Technology Assisted Active Learning: Aarna’s Case Study

Technology Assisted Active Learning: Aarna’s Case Study By Millie Smith , Stacy Chambers , Greta Graham and Allison Clark

blind / low vision

Technology Assisted Active Learning: Aarna’s Case Study Summary - This article will examine challenges to active participation in experiences necessary for the development of foundational se- mantic and cognitive skills in learners with severe intellectual disabilities, sensory loss and motor impairments. It will describe the interven- tion designed for one learner - Aarna. INTRODUCTION From the moment they are born, infants strive to learn everything they can about where they are and what is happening to them. Gradually, if environments are predictable, manageable and meaningful, they develop a sense of coherence. When environ- ments are coherent, learners seek more information about objects and people. When environments are incoherent, learners avoid interactions with objects and people that they cannot understand and therefore perceive as aversive or threatening. Development and maintenance of a sense of coherence is the primary goal of learning for humans throughout their lifetimes. How successful any given person is in achieving this goal is highly related to physical and psychological wellness (Amirkhan and Greaves, 2003).

MILLIE SMITH is a Teacher of Students with Visual Impairments (TVI) who consults in school districts nationally. She is a consultant and author for the American Printing House for the Blind (APH).

STACY CHAMBERS is a TVI who works in the Coppell Independent School District (ISD), Texas. She is a consultant for APH.

GRETA GRAHAM is an Assistive Technology Facilitator in the Coppell ISD, TX.

ALLISON CLARK is a Physical Therapist in the Coppell ISD, TX.

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Learners with severe intellectual disabilities, sensory loss and motor impairments need carefully designed interventions to help them develop the understanding that leads to a sense of well-being and the desire to learn more about the people and objects in their environments. Gradually, learners expand their experiential base to include new experiences and environments that are more complex. Consideration of three areas is essential for the development of coherence. • Active learning • Cognitive skill development • Semantic development Each of these areas, described below, presents unique challenges for learners with severe multiple disabilities. The case study described in this article examines the strategies for addressing these challenges, including the use of technology.

CHALLENGES

ACTIVE LEARNING Learners are active when they participate in an experience with the intent to move some part of their bodies to interact with something that is part of the experience. Active learning is important at any stage of learning, but it is crucial at the sensorimotor stage—birth to two years in typical development. Neurological evidence shows that motor responses increase brain activity to the levels required for long-term memory storage. Passive exposure during experiences stimulates short-term or working memory and is important for creating the alertness required for attention, but it is not sufficient for the assimilation and accommodation of in- formation that leads to the development of coherence (Moreau, 2012). A learner may like looking at the light emitted by an object as it moves in his visual field, but when the light goes away, he has not learned anything about the object or his relationship to it. In order for learning to occur, he must touch the object and try to do something with it. The motor responses necessary for long-term memory storage, the essential element of learning, do not require muscular execu- tion of movement. When learners mentally image desired movements, motor responses are sufficient for long-term memory stor- age. In other words, learning is active when movement is intended and imagined (Jeannerod, 2008). Early research using tomogra- phy to measure brain activity during motor events showed that activity was highest during the preparation and initiation stages of motor response and much less intense during the execution of response. More recently, the use of additional tools like functional MRIs to study motor cognition has led to the development of innovations such as robotic exoskeletons operated by mental imaging. Motor execution is highly desirable, but when it is not possible, learners may achieve coherence when teaching partners help them understand what is happening, so that they can think about what they want to do (Kappes and Morwedge, 2016). COGNITIVE SKILL DEVELOPMENT Cognitive skills develop over time as learners actively participate in interactions with people and objects. Brain scans show that when environments provide the right conditions for high quality interactions, experiences build new neural networks in the brains of all individuals with some viable cortex, regardless of age or ability level (Menshew and Williams, 2007). Interactions are high quality for learners with severe multiple disabilities when they are highly motivating, consistent, repeated frequently and contain needed supports and accommodations. The cognitive skills that form the foundation for all learning emerge largely hierarchically from birth to two years in typically developing children: the period known as Piaget’s sensorimotor stage. For learners with severe multiple disabilities, opportunities to learn cognitive skills are an essential part of programs at any age. In highly effective interactions, learners develop new cogni- tive skills and/or strengthen existing skills by participating in experiences at higher levels and by expanding existing skills to new experiences (Ormrod, 2012). Cognitive skills develop when learners actively participate in activities. When actions are intentional, brain function is primarily cortical. During the reflexive movement period of very early infancy, brain function is primarily sub-corti- cal. Over time and under the right conditions, some reflexive behaviors become skills. Sensorimotor stage cognitive skills typically include the following (Parks, 2004): • Anticipation • Exploration • Object permanence • Cause and effect • Imitation • Tool use or means/ends • Spatial relationships Passive attention makes cognitive development possible because it creates the neurological conditions necessary for active

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learning. Anticipation starts passively when learners associate two contiguous events initiated by and carried out by another per- son. A hungry infant might stop crying when she hears her approaching mother’s voice and anticipates feeding. Active learning is required for continued development (Ranganath and Richey, 2012). Exploration is intentional and active for two reasons: It processes sensory components of objects in an effort to find attributes that provide pleasure, and it uses those attributes to evoke memories of previous experiences with the sources of those attributes. This results in object identification. At first, a neonate reflexively sucks anything that touches his mouth. As he begins to move his mouth intentionally over his mother’s body, he learns that some parts of the body have the sensory components he finds pleasur- able and some do not. He sucks when he identifies the part of the body that provided food in the past (Richmond and Nelson, 2007). Object permanence, the understanding that a thing continues to exist when there is no direct sensory perception of it, develops as experiences store up in long-term memory. An infant explores a toy, discovers a sensory component that he likes, loses contact with the toy, and searches for it when he wants to experience the pleasurable attribute again. At first, an infant initiates a search almost immediately after separation. Gradually, longer intervals occur. During snack time, a learner might eat crackers for several minutes before he gets thirsty and searches for his cup of juice (Bremner et al, 2015). Cause and effect skills emerge when learners want to make something they enjoy happen again. The relationship between the learner’s body and the object acted upon is direct. The learner may achieve the desired effect with movement of any part of her body. She demonstrates understanding of cause and effect relationships with planned and initiated movements. The cognitive skill develops with or without full execution of the desired action. Searching for a spoon is object permanence. Picking it up and banging with it is cause and effect. The action of the hand with the spoon is the cause and the sound of banging is the effect. At first, cause and effect behaviors are egocentric. What other people do with spoons is not important yet (Saxe and Carey, 2006). When the relationship of objects to other people becomes interesting, the skill of imitation emerges. Attention to the actions of another person is typically visual. Visual attention activates mirror neurons that stimulate activity in the motor processing parts of the brain. The patterns of electrical activity in the watcher’s brain mirror those of the doer. Imitation occurs when the watcher plans and initiates the doer’s action. Full execution of the action is not necessary for coherence—understanding what is happening (Melt- zoff and Prinz, 2002). Visual modeling is a powerful tool for creating motor imaging. Tactile modeling also creates motor imaging. Tactile modeling is not hand-over-hand manipulation. Rather, it is hand-under-hand support during which, to the maximum extent possible, the watcher’s hand ‘rides’ the doer’s hand (Chen and Downing, 2006). When a learner wants something to happen (an effect) and cannot cause it to happen directly with the movement of some part of her body, tools solve the problem. Tool use or means/ends skills require the learner to understand the relationship not simply between her own body and the object she wants to effect, but also between her body, the tool she will use and the object that is the source of the desired effect. Using the hand, head or foot to tap the touch screen on a device to hear the sounds it produces is cause and effect. Using the hand, head or foot to press a switch that activates a sound source is tool use or means/ends. The rela- tionship between the body and the object is no longer direct. There is now a three-way relationship between the body, the tool and the object. Establishing direct body/object cause and effect relationships helps learners understand that the switch tool is not the source of the desired effect (Deak, 2014). The development of spatial relationships starts with exploration and becomes more refined as skills develop. First, an infant learns the spatial relationships related to his own body parts. He can put his thumb in his mouth. He then learns the spatial rela- tionships between his body and the objects around him. He can put a toy in his mouth. Still later, he develops understanding of the spatial relationships of objects to other objects. He can put the toy in a box (Vasilyeva and Lourence, 2012). SEMANTIC DEVELOPMENT Semantics is the study of the development of meaning in language. When a word has meaning, hearing it calls to mind expe- riences with the thing to which the word refers. This mental lexicon is a powerful tool for developing coherence. When learners understand the meaning of words, they can predict events and organize experiences into categories that generalize to multiple contexts. Meaning develops sequentially in interactions with objects and people (Pecher and Zwann, 2005). • Sensory component processing: How does the thing look, feel, sound, taste and smell? • Comparison: How is it similar to or different from other things? • Evoked memory: Do attributes call to mind previous experiences with it? • Use: What can I do with it? • Relationship to others: What do other people do with it? • Naming: What do people call it? Each step in the chain presents unique challenges for learners with severe multiple disabilities. When visual impairments, hearing loss and motor impairments limit access to information, accommodations for sensory component processing and comparison make

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learning more efficient. Random passive exposure to the sensory attributes of objects may create short-term attention, but in order to create coherence, an experience must be predictable, manageable and meaningful. When participation in an experience consists mainly of physical manipulation of a learner’s body, she may not have a chance to learn what other people do with objects, because no one modeled those actions for her. Names of things important to the learner may get lost in sentences containing many random unfamiliar words. In typically developing children, these important names are the words that acquire meaning first. Usually they include names of favorite people, foods, toys and actions. Infants and toddlers understand the meaning of words before they can say them. A typical two-year-old child comprehends the meaning of about 200 words and says about 20. A toddler knows he is going to get a cookie when he hears that word while sitting in his high chair, long before he can ask his mother for a cookie by saying the word (Hoff, 2013). Programs for learners with severe disabilities facilitate semantic development (i.e., understanding the meaning of words) most effectively when they build a solid experiential base for concepts about people and objects and when they pair symbols like words and pictures with the things they represent before using them alone (Kucker, McMurray, and Samuelson, 2015). Some programs tend to emphasize expressive communication skills almost exclusively. Words without meaning may be a useful stimulus for evok- ing a desired response in a specific context, such as an auditory scanning device, but they may not have the true symbolic content that makes them understood when used by different people in different contexts. Similarly, picture usage may occur with or without meaning. Conditioned stimulus/response relationships are useful. Most people’s phone displays have some images that are mean- ingful and recognizable in multiple contexts, while recognition of other images may rely on attributes such as color and location in one context only. Empowering learners in tasks such as choice making using non-representational arbitrary images can be effective; however, it is not semantic development. Understanding the meaning of symbols so that they can be used in multiple contexts is even more empowering. INTERVENTION The individualized education plan (IEP) team featured here used strategies and tools contained in The Sensory Learning Kit (SLK) (Smith, 2005) to design the intervention described here. The SLK organizes skills related to semantic development and cognitive development into three zones of sensorimotor stage function. The quiet alert or attention zone begins with the semantic devel- opment skill of passive sensory component processing and the cognitive skill of anticipation. The active alert or exploration zone includes active sensory component processing, comparison and egocentric use in semantic development and exploration, object permanence, cause and effect and imitation in cognitive development. In the partial participation or function zone, semantic devel- opment progresses to the understanding of what other people do with objects and to thinking of things named by others. Cogni- tive development expands to tool use and complex object to object spatial relationships. From October through December of one school year, Aarna’s IEP team used the SLK to assess her needs and plan her intervention. The team followed her progress from the initiation of instruction in January through the next five months. During that time, Aarna was a second grader receiving homebound services due to a repressed immune system. Her IEP team included her homebound teacher, teacher of students with visual impairments (TVI), physical therapist, occupational therapist and assistive technology spe- cialist. Her parents, grandparents and private duty nurse provided valuable information throughout Aarna’s intervention. After using SLK tools to review medical conditions and current evaluations, the team began the intervention by observing a regularly occurring familiar activity in order to establish a baseline or present level of cognitive/semantic performance from which to measure progress. Aarna’s present level was quiet alert/attention zone. During a lotion activity, she maintained alertness throughout, smiled and vocalized while responding to her teacher’s voice and touch and occasionally visually fixated on her teacher’s face. To see Aarna’s Lotion Activity watch December—Establishing Baseline at ( Beginning, next page ) The team designed the first instructional activities in Aarna’s intervention to develop the active alert/exploration zone cognitive skill of cause and effect. They knew that to be effective these activities would need to be highly motivating and consistent, repeat frequently and contain needed supports and accommodations. Aarna’s TVI and homebound teacher used an SLK assessment tool to identify attractive sensory topics for Aarna’s activities and to identify accommodations that made sensory access to media more efficient. Using this information, the team determined that the best topics for activities were the following: • faces (with complexity reduction in the visual field) • human voice • lotion (with slow rhythmic pressure)

• bells • iPad®

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Aarna’s Lotion-Activity watch December - Establishing Baseline at ( Beginning ) To see Aarna’s Move Bells Routine watch January—Exploration at ( Timeline: 46 seconds )

To see Aarna’s Patterns and Music Routine watch May—Function Level, Patterns and Music at ( Timeline: 6:07 ) To see Aarna’s Rufus Reading Routine watch May—Function Level, Rufus Reading at ( Timeline: 9:13 ) YouTube Video Link: https://www.youtube.com/watch?v=RbQnwin2Qz8

The instructional strategy used in the SLK is called ‘routines.’ It is based on the evidence that highly structured activities conduct- ed during direct instruction result in higher levels of achievement for learners with disabilities. Teams should design routines for maximum consistency, use the same sequence of steps, and guarantee they occur frequently—at least once daily. In January, Aarna’s team began her intervention with a Move Bells routine. The team collaborated to develop a lesson plan (Table 1: Sensorimotor Routine Lesson Plan—Move Bells) for the routine to ensure maximum consistency and to document progress on the embedded cognitive skill of cause and effect. When Aarna demonstrated mastery of active alert/exploration zone cause and effect skills, her team developed routines target- ing partial participation/function zone skills. The iPad® was the highly motivating topic for these routines. Aarna demonstrated in her Move Bells routine that she enjoyed moving her body to create sound. Her goal in her iPad routines was to demonstrate that she could use a tool to create sounds. Aarna’s team developed two iPad routines. In the first, as shown in Table 2: Sensorimotor Routine Lesson Plan—Patterns and Music, Aarna used an adaptive switch tool to activate visual patterns and music on her iPad. She moved her head to a pressure switch to restart the program after pauses. Team members made sure that Aarna’s homebound teacher taught her the routine with

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Table 1: Sensorimotor Routine Lesson Plan—Move Bells

Student Routine

Materials Position Frequency Duration Data period

Aarna

Bells, mat, wedge, now container

Move bells

Supine on mat, upper torso elevated with wedge

Teaching partner

Mallory

1 x daily

Observing team members

VI, PT

10 minutes Feburary 2-6

Location

Home, downstairs bedroom

Learner’s Steps

Partner’s Supports and Accommodations

Embedded Goals Target Level: Exploration

Documentation

1. Read object schedule: Look at bells in now con- tainer.

Present now container in right peripheral field and move slowly across midline to left. Move container to provide sound of bells ringing during presentation. Place orange fabric on bell bracelet to attract visual attention. Use now container to provide high contrast and com- plexity reduction. Use elbow support to help Aarna touch bells after looking.

2. Read object schedule: Touch object after 3-second visual fixation.

Round One: Mallory models the sequence 3. Move right hand.

Place bells on hand. Say, “The bell is on your hand. Move hand.” Tactually model action by moving hand. (Repeat for 4-9 with correct body part name)

4. Move right foot. 5. Move left knee. 6. Move left foot. 7. Move right foot. 8. Move right knee. 9 . Move head. Round Two: Aarna’s turn 10. Move right hand.

+/+/+/+/+

Aarna will demonstrate understanding of the cause and effect relation- ship between the part of the body she moves and the sound movement produces.

Place bell on Aarna’s hand. Say, “The bell is on your hand. Move hand.” Wait 12 seconds for Aarna to move. If she does not move after 12 seconds, repeat the prompt. If there is no movement after an additional 12 seconds, say, “I’m going to help you.” Move her hand. (Repeat for 11-16)

11. Move left Hand.

Same as above for 11-16 -/+/-/-/-

12. Move left knee.

+/+/+/+

13. Move left foot.

-/-/-/-/+

14. Move right foot.

+/+/-/+/-

15. Move right knee.

-/-/-/-/-

16. Move head.

-/-/-/+/-

To see Aarna’s Move Bells Routine watch January—Exploration at ( Timeline: 46 seconds ) https://www.youtube.com/watch?v=RbQnwin2Qz8

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Table 2: Sensorimotor Routine Lesson Plan—Patterns and Music

Student

Materials

Aarna

Wheelchair tray, arm clamp, yellow pressure switch, iPad, now container, finished container, book light

Routine

Position

Patterns an d Music

Seated in wheelchair

Teaching partner

Frequency Duration Data period

Mallory

1 x daily

Observing team members

VI, PT

15 minutes April 20-24

Location

Home, downstairs bedroom

Learner’s Steps

Partner’s Supports and Accommodations

Embedded Goals Target Level: Exploration

Documentation

1. Read object schedule: look at whole object symbol in now container

Turn off ceiling lights and attach book light to now container. Present now container with iPad in upper left field. Say, “It’s time for iPad.” Move container slowly across midline to right field. Wait 30 seconds after the ding to allow time for Aarna to think about what she wants to do. If Aarna does not start her program after 30 seconds say, “Are you done?” Wait another 30 seconds to see if Aarna wants to keep going. Say, “iPad done,” when initiation takes longer than 30 seconds or when 15 minutes is up.

Use tool (head switch) to activate device for specific purpose.

M: 7 activations T: 9

2. Move head to restart program.

W: 14 TH: 7

3. Put iPad in finished container.

To see Aarna’s Patterns and Music Routine watch May—Function Level, Patterns and Music at ( Timeline: 6:07 ) https://www.youtube.com/watch?v=RbQnwin2Qz8

Table 3: Sensorimotor Routine Lesson Plan—Rufus Reading Routine

Student

Materials

Aarna

Wheelchair tray, arm clamp, iPad, yellow pressure switch, now container, finished container, book light

Routine

Position

Rufus Reading

Seated in wheelchair

Teaching partner

Frequency Duration Data period

Mallory

1 x daily

Observing team members

VI, PT

30 minutes May 25-29

Location

Home, downstairs bedroom

Learner’s Steps

Partner’s Supports and Accommodations

Embedded Goals Target Level: Exploration

Documentation

1. Read object schedule: look at whole object symbol in now container

2. Turn pages in Rufus book. Wait up to 30 seconds for page turn. After 30 seconds, say, “Try again.”

Aarna will use a tool (switch) to activate a de- vice for a specific purpose (turning pages).

M: 20/20 pages T: 20/20

W: 20/20 TH: 20/20 F:

No school

3. help put iPad in finished container.

Say, “The end. Good reading Rufus.”

To see Aarna’s Rufus Reading Routine watch May—Function Level, Rufus Reading at ( Timeline: 9:13 ) https://www.youtube.com/watch?v=RbQnwin2Qz8

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Aarna uses a switch, positioned at her cheek, to change visual and auditory presentations during her Music and Patterns iPad Routine. The screen shows yellow shapes on a black background.

Aarna uses a switch with her cheek to turn the pages of her Rufus Reading iPad Routine.

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optimal accommodations and supports. Screen displays with high contrast and movement increased visual attention. Positioning for comfort and trunk stability allowed Aarna to move her head to press the switch and to shift her gaze between her teacher and the iPad screen. An arm clamp attached to her tray elevated the iPad so its positioning was in Aarna’s best viewing area, which is upper central. Sometimes routines become overly familiar and performance declines because of boredom. The team decided to develop a new iPad routine designed to maintain high motivation and to expand skills. Aarna’s new routine was Rufus Reading. One of the items on Aarna’s list of highly motivating topics for routines was human voice. Aarna paid intense attention to voices in her environment. She knew when someone addressed her and she worked hard to look at her social partners. In social speech, attention to attributes such as intonation and changes in pitch and rhythm provides cues for interpreting emotional content. In her Rufus Reading routine, Aarna used her head switch to turn pages as she listened to the language in her story. In this context, intonation and changes in pitch and rhythm are part of syntax development, (i.e., attention to the arrangement of words and phrases). In early development, interest in the structure and rhythm of language exists with or without semantic content (i.e., understanding the meaning of the words heard). Aarna may have understood some of the words she heard in her Rufus Reading routine. She clearly demonstrated that she understood some of the syntax of the language she heard. She waited until a sentence finished before she initiated a social comment directed toward her teacher—a smile or a laugh—and she anticipated favorite parts of her story as demonstrated by smiling and laughing when the preceding text was heard. CONCLUSION Learners with severe multiple disabilities need high quality interventions designed to help them understand what is going on in their environments. When they are free of the stress caused by incoherence, they confidently interact with people and objects. Semantic and cognitive skills develop because of these interactions. Active participation is required. When motor impairments pre- vent full execution of actions, a learner’s mental imaging of actions helps to achieve active learning. Learners must understand what is happening in order to imagine what they want to do. Aarna developed coherence for the three activities described here because they provided the motivation, consistency, repetition, and accommodations/supports she needed. She used mental imagery and limited movement, with and without assistive technology, to develop semantic and cognitive skills. Some motor responses, such as the movement of her left foot, improved over time. She progressed from a baseline of quiet alert/attention zone skills to partial participation/function zone skills over five months.

PRODUCT INFORMATION American Printing House

Sensory Learning Kit American Printing House for the Blind - The SLK is research-based and uses best practice strategies that align with the common administrative practices in place in most special education programs. The material contained in this product gives teachers of learners with visual and multiple impairments the tools to • conduct sensory efficiency and learning media assessments; • address IEP areas such as instructional settings, accommodations, and goals; and • provide highly effective instruction using a collaborative, consultation-service delivery model.

Sensory Learning Kit - American Printing House

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Big Bang Bundle (2013). Waxhaw, NC: ©Inclusive Technologies, Ltd. Novey, J. (2011). Rufus’ ROOAAR. Morrisville, NC: Lulu.com.

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