Effective Teaching methods for Individuals with Learning Disabilities

Effective Teaching methods for Individuals with Learning Disabilities Linda Mc. Cumber, MS, OTR/L, CDRS, CDI

• “Allowing a student with a hidden disability (ADHD, Anxiety, Dyslexia) to struggle Academically or socially when all that is needed for success are appropriate accommodations and expicit instruction, is no different than failing to provide a ramp for a person in a wheelchair. ” • The OT Clinic

Definition of Learning Disability • Practical Definition: covers a range of neurologically based disorders of learning and various degrees of severity • Disorders of processing (visual and auditory) • Difficulty prioritizing, organinzing, following instructions • Difficulty storing or retrieving information from long or short term memory

Definition of Learning Disability • Medical Definition: DSM-IV-TR • Reading disorder, Mathematics Disorder, Disorder of Written Expresson and Learning Disorder not otherwise specified (NOS)

Definition of Learning Disability • Legal Definition: The Individuals with Disabilities Act (IDEA) provides that “specific learning disability” means “a disorder in one or more of the basic psycholigical processes involved in understanding or in using language…may manifest itself in the imperfect ability to listen, think, speak, write or do mathematical calculations

Definition of learning Disability • Legal Definition: (IDEA) “…includes perceptual disabilities, brain injury, minimal brain dysfunction, dyslexia and developmental aphasia • Does not include “…a learning problem that is primarily the result of visual, hearing or motor disabilities, of intellectual disabilities, of emotional disturbance or of environmental, cultural or economic disavantage. ”

“Normal intellegence is within two standard deviation of the mean IQ within that range may not be predictive of driving ability. There is a subcategory of LD learners I call “Valedictorians that cant drive”

Incidence and Prevalence of Learning Disabilites According to The Condition of Education 2018, 14% of students age 3 -21 are receiving special education services Students with autism, intellectual disabilies, developmental delays and emotional disturbances account for 5 -9% served under IDEA

Learning Disabilities • ADD/ADHD: DSM-5 Criteria • Inattention: Six or more symptoms of inattention for children up to age 16, five or more for adolescents 17 or older and adults. Symptoms of inattention have been present for at least 6 months, and they are inappropriate for developmental level

ADD/ADHD • Often fails to give close attention to details or makes careless mistakes in schoolwork, at work or with other activities • Often has trouble holding attention on tasks or play • Often does not seem to be listening when spoken to directly • Often does not follow through on instructions and fails to finish schoolwork, chores or duties in the workplace

Autistic Spectrum Disorder • Persistent deficits in social communication and social interaction across multiple contexts • Deficits in social-emotional reciprocity • Deficits in nonverbal communication • Deficits in developing, maintaining and understanding relationships

ASD • Restricted repetitive patterns of behavior, interests or activities • Hyper/hypoactivity to sensory input • Insistence on sameness, inflexible adherence to routines • Highly restricted fixated interests

Nonverbal Learning Disability (LD) Significant discrepancy between higher verbal skills and weaker motor, visual-spatial and social skills Difficulty with spatial orientation, directional concepts and coordination Difficulty generalizing previously learned information Difficulty following multi step instructions

Executive Function Disorder • Theoretical construct of frontal lobe function that helps an individual manage time, pay attention, shift focus, plan and organize, remember details, multitask, problem solve or think creatively • Research indicates that the frontal lobe continues to develop well into a person’s mid 20’s

Client Factors Required for Driving • Operational Proficiency/Vehicle Control • Vision: acuity, depth perception, color discrimination, peripheral vision, fusion • Visual processing: perceptual reasoning, processing speed, visual attention • Ocular motor control: tracking, saccadic eye movements, visual scanning • Visual motor integration: hand eye coordination

Client Factors Required for Driving • Gross motor coordination: bilateral coordination, integration of motor control for movements of the upper and lower extremities • Reaction time • Fine motor coordination

Client Factors Required for Driving • Tactical: Ability to learn and retain the rules of the road/rules of right of way • Spatial orientation: Directionality, Understanding of the logical flow of traffic, ability to judge a safe gap when entering or moving across traffic • Ability to formulate and execute decisions in a timely manner

Client Factors Required for Driving • Strategic: Ability to safely interact with other drivers on the road (Defensive Driving) • Ability to interpret the intentions of other drivers • Ability to plan trips, remember directions or safely use a GPS

Client Factors Required for Safe Driving • Strategic: Ability to estimate the time required to get from point A to point B based on road and traffic conditions, weather, obeying speed limits • Strategic: Ability to evaluate and manage potential distractions such as cell phone use, behavior of passengers, environmental distractions • Strategic: Ability to manage emotions behind the wheel, internal distractions

Driving Evaluation Process • Referral from a physician or Vocational Rehabilitation Counselor (VRC) • Clinical Assessments to determine client’s strengths and challenges, best learning style • On-road Assessment to determine client’s current skill level, to predict prognosis for success and to estimate time frame for learning

Driving Evaluation process • Referral from VRC: diagnosis, medical history/medication use, psychological testing, impact of disability on work related skills • Relevant driving history • Educational or vocational goals • Social support: access to a vehicle for practice and involvement (if any) of parents or other responsible adults • Community resources for alternative transportation

New York City Subway Map

Capital District Bus Route Map

Driving Evaluation Process • Visual Assessment using the Optic 2000 • Binocular Vision/fusion Distance Acuity (NYS DMV minimum requirement is 20/40 in one eye) • Vertical and horizontal phorias • Depth Perception • Color discrimination • Peripheral vision • Visual scanning/organization

Driving Evaluation Process • Visual/perceptual processing and processing speed • Motor-Free Visual Perception Test (MVPT) tests for: • Visual discrimination-ability to discriminate position, shapes and forms of objects • Spatial Relationships-ability to perceive the positions of objects in relation to self, perception of figure rotations or reversals • Visual Memory • Figure-Ground-ability to distinguish an object from background • Visual Closure-the ability to perceive a whole figure when only fragments are presented • MVPT is normed by age for accuracy and time

Driving Evaluation Process • • Ability to follow directions One step instructions Multi-step instructions New learning

Driving Evaluation Process • • • Attention: Sustained Selective (stroop test) Alternating (double letter cancellation) Divided (Trails A and B)

Driving Evaluation Process • • Right/left discrimination Coordination Behavioral Observations Reaction Time Mobility: ambulation/assistive devices Transfers Neck and trunk rotation Upper and lower extremity function

Driving Evaluation Process • Ability to operate a standard vehicle or need for adaptive driving equipment such as: • Hand controls, spinner knobs, accelerator left of brake, pedal extenders, mechanical aids • Low tech (all of the above) vs high tech. • Ability to load wheelchair vs need for mechanical loading device

Driving Evaluation Process • Goals for On-road assessment • Determine how client’s challenges might impact learning to drive • Determine the prognosis for success: good, fair or guarded • Estimate the time frame for learning based on developmental readiness, current ability and social support

Adaptive Driver Training ACCESS-VR in New York will fund up to 40 hours How long does the typical learner need to become a safe, licensed driver? NYS DMV requires 50 hours, at least 15 of those hours at night, for learner’s under the age of 18 Clients with learning disabilities may require all 40 hours of training and at least that for practice outside of lesson time.

Adaptive Driver Training: Vehicle Control • Basic proficiency may take considerably longer…especially if there are visual/perceptual deficits, motor deficits and/or anxiety related to driving • Client may have tried driving with a parent off road, which might have been sufficiently alarming to trigger the need for professional help • Establish goals and clear expectations for each lesson and for the first 5 -10 lessons.

Adaptive Driver Training: Vehicle Control Lessons 1 -10 Start in an empty parking lot or quiet, residential areas. Can the client coordinate steering with speed control for turns? If not, we can allow for working on each separately (if driver’s ed car is equipped) Integrated control must be mastered before client is safe to practice outside of lesson time.

Adaptive Driver Training: Vehicle Control Lessons 1 -10 • Use reference points on the hood of the car to determine centered position but make sure client is not looking at the road directly in front of the car • Assist with steering to prevent over/under steering • Encourage client to get feedback from steering while in motion

Adaptive Driver Training: Vehicle Control Lessons 1 -10 • Assess the client’s grip on the wheel; anxiety may lead to grasping the wheel too hard. • Encourage a 9: 00/3: 00 or 8: 00/4: 00 hand position. • Client may need a demonstration of hand over hand steering and practice while not in motion • Provide explicit instruction for the timing of turns…when to start the turn, how much to turn the wheel and how to recover the wheel • When client can keep the car centered and make fairly accurate turns allow them to attempt to control the speed of the vehicle as well.

Adaptive Driver Training: Vehicle Control Lessons 1 -10 • Speed control: Make sure that the client knows which pedal is which and can find each pedal without looking at her feet. • With the car in park, practice moving from one pedal to the other with graded control by listening to the sound of the engine and/or looking at the tachometer. • Provide explicit verbal instruction when to start pressing the accelerator, how hard to press the accelerator, when to begin braking and how to stop smoothly. • Try to use the same practice area or practice routes for the development of specific skills. The familiarity of the driving environment may be helpful for both the client and the instructor.

Adaptive Driver Training: Vehicle Control lessons 1 -10 Speed maintenance: can the client maintain a target speed within a range of 5 mph? Does the client register changes in speed in this range? Provide verbal cues to check speed and/or estimate speed without looking at the speedometer. Can the client check the speedometer without drifting? A digital readout may be interpreted faster than an analog. (Ability to separate focus from the direction the vehicle is moving will be essential in higher level skills such as highway merges or lane changes)

Adaptive Driver Training: Vehicle Control Lessons 1 -10 • Sample Goal: By lesson 10, client will be able to control the vehicle for centered lane position, speed maitenance and turns in both directions up to 30/40 mph with minimal verbal cues or assistance 80% of the time. • Progress to higher speeds as possible…use two lane rural roads prior to work on control prior to multi-lane roads or highways

Adaptive Driver Training: Rules of the Road Lessons 1 -10 Stop Signs • Start with identification of stop signs: two way vs all-way. (tactical) • Provide instruction for full stop (complete cessation of forward motion) operational • Provide instruction for correct stopping distances: at the stop line, at the crosswalk, before where the sidewalk crosses the road if not actually painted on the road, or in the absence of any of these, at the place for best observation. (tactical)

Adaptive Driver Training: Rules of the Road Lessons 1 -10 Stop Signs • • Explicit instruction for observation: If at an all way, client must be able to observe if there is another vehicle at or approaching the stop sign at the same time to determine who is first If not an all way, did the client stop in the place that allows for adequate observation? Does he need to move up into the crosswalk? Does the client understand the logical flow of traffic? Use the concept of “biggest danger” to allow for focus in the correct direction. Use visual aids such as diagrams for stopping distances and “biggest danger” Park near an all way stop and have the client determine the order of other approaching vehicles. Encourage client to assert right of way/discourage waving other vehicles on or passively allowing other driver to take their right of way Expect to reinforce these concept continually throughout the learning process. Probe for understanding: make sure client isn’t overgeneralizing or applying the incorrect rule (doing the right thing for the wrong reason)

Adaptive Driver Training: Rules of the Road Lessons 1 -10 Traffic lights • Provide explicit instruction for how traffic lights work (assume nothing) I ask, “When the light turns green for us, who else will have a green light? ” • Provide the general rule: The car turning left needs to yield to oncoming traffic. Ensure that the client is reading the scene correctly for directionality (cars that are on the other side of the intersection will look as though the directional indicator is blinking on the right side for a left turn. ) Expect to reinforce this

Adpative Driver Training: Rules of the Road Lessons 1 -10 Traffic Lights • Instruct in the meaning of green turning arrows • News flash: meaning of a flashing yellow directional! (Yield to oncoming traffic for a left turn at a flashing yellow directional) • Provide instruction for if/when client should move towards the center of the intersection to position for left turns.

Adaptive Driver Training: Rules of the Road 1 -10 Traffic Circles • Start, if possible, with a larger circle or one with only one lane. • Provide explicit instruction when to enter the circle and where to exit at first. Expect to have to reinforce this in future lessons. • After practicing several times with cues, allow client to try more independently and/or follow signs for where to exit • Emphasize how dangerous it is to stop in a traffic circle or stop prior to entering if there is no need to yield

Adaptive Driver Training: Rules of the Road Lessons 10 -20 Multilane roads • Vehicle control must be essentially mastered prior to lane changes or highway merges • Provide explicit instruction for correct observation (assume nothing) • Have clients practice using mirrors and checking blind spot before actually attempting a lane change or merge • Try to instruct and practice on a road or at a time of day when the client is unlikely to encounter heavy traffic. Progress to more challenging situations when possible. • Work on selecting the correct lane first, if necessary, prior to having the client complete an actual lane change independently • Be prepared to prevent client from turning the wheel while observing (in either direction), be prepared to cue client to maintain speed prior to merging, be prepared to take control or abort the attempt

Adaptive Driver Training: Lessons 1 -40 Backing up • Drive the back of the car!!! • Instruct the client to turn as fully around as possible to steer in the desired direction when backing up • Expect ongoing difficulties due to perceptual and directional challenges • If possible, practice backing up for longer distances/backing into parking spots • Refrain from slapping your student on the back of the head, unless he is your own child, when they get it wrong over and over again.

Adaptive Driver Training: Lessons 2040 Maneuvers and Road Test Preparation • How do you teach 3 point turns (K turns)? • Use handouts, videos, verbal instruction and/or demonstration • Break down the process into discreet steps • 1 -signal and pull over to the curb • 2 -signal to leave the curb, turn wheel all the way to the left/away from the curb • 3 -check blind spot (over left shoulder) and start to pull across when it is safe

Adaptive Driver Training Lessons 20 -40 Maneuvers 3 point turns (con’t) • 4 -Stop, shift into reverse, turn the wheel as far as it will go to the right • 5 -Look out the rear window and begin backing up, stop as soon as there is enough room to pull forward • 6 -Shift into drive, check traffic in both directions, turn the wheel and begin to pull forward. • Typical learner may master this is a few as 2 -3 attempts, LD students may take several weeks to sequence through the steps accurately and with good safety awareness.

Adaptive Driver Training Lessons 20 -40 Parallel Parking • Use handouts, videos, verbal instruction and/or demonstration • Break down process into discrete steps • Use the one turn/two turn/one turn method • Emphasize proper observation • Cut your losses if necessary (if intersection management is good then PP probably won’t be a deal breaker) • Allow for several lessons for reinforcement

Adaptive Driver Training Lessons 20 -40 • Is the client ready for independent driving vs can she pass a road test? • What tools or measures do you use? • We use our standard evaluation route (used to assess skills for licensed driver with a change in physical and/or cognitive status

Adaptive Driver Training: Role of parent as “coach” • Optimally, a parent or other responsible adult should be present for lessons frequently. This allows for the use of the same terminology/cuing in practice • “Coach” role is to provide practice of skills that are partially mastered. All new skills should be introduced safely in the driver’s ed vehicle • It is likely that one parent may be better equipped to tolerate the anxiety of driving with a novice. • If no adult is comfortable driving with the client in a non-equipped vehicle, this needs to be explored. What is the client doing that is making them so nervous? • Give specific conditions for practice: time of day, traffic conditions, residential areas, amount of time spent in practice between lessons. It will be more productive if the coach is not shrieking or gasping out of fear.

Adaptive Driver Training: Difficult Conversations How do you deliver bad news in a compassionate but firm way? Use the SPIKES protocol: used by oncologists to deliver a poor prognosis for recovery but can be applied to many difficult converations The recommendation of driving cessation can be devastating to older drivers and the termination of driver training can be equally devastating to novice drivers

Adaptive Driver Training: Terminating Training using SPIKES • S: Set up the interview: arrange for privacy, involve significant other or “coach”, sit down, make connection, allow for adequate time without interruptions.

Adaptive Driver Training: Terminating Training using SPIKES • Perception: Gain understanding of the client’s perception of their progress. If they think everything is going great while you’re thinking of terminating then you haven’t communicated honestly or effectively up until this point (planting the seed)

Adaptive Driver Training: Terminating Using SPIKES • I: Invitation: obtain the client’s invitation to speak candidly about prognosis for success • K: Knowledge: warn of the disclosure of bad news, impart knowledge using language that the client is able to understand, avoid unnecessary bluntness, emphasize the importance of trying hard and that failure is part of every person’s experience

Adaptive Driver Training: Terminating Using Spikes • E: Emotions: observe emotional reaction on the part of the client, identify emotion by naming it (sadness, frustration) and identify with the emotion with empathy. Use examples from your own experience of disappointment or failure • S: Strategy and Summary: Is the door open for another attempt at becoming a safe licensed driver? Are they ready for further discussion? Do they have unrealistic expectations? Can you state fairly firmly that independent driving is unlikely to be possible?

Adaptive Driver Training: Summary and Conclusions If 14% of all public school students have a diagnosed learning disability then you are likely to be working with them in traditional driver’s education.

Adaptive Driver Training: Summary and Conclusions • The LD individual is less likely to be developmentally ready for independent driving at the same time as typical peers. Postponing driver training until late teens or early 20’s is usually recommended

Adaptive Driver Training: Summary and Conclusions • The LD individual is likely to require more time and instruction to develop driving proficiency than typical peers and more parental involvement. • It is not possible to adapt the task of driving; the adaptation is specialized instruction. • The success of an LD student is the instructor’s greatest reward!

Adaptive Driver Training: Discussion • What can we learn from each other to best serve the LD population?

Adaptive Driver Training: References and Resources • LDAAmerica. org (Learning Disabilities Association of America) • IDEA 1992 • NCES. ED. Gov (National Center for Education Statistics) • DSM-V • SPIKES- A Six-step Protocal for Delivering Bad News, Walter F. Baile, et al The Oncologist, June 2000