MANAGEMENT STRATEGIES FOR

MULTIPLE HANDICAP

Introduction
Children who have a combination of severe disabilities are called
“Multiply Disabled”. Caring for multiply and severely disabled children is
never easy and they need an enormous amount of time & patience.
The combination of disabilities and degree of severity is different in each
child. The time at which the disability occurs in the child, what is known as the
‘age of onset’, may also range from birth to a few days after birth, from early
childhood till late teens. Sometimes children are born with one disability but
acquire the second or third disabling conditions during childhood. The
characteristics and the needs of the children depend on the nature of
combination of the disabilities, the age of onset and the opportunities that have
been available to a child in his environment.
Definition of Multiple Disabilities
According to the Persons with Disabilities Act (1995), “Multiple
Disabilities” means a combination of two or more disabilities.
Disabilities under the National Trust Act are in fact Developmental
Disabilities caused due to insult to the brain and damage to the central nervous
system. These disabilities are Autism, Cerebral Palsy, Mental Retardation and
Multiple Disabilities. These are neither diseases nor contagious nor progressive.
They cannot be cured by drugs or surgery. But early detection and training
improve outcome. This is done using the services of Physio-Occupational and
Speech Therapists, Community Based Rehabilitation Workers and Special
Educators.
Multiple Disabilities refer to: a combination of two or more disabling
conditions that have a combined effect on the child’s communication, mobility
and performance of day-to-day tasks.
Multiple disabilities: can be combination of
 Mental retardation  Autism
 Cerebral palsy  Hearing impairment
 Learning disabilities  Attention deficit hyperactive
 Visual impairment disorder
  Orthopedic involvement

Causes of Multiple Disabilities

There are several factor that cause severe and multiple disabilities & can be
divided as follows:
Prenatal causes Perinatal causes Postnatal causes
Chromosomal  Lack of oxygen  Childhood infections
abnormalities supply such as meningitis &
Viral infections to the baby’s brain encephalitis
Drug and Alcohol use  Physical injury to the  Traumatic brain injury
during pregnancy baby’s brain at birth from an accident or
Mother’s malnutrition  Contracted infections abuse
Physical trauma to during birth  Lead poisoning
the mother  Reactions to
medication Exposure
to toxins or other
environmental
conditions

Incidence
In India the disability information has been collected through sample
surveys and censuses. The most recent is the National Sample Survey
Organization (NSSO) which conducted a survey of disabled persons in India.
The NSSO estimated the number of disabled persons in the country to be 18.49
million, which formed about 1.8 % of total population.
NSSO 2002 Total Male Female
% Numbers % Numbers %
Loco-motor Disability 10634000 58 6633900 36 4000100 22
Hearing disability 3061700 17 1613300 9 1448400 8
Speech disability 2154500 12 1291100 7 863400 5
Blindness 2013400 11 928700 5 1084700 6
Mental Illness 1101000 6 664500 4 436500 2
Mental Retardation 994700 5 625800 3 368900 2
Low vision 813300 4 369300 2 444000 2
Any disability 18491000 100 10891300 59 7599700 41
MANAGEMENT OF PEOPLE WITH DISABILITIES
Unlike for hearing-impaired people without additional handicaps, for hearing-
impaired individuals with other disabilities such as mental retardation, visual
impairment, CP, and autism the goals of aural rehabilitation may vary. The
extent to which functional residual hearing can be maximized does not depend
solely on the degree of the hearing impairment but more so on the extent,
degree, or impact of other dominant or multiple existing handicaps that may be
present.

Teaching Strategies for Children with MD

 Teach skills that are functional and meaningful: with the limited
opportunities available to the child, it is wise to teach him things that are
directly related to his environment and those that he has high chances of
doing throughout the day.
 Teach skills in natural settings: This point can never be stressed enough
number of times. The child is able to remember things that he learns while
going through his/her day to day routines. This helps him to learn better and
remember.
 Provide assistance as needed: Encourage the child in every attempt. Do not
laugh at or scold when he is trying his best.
 Take advantage of the teachable moment: Sometimes you may not plan to
teach an activity, but the child shows curiosity to explore a particular object.
Use this time to teach him more about that object.
 Provide repeated opportunities to practice: This will help the child to get
opportunities to try out the activity again and again.
 Use real objects: When experience to know about the world is so limited it is
better to use objects that he sees and uses everyday rather than expensive and
unusual things.
 Develop routines: Have fixed timetable for the day with the child. This helps
him to have more control over his life and to anticipate what is going to
happen with him next. This also helps to encourage communication attempts
by the child immensely.
 Multi-sensory approach: It is best to make use of all remaining sensory
abilities of the child- like seeing, hearing, touching, smelling and movements.
All should form a part of the teaching moments for the child.
 Plan inclusive activities: With highly individualized activities being planned
for the child, there is always a risk that either the parent or one caregiver is
 constantly trying to teach the child. It is important that the child should know
what others enjoy doing and for him to be part of that too. Plan certain
activities that he can do with other siblings in the family.

DEAF BLIND
The term deaf-blind makes us often imagine a person who is unable to
hear and see anything. Deaf-blind is used to define a heterogeneous group of
individuals who may suffer from varying degrees of visual and hearing
impairment, perhaps combined with learning and physical disabilities which can
cause severe communication problems. Visions and hearing are two primary
sensory modalities by which the individual experiences the world.
Individuals with deaf-blindness are categorized into 4 groups on whether the
deaf-blindness is due to:
1) Congenital or early onset hearing and visual impairment

2) Congenital or early onset of hearing impairment with acquired visual

impairment

3) Congenital or early onset of visual impairment with acquired hearing

impairment

4) Late onset hearing and visual impairments

Characteristics of children with deaf-blindness:

 Limited non-verbal communication  Self-stimulatory behaviors

with a desire to communicate  Pleasure sought through
 No spontaneous interpersonal movements
interactions  Total dependence for daily living
 No interactions with the environment skills
 May become frustrated

Impact of deaf-blindness:
1) Finding out/getting information: individuals who are deaf-blind have more
difficulty in finding out information about our everyday ordinary
experiences like seeing familiar person, facial expressions, objects or people
beyond their reach.

2) Communications with others: communication with other persons is the

obvious challenge to individuals who are deaf-blind and for others who
want to communicate with them.
 3) Difficulties in moving around in the environment: persons who are blind
will be able to compensate for the lack of sight by using navigational cues
like noise in the street, to know the road approaching or even smell to locate
the kitchen. However the person who are deaf-blind will not be able to
compensate for both vision and hearing or vice versa and are vulnerable
especially in unfamiliar surroundings.

Communication in deaf blind: The effect of deaf blindness has a major impact
on communication development. For a baby who is born deaf-blind, the normal
process of communication is affected from the moment the child is born.
Depending on the severity of the impairments the cues the child will be getting
from environment will be very limited and may be even threatening to the child
as she/he cannot anticipate what is happening or going to happen.
Modes of communication: There are various methods/modes of communication
will depend on factors such as age of onset, cause and degree of hearing and/or
visual impairment, language capabilities and previous experiences.
Communication by a deaf -blind individual (who has little useful hearing &
vision) use the sense of touch. Touch can be classified as-
 Passive touch involves skin sensitivity to pressure, temperature, pain and
other sensation when objects make direct contact with the skin. Information
obtained by passive touch is called tactile.

 Active touch involves tactile information obtained by a combination of the

skins cutaneous sensation (tactile) and the body’s kinesthetic sensitivity to
spatial position and movement.

The type of communication modes, aids and devices are grouped into 3
categories depending on the primary sense used by the deaf blind individual
that is
1) Residual vision They may use any one of the three or

2) Residual hearing combination of these depending on the

degree of loss of vision and/or hearing.
3) Tactile sense

Children who are deaf-blind need to develop skills in using auditory

information.
Children who are deaf-blind need to learn to use whatever residual hearing they
may have for a variety of reasons including travel safety, identifying people,
literacy, communication, and so forth. They also need to learn how to use
adaptive devices and equipment such as cochlear implants, hearing aids, and
voice output devices.
Learning to listen, a skill we all need help with, is a skill that is critical for these
children.
Steps in Providing Auditory Training
• For children with visual impairment or deaf-blindness the first step in
auditory training is to provide access to as much auditory information as
possible.

• Key to the use of HA/CI devices is good behavioral audiological

assessment. This is because the best hearing aid or implant fit can't be
obtained without behavioral testing.

• A hearing aid or implant is of no help to the child if the child doesn't wear
it regularly.

• It is important to understand that, even though a child consistently wears

an appropriate device in good working condition, he may still not have
the same access to auditory information as another child.

• Each child will have a unique blend of abilities in the areas of hearing,
vision, thinking and communication.

 Sign language: It is the most widely used communication by deaf blind

person.

American Sign Language (ASL) which uses various hand-shapes with

specific movements in a defined signing space. Each sign represents a whole
word concept. ASL is a language different from English with its own syntax and
grammatical rules.
Manual English, however, borrows many of the same sign from
American Sign Language, but approximate English word order in its choice of
signs, and “invents” sign to parallel English tenses and endings that are
characteristics of the spoken language. It is important for any attempting to
communicate in sign language to identify the form used by the deaf-blind
person for ease of communication.
 For the deaf-blind person functioning within restricted field of vision, all
signing must be done within their visual field. Deaf-blind person who do not
have sufficient residual vision will need to rely on some tactile modes. The
speaker uses both hands to form signs in the same manner as in the visual
mode.
 Finger spellings: American one hand- alphabet & British two-hand manual
alphabet

1) American one-hand alphabet: The letter a-z and numbers are formed by
positioning the fingers of one hand into specific hand shapes. Letters are
presented in succession to form words and sentences. This method assumes
proficiency in English language.

When using the residual vision, the letters must be presented within the
visual field of deaf-blind person. To assure effective reception, it is advisable
for the deaf-blind person to position the speaker’s hand. The most commonly
used method of tactile communication is tactile finger spelling which uses the
same hand shapes as the visual modes.
2) British two-hand alphabet: This alphabet is used in Great Britain and
members of the commonwealth. This alphabet uses both hands to represent
the letters of the alphabet, and numbers. The tactile modifies its usage by
having the deaf-blind person keep one hand stationary, while the speaker
uses his or hand on the appropriate position on the deaf blinds persons,
hand.

 Braille: It is a system of touch reading that uses raised dots to represent the
letters of the alphabet and numbers 0-9. Six dots are arranged in two vertical
columns of three dots each. The six dots of the cell are numbered 1, 2, 3
downward the left and 4, 5, 6 downward on the right.
Braille has two levels or grades - Grade 1 and grade 2
 In Grade 1 braille, each word is spelled out, letter by letter. It consists of
the letters of the alphabet, punctuations, numbers and composition signs.

 Grade 2 braille incorporates 189 specific contraction and short term

words which eliminates need to spell every word letter by letter.

 Aural/oral method (speech): This method is used by deaf blind persons who
have sufficient residual hearing to hear and understand speech with the use
 of amplification, and/or who can express themselves through speech. The
deaf blind person will determine the appropriate distance from speakers to
facilitate the use of amplified residual hearing and the speaker should be
sensitive to this cues.

 Print in the palm: This is a tactile form of communication and the palm is
used as the writing surface. The speaker holds the deaf-blind persons hand
and prints (using the finger index) the letters of the alphabet to from words
and sentences. The end of the word is indicated by the speakers hand placed
flat on the receiver’s hands. Mistakes are corrected by rubbing the receivers
hand as if erasing the word. The same procedure can be used for printing
another part of the body, usually the arm, if the persons palm is not
sufficiently sensitive.

 Tadoma: The Tadoma method of speech reading is based on vibro-tactile

reception of the articulatory movements and actions that occur during the
production of speech. The Tadoma method was developed by educators to
provide children who were both deaf and blind with access to speech and
language. In this method, the hand of the deaf-blind receiver is placed over
the face and neck of the talker such that the thumb rests lightly on the lips
and the fingers fan out over the cheek and neck. Methods of instruction were
developed for teaching children both to receive and to produce speech. The
most active period of instruction through the Tadoma method in programs
for the deaf-blind occurred in the years between 1930 and 1960, primarily
for a population of children who had become simultaneously deaf/blind as a
result of meningitis.

A number of children who received instruction in the Tadoma method

at schools for the deaf-blind in various locations around the country
eventually became highly skilled in the use of this method. On the basis of
their ability to receive speech and language through tactual input alone,
these individuals afford researchers the opportunity to explore the capacity
of the sense of touch for communication. A series of analytic studies
exploring speech reception, speech production, and linguistic ability through
Tadoma has been conducted in cooperation with a small group of
experienced deaf-blind users of the Tadoma method.
 Assistive Devices:

The assistive listening devices used widely to enable the deaf-blind

person to make optimal use of residual vision, hearing and the tactile senses.
1) Large print material: This includes books and newspaper that are
photographically enlarged to 18 point type which can be purchased from a
variety of publishers. The print is usually off-white or buff-colored paper.
Many persons with residual vision can read this type or may use magnifier
to enhance readability. Typewriters that produce large types are also
available.

2) Magnifiers: These range from 2X to 20X and can be hand-held, stationary,

with platforms, self-illuminating, loops attached to glasses, and
microscopic lens systems. The low vision specialist and deaf-blind person
can best decide which type of magnifier is most appropriate.

3) Hearing aids and cochlear implants: Hearing aids and external electronic
devices and cochlear implants are surgically implanted electronic gadgets
with an external device, both which aims at amplifying sound thus making
it available to the deaf-blind individual to effectively make maximal usage
of their residual hearing.

4) Reading machines: It is a device that translates printed page into spoken

words, especially useful for the person with good residual hearing.

A synthetic voice “reads” the material a few minute after a scanning

mechanism locates the first line. A period of training is necessary to become
accustomed to electronic voice.
5) Low- technology devices: The braille alphabet cards, raised line drawing
kit, communication boards and tangible symbols are some of them.

Communication board can be tactile or visual. Letters, line drawings can be

embossed or cut out from plastic or wood to from messages.
 Moon alphabet: It was developed by Dr. William Moon in 1947. Since it
has similarities to ordinary print characters, it is easier to learn for people
who have previously read visually. However, it has a disadvantage of
having about 80 times the print version and four times that of the braille
version.
  Robotic Alphabet: A Finger Spelling Hand- A fourth generation
computer-controlled electromechanical finger spelling hand called Ralph
(for Robotic Alphabet) has been developed at the Rehab R&D Center.

 The device offers deaf-blind individuals improved access to computers

and communication devices in addition to person-to-person
conversations.

 Enhancements in this design include better intelligibility, smaller size,

and the ability to optimize hand positions.

 Talking gloves:
Gloves that can translate sign language into English are currently being
developed at the University of New South Wales.
 A signer wears gloves that are connected to a computer that has been
programmed to tell the signs apart and can translate the signs into
written words on a monitor.

 Each glove worn by the signer has 20 ways of measuring the movement
in their hand and the information is translated to the computer via two
wires.

 Tactile aids for deaf blind:

Tactile aids vary in number of channel into which the frequency spectrum
divided.
 A multichannel tactile aid takes the advantage of sensitivity to
differences in the location of the stimulation.

 Brown and Stevens (2005) pointed out that the stimulation of the major
trunk may result in muscle stimulation. The wrist is a favored site for
two channel aid and the abdomen or sternum for multiple arrays.

Tactile sound recognition device:

 The tactaid II+ and tactaid 7 converts sounds to vibration on small pads
and therefore 2 channels on the tactaid II+, whereas there are seven
 channels and pads on the tactaid 7. Each channel corresponds to a
frequency band.

 Tactaid 7 also has an automatic noise suppression circuit that reduces

steady background sounds. It is able to provide information on speech
characteristics including voiced or voiceless, inflection, temporal cues
and the first 2 formants that aid in vowel recognition. Tactaid 2000 is a
six channel modification of tactaid7.

 It is designed to present tactile cues that allow differentiation of the

difficult to hear high frequency speech sounds. 5 vibrators cover the
speech spectrum from 2000 to 8000 Hz allowing detection and
discrimination of sounds in this range.

 And a single detachable vibrator provides the output for sound

frequencies less than 2000 Hz. The device can be used alone or together
with hearing aids or CI.

 Tellatouch: 
- This device is portable and weighs less than four pounds. 

- It consists of a small typewriter keyboard which the interpreter uses to

pass on information.  

- The deaf-blind person sits opposite the typist and places a finger on a
small Braille "screen." 

- Each letter that is typed appears briefly under the finger of the deaf-blind
person. 

- The letter can be felt as long as the typist holds down the key.  Only one
letter can be felt at a time. 

- Fifty words per minute is probably the maximum speed of the device.

- The chief advantage of the Tellatouch is that it allows people who have
no specialized training to communicate quickly with the deaf-blind.

Communication & Language Teaching Strategies:

  Mclnnes and Treffy program:
This program is developed by Mclness and Treffry (1982) for the low
functioning, hypoactive, introverted, self-stimulating severely deaf blind
children. The instructions begins at the signal level with simple body signals
and for the hyperactive, inattentive children, instructions begins with bonding
and co-active movements in enjoyable activities. Following series of steps has
been suggested-

a) Alert the child to the presence of the instructor

b) Alert the child of forthcoming activity

c) Introduce the activity

d) Demonstrate the activity

e) Review what has been done.

 Bricker and Dennison program:

Bricker and Dennison (1978) described six stage imitation training program
which serves as prerequisite for teaching expressive languages. The stages are
as follows-
1) Increase vocalizations

2) Gross motor imitation (familiar),

3) Gross motor imitation (unfamiliar)

4) Sound imitation (self-initiated)

5) Sound imitation (model-initiated) and

6) Speech sound imitation

They suggested methods to increase the frequency and number of the

Child’s vocalizations by imitating the sounds the child makes and encouraging
the child to imitate these sounds. To increase a child’s understanding of
imitation she/he should be encouraged to imitate his own familiar actions in
various settings, and then imitate unfamiliar easy motor actions. Beginning with
imitation of sound made by child try to make a game of sound chaining: child
makes sound, teacher imitates, child repeats sound, etc.

 Functional approach:
Kaiser et al (1987) advocated this approach. The main goal of the functional
approach is to enable child to use communication functionally and socially
during their daily activities.
Child specific and situation specific the functional words are taught to the
child so that the child can interact communicatively with in his environment.
They suggested beginning functional language through a process of
encouraging nonverbal interactional strategies including-
a) Directed attention to the conversational partner

b) Joint attention on the environmental topic of interest &

c) Joint activity focused on the environmental topic of interest

 Van Dijk (1986) provides a curriculum for deaf-blind children. The first
step begins with developing attachment or bonding between
teacher/professional or caregiver and the child. Attachment process
involves 3 steps.
a) Coactive movement
b) Structuring the child’s daily routine and
c) Characterization.

Coactive movement refers to the teacher and child participating together in a

ctivities usually initiated and enjoyed by the child. Co-active movements help
the child to communicate by furthering the awareness of what he/she is doing:
by isolating movements as identifiers for activities; by initiating signal behavior
and thereby starting communication and by reinforcing memory and
anticipation. This is done by the adult moving co-actively and directing the
child into the desired movements and activities, the adult responding
immediately to signal behavior of the child and the child identifying activities
through movements.

Calendar systems

Calendar systems provide a structured way in which to refer to events in a

child’s day.  Sometimes called “Anticipation Boxes” or “Object Calendars”, a
series of meaningful symbols are arranged in sequential order to let the child
know what will happen next.  

Calendars also provide a way to make clear the beginning, middle, and end of
an activity, as well as time concepts, such as before, after, later, and now

 Intensive interaction approach:

Melanie Nind and Dave Hewett (1996) developed this approach which
involves the use of an appropriate interactive style and range of interactive
games found in caregiver and infant interaction. This interactive game forms
the core of the curriculum and has been given structure to the processes that
are normally intuitive and are developed in deliberate progression.

 Scripts/routines:
It is generally known that deaf-blind children benefit in a numerous ways
from the establishment of strong routines for the day. A script can be
developed around any activity which can be carried out frequently and
regularly by an adult and child in fairly close contact. It may be routine such as
eating lunch, a sensory experience such as message or a physical routine such
as movement sequence.

 Developing nurturance:
This relates to helping children develop a sense of well-being arising
directly from their contact with adults. It is essential that adults engaged in the
physical care of children do so in such a way that the children feel relaxed and
cared for. One of the effective ways of establishing contact with deaf-blind
children and so encouraging a communicative response is to share activities
with a high level of physical contact and pleasant sensations.

 Sequencing experiences:
This is key concept in the education of deaf-blind children.
 Promotes the understanding of contingencies, that certain behaviors are
likely to be followed by specific responses.
  Encourages communicative behavior by helping the child to anticipate
the next step and so to signal appropriately.

Increasing opportunities to communicate:

Deaf-blind children need explicitly to create opportunities for
communication by: increasing the number of opportunities; extending the range
of communication; ensuring that communication is functional.

CEREBRAL PALSY
Cerebral palsy is a non-progressive, nonfatal, non-curable, irreversible chronic
motor disability resulting from damage to the growing brain due to pre, peri &
postnatal causes.
 Hearing impairment is common in children with CP.

 Sensorineural, conductive or mixed type of loss may be present.

 HAs recommendations should be specially dealt while prescribing for a

child with CP. Because the child can knock off the aid while controlling the
volume. If the individual is on wheel chair then care should be taken that the
headrest does not push Childs ears. The use of HA is not warranted for
individuals who have the tendency to fall off.

 The educational program for a cerebral palsied must encompass the total
educational process with a consideration to the special distinct need of the
children with CP. The educational program must be planned to meet the
differing intellectual, physical and personality problems of the CP group.

 Vocational, technical or trade school program must be considered for the

individual with CP who can derive benefit from them. The main factor
which has to be considered is the intelligence level of the child.

AAC for cerebral palsy children:

- Children with CP may not use their AAC aids as often.

- This has the potential to lead to delays or failure to develop the full range
of communication skills such as initiating or taking the lead in
conversation, using complex syntax, asking questions, making commands,
or adding new information.

- Training of communication partners may prevent the development of

learned helplessness in children with CP that can result from being passive
 communicators, and training of the AAC user about how to communicate
effectively with others, to control their environment through
communication, and using their AAC system to make choices, decisions
and mistakes.

MENTAL RETARDATION
 The effect of mental retardation is aggregated considerably when there is
hearing impairment. Teaching sign language is a better option in such cases.
Teaching sign language is to be carried out in a relaxed atmosphere with
emphasis on socialization.

 Signs should be initially thought from flash cards whenever possible and
reinforced buy use of appropriate objects and remedial language material.
The magnitude of the management for the mentally handicapped depends
upon the severity of the problem.

 The schooling and classroom education can be divided into.

Trainable level: moderate to severe mental retardation with hearing loss where
basic training is daily living like marketing, simple arithmetic are rendered.
Educable level: mild to moderate MR with HL with basic education according
to circumstances provided.
AAC for Mental Retardation:
- Prior to the mid-1980s, individuals with mental retardation were often not
provided with AAC devices as it was believed that they did not demonstrate
prerequisite skills for AAC or because of the notion that AAC would
interfere with speech development.
- From simple single-switch VOCAs to dynamic displays with visual scenes,
studies have shown that appropriate use of AAC devices can modify
classroom, home, and social environments for children and adults with
intellectual impairments to increase participation, make choices enhance
communication skills, and even influence the perceptions and stereotypes of
communication partners.
- AAC interventions in this population are highly individualized, taking into
account specific abilities of language comprehension, social-relational
characteristics, learning strengths and weaknesses, and developmental
patterns for specific types of MR.
 - While most individuals with mental retardation do not have concomitant
behavioral problems, it is known that behavioral problems are typically
more prevalent in this population than others.
- In the past, strategies to "manage" behavioral problems included
incarceration, medication and aversive behavior modification techniques.
Since the mid-1980s, greater emphasis has been placed on teaching
functional communication skills to individuals as an alternative to "acting
out" for the purpose of exerting independence, taking control, or informing
preferences. This paradigm shift in the management of behavioral problems
for this population has placed new emphasis on AAC because many of these
individuals do not have functional speech for communication.
- Individuals with mental retardation face challenges in developing
communication skills, including problems with generalization (the transfer
of learned skills into daily activities).They also often lack naturally
occurring communication opportunities and responsive communicators with
whom they can interact in the home, school and community environments.
As a result, AAC intervention for this population emphasizes partner
training as well as opportunities for integrated, natural communication.

People with Down syndrome may experience hearing losses while in their
early twenties or younger. 
- Have conductive HL resulting from frequent ME infections in childhood. 
- People born with malformations of the OE typically have very small ear canals
that can be blocked by small amounts of earwax. 
- Many people with Down syndrome, as well as people with other
developmental disabilities, may have narrow ear canals.
People with Down syndrome, who may experience hearing losses earlier in life,
should have periodic hearing tests throughout their life.

Rehabilitation of hearing impaired learning disability, PDD & ADHD

Children with hearing impairment can be associated with learning
disabilities, PDD or ADHD. The features of these problems may vary from
individual to individual. If a child with hearing impairment shows signs of
having any of the above problems, professional should treat deficits/excess
areas along with the auditory and speech language intervention strategies used
for hearing impairment.
AUTISM
 Autism can be characterized by problem in social skills.

 It is a disorder distinguished by qualitative impairments in communication

and social interactions and typically has more difficulty acquiring
expressive skills.

 If autism is associated with hearing impairment than these problems will

be more severe, and gestures and sign language can be used but it will not
so effective.

 Voice output communication aid used for children who do not have
speech.

AAC for Autism:

- Children with autism have been found to have strong visual-processing
skills, making them good candidates for an AAC device.
- AAC intervention in this population is directed towards the linguistic and
social abilities of the child, including providing the child with a concrete
means of communication, as well as facilitating the development of
interaction skills. Existing functional communication skills, such as joint
attention, predict better use of AAC.
- AAC systems for this population will generally begin with communication
boards as well as with object or picture exchanges such as the Picture
Exchange Communication System.

LEARNING DISABILITY
Learning disability is a classification including several disorders in which
a person has difficulty learning in a typical manner, usually caused by an
unknown factor or factors. A common reason for referral of children with
learning disabilities is a conflict between parents and the school over the
management of child’s difficulties.
Speech therapy techniques for children with Hearing impairment with learning
disability/ADHD/PDD:
The following are the important goals to be achieved in children with HI with
additional problem:
 Establishing Eye Contact Behavior:
 Any activity used to create this behavior should concentrate on getting the
child to look at the therapists face, either directly or indirectly by attracting the
child’s attention with some other object of interest. The following are some
activities the therapist can use to engage and maintain eye contact behavior in
children with HI with additional impairment.
Activities:
- Peek-a-boo - Follow the candle
- Attention

 Building of attention:
The following are some activities that the therapist can use to try and build
attention.

Activity
- Fill the bucket/Empty the - Picking grapes
bucket - Let’s look at pictures
- Joining the pictures - Find the ball
- Let’s clean up

 Encourage appropriate symbolic play:

Play is a universal human activity that blends cognitive, social, emotional,
linguistic and motor components. It is an effective context for teaching
children. During play, children can learn new skills as part of whole,
meaningful activities.
Activity:
- Dolly’s bedtime - Call me
- I am hungry - Oh… I am sick

 Developing communicative intent (gestures & Vocal)

Communication intent is a required skill for any individual to be able to
initiate or sustain a conversational interaction with another individual.
Communication intent has several communicative functions such as requesting
an object or action, a protest and a greeting.
 Developing differential expression of yes or No
 To reply yes or no to a probe usually requires decoding the questions, mentally
responding to the message and choosing the appropriate answer.
 Improving personal pronoun usage:
Activity:
- Who has it? - Intensive repetition
- Pass-the-ball - General modeling

 Improving word, sign or phrase retrieval skills

The child is instructed to name as many items in a category as he can in a
given amount of time.
 Establish rules of conversational exchange (listening & turn taking):
A conversation is like a game between two or more players, who may or may
not be able to talk. It is a complicated game as it has so many rules. And the
only way an inexperienced player (the child) is going to learn these rules are
by playing the game with a more experienced player (the therapist).

RESEARCH STUDIES
Pyman, Blamey, Lacy, Clark, and Dowell (2000)
• Examined speech perception outcomes following CI

• 75 children aged up to 5 years, comparing the results of children with and

without cognitive and/or motor delays.

• They found that the former group was significantly slower in developing
speech perception skills following implantation

Holt and Kirk (2005)

• Examined the speech & language outcomes of children with CI who
have a cognitive delay (scoring more than 1 SD below the mean on tests
of cognitive function and/or identified as developmentally delayed by a
psychologist)

• They compared 19 children with cognitive delays (average estimate of

cognitive functioning in the borderline to mildly impaired range) with 50
children with no additional disabilities, up to 2 years after
implantation.
 • Both groups demonstrated significant improvements in speech &
language skills over time, but the children with cognitive delays had
significantly lower scores. Children with cognitive delays made
relatively good progress in developing speech perception skills but
struggled with the tasks involving higher level language skills such as
sentence recognition and receptive & expressive language.

Language development of a multiply handicapped child after cochlear

implantation
- Shoichiro Fukudaa, Kunihiro Fukushimab, Yukihide Maedab, Keiko
Tsukamuraa, Rie Nagayasub, Naomi Toidaa, Namiki Kibayashib, Norio
Kasaib, Akemi Sugatab, Kazunori Nishizakib (2003)

The presence of additional handicaps in hearing-impaired children makes

the prediction of language ability after cochlear implantation unreliable. Only
limited follow-up data on developmental improvement after implantation
among multiply handicapped children is available. The present study reports the
course of development (audiological and linguistic) after cochlear implantation
in one subject with moderate mental retardation.
Preoperatively, his language development showed 34 months delay when
compared to chronological age. The difference had shortened to 23 months by 2
years post-surgery. The subject's cognitive delay had not changed upon 2-year
follow-up. The cochlear implant can be credited to his improvement in language
development.

Cochlear implantation in pre lingually deaf persons with additional disability

A Daneshi, S Hassanzadeh, Journal of Laryngology & Otology (2006)
AIM: This article is aimed to document the development of auditory
perception in patients having one of these additional disabilities such as mild
and moderate mental retardation; learning disability; attention
deficit/hyperactivity disorder; cerebral palsy; congenital blindness; and autism.
Methods:
 They examined the records of 398 cochlear-implanted, pre-lingually deaf
patients who had received a cochlear implant at least one year
previously.
 Patients were selected who showed a delay in motor, cognitive or
emotional development.
  The selected cases were referred for psychological evaluation in order to
identify patients with additional disabilities.
 Then, they compared these patients’ auditory perception prior to and one
year following cochlear implantation.

Results:
 Total of mild mental retardation in eight cases (13.33 per cent); moderate
mental retardation in five (8.33 per cent); learning disability in 20 (33.33
per cent); attention deficit/hyperactivity disorder in 15 (25 per cent);
cerebral palsy in five (8.33); congenital blindness in three (5 per cent);
and autism in four (6.66 per cent). Implanted in multiple handicap
children.
 All patients showed significant development in speech perception, except
for autistic and congenitally deaf-blind patients.

Conclusion:
 Although cochlear implantation is not contraindicated in prelingually deaf
persons with additional disabilities, congenitally deaf-blind and autistic
patients showed limited development in auditory perception as a main
outcome of cochlear implantation.
 These patients require unique rehabilitation in order to achieve more
auditory development.

Performance of children with mental retardation after cochlear implantation:

Speech perception, speech intelligibility, and language development
Young-Mee Lee, Lee-Suk Kim , Sung-Wook Jeong, Jeong-Seo Kim & Seung-
Hyun Chung (2010)

Objective: The purpose of this study was to investigate the performance of

children with MR after implantation, and to explore their progress according to
the degree of MR.

Methods: Fifteen implanted children with MR were included. Progress in

speech perception, speech intelligibility, and language was measured using
Categories of Auditory Performance, monosyllabic word test, Speech
Intelligibility Rating, and Language Scale before and after implantation. They
retrospectively examined outcomes and explored the association between the
progress and the degree of MR after implantation. We compared monosyllabic
word test scores using repeated-measures ANOVA.
 Results: Speech perception and speech intelligibility for children with mild
MR improved consistently after implantation. After implantation, monosyllabic
word test scores did not differ significantly between children with mild MR and
children with no additional disabilities. Although language development of
children with mild MR was slow, they could communicate verbally 3 years after
implantation. Children with moderate MR progressed more slowly and had
limitations in speech and language development, and these children could
communicate by vocalization and gesture 3 years after implantation.

Conclusion: Children with mental retardation (MR) obtain demonstrable benefit

from cochlear implantation, and their postoperative performance was tempered
by the degree of MR.

References

 Cochlear implant in special cases: Acta larynogology, 2004

 Auditory prosthesis for children with multiple handicap (2006).

 Aural rehabilitation issues with multiple handicapped 2006)

 Schow and Nerborune. Introduction to audiological rehabilitation