual-perceptual skills, inhibiting behaviors, and navigating complex social situations. Some children with spina bifida have difficulty with language skills such as comprehension, initiating and maintaining conversations, interpreting meaning in complex conversations, mentally organizing verbal responses, and exhibiting verbosity. Adaptations and skillfully designed instructional strategies are needed in order to provide an appropriate education for these pupils. 

Degenerative diseases that affect motor movements make up the second group of disabilities within the category of orthopedic impairment. Degenerative diseases typically are grouped separately because of their unique and poignant impact on individuals. The student with a degenerative disease will need increasingly more complex adaptations and assistive technology to permit continued participation in school activities. Additionally, teachers who work with students who have degenerative conditions are confronted with emotional issues regarding the loss of capabilities and dying. One of the most common degenerative diseases in school-age children is Duchenne muscular dystrophy. 

 
Muscular dystrophy includes a group of inherited diseases characterized by progressive weakness of skeletal muscles from degeneration of muscle fibers. When an infant is born with Duchenne muscular dystrophy, no disability is initially apparent. 

Usually by age 3, leg weakness begins to manifest in difficulties with walking and running, often resulting in frequent falls. During the early school years, these children may walk on their toes or the balls of their feet with a waddling gait and pulled-back shoulders. They may have trouble raising their arms and may fall frequently, in addition to experiencing difficulty walking long distances and getting up from the floor. Usually between 7 and 12 years of age, the individual cannot walk and requires a wheelchair. Through the teenage years, muscle weakness continues, and the adolescent is no longer able to push a wheelchair; consequently, a power wheelchair is often needed. Over time, it becomes increasingly difficult to move the arms or keep the head upright. As the muscles used for breathing weaken, most individuals will develop heart and/or respiratory complications and die in their 20s. Life expectancy into the 30s, 40s, and even 50s, however, is becoming increasingly common. 

There currently is no effective treatment for Duchenne muscular dystrophy. The aim of treatment is to try to maintain functioning and help the person maintain some degree of independence as long as possible. Physical and occupational therapies as well as braces and splints are used in an effort to prevent deformity of the legs and arms. Proper positioning is important to reduce development of scoliosis. Medications are frequently prescribed for a variety of problems, such as respiratory infections and heart conditions. Surgeries may be performed to release contractures or stabilize the spine. 

About one third of students with Duchenne muscular dystrophy have mild learning difficulties because of changes in a brain chemical (dystrophin) associated with this disease. Cognition, however, remains stable as the muscles degenerate. These students will need strategies and adaptations to make learning accessible. Teachers need to be observant of the disease’s progression and inform the special educator if problems develop. Sometimes, worsening problems indicate that the pupil’s assistive technology needs modification. For example, a student who was using a pencil to write may need to change to a keyboard and then to a smaller adapted keyboard as motor movements are lost and fatigue increases.


Musculoskeletal Disorders 

The severity of physical disability varies greatly for students with musculoskeletal disorders. Although some musculoskeletal conditions can result in severe physical limitations, most musculoskeletal disorders are not accompanied by cognitive, learning, perceptual, language, or sensory issues to the extent that is found in many neuromotor impairments. Two examples in this category are juvenile idiopathic arthritis and limb deficiencies. 

1. Juvenile Idiopathic Arthritis. Juvenile idiopathic arthritis (JIA) is a chronic arthritic condition affecting the joints that occurs before 16 years of age and lasts more than six weeks. Although there are different types of JIA, the main features are joint effusion (swelling of the joint) that may be accompanied by reduced range of motion, pain on movement, and warmth over the affected joints. Morning stiffness and more prominent pain in the morning or after inactivity are typical. Over time, this disease may go into remission, stabilize, or progress and cause permanent deformity of the joints. The disease may result in additional disabilities such as contractures and visual impairments. Treatment of JIA consists of aggressive interventions using a range of medications with an aim of early disease remission.

As with any condition that involves pain, students’ learning will be affected when pain is present. Fatigue and lack of stamina also may interfere with learning. Students with juvenile idiopathic arthritis often need adaptations to address these issues. For example, sitting too long may result in stiffness and pain when getting up. The student may need to stand or move around the classroom periodically during instruction. Pupils with JIA may need to leave class early in order to get to their next one to avoid being bumped in the hallways. In some instances, adaptations of writing assignments may be necessary such as decreasing assignment length, increasing time for completion, or allowing a classmate or adult to serve as a scribe as the student dictates. If significant joint deformity has occurred, assistive technology (such as an adapted keyboard or a speech-recognition app) may be required. 

2. Limb Deficiency. A limb deficiency refers to any number of skeletal abnormalities in which a limb, or more than one limb, is partially or totally missing. A student may be born missing an arm or a leg or may lose a limb in an accident. Typically, individuals with limb deficiencies will be fitted with prosthetic devices (artificial limbs). There are many different types of prosthetic devices with different levels of complexity. A student may have a leg prosthetic that allows for walking and running or an artificial hand that permits grasping and writing. If the limb has been missing from birth, the child may have learned to do things using other limbs. For example, some individuals who are missing both arms can write or type and feed themselves with their feet. Whether a prosthetic device is used or not, many students with limb deficiency require adaptations and may need specialized instruction in such areas as one-handed keyboarding.


Characteristics of Students With Multiple Disabilities 

Multiple disabilities is an umbrella term under which various educational, rehabilitation, government, and advocacy groups include different combinations of disabilities. In IDEA, this category refers to persons with concomitant impairments whose needs cannot be met in a special education program designed solely for one of the impairments. Although there is no single definition, the term does imply a combination of two or more disabilities that creates an interactional, multiplicative effect rather than just an additive one. Some examples include learners with the following conditions: 

~Behavior disorder and muscular dystrophy Cerebral palsy and deafness
~Intellectual disability and spina bifida Learning disabilities and asthma 

~Depending on the type of multiple disabilities, cognitive functioning may vary from giftedness to profound intellectual disability. Usually there will be a need for adaptations, assistive technology, and specialized teaching strategies.

Characteristics of Students With Traumatic Brain Injury 

Traumatic brain injury refers to temporary or permanent injury to the brain from acquired causes such as automobile accidents, accidental falls, sports injuries, recreational activities, and even gunshot wounds to the head. The term does not include congenital or degenerative conditions or birth trauma. It is estimated that approximately 2.8 million people in the United States have experienced a traumatic brain injury resulting in a visit to an emergency department, hospitalization, or death (Centers for Disease Control and Prevention, 2018f). Traumatic brain injuries can occur at any age, including in very young children; however, one of the highest rates of injury occurs among teenagers and young adults. 

The effects of an injury will differ depending on the cause. A penetration injury, such as a bullet going through the brain, will result in certain specific effects. The effects of the injury are usually localized to the site of injury, with secondary effects occurring in other areas as a result of complications. 

An acceleration injury arising from a car accident results in diffuse damage throughout the brain. When the head hits the steering wheel of a car, for example, the brain (which is floating in cerebrospinal fluid) is thrown violently forward against the skull. The injury to this initial site of impact is referred to as coup. The brain is then thrown backward and hits the back of the skull. The injury to this second site of impact is known as contrecoup. The brain continues to move back and forth, hitting against the skull, and suffering further damage against any sharp bony protrusions. Often the brain will be twisting as well, breaking and damaging nerve cells throughout. The result is diffuse damage across the brain. Complications such as hemorrhage (bleeding) and edema (swelling) often cause further damage to the brain. 

The effects of traumatic brain injury range from no lasting effects to ongoing, severe disabilities. Most head injuries are mild, with no abnormalities found on neurological exams, and the person often does not require medical treatment. Even following a mild injury, however, problems such as headache, fatigue, distractibility, memory problems, and perceptual motor slowing can occur and persist for months, for years, or permanently. These problems often go undetected until difficulties arise during classroom activities. In one case, a girl fell out of a window and was taken to the emergency room. Although she had no apparent damage, she failed the school year. In retrospect, the teacher and parent were able to trace the student’s academic difficulties as beginning after the accident and realized that some cognitive deficits must have occurred. 

• Highly inquisitive 

• Demonstrates interest in a variety of areas/activities
• Generalizes knowledge to novel settings 
• Intellectually curious 
• Highly motivated, persistent learner 
• Sees relationships among seemingly unrelated items, facts, and ideas 
• Early reader 

• Exhibits sustained attention and concentration 
• Excellent memory 

• Highly verbal 

• Generates elaborate and possibly nontraditional responses to questions
• Good problem- solving skills
• Conceptualizes and synthesizes inform

Social and Emotional Characteristics 
• Works well independently 
• High energy level 

• Self-confident 

• Exhibits qualities of leadership 
• Relates well to older classmates, teachers, and adults 
• Sensitive and empathetic 
• Intrinsically motivated 
• Risk taker 

• Critical of self, strives for perfection 
• Concern for justice and idealism 
• Intense 

• Dislike of routine, rules, and regulations 
• Likely to have internal locus of control 

~Allowing sufficient time for the student to respond Being 
   patient
~Modeling correct speech
~Prohibiting ridicule of speech difficulties/errors Repeating 
   important phrases 
~Slowly giving directions, repeating if necessary Using    
   gestures to clarify information
~Using graphic organizers and visual aids
~Using short sentences 

• Allow extra time for low vision readers, as they may experience eye fatigue. 

• Provide reading materials to the teacher of students with visual impairments in advance to be enlarged, scanned, Brailled, or recorded. 

• Textbooks and books commonly used in educational settings are available electronically. 

• Recreational books in recorded or Braille format can be ordered through the National Library Service for the Blind and Physically Handicapped (www.loc.gov/nls). This is a free service, but users must be registered before ordering. 

• Many local library systems have popular books available electronically.

Writing:
• Some pupils with low vision need dark, bold, or raised line paper for writing assignments. 

• Some individuals will need to use an electronic device for completing written assignments. 

• Braille readers may receive Braille assignments and transcribe them into print. 

• Some Braille readers use an electronic Braille note-taker for written assignments. The assignment is entered in Braille and then translated into a print copy for the classroom teacher.

Note-Taking:
• Students with visual impairments may take notes on their Brailler, electronic note-taker, or computer. 

• Any notes written on the board should be spoken aloud for the pupil who is visually impaired. 

• Students with visual impairments should be seated as close to an object or a display as possible. 

• Keep information in a visually simple and organized format for all students with visual perceptual difficulties. 

• Use high-contrast writing tools when using an overhead, a chalkboard, or a dry-erase board. 

• Use of a touch screen attached to the student’s or the classroom computer can provide the individual with an accessible version of the notes. 

• Use of a touch screen with text conversion software allows the student to access the electronic version of the notes with a screen reading or voice output program. 

~Use adaptations and assistive technology as determined by the special education teacher and educational team to provide access to the learning environment (for example, slant board and stabilization of material on desk, alternative keyboard, augmentative communication device, books and worksheets scanned into computer).

~Assist students with physical disabilities to participate as much as possible in classroom activities requiring a motor response (for example, help student manipulate materials, partner student with peer to assist each other with task).
 
~Use a variety of systematic instructional strategies that effectively address the student’s individual learning needs (for example, learning strategies, content enhancement strategies, antecedent prompts, response prompts).

~Use specialized instructional strategies specifically developed for students with physical disabilities as appropriate (for example, teach students who do not use verbal speech to use internal speech to decode words using the Nonverbal Reading Approach). 

~Assist students who use augmentative forms of communication to learn to use their communication devices successfully across learning and social environments during the school day. Also, allow students to answer questions using their most reliable form of communication.

~Allow more time for the student to respond, take tests, or hand in assignments when oral or written communication is affected by his or her disability.

~Adapt assignments or tests to accommodate the student’s disability (for example, reduce paper tasks, break up assignments into shorter segments, alternate test or assignment format). 

~Maintain a safe, healthy environment by observing for health- related problems and knowing the steps to take should a problem occur (for example, seizure, fatigue, medication side effects). 

Effective instruction for learners with gifts and talents involves five steps: 

Step 1. Pre-assess. 

Once you have planned the unit of study, the starting point in planning differentiation must be to pre-assess. 

Step 2. Group children for instructional purposes. 

Pre-assessment results provide information to help you decide which students can be clustered for instructional purposes for a particular unit of study. Grouping facilitates learning, providing the vehicle for differentiating learning experiences. 

Step 3. Match learner experiences to the pre-assessment data (level of readiness and/or interests). 

Differentiation does not just mean providing different learning experiences or offering choice; rather, differentiation is the intentional match of content (basic to complex), process (level of cognitive skill), and product (visual, written, oral, kinesthetic, and technological).

Step 4. Provide products (ways to demonstrate what has been learned) that will motivate and teach. 

A variety of products can be used that will allow students to show what they have learned but in ways that will motivate them to learn. 

 
Step 5. Reflect, reflect, reflect. 

Learning experiences that remain isolated do not promote lifelong learning. If learning is to be ongoing, it is essential to reflect on what has been learned and what one wants to learn next.