1

Assessment ofYoung Children

with Severe MultipleDisabilities

Jan van Dijk, PhD, Catherine Nelson, PhD - APH

For use at AER Conference

March 2012

2

Areas to Assess and Data Collection

Developmental Skills using tools such as INSITE, HELP, Callier

Qualitative Aspects (biobehavioral states, sensory channels)

Vision (Functional Vision Assessment, CVI Range)

Communication Matrix Write a case story about the child Progress on IFSP/IEP goals

3

Child Guided Strategies: The Van Dijk Approach – APH

8 observation areas to conduct assessment:

1. Behavioral state2. Orienting response3. Learning channels4. Approach –

Withdrawal5. Memory6. Social Interactions7. Communication8. Problem Solving

4

General Guidelines

1. Prior to Assessment: interview2. Beginning the Assessment:

respect/adapt environment, emotions, interests and respond to behaviors.

3. Establish a Routine – turn-taking conversation and anticipation

4. Modifying Routine- add dilemma, delay your response, observe arousal patterns, create learning experiences.

5

Hannah and Brian clips 1-3 H, 12-13 B

7 Y.O., HIGH MYOPIA, CVI AND UNDETERMINED HEARING LOSS. VOCALIZES, NO WORDS, WOLF HIRSCHHORN SYNDROME

25 MONTHS WITH ZELLWEGER (DEGENERATIVE), LP, VERY TIRED, DID HAVE WORDS.

6

Information Processing in Infants

7

Behavioral State

Controlled by internal needs and external environment

Children with impairments of the CNS have difficulty moving smoothly between states and controlling/maintaining their states

These children may become easily over stimulated and agitated if there with too much stimuli or move into a sleep state to protect themselves.

8

Techniques for Assessing Behavioral State

Ensure the child is mostly in either a quiet awake or active awake – optimal learning

Gather info about the variety of states, sleep patterns, wake patterns.

Watch the child for signs of overstimulation (examples?).

CRIB – Carolina Record of Individual Behavior

9

10

7:30 8:00 8:30 9:00 9:30 10:00 10:30 11:00 11:30 12:00 12:30 1:00 1:30 2:00 2:30 3:00 3:30 4:00 4:30

Sunday

Monday

Tuesday

Wed

Thursday

Friday

Saturday

Sunday

Monday

Tuesday

Wed

Thursday

Friday

Saturday

Comments

Directions: Mark the state the child was predominantly in at the end of each half hour interval. Refer to the attached handout for a description of the states and examples of comments.

0 - Seizure1 - Deep Sleep2 – Intermediate Sleep3 – Active Sleep4 – Drowsiness

5 - Quiet Awake6 - Active Awake7 – Fussy Awake8 – Mild Agitation9 – Uncontrollable Agitation

Adapted from the Carolina Record of Individual Behavior (CRIB) Rune J. Simeonson

a.m. p.m. p.m.

11

Let’s Take a Peek! – observation worksheet

What behavioral state is Hannah in during clips 1 and 2?

In what states do you see Brian? How does he control his state and protect himself?

Repetition soothes, variety awakenscalming stimuli (slow, rhythmic, firm, warm) vs. arousing (fast, irregular, bright, cool, irregular rhythm an varied vocal patterns)

12

Orienting Response

Crucial to information gathering and learning (Als et al., 1976, Richards and Richards, 1997, Van Dijk, 1997)

Determine by our internal state Too much? Too little?

13

How does a child gather information (assessment of orienting)

Consider: Type of stimuli that gathers attention Intensity or strength that attract Sensory channels used to gather info Sensory channels to show that he is orienting The child’s behavioral state

Hannah – 1 and 6, Brian 5 and 9 worksheet review

14

Intervention Strategies

Bring the child’s state up to an awake level

Present stimuli in a way they can perceive – limit to one stimulus to start.

Highlight and draw attention for them Incrementally add more stimuli, watching

for overload

15

Learning Channels

Observe child’s orienting responses carefully to see which sensory stimuli attract attention.

Ask others for a list of what they have seen the child respond to

Watch for responses to:Vision, Sound, Touch, Vibration, Movement• Do they use more than one sense at a

time?Engaging vs. disengaging?Routine vs. novel

16

Hannah – clip 5, Brian, 3,4 10

Which learning channels does Hannah use in this video clip and what sensory channels does she use to respond. How does she respond when the tie goes from side to side rather than up and down?

How does Brian respond to the voice of the assessor and then how does he respond to the voice of his mom? Which learning channels does he us and which does he use to exhibit responses?

17

Intervention Strategies

Build on sensory strengths and plan learning around those.

Pair weaker sense with a stronger one.

18

#4 Approach-Withdrawal

Likes = Approaches – Starting points for building routines

vs. Dislikes = Withdraws -

19

Habituation

Filtering out what is meaningful and what doesn’t need attention. Info must be processed and compared to what

we have previously learned Neutral stimuli – change attention to

something more important if stimulus is familiar or neutral

Minimally aware of the habituated one unless it changes (child’s cat) – dehabituation.

20

Perception, time and missing components – oh,

my!!!

21

Assessing Habituation and Dishabituation

Does the child turn their attention from an oriented stimulus to another?

How long (how many times) does the stimulus need to be presented?

Does the child attend again if features change?

Does the child have different reactions to different stimuli?

22

Back to Hannah((1) and Brian(4) :O)

Hannah - Why did she turn away? How long before she

habituated? Did she return attention

or dishabituate with the singing?

What would you suggest for intervention?

Clip 7 - What techniques is Dr. van Dijk using to help her develop object permanence?

BrianClip 4 -What happens

when mom begins to talk?

Clip 11 – to which of the stimuli is Brian attending?

Clips 10 & 11 – what does Brian do when the balloon is no longer within reach of his hands?

23

Intervention for Habituation

Provide increased time Highlighting the important features and

pointing them out = generalization and discrimination

Information presented in context – within complete schemes and not fragments

Eliminate extraneous stimuli (auditory or visual, i.e.) as needed.

24

Anticipation and Routine Learning

25

What the baby learns

Cry brings mom Phone ringing may interrupt this Unpredictable environment but mom still

exists even if out of sight Crying bring her back. Mom’s footsteps = goood

Phone ringing = opposite Child learns communication through the

intentional use of crying

26

Infant with Deafblindness

Infant may not see or hear mom coming = difficulty learning object permanence.

Doesn’t hear the phone and doesn’t see his mother walk away, cries failed=unpredictable, scary environment :O(

27

Assessing A/R Learning

ROUTINES - key is the establishment of predictable and interest ones

Pause – let the child communicate a desire for routine to continue

Mismatch or surprise added to see how well routine was learned

Discontinue –assesses memory of the routine and then come back.

**Memory Observation Checklist**

28

Observing A & R Learning

Hannah – clip 5

What stimulus does H initially use to follow the routine of the tie moving?

As the routine continues, what does she use?

At the end, how does Hannah demonstrate anticipation?

How does she react to the mismatch of tie on head?

What does this indicate about Hannah’s functional use of objects?

29

Intervention Strategies

Establish consistent and understandable chains or routines which are based on child’s interest. Begins with imitating what the child does and

expand. At each step, the child should be given

opportunities to demonstrate anticipation – slowlyDaily activities = important context for learning

routines.Routines = complete activities which include

preparation, the activity, clean up, and transition (i.e., calendar boxes or schedules).

30

Social Interactions

Secure attachment can be threatened by: Time in the NICU Health problems lower interactions If arousal is low and awake states low, no time Too high of arousal and they are

overstimulated Unusual or difficult to read communications Limited ability for the child to read caregiver

cues.

31

Assessment of Social Interaction

Interest in human faces and voices

Examine attachment (separation)

Ability to engage in turn-taking interactions.

32

Techniques for Assessing – worksheet in handouts

What do you think about Hannah’s attachment with her mother?(clip 8)

Why is it important that she reaches out and touches Dr. VanDijk?(clip 3)

Does Hannah take her turn , if so, what does she do when it is her turn?(clip 4)

How does Brian take his turn? (clip7)

Does Brian initiate new actions?

33

Intervention Strategies

Should involve caregivers – the need assistance as they learn to read their child’s unusual social and communicative cues and then adjust their behavior according to the child’s cues. Learning the nuances of the child’s behavior and emotions is increased as proximity to the child increases (van Dijk, Carlin & Hewitt, 1991).

Caregiver should follow each of the child’s movements and the pause to allow the child to take a turn. Read the child for engagement and disengagement.

When disengagement occurs, caregiver should give him a break to avoid overstimulation

34

Engagement and Disengagement Cues

35

36

37

38

39

http://www.designtolearn.com/pages/matrix.html

The Communication Matrix (©1996, 2004 Charity Rowland) is a

communication skills

assessment instrument.

Project PLAIBy Deborah ChenVideo and Manual

on Developing EarlyCommunication withInfants and Toddlers

who are Deafblind

Assessing Communicationand Learning in Young

Children who are Deafblindor Who Have Multiples

DisabilitiesDesign to Learn

Look at Early Communication

40

Assessing Communication

Choices Enjoyable ,

motivating Intent behind all Look at behavior

before and after Wait time Need Start-stop

technique

41

Intervention Strategies

Respond to all attempts – if not reinforced, they will fade away or be replaced by unwanted communication

Take time, carefully observe and try to understand communicative meanings behind a child’s behaviors (Durand and Crimmins, 1998)

42

(con’t)

Warm communicative environment – communication partners are sensitive to each other and pause to allow the partner to take his turn - child with MD may take longer to process

Routines facilitate communication – they give the partners a shared subject/topic – calendars, not just for transition.

Nonsymbolic as well as symbolic – should continue after symbolic comm is established

Communication is NEVER separate from other developmental areas.

43

Problem Solving

Previous skills are also used in problem solving. Must be alert and

aware Maintain attention Integrate

previously learned info into schemes

Cause and effect

44

Techniques for Assessing Problem Solving

Begin a routine and then stop to create a need for a child to begin it again.

After they are comfy, add a dilemma.

Provide enough time See how long the child

persists and what techniques they use to solve.

Problem Solving Worksheet

Hannah – clip 6 does she attempt to

solve the problem of tie on head?

does she persist?Brian – clip 5 what leads you think

that Brian understand cause and effect?

which of the techniques that Brian uses demonstrates a beginning concept of means-end?

45

Problem Solving Intervention Strategies

Be sure there is a need to practice skills They could acquire the “good fairy

syndrome” when things are brought and taken easily away.

These children could become very passive.

As they are actively involved this syndrome can be cured easily if they are involved in ALL stages of activities.

46

47

48

Position State Leg Mouth Eye Ear Cheek Chin Neck Head Arm Shoulder Hand Foot Other

Initial

#1 Supine Changes

Main

Initial

#2 Prone Changes

Main

Initial

#3 Sidelying Changes

Main

Initial

#4 Sitting Changes

Main

Child: Date: Observer: Location:

Summary

Position Voluntary/Intentional Movements Possible in this Position

IFSP/IEP Activities for this Position Staff State Observations

Supine

Prone

Side

Sitting

Adapted from Every Move Counts

49

Case Study Stories Discuss child’s medical conditions and

treatment, results, prognosis. Discuss interventions, team involved,

how often seen and by whom. Share family’s story and impressions.

How would child be different without EI? How would family life be different without EI?

Discuss what child was like in the beginning, how he/she changed, what doing now; the progress.

Discuss child strengths, concerns, etc.