Severe Multiple Handicaps Research Articles

Modellprojekt „Wohnen mit Intensivbetreuung (WmI)“: Die Sicht von Stiftung und Mitarbeitenden

The Fürst Donnersmarck-Foundation (FDSt) initiated the housing projekt 'Living Independently with Intensive Support (WmI)' to show that such a concept is feasible even with persons with severe multiple handicaps. It is reported how financial, organisational and communicative problems can be solved. Overall, the housing project is not much more expensive than inpatient concepts, but a change of traditional concepts of administration was required. The new service mode presupposed a careful preparation and high motivation of the staff. Finally, existing discrepancies between traditional and modern concepts could be resolved.

MRI of the head in the evaluation of microcephaly.

Fifty-five patients with microcephaly (head circumference < -2SD) were identified. The 55 patients were divided into two groups, consisting of group 1 (34 cases) in which genetic causes were considered primary, and group 2 (21 cases) in which intrauterine and/or postnatal acquired factors were thought to be responsible. MRI abnormalities were present in 80% of the total series: 68 and 100% in groups 1 and 2, respectively. In group 1, migration abnormalities were the most prominent and mental retardation was the major neurological handicap, while in group 2, hydranencephaly and infarction secondary to brain circulatory derangements were the most frequently observed abnormalities, with severe multiple handicaps such as cerebral palsy, epilepsy and mental retardation seen. Head MRI was considered indispensable in the investigation of the causes of microcephaly and in determining the neurological prognosis of affected patients.

Assessment of reinforcer preference in multi-handicapped students

This study investigated the use of electronic adaptive devices (switches) with students with severe multiple handicaps. In Experiment I, studients were assessed on “contingency awareness” by evaluating their responding to feedback from toys contingent upon switch activation. In Experiment II, students were given an opportunity to select preferred modalities of feedback contingent upon switch activation (i.e., reinforcer preference testing). The results of Experiment II showed that students with multiple handicaps can learn to use switches to control stimulus presentations and to identify reinforcers. These finding are discussed in terms of their classroom applications and implications.

Augmenting Assessment Procedures for Children with Severe Multiple Handicaps and Sensory Impairments

Functional visual assessments of children with severe neurological and physical handicaps are difficult to conduct and frequently do not provide clear guidelines for training. The addition of a learn a routine procedure, which capitalizes on the child's interest of the moment, provides information on the child's patterns of responses, ability to accommodate to variations of a stimulus, and strategies for interaction.

The effects of fifth graders' socially directed behavior on motor and social responses of children with severe multiple handicaps

Two elementary-aged boys with severe, multiple handicaps participated in social play activities with nonhandicapped fifth graders. Increases in all participants' socially directed behavior were observed consistent with teachers' instructions to play together. In addition to social behavior increases, both boys with handicaps showed increases in targeted motor responses when interacting with the fifth graders. Donald, for example, substantially increased the amount of extended arm reaching and grasping/manipulating. David increased the amount of time he kept his head in either a full or partially upright position. The results of the investigation are considered in terms of extending the positive outcomes of handicapped-nonhandicapped peer social interactions.

USE OF NEGATIVE REINFORCEMENT IN THE TREATMENT OF SELF‐INJURIOUS BEHAVIOR

Behavioral assessment procedures were used to determine the maintaining conditions of self-injury exhibited by 2 children with severe multiple handicaps. For both children, negative reinforcement (escape from grooming activities) was determined to be the maintaining reinforcer for self-injury (hand/arm biting) within an alternating treatments design. The treatment packages involved the use of negative reinforcement (brief escape from grooming activities) contingent upon a behavior that was incompatible with self-injury (reaching and pressing a microswitch that activated a pre-recorded message of "stop"). Treatment was evaluated with a reversal design for 1 child and with a multiple baseline across grooming activities for the 2nd child. The treatment led to a marked decrease in self-injury for both children. At follow-up, high rates of self-injury were reported for the 1st child, but low rates of self-injury and an increase in task-related appropriate behavior were observed for the 2nd child.

THE USE OF BEHAVIORAL ASSESSMENT TO PRESCRIBE AND EVALUATE TREATMENTS FOR SEVERELY HANDICAPPED CHILDREN

Behavioral assessment procedures were used to prescribe and evaluate treatments of maladaptive behavior for 2 children with severe multiple handicaps. In Experiment 1, the results of an assessment of reinforcer preference were used in conjunction with a functional analysis of the conditions maintaining self-injurious behavior to prescribe a treatment for a child with severe disabilities. The treatment procedure involved the use of a pressure-sensitive microswitch to activate reinforcing stimuli during two solitary conditions, during which self-injurious behavior had occurred at high rates. The results were evaluated with a multiple baseline across settings design and indicated that self-injury decreased with concomitant increases in microswitch activation. Results were maintained at 6 weeks, 8 weeks, and 6 months. In Experiment 2, the results of behavioral assessments of reinforcer preference and self-injurious behavior were combined to develop a treatment for a second severely handicapped child, who exhibited high rates of self-injury in demand situations. This treatment was evaluated with a multiple baseline across tasks design and resulted in the elimination of self-injury for up to 15 months.

Head-erect behavior among three preschool-aged children with cerebral palsy.

This article presents the results of a multiple baseline design, across subjects, to assess the effect of vibratory stimulation on head-erect behavior in subjects who were prone. The subjects were three children with severe multiple handicaps whose mean age was 2 years 4 months and whose conditions included seizures and muscle tone disorders. Frequency of head lifts and cumulative duration of head-erect behavior were recorded during three-minute sessions with the subjects positioned prone on their forearms over a wedge. After baseline observations were recorded, vibration was applied to the paraspinal muscles of the neck and upper back for the first two minutes of each intervention session. In addition, electromyographic activity was recorded for a three-minute session at least once during both the baseline and intervention conditions. Results of the study demonstrated an increase in the cumulative duration of head-erect behavior for the three subjects and an accompanying increase in EMG activity during muscle vibration. The diversity of handicapping conditions (ie, seizures, hypertonia, and hypotonia) appeared to have no effect on the benefits received from muscle vibration for these subjects. Limitations of the study and implications for future research are discussed.

Surgical Treatment of Myelomeningocele

With the spread of a policy that the infant with myelomeningocele should receive surgery as early as possible after birth, the survival rate of the infant with this serious malformation has greatly improved. However, this early operation for myelomeningocele has also increased the number of severely handicapped survivors. Such a dilemma in treatment of myelomeningocele forced some clinicians to select the patients for surgical treatment. Lorber advocated a policy of strict selection in which the infant with severe paraplegia, severe hydrocephalus, kyphoscoliosis, or other gross malformations should be managed conservatively without any surgical intervention. During 1969-80, 77 unselected infants with myelomeningocele received early operations almost within 48 hours after birth. There were 25 infants who had one or more of Lorber's adverse criteria on admission, out of which 13 patients (52%) are still alive. All of these survivors, however, have severe multiple handicaps especially in locomotion and bladder control. By contrast, of the remaining 52 infants who did not have any of Lorber's criteria, 45 (86.5%) are alive and 33 have no or only moderate handicaps. Severe mental retardation occurred in 6 survivors, 4 of which were those with Lorber's criteria, but this extreme handicap could be considered the result of diffuse ventriculitis caused by infection at the myelomeningocele site. It is true that the future status in locomotion may be predicted by assessment of the leg movement of the neonate, but intellectual potential cannot be determined even when complicated with hydrocephalus. The most decisive factor influencing the functional prognosis of an infant with myelomeningocele should be its intellectual quality. Until an appropriate evaluation method for the intellectual potential at birth is established, all infants with myelomeningocele should be treated surgically regardless of the neurological status at the neonatal period.

Delayed cutaneous hypersensitivity in children with severe multiple handicaps treated with phenytoin.

Peripheral lymphocyte counts, T-cell and B-cell populations, DNCB skin reactions, Mantoux reactions, mitogenic transformation using PHA, and determination of serum phenytoin concentration were carried out in 45 children with severe handicaps. Twenty two of these patients were receiving phenytoin treatment. When compared with control subjects, the skin reactions were significantly depressed in the handicapped children, amongst whom those treated with phenytoin had more impaired reactions than those who were untreated. No significant relationship between the results of the skin reactions and the other parameters was found.

Changing pattern of disease and disability in schoolchildren in England and Wales.

One appreciates how much has been achieved in these islands when one visits a developing Asian or African country where there is still a mass of untreated physical disease among children, including tuberculosis, diphtheria, typhoid, virulent measles, the tropical diseases, and severe malnutrition. But already in these countries there are doctors and educationists who recog nize that there are also boys and girls with emotional and behaviour problems, and with speech and language disorders, for whom there is no diagnostic, treatment, or special educa tional provision, and whose needs are submerged by the many with gross and grave physical illness. Recently I visited two of these countries, one in Africa the other in Asia, where there was only one psychiatrist in each. One of the countries had a single mental hospital with a nominal 700 beds for adults and children but, on average, 1,500 inpatients, more than half of whom had to lie on the stone floor of the wards. The other country had 100 psychiatric beds for an estimated population of about 12 million; patients, including children, who were considered to be refractory were sent to a home for the destitute. Though such conditions no longer exist in this country we have no cause for complacency. It must be emphasized that children wiith handicaps and disabilities do not often fall naturally into clear-cut separate categories. It is administratively convenient to have categories of handicapped children, but, in fact, many handicapped boys and girls have more than one disability; children with severe multiple handicaps, particularly those with grave defects of hearing and vision, present specially difficult problems to the medical, educational, and social services and, not least, to their parents. Parent counselling is vitally important but is outside the scope of this lecture. Though most schoolchildren with severe handicaps and dis abilities are in special schools quite a number attend the regular classes of ordinary schools, as do many children with less severe handicaps. There is still much to be learnt about what is the best educational provision that it is practicable to arrange for handicapped children, and the more closely the educational and medical services co-operate in this work the better it will be for the children and their parents. The official Ministerial policy is that No handicapped pupil should be sent to a special school who can be satisfactorily educated in an ordinary school. 21