teaching choice making

Teaching Choice Makingto Children with VisualImpairments and MultipleDisabilities in Preschooland Kindergarten ClassroomsChristine Clark and Andrea P. McDonnell

Abstract: This study examined the effectiveness of an intervention package thatincluded visual accommodations, daily preference assessments, and naturalisticinstructional strategies on the accuracy of choice-making responses for threeparticipants with visual impairments and multiple disabilities. It also examinedthe participants' ability to maintain and generalize responses across settings,items, and individuals.

A main focus for educators in creatingappropriate learning environments foryoung children with disabilities is theneed to present the children with choicesto allow them to participate in shapingtheir learning (Bailey & Wolery, 1992;Bishop, 1996; McCormick, Jolivette, &Ridgley, 2003; Sacks, 1998; Sadler,2003). Engaging children with disabilitiesin classroom activities may reduce theirsense of helplessness and increase theirability to learn. When an individual isable to influence and create change, suchas by making a choice, he or she begins toopen doors to an endless number of pos-sibilities. "Choice provides children theopportunity to use cognitive skills, com-munication skills, motor skills, and socialskills" (McCormick et al., 2003, p. 5).Potential strategies for increasing the en-gagement or choice-making skills ofyoung children with visual impairmentsand multiple disabilities are new areas

that researchers are beginning to explore(Jolivette, Stichter, Sibilsky, Scott, &Ridgley, 2002; Roman, 2004).

Typically developing preschool chil-dren do not require accommodations oradaptations to assist them in choosing andparticipating in activities. These childrenlearn through watching others or explor-ing on their own. Several opportunitiesfor making choices are presented in mostpreschool classrooms during large- andsmall-group activities, individual learn-ing sessions, and free-play opportunities(Stafford, Alberto, Fredrick, Heflin, &Heller, 2002), encouraging children tomake independent choices based uponwhere and with what items they wouldlike to play. Gradually, children learn theimportance of choosing wisely as they seethe effect of the choices on their interac-tions and play opportunities (Hanley,Iwata, & Lindberg, 1999; McCormicket al., 2003; Stafford et al., 2002).

AFB, All Rights Reserved Journal of Visual Impairment & Blindness, July 2008 3 9 7

Children with disabilities do not de-velop the ability to choose items or activ-ities within the classroom as easily as dotheir typically developing peers, and thisability may be substantially reduced be-cause of the complexity of their disabili-ties (Church, 2000; Downing & Bailey,1990; Li, 2003; Sacks, 1998; Utley, Ro-man, & Nelson, 1998). Many childrenwith multiple disabilities are diagnosedwith cortical visual impairment (CVI).Children with CVI have normal eye ex-aminations, but their vision fluctuates, de-pending on the environment, because ofdamage to the visual systems in theirbrains (Blind Babies Foundation, 2000;Erin, 2004; Roman-Lantzy, 2007; Sacks,1998). When children have the challengeof a combination of disabilities, such asvisual impairments and cognitive or phys-ical disabilities, the necessary level of ad-aptations these children need may signif-icantly increase, and they may fail torespond to a request because of their needfor extended time to process incominginformation (Janssen, Riksen-Walraven,& Van Dijk, 2003). The best opportuni-ties for learning for such children mayalso require limited stimulation and spec-ified objects (Alexander, 2001; Downing,1999). Many adults simply find it easierto complete tasks or make choices forthese children, rather than to assist them(Head, 1992; McCormick et al., 2003).

Research has presented a clearer under-standing of what choice making entails,the independence and participation it pro-vides, naturalistic instructional strategiesthat may be implemented, and barriersthat need to be overcome to allow oppor-tunities for all children (Church, 2000;Daugherty, Grisham-Brown, & Hemme-ter, 2001; McCormick et al., 2003). When

an individual is able to communicate achoice, he or she is able to learn aboutitems, explore his or her environment,and participate in various activities(D'Allura, 2002; Stafford et al., 2002).

Although past research investigatedchildren with disabilities in reference tochoice-making opportunities and the de-velopment of skills, little research hasbeen conducted on children who strugglein these areas when dealing with a uniqueand individualized combination of two ormore disabilities. Jolivette et al. (2002, p.396) noted that research has been "incon-clusive as to what constitutes best prac-tice for both the delivery and type ofchoice-making opportunities for youngchildren with and without disabilities."

The study presented here examinedthe effects of planning by an educa-tional team to offer choice-making op-portunities to children with disabilitiesand measured the accuracy of the chil-drens' responses. The following werethe specific research questions that wereaddressed:

1. Will the use of CVI accommodations;daily preference assessment; naturalis-tic instruction, including responseprompts and constant time delay; andnaturalistic consequences be effectivein increasing the accuracy of choicemaking from current levels as demon-strated by motor response (pointing ortouching) for children with visual im-pairments and multiple disabilities inpreschool and kindergarten settings?

2. Will children with visual impairmentsand multiple disabilities be able togeneralize choice making accurately toother preschool and home routines?

3 9 8 Journal of Visual Impairment & Blindness, July 2008 ©2008 AFB, All Rights Reserved

3. Will the classroom staff members beable to implement procedures accu-rately and across time?

4. How do the classroom staff membersrate the intervention package with re-gard to ease of implementation andeffectiveness in increasing choicemaking for children with visual im-pairments and multiple disabilities?

MethodPARTICIPANTS AND SETTINGS

The three participants who were selectedwere aged 3 to 6; attended a preschool orkindergarten classroom a minimum oftwo days per week; met the criteria forlegal blindness (visual acuity of 20/200 orless) or a diagnosis of CVI; and werediagnosed with multiple disabilitiesthrough formal and informal assessmentsin the areas of cognitive, academic, lan-guage and communication, social, andsensory motor skills (Utah State Board ofEducation, 2000). In addition, their class-room teachers were interested in develop-ing choice-making behavior, as deter-mined through their completion of aquestionnaire.

Participant 1, Aaron, aged 4 years, 10months (58 months), was diagnosed witha brain tumor and CVI at age 1. Partici-pant 2, Carson, aged 5 years, 5 months(65 months), was diagnosed at birth withcerebral palsy, moderate hearing impair-ments, CVI, and severe cognitive disabil-ities. Participant 3, Cathy, aged 5 years, 8months (68 months), was diagnosed withsevere developmental delays in cognition,gross motor skills, and communication;her visual acuity was approximately 20/400. The participants did not interact inclassroom activities unless they were di-

rectly assisted by a teacher or paraprofes-sional. The selected response, based onindividual needs and skills, for all threeparticipants required them to reach for ortoward a preferred item.

MATERIALS

A variety of materials (such as favoriteobjects, foods or beverages, and activitiesfrom both the home and school settings)were selected by the participants' parentsand classroom teachers. As Roman-Lantzy (2007) noted, many children withCVI typically respond best to objects of asingle color, often a preferred color, andare attracted to objects that have the ap-pearance of motion. This information as-sisted in the selection of the materials. Aminimum of 10 items were selected foreach participant. A preference assessmentor observation was completed duringwhich the identified items were randomlypresented three times over a two-day pe-riod to determine whether the childrenresponded to or showed interest in theitems. Potential "neutral" items, or itemsthat would hold little interest to the par-ticipants, were also presented during thepreference assessment. The top 6 pre-ferred (and 4 neutral) items were selectedfor use during the baseline and interven-tion phases of the study, with 4 itemsreserved for the generalization probes, asshown in Table 1. Responses were iden-tified by the participants' facial expres-sions (such as smiling), eye gaze (for ex-ample, looking toward, away, or both), ortouch (for instance, reaching toward andpushing away). The participants' re-sponses were noted and discussed by theresearcher and classroom teacher for ac-curacy in determining preferences. In ad-dition, the participants' facial expressions

©2008 AFB, All Rights Reserved Joumai of Visual Impairment & Blindness, July 2008 3 9 9

Table 1Participants'

Participant

Aaron

Carson

Cathy

preferred and neutral items.

intervention

Preferred

Ciear ballStar stackerRain stickTelephoneRoiling dogBoat with ballsRoliing dogBubbiesButterflyBuggy rattleSpinnerLadybugOctopusSwitch with iightsSwitch with glitterRed ballGlitter dumbbellToothbrush

Neutral

BlockBubblesKleenexPicture

KieenexBlockElastic bandageYeiiow Post-it

WeightKleenexPictureString

Maintenance and

Preferred

CliffordPink bailHairy ballFeathers

JukeboxDumbbellBead curtainReflective paper

Tape playerYellow ballTrack ballHairy ball

generalization

Neutral

StringWhite rabbit

StringPicture

SpoonRubber band

and reaches were discussed to identify thespecific desired responses for the study.

MEASUREMENT AND DESIGN

The dependent measure for this study wasthe percentage of choices that were com-pleted successfully by the participantsreaching for or touching the items. Eachparticipant was presented with a preferreditem and a neutral item while beingprompted to make a choice through apredetermined method for him or her. Theteacher recorded the number of times theparticipants exhibited the target behaviorand calculated the percentage of correctresponses from the number of possibleopportunities.

A multiple baseline probe design (Taw-ney & Gast, 1984) was used for all par-ticipants to evaluate the effectiveness ofthe intervention package on teachingyoung participants with visual impair-

ments and multiple disabilities to makechoices within activities.

PROCEDURES

The study consisted of the following fourphases: the preliminary assessment phase,baseline phase, intervention phase or im-plementation of the intervention package,and follow-up phase.

Preliminary assessmentA functional visual assessment (Levack,1991) was completed to help determinethe participants' functional vision andspecific visual accommodations. The as-sessment was modified to eliminate itemsthat were not relevant to the participants.The appropriate physical placement ofitems was noted on the Visual Accommo-dations Checklist. Passive visual accom-modations combined the placement andcolor of the preferred items. Active visual


Table 2Participants' Visual Accommodations.

Accommodations

Passive accommodationsPlacement of object

FieldDistance

Color of objectSingle "preferred" color1 to 2 colorsMultiple colors

Active accommodationsTask lighting

Regular classroomDimmed classroomBack lightingFront task lightingOther

Modification of environmentRegular classroom

Separate roomSolid color backdrop

Modification of objectMovement or reflective propertiesSound

Aaron

Central6" to 8"

NoYesYes

YesNoNoYesNo

YesYesNo

YesYes

Carson

Central/upper1"to6"

NoYesNo

YesNoNoYesNo

YesYesNo

YesYes

Cathy

Central/rightUp to 12"

NoNoYes

YesNoNoNoNo

YesYesNo

YesYes

accommodations included modificationof the location, lighting, and object qual-ities (for example, reflective qualities).The specific passive and active visual ac-commodations for each participant arepresented in Table 2.

A daily preference assessment wascompleted to ensure the use of preferreditems and to reduce the possibility that aparticipant would not respond because heor she did not desire an object on a par-ticular day. The assessment required fourpreferred items and three neutral items tobe presented to the participant briefly inrandom order and the participant's re-sponse to the items to be noted. A secondobserver (the researcher or a member ofthe classroom staff) participated in thedaily preference assessment to monitorthe accuracy of the process. The two pre-

ferred items that the participant re-sponded to with the most interest wereused as the preferred items during theintervention for that day. The neutralitems were selected after observing theparticipant's lack of interest in the itemsduring the daily assessment.

Baseline phaseDuring each subsequent phase, the partic-ipants were given five opportunitieswithin each activity (free choice andsnack time) to make a choice. During thebaseline phase, appropriate passive visualaccommodations were provided (like thecolor and texture of an object) for eachparticipant as a preferred item and a neu-tral item and were presented to the par-ticipant within the identified distance. Af-ter the participant visually located both

©2008 AFB, All Rights Reserved Journal of Visual Impairment & Blindness, July 2008 4 0 1

items, he or she was asked to respond bythe teacher randomly stating one of thefollowing: "Show me what you want,""what do you want," or "touch what youwant to play with [or eat]." If the partic-ipant made a choice, the teacher provided

verbal reinforcement ("You want the "and "That's right!" for example) in ad-dition to the positive natural conse-quence of a two- to three-minute periodin which the participant was allowed toexplore, play with, or eat the item. Theparticipant received the chosen item re-gardless of whether he or she chose thepreferred or neutral item. The conse-quences for an incorrect response in-volved the participant not being able toacquire either item, since the items werebriefly removed from the participant'simmediate environment.

Probe trials during the baseline phasewere conducted to determine the parti-cipants' ability to make a choice beforethe intervention strategy was introduced(Tawney & Gast, 1984). Once a stablebaseline was established that allowed forthe prediction of future responses throughdata probes, the intervention phase wasimplemented (Horner et al., 2005).

Intervention phase

During the first intervention, the active vi-sual accommodations, including move-ment, reflective properties, and specificplacement of the preferred items, were im-plemented. Again, the participant was askedto respond as a preferred item and a neutralitem were presented, as described for thebaseline phase. The second interventionincluded the addition of the independentvariable (naturalistic instruction, responseprompts, and constant time delay in addi-tion to the CVI accommodations). The

teacher initiated the verbal request, fol-lowed by a one-second time delay, beforethe desired response prompt. The verbal(stimulus) prompt cued the participant thata response was requested, and the physicalcontrolling prompt was provided to assistthe participant in responding correctly. Theprompts were reduced as quickly as possi-ble, allowing the participant the opportunityto respond independently. Partial physicalprompts (such as nudging and light push-ing) were used to encourage the participantto exert the effort to respond correctly to theteacher's request. The one-second delaywas presented during the first four days ofthe intervention phase, providing a mini-mum of 40 opportunities prior to the imple-mentation of a brief delay before the class-room teacher physically prompted thedesired response. A one-second delay,rather than the more typical no-second de-lay, was used because of the substantialincrease in accuracy of choice making withthe inclusion of the active visual accommo-dations. The one-second delay gave the par-ticipant the opportunity to initiate the de-sired response before the teacher presentedthe controlling prompt. However, theteacher was positioned immediately to pro-vide a physical prompt for the correct re-sponse if the participant did not initiate re-sponding after one second. Beginning onthe fifth day of the intervention, a constantfive-second delay was implemented. If theparticipant did not respond within the timedelay, the teacher provided the controllingresponse prompt, and the correct promptedresponse was reinforced. When the partici-pant was responding correctly prior to theresponse prompt for a minimum of 80% ofthe opportunities each day for two weeks(four to eight days), the intervention phaseended.


Follow-upDuring the follow-up phase, probes on themaintenance and generalization of skillswere collected. Maintenance data werecollected using probe trials during free-choice activities and snack time to deter-mine whether the participants continuedto use the newly acquired skill of makinga choice. Generalization data were col-lected using probe trials during a varietyof activities, with different individuals(such as members of the classroom staff),and the additional four preferred itemswere set aside for this phase.

INTEROBSERVER AGREEMENT

Interobserver agreement was used todetermine the accuracy of the data thatwere collected through the assessmentof consistency, minimization of bias,and definition of the target behavior aminimum of once per week, achieving apercentage of agreement within the rec-ommended percentage range (Kazdin,1982; Kennedy, 2005). The classroomteacher and researcher collected data onthe participant at the same time and re-viewed the data for accuracy. When theagreement was lower than 100% in a set-ting, they reviewed the data to clarify andreduce the potential for future disagree-ments. The range for interobserver agree-ment for all participants was 88% to 97%.During periods in which the researcherwas collecting data on the participants'behavior, data were also collected on theaccuracy of the presentation of the inter-vention package. Procedural fidelity wascompleted through the use of a checklistin which each step of the intervention waschecked off after the step occurred (ap-propriate prompting and interspersingother interactions between learning prac-

tice trials). If the data were less than 90%accurate, or any deviations were notedfrom the predetermined steps, the datawere reviewed with the classroom teacherto clarify the process.

DATA ANALYSIS

The data collected regarding the depen-dent variable were plotted on a graph toallow for a visual analysis of potentialchanges in the level of responses for eachparticipant among the baseline, interven-tion, and follow-up phases (Tawney &Gast, 1984). The graphs were reviewedfor patterns that assisted the researcher indrawing conclusions about what occurredand the implementation of the next step orphase of the intervention (Kennedy, 2005;Wolery & Dunlap, 1999).

ResultsACCURACY OF CHOICE MAKING

During the baseline phase, the three par-ticipants exhibited minimal choice-making skills. For all opportunities of un-prompted choices, the average percentageof unprompted correct responses were asfollows: 12.5% (Aaron), 10% (Cathy),and 8.3% (Carson) (see Figure 1). It isimportant to note that a miscommunica-tion between the teacher and researcherregarding Aaron's data for Session 4 ini-tiated the beginning of the interventionbefore a stable baseline was reached. Thefirst intervention phase resulted in an im-mediate and substantial increase in theaverage number of correct choices, withan average of 58% (Aaron), 73% (Cathy),and 57% (Carson) for all opportunities ofunprompted choices. The second phase ofthe intervention brought Carson's accu-racy to 100% and Aaron's and Cathy's to88% each. After four days of presenting

©2008 AFB, All Rights Reserved Journal of Visual ¡mpairment & Blindness, July 2008 4 0 3

Baseline

(Passive visualaccommodations)

Intervention

(Active visualaccommodations)

1-second 5-seconddelay ; delay

Maintenance/generalization Correct before prompt

Correct after prompt

Maintenance

Generalization

Figure 1. Percentage of correct responses.

the controlling prompt with the one-second delay, the five-second delay wasimplemented. During this portion of theintervention, Carson averaged 90% andAaron and Cathy averaged 80% on cor-rect unprompted choices. When the par-ticipants did not respond within five sec-onds, a delayed prompt was provided.With the delayed controlling prompt, Car-son and Cathy averaged 100% and Aaronaveraged 94% on correct unprompted andprompted choices.

Maintenance and generalizationDuring the two months of weekly main-tenance and generalization probes, Aaronaveraged 78% (maintenance) and 67%(generalization) for correct unpromptedchoices. The generalization probes forAaron were collected in the classroomduring a variety of nontraining activities(like small groups and library time) and

20 25Session

by members of the classroom staff whowere not involved in the interventionphase. Data were collected only once dur-ing this phase for Carson because of asevere injury that had occurred outsideschool that kept him home for the remain-der of the school year. The school yearended before maintenance and generali-zation probes could be collected forCathy.

Child outcomes in individual settingsThe foregoing findings focused on thecombined data from the two settings. Anexamination of the data for each settingindependently provided additional infor-mation on the impact for each participant(see Figures 2 and 3). The data were alsoreviewed for potential effects in the par-ticipants' responses (e.g. increase or de-crease) because of the presentation of thepreferred item on the right or left side. For


Baseline

(Passive visualaccommodations)

Intervention(Active visualaccommodations) 1-second

delay5-second

delay

Maintenance/generalization

Correct before prompt

Correct after prompt

Maintenance

Generalization

20 25Session

40

Figure 2. Percentage of correct responses for free-choice setting.

Aaron and Carson, no significant differ-ence was noted in the number of accuratechoices when the preferred item wasplaced in the teacher's left or right hand.A difference was noted for Cathy, whocompleted more accurate choices whenthe preferred item was presented in theteacher's right hand than in the lefthand, perhaps because Cathy's visionwas slightly better in her left eye.

SOCIAL VALIDITY

Perceptions of the classroom teachers

District preschool special education anddiagnostic kindergarten teachers whosecaseload included children with multipledisabilities, visual impairment, or bothwere given a questionnaire on the impor-tance of choice-making skills and oppor-tunities within the classroom before thestudy was conducted. Fifteen teachers(100%) responded to the questionnaire

and agreed that choice making is an im-portant skill for their students to have,that many students have difficulty makingchoices when choices are presentedwithin the classroom, and that most oftheir students have the potential to learnto make choices and to benefit from mak-ing choices.

A review of a postintervention ques-tionnaire, completed by the participatingteachers, showed that two strongly agreedand one was neutral that the interventionpackage was effective in increasing thestudents' accuracy in making choices andthat the students were likely to continue touse this newly learned or enhanced skill.The teachers further agreed that the inter-vention package was easy to implementand did not interfere with classroomactivities and that the time required toimplement the package was worth theoutcome. In addition, the teachers


Baseline

(Passive visual

Intervention

(Active visual

accommodations) accommodations)1- second 5- second

delay .

Maintenance/generalization

-•- Correct before prompt

••- Correct after prompt

A Maintenance

X Generalization

15 20 25

Session

Figure 3. Percentage of correct responses for snack time setting.

agreed that other students in their class-rooms could benefit from the interven-tion package.

DiscussionThe purpose of this study was to deter-mine whether children with visual im-pairments and multiple disabilities couldincrease the accuracy of their choicemaking through a predetermined motorresponse on the basis of an interventionpackage that included CVI accommoda-tions, daily preference assessments, natu-ralistic instruction, response prompts,constant time delay, and naturalistic con-sequences. The study also examinedwhether the children could accuratelygeneralize the skill of choice making toother preschool, kindergarten, and homeroutines; whether the classroom staffmembers were able to implement proce-dures accurately and across time; and

how the classroom staff members ratedthe intervention package for ease of im-plementation and effectiveness in increas-ing the opportunities for the children tomake choices.

The results suggest that the interven-tion package was successful in increasingthe accuracy of the participants choiceswhen the participants were presented withpreferred and neutral items. Additionalfindings included the beneficial impact ofactive visual accommodations on thelevel of accuracy of the participants'choices. In addition, systematic instruc-tion further increased the accuracy ofchoices made. Since no other known stud-ies included children with visual impair-ments and multiple disabilities regardingchoice making, this study contributes tothe literature and provides a referencefor future research. The findings are alsoimportant because the effectiveness of


active visual accommodations on the par-ticipants' acquisition of skills is an area inwhich research is being implemented buthas yet to be reported.

LIMITATIONS

Limitations relevant to this study includethe generalizability of findings to otherstudents, locations, or activities; the lim-ited data on maintenance and generaliza-tion; the difficulty encountered when col-lecting data on students with multipledisabilities and health problems; andthe inability of parents to observe theintervention.

Three children participated in thestudy, and all but one of the classroomswere located within the same school dis-trict. Thus, the small number of partici-pating children and their extended ab-sences may limit the maintenance andgeneralizability of the results, especiallyto teachers who may be less willing toimplement the intervention package dueto large caseloads or concerns regardingthe additional, although minimal, time re-quired to implement the intervention.Replications of the study through an in-creased number of participants, disabili-ties, teachers, and environments may pro-vide information that is necessary toincrease the generalizability of the find-ings. Future research using longer periodsfor data collection may provide a morecomprehensive look at the long-term suc-cess of the intervention package within apopulation that experiences a high absen-tee rate because of health issues.

IMPLICATIONS FOR FUTURE RESEARCH

The accuracy of the participants' choice-making skills increased markedly fromthe baseline levels. However, future re-

search is needed to determine whetherthis skill is maintained over time and maybe generalized to a variety of items; toother staff, peers, and family members;and to settings outside the participants'classrooms. Replication of the resultswith other students with visual impair-ments and multiple disabilities is alsoneeded to increase the generalizability ofthe findings. Future research should alsofocus specifically on the impact of activevisual accommodations and other compo-nents of the intervention separately. Theimmediate increase in the accuracy of thechoices made by the participants withthe implementation of the active visualaccommodations, in addition to the pas-sive accommodations that were present inthe baseline phase, are worthy of furtherreview to examine the impact of eachcomponent of the intervention package.Active visual accommodations alone mayprovide educators and parents with sim-ple ways to assist children to see theirworld with limited vision, making bothsystematic instruction and incidentallearning more effective. Furthermore, re-search should be conducted on the inter-rater reliability of the functional visualassessment and on determination of theindividual active and passive accommo-dations to determine the impact of theselection of these accommodations forparticipants.

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Christine Clark, Ph.D., assistant professor. De-partment of Special Education, Illinois StateUniversity, Campus Box 5910, Normal, IL61790: e-mail: <[email protected]>. Andrea P.McDonnell, Ph.D., professor. Department ofSpecial Education, University of Utah, MiltonBennion Hall, 1705 East Campus Center Drive,Salt Lake City, UT 84112-9253: e-mail:<andrea.mcdonnell@ ed.utah.edu>.

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