Including Every Learner: How schools, families,

and experts can better educate children with challenges

David Black, PhDPediatric Neuropsychologist

Laura Kenealy, PhDChildren’s National Medical Center

Dr. Black’s presentation is based on his expertise with autism and as a pediatric neuropsychologist, and is not acting in an official capacity for the National Institutes of Health.

Including Every Learner:Why it matters

Major trends in education1. Inclusion of special needs learners at

every level2. Larger population in early education

settings than ever before3. Stakes are higher than ever

Exploring barriers

Teachers may feel unprepared to cope with special needs learners…

Parents may wonder what is best for their child…

Some students are less able to benefit from inclusion…

Making it Work

Five factors associated with successful inclusion (Webber, 1997)

Making it Work

1. Sense of Community and Social Acceptance

“I am as good as others here”

“Everyone makes a valuable contribution to our group”

2. Appreciation for Diversity

“I like to learn about how we’re different.”

3. Attention to Curricular Needs“What I teach meets the needs of my learners”

4. Effective Management and Instruction

“I know what works”

“Everything about my class helps me learn”

5. Personnel Support and Collaboration

“I have the support of my team.”

Overview

Learning about our learners with special needs:

* Autism Spectrum Disorders* Language Delays* Sensory Processing Problems* Learning Difficulties* Attention and Impulsivity

Problems

Overview

What it is What it looks like in the early education

setting What the science tells us Classroom strategies that work: Tips

and Tricks for all kinds of special needs kids

Autism Spectrum Disorders

Autism Spectrum Disorders

Prevalence Rates What is Autism Recognizing Autism in the Classroom Latest Research Autism in inclusion classrooms

Prevalence of Autism

Rate of autism is ~1%› 2008: CDC Estimates 1/110 diagnosed with autism› 2007: UK Adult Psychiatric Comorbidity study estimate 1% › 2007: National Survey of Children's Health (sample size:

78,037)

Gender ratio: 4-5:1 male: female No differences across racial/ethnic groups

› Some research suggests African American children diagnosed later, however

59% (range 49-70%) have IQ > 70› CDC, 2007; 2002 surveillance data

Prevalence Rates

Rates have been steadily increasing over past 20+ years

Recent study of special education enrollment data in Wisconsin suggest the increase may be leveling off in some areas (Maenner and Durkin, 2010).

Autism Prevalence: Past 15 Years

Number (per 1,000) of children aged 6–17 who were served under the IDEA with a diagnosis of autism, from 1996 through 2007.

Maenner and Durkin, 2010, Pediatrics

What Causes Autism

~90% of cases, we don’t know ~10% of cases associated with known

chromosomal or genetic disorders Most heritable of all neuropsychiatric

conditions› Identical twin concordance: 60-96%› Sibling risk: 2-8%

Poor parenting practices DO NOT cause autism

Research has NO LINK between vaccines and autism

CDC.gov, 11.3.2010

Autism Spectrum Disorders Include …

Autism/Autistic Disorder Asperger’s Syndrome Pervasive Developmental Disorder, Not

Otherwise Specified (PDD-NOS) Autism Spectrum Disorder **Nonverbal Learning Disability**

Autism Spectrum Disorders: Symptoms in Three Main Areas

Social Impairment

Repetitive Behaviors & Restricted Interests

Speech/Communication

Deficits

Core Symptom Domains

Social Impairment

Repetitive Behaviors & Restricted Interests

Speech/Communication

Deficits

Autism

Language Disorders

Asperger’s

Sensory Integration problems

ASD is Very Broad

Broad range of….› Intellectual functioning› Social Interest and motivation› Social competence› Language ability › Repetitive, unusual, challenging behaviors

http://www.cdc.gov/ncbddd/autism/signs.html

Impaired Social Interaction

Includes: Deficits in nonverbal communication Failure to develop peer relationships Spontaneously seeking to share

enjoyment Lack of social or emotional reciprocity Impaired social cognition

Impaired Nonverbal Communication

Eye contact Communicative use of gestures/body

language Directed facial expressions Flat or limited range of facial

expression Inappropriate facial expressions

Failure to Develop Peer Relationships

Unable to sustain reciprocal friendships Lack of interest/oblivious Lack of responsiveness when other

children approach Avoidance of peer interactions Preference to play alone Overly rule bound in social interaction Lack of sharing

Lack of Shared Enjoyment

Limited social initiation Lack of bringing or showing objects Unlikely to share interest or excitement

of activities No reaction to praise No desire to please

Social Reciprocity

Lack of social awareness Little interest in social interaction Tends to be more “object oriented”

than “socially oriented” Excessively directive or rigid in social

interactions Does not notice another’s lack of

interest

Social Cognition: Social Thinking

Impaired ability to … Make social predictions Grasp impact of actions on others Imagine thoughts and feelings of others Develop, maintain, and repair a social

interchange Recognize social mishaps Recognize/follow social convention Recognize distress in others

Impaired Communication

Language delay Inability to sustain a conversation Stereotyped, repetitive, idiosyncratic

language use Lack of varied make-believe, or social

imitative play

Language Delay

Understanding spoken language Communicating verbally Lack of compensation through other

means*› Gesture› Facial expression› Bringing of objects

*Differs in children with ASDs and language delay

Reciprocal Conversation

Conversation may be one-sided Limited in flexibility or range of topics Back and forth of interchange may be

limited Minimal “social chat”

Stereotyped Speech

Scripted, repetitive use of speech Echolalic speech Unusual use of language Neologisms Pedantic “little professor” speech Odd intonation, rhythm, or pitch to

vocal quality

Limited Imaginative Play Skills

Play tends to literal, functional, concrete Difficulty ascribing agency to figures

› E.g. Elmo feeding Buzz Light Year Impacts social play and cooperative play In young children, functional play skills

may also be limited

Repetitive Behaviors and Restricted Interests

Excessive preoccupation with stereotyped pattern of interest

Inflexible adherence to routine and rituals

Persistent preoccupation with parts of objects

Stereotyped repetitive motor mannerisms

Stereotyped Pattern of Interests

Fixated interest May be odd – doors, bumpers on cars May be a conventional interest but

extreme – obsession with dinosaurs, maps, or a favorite movie

Excessively perfectionistic Socially interfering, limiting other

activities

Difficulty with Transition & Changes in Routine

Rigid adherence to routines Transition between activities (even

preferred activities) very difficult Unusual compulsion or rituals with

routine events Catastrophic reaction to minor changes

in environment Lining up objects

Hand and Whole Body Mannerisms

Hand flapping Finger flicking Repetitively bouncing or spinning

Repetitive & Unusual Use of Objects

Non-function use of a part of an object – spinning wheels, opening/closing doors

Sensory interest in objects› Smelling people or objects› Preoccupation with texture› Close visual inspection› Seeking proprioceptive input

Cognitive Profile

Developmental delay/Intellectual deficits Splinter strengths Language deficits Poor self-regulation Weaknesses in executive functioning Poor motor planning/graphomotor control Sensory sensitivity/sensory integration

weaknesses

Sensory Processing ProblemsOversensitivityUndersensitivity

Sensory Processing Problems

Difficulty with the processing of sensory input› Sight, sound, taste, texture, proprioception

Oversensitivity or undersensitivity No formal criteria to diagnosis Usually identified by an occupational

therapist

Sensory Processing Problems

Oversensitivity: Aversion to› Texture (play dough, rice, finger paint,

grass)› Light (fluorescent light, bright sunlight)› Sound (classroom noise, lots of children

talking, loud music)› Being touched

Undersensitivity usually to pain, but also to hot and cold

What do we know…

Higher rate of oversensitivity in clinical populations› ASD – 56%› ADHD – 69%

Undersensitivity also very common in ASD

What do we know…

Oversensivity has been associated with› Anxiety/internalizing problems› Difficulty modulating response to input

If distracted by sensory input, then harder to respond in a socially appropriate, well-modulated manner

What do we know…

Birth cohort study n=925 › Developmental disorders excluded

16% of elementary children reported tactile sensitivity – 4 tactile sensations› May not be impairing, however

Oversensitivity › 4-fold increase in internalizing problems› Less social competence (empathy,

prosocial behavior)Ben-Sasson, Carter, Briggs-Gowan, 2009, Journal of Abnormal Child Psychology

Language Disorders

Comprehension of languageSpeech sound disordersPhonological disorders

Language Disorders

Impairment in comprehension and/or use of language › Speech sound disorders very common

8% of kindergarteners have a specific language impairment (SLI)

5% of 1st graders have a recognizable speech (phonological) disorder › Range from sound substitutions to

impaired communication

http://www.nidcd.nih.gov/StaticResources/about/Plans/strategic/strategic06-08.pdf

Language Disorders

Affects boys 1.5 times more than girls 20-40% have family history of SLI Associated with future learning

disorders› Especially reading› Phonological disorders associated with

math and written language weaknesses Common in autism Early intervention effective in treating

language disordershttp://www.asha.org/research/reports/children.htm

Who Can Be Included

Reasonable Classroom Fit

Consideration of: Cognitive functioning Receptive language Expressive language Self-regulation Social abilities Emotional maturity

Who can be included: Autism

Social motivation: highly aloof children may not do as well

Ability to follow basic social rules and direction

Functional speech Repetitive behaviors can be redirected

Ferraioli and Harris, 2010, Journal of Contemporary

Psychotherapy

Outcomes of Inclusion Models in Autism

Research Cautions…

Minimal research available Research is largely based on case

studies and a handful of group studies Many studies are of children “trained”

to produce a specific response› Unknown whether behavior will generalize

Not clear which children will benefit

General Observations

Inclusion better for younger than older kids (4th grade)› Older children Less tolerant of “differences”

Paradox: there is less peer acceptance of more socially competent ASD kids

Limited evidence of benefit for inclusion without additional support

With adequate support emerging research suggests inclusion models support social competence

Low Social Involvement: Mainstream setting/no support

K-1st Grade 2nd-3rd Grade

4-5th Grade

Typical ASD Typical ASD Typical ASD

Social network Centrality Status*

95% 55% 92% 57% 86% 24%

Acceptance .55 -.39 -.02 -.78 .00 -.89

Rejection .55 .44 .27 .19 .42 .67

*% with nuclear/secondary status

Rotheram-Fuller, Kasari, 2010,Journal of Child Psychology and Psychiatry

Reasons for Low Social Involvement

Misperceptions of social involvement Typical peers become less tolerant of

differences and aberrant behavior Limited cooperative play skills Poor motor skills – social involvement

of boys is largely sports oriented

Rotheram-Fuller, Kasari, 2010,Journal of Child Psychology and Psychiatry

What predicts social rejection?

Low levels of cooperation Being regarded as shy More help-seeking

Jones & Frederickson, 2010, Journal of Autism and Developmental Disorders

Will Inclusion Adversely Affect Typical Children?

Concerns:› Takes away teacher time› Decreases classroom instruction› Typical children may feel uncomfortable

Research (limited):› When done appropriately, typical children

develop better social competence› No adverse impact on learning

Ongoing monitoring is important

Diary Study in ASD: General Observations

School is stressful and anxiety provoking

Social isolation & bullying are common High risk for deliberate teasing Anxiety worse in ASD than other

groups› Secondary to social deficits› Need for order, consistency, and routine

Humphrey and Lewis, 2008, Autism, 12, 23-46.

Diary Study in ASD:Take Home Points

Quiet classrooms, hand-pick teachers Time out/break from busy classrooms Try not to treat ASD kids differently,

especially as they get older› Provide ‘behind the scenes’ support closely

integrated with classroom teacher Leverage ‘special interests’ to motivate

Humphrey and Lewis, 2008, Autism, 12, 23-46.

Diary Study in ASD:Take Home Points

Peer relationships more important than teacher for inclusion success

Facilitate development of peer relationships› Stick up for kids with ASD› Support positive sense of self

Humphrey and Lewis, 2008, Autism, 12, 23-46.

Life in school, Student with ASDHumphrey & Lewis, 2008, Autism

Student with ASDHumphrey & Lewis, 2008, Autism

Diary Study in ASD:Teachers Need Support…

Training to:› Individualize instruction› Modify curriculum› Manage the social and self-regulation needs

Disorder specific education, support and problem-solving resources

Access to an ASD specialist

Humphrey and Lewis, 2008, Autism, 12, 23-46.

When Does Inclusion Work?

Explicit social instruction Education about differences Peer mediated intervention Teacher prompting, modeling, support

Peer Mediated Intervention

Case study of two kids with ASD Intervention:

› 4-5 minute training of whole classroom› Adult prompting throughout day› Explicit modeling, prompting, and

reinforcement Increased peer to peer interaction &

social skills

Banda, Hart, Liu-Gitz, 2010, Research in Autism Spectrum

Disorders

Facilitating Social Inclusion

Select tasks that require social interaction – e.g. frequent requests for more materials

Adult supported group activities

Learning Disability

“Sophia”

• A little slow to talk• Unclear articulation, mixing up syllables (“aminals”)

• Preschool: • Alphabet, nursery rhymes, memorized sequences

• Letter and color names• Counting and 1:1 correspondence

By Kindergarten› Not associating sounds with letters› Trouble with rhyming› Confusing similar-looking letters

End of first grade› Delay in reading and

writing skills

Tested and found to have a learning disability

Learning Disabilities

Definition – Controversies and Changes!

* 1960’s: “minimal brain dysfunction”

* 1970’s-2004: IQ-Achievement “discrepancy”

* 2000’s: Low achievement, assess Response to Intervention (RTI)