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11.1 Students With Orthopedic Impairments

Students with orthopedic impairments have mobility difficulties related to a disability. Impairments have a wide range of causes, and students can vary widely in terms of their movement and mobility. This is true even of students with the same disorder. Students with orthopedic impairments often require classroom accommodations to allow them access to physical materials.

What Are Orthopedic Impairments?

Orthopedic impairments limit an individual's body movements and mobility. Some students have limited mobility in their arms or legs, and some may use wheelchairs or braces to move around (Johnson, Dudgeon, Kuehn, & Walker, 2007). Orthopedic impairments are often referred to as physical disabilities because the student's physical body is affected (Shapiro & Martin, 2010).

The IDEA 2004 definition of orthopedic impairment includes "impairments caused by a congenital anomaly, impairments caused by disease (e.g., poliomyelitis, bone tuberculosis), and impairments from other causes (e.g., cerebral palsy, amputations, and fractures or burns that cause contractures)," and it requires that the student's academic performance be affected. Of the student population, 0.08% is identified with orthopedic impairments.

Each student with an orthopedic impairment has different characteristics. Some students have limited mobility in one arm, whereas other students may have difficulty controlling their entire body. Orthopedic impairments are not temporary; for example, a broken leg is not considered an orthopedic impairment. Most schools consider orthopedic impairments as such only if they last more than 60 days and if the impairment appears to have a semi-permanent or permanent effect on the student's movement and mobility.

Typically, orthopedic impairments are divided into three categories: impairments caused by degenerative disorders, impairments caused by musculoskeletal disorders, and impairments caused by neuromotor impairments.

Orthopedic Impairments Caused by Degenerative Disorders

Degenerative disorders cause the body to weaken as it ages, resulting in a reduction in mobility and movement. At this time, there is no cure for any of the degenerative disorders. The most common group of degenerative disorders falls under the umbrella term of muscular dystrophy (MD), of which there are over 40 types. With most types, the muscles of the body weaken, and mobility becomes severely limited. Some of the more common kinds are Duchenne Muscular Dystrophy, Spinal Muscular Atrophy, and Amyotrophic Lateral Sclerosis (ALS). You may know ALS as Lou Gehrig's disease. Another degenerative disorder is multiple sclerosis.

Duchenne Muscular Dystrophy affects boys because the gene affected by Duchenne is on an X chromosome. (Because girls have two X chromosomes, a girl with the Duchenne gene does not develop the condition; her other X chromosome overrides it.) Boys with Duchenne often show symptoms between 2 and 6 years of age. The muscles of the body weaken over time, eventually causing paralysis of the arms and legs. Boys start out walking, but as their muscles weaken, they require wheelchairs. Most boys with Duchenne only live to 20–30 years of age.

Spinal Muscular Atrophy (SMA) is also related to a defective gene, but both boys and girls can have SMA. There are several types of SMA. One type affects babies, and the babies typically only live weeks or months because their muscles (including heart and respiratory muscles) are very weak. SMA type II affects children. Young children might be able to sit up, but their weak muscles never allow for walking. As the child ages, muscles become weaker and weaker, leading to paralysis. Many adults with SMA type II have respiratory issues and may have a shortened life expectancy. SMA types III and IV affect the muscle functions of adults, but life expectancy is not shortened.

Amyotrophic Lateral Sclerosis (ALS) is another degenerative muscle disease that causes weakness in movement, speaking, and breathing. ALS is caused by a defective gene that affects how neurons communicate with the brain and muscles of the body. ALS causes death in all patients, but some people can live with ALS for a number of years. Though rare, ALS can affect children.

Another type of degenerative disease is multiple sclerosis (MS). With MS, scar tissue develops around nerves, and the person can experience a wide range of difficulties, including loss of vision, difficulty with speech, and paralysis. The cause of MS is unknown, but it may be related to the body's immune system. Mostly, MS affects adults, but children can have the disease. Children and adults with MS can learn to live with the symptoms of their MS, and most people live a normal life span.

Orthopedic Impairments Caused by Musculoskeletal Disorders

Orthopedic impairments may be caused by musculoskeletal disorders. These are disorders related to the skeleton and muscles of the body, and they cause mobility limitations. Two of the most common musculoskeletal disorders are juvenile rheumatoid arthritis and limb deficiency. (While degenerative disorders, such as MD, also affect the muscles, their degenerative nature causes them to be classified under degenerative disorder instead of musculoskeletal disorder.)

Juvenile rheumatoid arthritis (JRA) causes swelling or stiffness of the joints and limitations in mobility. Some children with JRA may experience difficulties related to bone growth (i.e., shorter height) and deformity. There is no known cause for JRA, although the disorder might be related to the immune system. Although there is no cure, students with JRA have typical life expectancy.

Another musculoskeletal disorder is limb deficiency. Limb deficiency can be caused by genetic mutations, as when children are born missing part or all of an arm, hand, finger, leg, foot, or toe. It can also be caused by illness or accident. For example, a child may have an amputation after an infection (e.g., gangrene) or amputation in an accident.

Orthopedic Impairments Caused by Neuromotor Impairments

A third cause for orthopedic impairments are neuromotor impairments. Neuromotor impairments are caused by damage to the spinal cord or other parts of the nervous system that lead to difficulty with mobility and movement. Students who experience traumatic brain injury may have physical mobility issues related to neuromotor impairments. The two most common types of neuromotor impairments are cerebral palsy and spina bifida.

Cerebral palsy (CP) is a condition in which students experience tight muscles that cause stiff mobility, abnormal movement, and poor balance. CP may affect one side or both sides of the body. Some students with CP can walk unassisted, while others need braces, canes, walkers, or wheelchairs. Students with CP may also experience seizures, hearing impairment, or visual impairment. Cerebral palsy is often caused by a prenatal or perinatal experience in which brain development is interrupted. Some causes may include asphyxia during delivery, an infection in the brain, or a traumatic brain injury. There is no cure for CP.

Spina bifida is a disorder where babies are born without full formation of the spinal column. This often causes paralysis in some parts of their bodies. Students are born with spina bifida, and there is no cure. They may use wheelchairs, braces, or other walking aids (Thomson & Segal, 2010). Most students with spina bifida also have bowel and bladder difficulties.

How Has the Field of Orthopedic Impairments Evolved?

For millennia, children have experienced orthopedic impairments. Wheelchairs (in a crude form) have been documented as early as 3500 BCE (Woods & Watson, 2004). Early wheelchairs had two large wheels with one small wheel in front, which then changed to two large wheels with two small casters in front (Cooper & Cooper, 2010). With advances in technology, wheelchairs have become less bulky, as they are made with stronger, yet lighter, materials (Cooper & Cooper, 2010). Now wheelchairs are available in manual or motorized versions. For students with limited hand control, wheelchairs can even be directed by movements of the tongue. Wheelchairs are expensive, and many families use insurance to cover the cost or rely on donations from charities and organizations.

Early versions of leg braces were crude and difficult to wear. People used wood and metal to restrict or improve the movement of the legs. They became widely used during the polio epidemic in the middle of the 20th century, and leg braces today have become strong, lightweight, and relatively easy to put on and take off.

Canes, which help people keep steady while standing or walking, have also been around for centuries. Crude canes carved from wood have been replaced with today's lightweight and strong models, as well.

People with orthopedic impairments received access rights with the Americans with Disabilities Act (ADA) of 1990. Not only did they gain the right for non-discrimination in employment, but the ADA also stated that public buildings, buildings that received federal funding (e.g., libraries, airports, schools), and public transportation (e.g., buses, trains) needed to be accessible. The ADA Accessibility Guidelines and Buildings and Facilities outlines criteria for access in terms of ramps, restrooms, elevators, parking spaces, and other facilities.

What Are the Characteristics of Students With Orthopedic Impairments?

Students with orthopedic impairments experience a wide range of difficulties. Most struggle with physical motor skills because the brain and body have problems working together to perform a motion. Students with orthopedic impairments may use braces, canes, walkers, and wheelchairs for mobility. They may struggle with gross motor skills, fine motor skills, or both. Gross motor skills, which include walking, running and hopping, are skills related to big movements of the arms, legs, or trunk of the body. Fine motor skills are skills that require small movements, usually of the hand, and include writing with a pencil or using a spoon and fork.

Some students struggle with communication skills (Waring & Woodyatt, 2011). For example, some students with MD develop speech difficulties because of problems with the muscles that control how their tongue and mouth move. Students with CP may have difficulty controlling the head and mouth, as well. Many students with orthopedic impairments have difficulty with written communication because of the fine motor skills necessary to hold and control a writing utensil. In some cases, students may use assistive technologies, such as speech-to-text software or picture communication devices, to communicate.

Many students with orthopedic impairments experience average to above-average intelligence. Accommodations for such students will focus on how the student accesses classroom material and participates in activities. For example, students may require use of a scribe for writing essays or extra time to complete assignments. People unfamiliar with orthopedic impairments sometimes see a child in a wheelchair and assume the child has deficits in intellectual functioning. It is important to not allow a student's physical limitations to cloud a teacher's judgment about the student's academic skills.

Students with orthopedic impairments may have medical issues related to their disability. Many students with CP experience seizures. Students who are non-ambulatory (i.e., use a wheelchair) may use diapers or need assistance with self-care related to the bathroom. Students may have bladder or incontinence issues related to their physical disability. Some students may have to undergo surgeries or procedures related to their impairment, causing them to miss chunks of time during the school year.

What Are the Causes of Orthopedic Impairments?

More than 50 types of disorders and diseases can cause orthopedic impairments. The previous discussion covered the most common: degenerative disorders (MD and MS), musculoskeletal disorders (JRA and limb deficiency), and neuromotor impairments (CP and spina bifida). Orthopedic impairments may also be caused by the following:

Bone tuberculosis. Tuberculosis is a bacterial infection that is often respiratory, but the infection can spread to bones. Symptoms may include weakened joints or bones that cause difficulty with movement.

Clubfoot. Clubfoot is a birth defect where one or both feet of the baby are turned in at the ankle. Many children with clubfoot can wear shoes to help correct the problem. Children with clubfoot may experience difficulty with walking.

Epilepsy. Students with the neurological disorder epilepsy experience seizures. Some seizures can be severe enough to cause twitching of muscles and limbs. Students can fall unexpectedly during a seizure and injure themselves.

Polio. Poliomyelitis is a disease caused by infection that spreads to the spinal cord. While rare, the infection can cause muscle weakness or paralysis. A vaccine can prevent polio.

Scoliosis. A child with scoliosis has spine curvatures that can lead to orthopedic impairments. Students may wear braces to help straighten the spine or undergo surgery to straighten the spine.

Accidents, such as car accidents or burns. Any accident may cause damage to a student's arms, legs, or trunk. This damage may cause an orthopedic impairment.

How Are Students Diagnosed With Orthopedic Impairments?

Most children with orthopedic impairments—whether caused by disorders, diseases, accidents, or illness—receive a diagnosis from a medical professional before they enter school. When students develop orthopedic impairments after they begin their schooling, teachers may notice changes, such as frequent falling or not being able to grip a pencil. In these cases, the family should have the child undergo a formal evaluation by a licensed physician.

The physician will do a thorough evaluation of the student. An evaluation may include brain scans, body scans, genetic testing, or blood sampling. The doctor should also gather observational data and information about how the student's impairment may affect learning in the educational environment. For example, the doctor may test a student's range of motion or ability to walk or skip. The doctor may check a student's reflexes and dexterity.

Once a diagnosis has been obtained, the IEP team then works with the family and student to determine if the student qualifies for services under IDEA 2004—that is, whether the student's educational outcomes are adversely affected. Many times, the student will undergo an academic evaluation (e.g., an intelligence test or achievement test) to understand if the student has any academic needs that need to be addressed. An evaluation by a speech-language pathologist or speech therapist may determine if the student has any speech or language needs. A physical therapist, an occupational therapist, or both may be members of the IEP team, because they will provide services to the student (see the feature, "What Do Physical and Occupational Therapists Do?"). The IEP team addresses deficits in gross and fine motor skills and puts together a plan to address the student's needs.

The team will also address how the student will get around the school in terms of access to classrooms, cafeterias, libraries, and other spaces. Some schools will need to make changes to the physical space of the building to ensure that the student has the same degree of access as students without disabilities. For example, a ramp may need to be constructed so all students can access the stage in the auditorium or an elevator may need to be installed so all classrooms are accessible.

How Do I Teach Students With Orthopedic Impairments?

Teachers focus on access for students with orthopedic impairments—access not only to places, but also to information and activities. Many students with orthopedic impairments have difficulty accessing information and activities in the same way as nondisabled peers. For example, a student may have trouble writing a five-paragraph essay because of difficulty with fine motor skills, or a student may not have the hand strength to pour liquids from beaker to beaker during a science experiment. Teachers need to come up with ways to include the student in classroom activities. In the examples above, the student may choose to type the essay rather than handwrite it, and the student may work with a lab partner. It is important, however, that teachers think of novel ways to have students with orthopedic impairments participate actively, instead of always letting another student do the hands-on work. For example, in a math class, instead of manipulating rubber bands on a geoboard (which requires quite a bit of dexterity), the teacher may use a computer program so that all students in the classroom interface with an electronic version of a geoboard.

Teachers need to think about the arrangement and organization of the classroom space. If the class includes a student using a wheelchair, the classroom floor must be free of rises or impediments. The student should be able to maneuver down rows of desks. No part of the classroom should be off limits. Students in a wheelchair may not be able to reach books on a high shelf, but they should be able to get to the bookshelf. Students may also need accessible desks or tables, as most school desks do not accommodate a wheelchair.

The physical education teacher may need to adapt gym activities. In fact, there are Adapted Physical Education National Standards (APENS). Adaptations may involve playing in a smaller area (when running is difficult) or larger area (when wheelchairs are involved). Students may use a larger ball that is easier to grab, or gloves with Velcro that can easily catch Velcro balls. Recess activities, school plays, and field trips may also need to be made more accessible for students. For example, a trip to a waterpark may not be accessible to a student in a motorized wheelchair. The class could visit a zoo, movie theatre, or bowling alley instead. (Many bowling alleys have a device that can be moved up to a student's wheelchair that allows the student to roll the ball down a ramp onto the bowling alley.)

Schools must address the accessibility of the school building and grounds. The teacher should develop a routine to help the student get around the school. If the school has an elevator, a pair of students may accompany a student in a wheelchair to help push buttons or keep the elevator doors from shutting too quickly. The playground should be made accessible, and lunchrooms may need to be organized more efficiently (Pinter, Filipcic, Solar, & Smrdu, 2005). For example, lunch tables may need to be placed in rows that allow easy access to and from the food line, trash can, and all exits.

To accommodate students that have difficulty with fine motor skills, especially handwriting and drawing, teachers may need to create ways for these students to use classroom materials. For example, worksheets may be printed with a larger font (Avant & Heller, 2011). This strategy might be particularly useful when, say, the student is asked to underline certain clauses, fill in a missing word, create a graph, or solve a computation problem.

Some students may experience hand trembling or hand paralysis (Avant & Heller, 2011). Teachers need to be creative in devising ways in which these students can play board games, write in a journal, read a book, or do any number of other classroom activities. Students can use technologies (e.g., computer keyboard, speech-to-text software, electronic page turner) to help with fine motor skills. Teachers may want to use bigger game pieces (e.g., a 3-D rectangle that is easy to grab) rather than flat pieces for games or other classroom activities.

Teachers need to provide assistive technologies when appropriate. Students who have difficulty with writing may use recorders to record class lectures. Speech-to-text or text-to-speech programs (that transcribe the spoken word into written text or vice versa), scribes (a person who transcribes a student's spoken word), or large-print paper (with writing lines further apart to accommodate larger handwritten letters) may be helpful. Teachers may use clipboards or tape to secure student work to a writing space. Students may use markers or larger pens to write instead of pencils. Slip pads may be placed on laptops, calculators, or manipulatives to secure the materials needed for work.

When a classroom includes students with orthopedic impairment, the entire classroom will require social skills education (Donders & Taneja, 2009). Teachers need to work with all students to create a positive classroom environment that is welcoming and built on acceptance. They also need to educate the students about individual differences and how to interact with someone with a physical disability. Teachers may need to establish rules to help with safety. For example, "No riding on the back of a wheelchair," or "The only person who uses the walker or cane is Margarita."

Some students may have to miss a day of school for a doctor's appointment, or they might miss weeks of school due to surgery or illness. In such cases, teachers must help students keep up with their work. Teachers may allow the student to do some work at home during recuperation if the student is healthy enough to do so. Teachers may also record lessons using video or audio so the student can watch or listen via the internet or at a later date. Teachers could also have the student participate in class remotely with a live video feed.

In addition to academic needs, some students may need physical care during the school day. This may involve changing a student's stoma (i.e., colostomy) bag or refitting a student's leg braces after nap time. The school and IEP team must decide who is responsible for any physical needs during the school day. Often, a specialist, school nurse, or special education paraprofessional may help out with such activities, but the general classroom teacher may be involved. Regardless of who helps with the care of the student, all personnel should receive proper training from an agency, medical professional, or the student's family.

11.2 Students With Traumatic Brain Injury

Students who experience an injury or accident that causes difficulty with brain function may have traumatic brain injury. Causes can be related to any accident or injury, and the head does not have to be directly involved in the accident. Students can experience academic difficulties similar to students with SLD or SLI and behavioral difficulties similar to students with EBD.

What Is Traumatic Brain Injury?

A traumatic brain injury (TBI) is an injury to the brain that causes brain function to be impaired. This injury may be caused by being shaken violently or being hit in the head. Most TBI are caused by car accidents, falls, sports injuries, or physical abuse. Injuries can be closed (i.e., within the skull) or open (i.e., the skull cracks or breaks). Congenital or birth trauma brain injuries are excluded, and are often related to cerebral palsy or classified under intellectual disability instead.

According to IDEA 2004, TBI is:

an acquired injury to the brain caused by an external physical force, resulting in total or partial functional disability or psychosocial impairment, or both, that adversely affects a child's educational performance. Traumatic brain injury applies to open or closed head injuries resulting in impairments in one or more areas, such as cognition; language; memory; attention; reasoning; abstract thinking; judgment; problem-solving; sensory, perceptual, and motor abilities; psychosocial behavior; physical functions; information processing; and speech. Traumatic brain injury does not apply to brain injuries that are congenital or degenerative, or to brain injuries induced by birth trauma.

Approximately 0.04% of school-age students are categorized as having TBI. TBI is the leading cause of child disability (i.e., disability caused by an accident) and death in the United States. Boys experience TBI approximately 1.5 times more than girls (Arroyos-Jurado & Savage, 2008).

A TBI can affect the academic performance and behavior of the student. The student may experience deficits in intellectual functioning, and some students experience anxiety, anger, restlessness, and emotional outbursts. Some students may also experience physical difficulties, such as orthopedic impairments, because of their TBI. Students may also have physical scars or deformities related to their accident.

The severity of TBI can vary widely, and it depends upon the accident and the healing of the brain afterwards. Students with mild TBI, such as caused by a concussion, demonstrate no significant academic or behavioral deficits (Vu, Babikian, & Asarnow, 2011). Students with moderate TBI demonstrate some impairment of academic and behavioral skills, and students with severe TBI demonstrate significant deficits with academics and behavior (Walz, Yeates, Taylor, Stancin, & Wade, 2009). The brain function of many students with TBI may improve over time, but some individuals experience permanent damage that does not improve, even with therapy and instruction.

What Are the Characteristics of Students With TBI?

Students with TBI may have physical, academic, or behavioral difficulties. Because students with TBI have difficulty with academics, they may experience difficulties similar to students with SLD or ID. Students may experience behavioral and emotional difficulties similar to students with EBD. This section will cover a few common characteristics, but keep in mind that every student with TBI is different.

In terms of physical difficulties, students may experience slurred or delayed speech, visual impairments, and hearing impairments. Some may experience paralysis on one or both sides of their body, may appear clumsy, and may have difficulty with balance. Students might struggle with gross or fine motor skills, or seizures. After a long school day, they may experience fatigue. Some students may use a wheelchair, cane, or braces for mobility.

Students with TBI may experience difficulty in academics related to thinking and reasoning. They may appear distracted or have difficulty paying attention for long periods of time. Students may be slow to respond to teacher questions or class discussions. It may take students longer to complete assignments or tests. Their short- and long-term memory skills may be compromised. Students may have difficulty remembering steps to solving problems or organizing a written essay. They may have difficulty with vocabulary and learning of new information.

Students may have difficulty relating to peers in social situations (Levin, Hanten, & Li, 2009). Other behavioral difficulties may include mood swings, anxiety, and depression. Often after TBI, students have to come to accept their "new normal," and many need to relearn things that they were able to do before their accident. Some students with TBI may appear restless and have difficulty controlling emotional outbursts.

What Are the Causes of TBI?

TBI is caused by an accident that contributes to brain injury. Falls, sports injuries, car accidents, and firearm accidents can cause TBI.

Falls can cause TBI. Children slip in the bathtub, or fall out of bed, down the stairs, over a balcony or ledge, or from a ladder. Sports injuries are also a fairly common culprit. Bicycling, boxing, diving, football, horseback riding, lacrosse, skateboarding, skiing, and soccer have all been known to lead to head injuries and TBI (Bullock, Gable, & Mohr, 2005). TBI can also be caused by car accidents or accidents involving other moving vehicles, such as personal watercraft or off-road vehicles. Firearm accidents or blasts (perhaps from fireworks) can also lead to TBI. Finally, physical abuse can lead to TBI. Shaken Baby Syndrome (SBS) occurs when an infant or toddler is shaken violently and bleeding and bruising occurs in the brain.

When the TBI is severe, children often are taken to emergency rooms or doctor's offices for evaluation. Sometimes, however, the TBI may not be apparent until days or weeks after the initial injury (Bullock et al., 2005). Often, when there has been an accident, the student may be recovering from physical injuries and the TBI goes unnoticed as the student recuperates. Medical professionals may be so concerned about healing a student's more obvious physical wounds that the brain injury is unintentionally ignored. In other cases, the brain actually goes into a state of over-working in reaction to the traumatic injury. When the brain is ready to resume its normal routine, that routine may not be as it was before.

How Are Students Diagnosed With TBI?

All cases of TBI are diagnosed by medical professionals. The doctor may image the brain via Computed Tomography (CT), Magnetic Resonance Imaging (MRI), or functional Magnetic Resonance Imaging (fMRI) to determine if an injury has occurred (Karunanayaka et al., 2007). A neurologist or neuropsychologist will conduct a neuropsychological assessment to better understand brain functions (Stavinoha, 2005). Part of the assessment includes an interview with the patient's family to understand what the child was like before the injury. The assessment may include tests of a student's attention, memory, concentration, orientation, language, mathematical reasoning, and spatial ability. The student's performance is compared with that of students without TBI to better understand differences and deficits.

How Do I Teach Students With TBI?

Students with TBI may display characteristics of SLD, ED, or ID. Thus, some of the teaching strategies for these disability categories may be appropriate for students with TBI because the academic and behavioral difficulties may be similar.

The most difficult part for many students with TBI is adjusting to their "new normal" (Arroyos-Jurado & Savage, 2008). They probably were "typical" students before their accident; they now have different physical, academic, and behavioral needs. Some students with TBI may physically appear the same but have different behaviors and academic needs (Schutz & McNamara, 2011). Ensuring that the emotional well-being of the student is addressed is as important as addressing the educational needs of the student.

Teachers should use explicit instruction in academics (Arroyos-Jurado & Savage, 2008). To provide explicit instruction, teachers demonstrate and model concepts with the students and lead the students with guided practice activities. Task analysis will help them better understand which steps of assignments or tasks students can and cannot do. In a task analysis, teachers break down a skill or task into each individual step necessary to complete it. Students may also need help with self-regulation or self-monitoring. Teachers may teach students to use checklists to help monitor their progress as they work through an assignment or through the school day.

Teachers may also want to emphasize problem-solving skills, as some students become overwhelmed with assignments that have too many steps (Catroppa & Anderson, 2006). Many students will require the use of accommodations and modifications that were outlined in Chapter 2. Examples of accommodations that might be most appropriate for students with TBI include breaking large assignments into smaller ones, providing more time to complete assignments, or giving students various options for completing an assignment (Arroyos-Jurado & Savage, 2008).

Teachers should use behavior supports with motivational tools that are positive and meaningful to the students (McCauley et al., 2011). The staff of the school should work together to ensure that the student is expected to follow the same rules (and receive positive feedback on following rules) across classrooms and settings. Students may have to relearn basic social skills, so teachers need to provide opportunities for students to practice these skills. Teachers may also need to spend time educating the peers of a student with TBI. Many may be frightened or unsure of how to interact with a friend who seems "different" after an accident.

Often, the student and family will have experienced a traumatic event (e.g., a car accident) in conjunction with the student's injury, so the school needs to be tactful in working with the student's family (Gfroerer, Wade, & Wu, 2008; Wade et al., 2011). Schools should provide appropriate counseling services to the student (and the student's school-age siblings) if necessary. In some cases, a student with TBI may have been involved in an accident in which another family member was severely injured or killed. Counseling services can be provided by a guidance counselor or school psychologist. Schools should also provide allowances for student absences, especially if the student's parent or sibling was also injured. Some students may not return to school for weeks or months after their accident due to hospitalization and rehabilitation (Bullock et al., 2005). The school can prepare for the student's reentry by developing the student's IEP and putting in place proper services.

11.3 Students With Other Health Impairment

The IDEA 2004 category of other health impairment encompasses many disabilities not covered by the other 12 disability categories. OHI causes are as wide and varied as the disabilities that qualify under OHI. Teachers can use strategies learned in other chapters to help the academic and behavioral needs of students with OHI.

What Is Other Health Impairment?

Other health impairment (OHI) is a catch-all category for disorders, diseases, and conditions that do not fall under the other 12 IDEA 2004 disability categories and for disabilities that are very rare (Bishop, McLaughlin, & Derby, 2011). As discussed in Chapter 5, Attention Deficit/ Hyperactivity Disorder (ADHD) falls under OHI because ADHD is not a separate disability category at this time (Wodrich & Spencer, 2007). There are not many similarities among the disabilities that qualify as OHI.

The official definition of OHI under IDEA 2004 states:

OHI means having limited strength, vitality, or alertness, including a heightened alertness to environmental stimuli, that results in limited alertness with respect to the educational environment, that (i) is due to chronic or acute health problems such as asthma, attention deficit disorder or attention deficit hyperactivity disorder, diabetes, epilepsy, a heart condition, hemophilia, lead poisoning, leukemia, nephritis, rheumatic fever, sickle cell anemia, and Tourette syndrome; and (ii) adversely affects a child's educational performance.

Approximately 1.07% of the student population is identified with OHI. Here are some common OHI conditions (DePaepe, Garrison-Kane, & Doelling, 2002; Wodrich & Spencer, 2007):

Table 11.1: Common OHI Conditions

Condition	Description
Allergies	Students have allergies (ranging from mild to life-threatening) that can make  participating in some activities difficult or dangerous.
Asthma	Students have issues related to the respiratory system that can make participating  in some activities difficult.
ADHD	Students experience inattentive or hyperactive-impulsive behavior.
Cancer	The treatment for cancer can cause students to miss school days, which may  contribute to adverse educational outcomes.
Cystic fibrosis	Students with cystic fibrosis have a disease that causes lung infections. The lung  infections can make participation in some activities difficult.
Diabetes	The bodies of students with diabetes have difficulty regulating insulin levels. At  school, students may requireassistance with measuring blood glucose levels or  administering insulin shots.
Epilepsy	Students with epilepsy may experience mild to severe seizures. Teachers and other  staff may need to be trained torespond to a student experiencing a seizure.
Fetal Alcohol Syndrome Disorder(FASD)	When a mother drinks excessive amounts of alcohol during pregnancy, a baby may  be born with birth defects. Thesebirth defects can contribute to academic and  behavioral difficulties.
Hemophilia	The blood of a student with hemophelia does not clot as expected. If involved in an  accident or fall, a student can require medical attention.
HIV/AIDS	The Human Immunodeficiency Virus (HIV)—and the later stage of Acquired  Immunodeficiency Syndrome (AIDS)—cause students to have a weakened immune  system. HIV is transmitted through  blood. Schools must provide trainingfor all staff about the exposure to the blood of  a student with HIV or AIDS.
Lead poisoning	Lead poisoning occurs when a student is exposed to dangerous levels of lead  through lead paint or other lead-basedcontaminants. Students with lead poisoning  may experience deficits in intellectual functioning.
Leukemia	The treatment for leukemia can cause students to miss school days, which may  contribute to adverse educational outcomes.
Nephritis	Students may experience kidney or bladder infections related to nephritis, an  infection of the kidney. Students mayrequire assistance with issues related to  going to the bathroom.
Rheumatic fever	If students do not have a strep infection (e.g., infection in the throat) treated, the  infection may lead to rheumaticfever. Students can experience joint pain or  damage, and some students experience heart damage.
Sickle-cell anemia	Students with sickle-cell anemia have blood cells that contribute to a wide range  of medical difficulties includingulcers, stroke, visual impairment, bone and joint  difficulty, and loss of bladder control.
Tourette syndrome	A student with Tourette syndrome has tics (i.e., repetitive physical movements  or voiced sounds/sayings) that occurspontaneously.

Not every student who has one of these conditions—for example, allergies or asthma—needs to be identified as having an OHI. It is only when these conditions are so severe that the child's educational programming requires alteration that they are considered OHI. For some students with food allergies, for example, policies and emergency procedures need to be established so the student does not come in contact with the allergen and the school knows what to do if this happens (DePaepe et al., 2002). Section 504 plans are especially helpful in situations where the student needs school support or accommodations, yet the student does not qualify under IDEA 2004. Members of a 504 team can outline treatment, accommodations, modifications, or emergency treatment plans for students requiring school support.

You may have noticed that a few of the OHI conditions can be categorized under other disability categories (Adams, Smith, Bolt, & Nolten, 2007). For example, some schools may place epilepsy under an orthopedic impairment if the condition affects the student's mobility and academic outcomes. If other students' epilepsy adversely affects their academic outcomes, but not their mobility, those students may qualify for special education accommodations under OHI. Some schools may categorize a student with Tourette syndrome as having an ED when behavioral outcomes are affected, while others might categorize the disability under OHI if the ED definition is not appropriate. Categorization of disability category is determined by the school. The school often favors a specific category over the category of OHI, unless the student does not meet criteria in the specific disability category.

What Are the Causes of OHI?

Disabilities, disorders, and diseases that fall under OHI have any number of causes. Some causes might be related to genetics (e.g., cystic fibrosis, sickle-cell anemia), exposure to blood pathogens (e.g., HIV), infection (e.g., rheumatic fever), or complications during pregnancy (e.g., FASD). Many may not have an exact cause (e.g., leukemia, Tourette syndrome).

How Are Students Diagnosed With OHI?

Often, the conditions that qualify under OHI are diagnosed by medical professionals. Parents may refer their child for evaluation or a medical professional may suspect a disability, disorder, or disease. Students can be diagnosed at birth or at any point in their childhood, depending upon the condition.

How Do I Teach Students With OHI?

Because many of the conditions that cause students' OHI are uncommon, teachers may need to consult medical professionals or other specialists to understand the student's needs. The team writing the IEP of students with OHI should obtain as much information as possible from any medical professionals who have diagnosed or treated the student. Schools may involve physical therapists, occupational therapists, behavioral therapists, or speech-language pathologists as members of the IEP team, because these professionals will provide services to the student.

Physical therapists and teachers should aim for optimal physical mobility for the student. Teachers and occupational therapists should ensure that students have all the skills necessary to participate in the school day. Academic or behavioral accommodations may be required when students have difficulty with classroom content or with behavior during the school day. Many of the teachinge suggestions mentioned in Chapters 3 and 4 can be useful for students. Some students may need help with speech and communication, so the teaching suggestions from Chapter 7 would be appropriate. As with most of the disability categories, assistive technologies should be used when appropriate (e.g., a timer that beeps at intervals to increase the attention of a student with ADHD), and schools should keep abreast of new and emerging technologies.

Students with OHI may need medical or health assistance during the school day (DePaepe et al., 2002). For example, some students may wear diapers and need these changed during school or require cleaning of a catheter (Obringer & Coffey, 2010). General education teachers often do not help with such tasks, but teachers must be aware of the student's needs. Other students may need to take medicine or have shots administered. Schools without full-time school nurses must determine which adult is responsible for helping the student attend to these needs.

11.4 Students With Multiple Disabilities

The category of multiple disabilities is reserved for students who experience two or more severe disabilities. Causes are related to the distinct disabilities of the student. Many students receive services in special education classrooms, but some students may participate in part of the general education curriculum.

What Is Multiple Disabilities?

The category of multiple disabilities is for students who have two or more disabilities that are significant enough that the student cannot be serviced appropriately under one disability category. A student might have an intellectual disability plus a visual or hearing impairment, or both. Other combinations might be orthopedic impairment plus intellectual disability, orthopedic impairment plus speech-language impairment, or autism spectrum disorder plus visual or hearing impairment (Cross, Traub, Hutter-Pishgahi, & Shelton, 2004; Snell, Chen, Allaire, &Park, 2008; Wodrich, Kaplan, & Deering, 2006). Students with multiple disabilities often have severe disabilities that significantly affect their lives.

According to IDEA 2004, "Multiple disabilities means concomitant (accompanying) impairments, the combination of which causes such severe educational needs that they cannot be accommodated in special education programs solely for one of the impairments. Multiple disabilities does not include deaf-blindness." (You'll remember from Chapter 10 that deaf-blindness is its own disability category.) Approximately 0.18% of the student population is identified as having multiple disabilities.

What Are the Characteristics of Students With Multiple Disabilities?

Students with multiple disabilities exhibit the characteristics of their two or more disabilities. For example, if a student has ID and a visual impairment, the student would experience the characteristics associated with ID and the characteristics associated with visual impairments.

What Are the Causes of Multiple Disabilities?

The causes related to multiple disabilities stem from the two (or more) disabilities of the student. For example, if a student has ID and a visual impairment, the causes related to ID would be those found with other students with ID. The causes for the visual impairment may be related to those of other students with a visual impairment.

How Are Students Diagnosed With Multiple Disabilities?

Typically, the diagnosis of individual disabilities occurs, and then the IEP team decides whether the student qualifies for special education services under the category of multiple disabilities. As explained in IDEA 2004, a student qualifies for the category multiple disabilities when the student's needs for disability-related services or accommodations do not fit into only one disability category.

How Do I Teach Students With Multiple Disabilities?

The teaching strategies for the individual disabilities apply to students with multiple disabilities. See Chapters 3–11 for teaching suggestions by disability category.

References

Powell, S. R., & Driver, M. K. (2013). Working with exceptional students: An introduction to special education [Electronic version]. Retrieved from https://content.ashford.edu/