The following materials are published and used by CDA as outlines for conducting continued education clinics.

Developmental and Cognitive Disabilities, An Outline

December 2003
Mental Retardation, Down's Syndrome, Autism, Asperger, Epilepsy.

GENERAL INFORMATION

By definition, a developmental disability is a condition resulting from congenial abnormalities, trauma, disease, or deprivation that interrupts or delays normal fetal, infantile, or juvenile growth and development. The onset is before age 18, and duration is indefinite. Some of the more common conditions include mental retardation, cerebral palsy, autism, epilepsy, and Down's syndrome.

A cognitive disability consists of damage to, or deterioration of, any portion of the brain that affects the ability to process information, coordinate and control the body, or move in space. Cognitive disabilities are classified as either organic (related to diseases such as Alzheimer's, Parkinson's, Huntington's, brain tumors, cerebrovascular disease) or non-organic (cause by injury or trauma, such as traumatic brain injury).

Mental Retardation

Mental retardation (MR) refers to subnormal intellectual ability present from birth or early infancy, manifested by abnormal development and associated with difficulties in learning and social adaptation. This disability constitutes the largest percentage of all people with developmental disabilities. More than 250 specific causes have been identified and grouped into two main categories: medical (hereditary, prenatal, trauma to mother/infant) and social (lack of mental stimulation, physical abuse, poverty).

A classification system has been developed to describe MR based on the person's mental ability (IQ), social behavior (social quotient), and rate of infantile physical development. The four levels and their relative percentage of MR individuals are:

Mild - IQ between 51 and 70; capable of learning academic and prevocational skills with some special training.
Moderate - IQ between 36 and 50; capable of learning academic skills during school age and can be independent in familiar surroundings. Can perform semi-skilled work and function in community homes as adults.
Severe - IQ between 21 and 35; physical disabilities such as visual deficiencies or motor dysfunction are common. May have limited communication skills but are able to care for personal needs.
Profound - IQ of 20 or less; show minimal responsiveness and may have physical disabilities. Self-care skills and communication may be somewhat limited.

Down's Syndrome

Down's syndrome is the result of having three of chromosome 21, instead of the usual two of each chromosome. Down's syndrome causes mild to severe retardation in 100 percent of the cases. It occurs in one of every 660 newborns, making it one of the most common malformation in human embryos that survive to birth.

Common characteristics include a flat face, a short neck, oval eyes, hypotonia (flaccid musculature), hypoplasia of the midphalanx of the fifth finger (a short middle bone in the middle bone in the little finger), a wide gap between the first and second toes, heart defects in 30 to 50 percent of cases, gastrointestinal defects in 10 percent of cases, and cervical instability due to poor development at C1 and C2.

Autism

A very short definition: uneven developmental patterns in the acquisition of motor, sensory, social, play or learning skills.

Autism is a life-long disability that becomes evident sometime during the first three years of a child's life. Autism is a neurologically based disorder; it affects the way a child communicates, interacts with other people and perceives and reacts to the world.

Patterns of behavior that are characteristic of autism include impairment of reciprocal social interactions, impaired communication skills, repetitive behaviors and a restricted range of interests. Not all children with autism behave in the same way. Each child might display a different combination of behaviors ranging from mild to severe. This is what is meant by Autism Spectrum Disorder (ASD). Five sub-categories of ASD have been defined: Autistic Disorder, Pervasive Developmental Disorder (PDD), Asperger's Syndrome (AS), Rett's Syndrome, and Childhood Disintegrative Disorder.

Characteristics of Autism

A child with autism may exhibit one or more of the following characteristics:

Various levels of delayed communication, including impaired language acquisition and comprehension as well as other related difficulties.
Difficulties or differences in understanding social situations and/or relationships.
Responses to sensory information that are unusual, inconsistent, repetitive or unconventional.
Stereotypic or repetitive patterns of behavior; persistent preoccupation with or attachment to objects.
Difficulties in adjusting to change in routines, environments, activities and/or schedules.
Difficulties in abstract thinking involving awareness, judgment and generalization.

Epilepsy

Epilepsy is the result of a temporary electrochemical imbalance within the regulatory mechanism of the brain. A sudden overload of energy may swamp the brain, causing partial or complete, brief or prolonged lapses in consciousness, known as epileptic seizures. It is estimated that one in every 100 hundred people may have some form of epilepsy.

MEDICATIONS: USE OF MEDICATIONS AND POSSIBLE SIDE EFFECTS

Type	Examples	Uses	Side Effects
Antibiotic	Penicillin, Keflex, Ceclor, Cipro, tetracycline	infection	dizziness, drowsiness, sun sensitivity
Antispasm	Flexeril, Valium, Robaxin, Soma	back pain, cerebral palsy	lethargy, blurred vision
Anti-inflammatory	Motrin, Advil, Naprosyn, Indocin	swelling, joint pain, arthritis, gout	headaches, rash, convulsions
Analgestic	Tylenol w/codeine, Percodan, Demorol	seizures	sun sensitivity, rash, blurred or double vision
Anti-Depressant	Elavil, Prozac, Zoloft	depression	drowsiness, dizziness, blurred vision
Anti-Coagulant	Coumadin, Heparin	blood clot prevention	hemorrhage
Anti-diabetic	Insulin, Diabinese, Glucophage	diabetes	nausea, vomiting, hypoglycemia

EVALUATION

A medical history should contain a written evaluation of a student's abilities. Using this as a guideline, an on-site, practical assessment is completed prior to skiing or snowboarding. Appropriate equipment may then be selected.

The Cognitive Assessment

The cognitive assessment occurs throughout the evaluation process. Evaluate the following to help you develop the best lesson plan for the particular student:

Is the level of cognitive functioning appropriate for chronological age? Remember to address the student in a manner suitable to chronological age.
Can the student hear, understand, and answer your questions?
What is the person's emotional state: motivated, confident, timid, anxious, eager, elated, reserved, confused, or patient?
Is the student easily distracted? Lack of concentration and reduced attention span are characteristic of some disabilities.
Can the student easily process information, follow directions, and stay focused?
What are the student's long-term goals and goals for the day? Motivation is key to developing the lesson plan for the day and for the future.

Assessing Cognitive Development

Indications of arrested cognitive development include:

Seeing images but being unable to manipulate them mentally (i.e., images cannot be transposed) - For example, if the instructor stands facing the student and demonstrates a wedge, the student will imitate the wedge with heels together and toes apart.
Acting impulsively and disregarding consequences - A student may understand that an action will have undesirable consequences but cannot stop taking the action.

Questions to assist the instructor in assessing cognitive development include the following:

What is the developmental age as well as the chronological age of the student?
How does this student learn? Start by observing the student and asking some simple questions to assess the following:

ability to understand basic instructions or complex commands
short-term memory
attention span
ability to solve a simple problem
how easily distracted or confused
ability to verbalize thoughts
ability to imitate a simple movement patterns
receptivity to a "hands-on" approach

Assessing Physical Development

The physical assessment allows the instructor to gather specific information about the student's disability and physical condition beyond that provided in the student information form. Before conducting a physical assessment, ask questions that will help you understand your student's disability. The information gathered can guide you in selecting and teaching techniques:

Does the student have any related or unrelated secondary disabilities? You must consider secondary disabilities when setting up equipment and teaching. For example, visual, hearing, or cognitive impairments may accompany multiple sclerosis, traumatic brain injury, or cerebral palsy.
How long has the disability has been present? People with a recent injury may be weak or unaccustomed to their current situation.
Has the student undergone major surgery within the last year? If so, the student may need a doctor's release or tire easily.
Is the student taking any medications and, if so, what are the side effects? We keep a "Physician's Desk Reference" at the office.

As you gather more information, the student may need to do some simple exercises to help you evaluate:

Functional Musculature - determine which muscle groups the student can or cannot use.
Strength - Evaluate the primary muscle groups needed for a specific discipline.
Balance - have the student lean to one side and return to upright, repeat to the other side, and then try it with eyes closed.
Coordination - Watch the student perform physical tasks, with an eye for fluidity and efficiency of motion. (Watching the student move around our office, open doors, or put on a jacket will help you assess gross motor movements. Watching the student write will give you an idea of the level of fine motor movement).
Flexibility and Range of Motion - Disabled students often have restricted range of movement due to joint fusion, muscle hypertonicity (rigidity), or muscle atrophy.
Motor and Sensory Deficits - Use questions and simple tests to determine what parts of the body the student can feel and control. If the student has feeling in body parts with limited function, determine the types of sensation felt: heat, cold, pain, or pressure. If the student has incomplete sensation, determine the extent.
Vision and Hearing - Some students or their guardians may forget to mention secondary visual or auditory impairments that are less obvious than the primary impairment. In the case of visual impairment, find out what the student can see. Vision should be tested both inside and outside to assess the effects of bright light and shadows. Find out if the student sees better out of one eye or the other. Impairment in one eye may cause a lack of depth perception. Test the student's field of vision as well as visual acuity. If the student has a hearing impairment, find out how severe it is. Does the student wear a hearing aid, read lips, or use sign language? Does the student hear better out of one ear than the other? All of these factors will influence how you conduct the lesson.

In addition to these physical issues, ask about the student's prior experience with skiing, snowboarding, and other sports. Did the student ski or snowboard or participate in some other sport before becoming disabled? Prior athletes have good body awareness - an advantage when learning to ski or snowboard with adaptive equipment. If the student currently participates in another sport, you can usually draw similarities to help the student learn the snowsport.

Equipment

Use the above evaluations to choose the appropriate equipment. Equipment needs will vary with each individual.

Ski Bra	Helps with lateral stability and muscle control. A metal device that clamps onto the tips of the skis to keep errant ski tips together. A variation, the trombone ski bra, is useful for maintaining the skis in a parallel position. It can slide back and forth to allow for walking and independent leg movement while skiing.
Bamboo Poles	Used when guiding, the instructor holds one bamboo pole in each hand, and a student is either directly behind or in front of the instructor, holding the opposite ends of the poles at hip level. They also allow student and instructor to ski side by side.
Reins	Lengths of one-inch webbing with clasps on one end. We use them from behind the student to help control speed and turns. They can be attached to a ski bra or around boot cuffs at the ankle. Reins can also be used to pull your student through the lift line or flat terrain.
"Blind Skier and "Blind Skier Guide" bibs	We use these bibs while skiing or snowboarding to alert other Powderhorn guests of your student's presence on the slopes. Must be worn while on the mountain.
Two-Way Radios	They eliminate the need to yell and provide you with a backup signaling system.

TEACHING INFORMATION

The teaching progression for developmental and cognitive disabilities closely follows the method set forth by the PSIA. In addition, the instructor needs to consider the student's comprehension level, sequencing abilities, and behavior to form a successful lesson plan. Instructors will also benefit from familiarity with the behavior modification techniques and teaching alternatives.

Using Fun, Games, and Props for Learning

Props can often be very helpful in establishing physical boundaries for each student.

Examples include:

tennis ball cut in half (to demarcate slalom courses)
traffic cones
edible treats (with permission)
a Hula Hoop
a Frisbee
a ball to toss
colored dots for the gloves, boots, and skis (one color for the right, another for the left)
food dye in squeeze bottles (combined with water to create "ribbons" in the snow)
a communication card (for nonverbal communication)
a teaching environment made up of props

Example of Communication Card

Behavior Modification

Behavior modification is the use of some system of reward or punishment to change undesirable behavior. The following examples may help when giving ski lessons:

Time-Out

A time-out is when the lesson is suspended for a prescribed amount of time. Avoid excess stimulation or any activity that may be regarded as pleasurable or rewarding. Use the time-out as a teaching aid, rather than punishment. A break in the action removes any positive reinforcement for the inappropriate behavior and gives the student a chance to change it. Remember the following time-out tips:

Make sure the length of time-out fits the behavior.
Use the time-out to shift attention from student's "manipulation" to your leadership and avoid overemphasizing the negative behavior.
Enforce the rules established at the start of the lesson consistently to avoid mixed messages.
Respond to inappropriate behavior the first time rather than putting it off and hoping it is not repeated. Consider issuing a warning that allows the student to make the correct choice: "You have a choice, John. If you hit me again, we will go inside and stop skiing. If you don't hit me, we will keep skiing."
Be patient when using "discipline" and do not get angry; instead, be blasé. Students may have trouble distinguishing between positive and negative comments.
The length of the time-out in minutes should equal the child's age.

Be firm when preventing or putting an end to inappropriate behavior. Try to use time-outs for the more aggressive or antisocial behaviors, such as hitting or talking back. For "minor" infractions, consider ignoring the behavior or redirecting it to another activity. Forget about softening the blow of a time-out. Simply tell the student when the time-out is over, and then act as if nothing unusual has happened.

Modeling Behavior

Through modeling, the instructor can guide the student toward appropriate and effective interactions on the hill. Students will tend to imitate the instructor at even the subtlest level. They duplicate not only behavior, but also attitudes; keep yours positive.

Motivators

These can range from favorite munchies (dispensed with discretion) to using a number system to count down the remaining runs until going in for a treat. Returning to a student's favorite run or lending the student a favorite article of clothing might also be used as motivators. Experiment with methods that stimulate the student and provide an incentive to continue.

Written behavior contracts

If student has a history of behavior problems, a simple, one-line contract such as "I promise to ski safely and keep my speed down on the hill" may suffice. The student and instructor sign the contract, and the instructor then keeps it handy during the lesson and shows it to a student as needed. Be sure that the student has the intellectual capacity to understand the concept of a contract.

Deep Breathing

This can be used as a relaxation technique. Have the student stop and take a deep breath or do rhythmic breathing exercises to relax the mind and muscles.

Environmental Changes

Removing the student from an over-stimulating or threatening environment can bring about behavior change or calmness. Examples of negative environmental stimuli are noisy, crowded buildings, loud snowmaking guns, or the presence of an overprotective caregiver. Simply move the student to another location.

BAG OF TRICKS

If your student is afraid of loud noises and you happen to be on a lift passing by noisy snowmaking equipment, have your student "cancel" out the noise by screaming. Make it fun and scream with your student.
If you student is touch sensitive, have him or her get used to touching you. When guiding your student from the front while skiing backwards, have your student use your stretched out hand as a "bumper." This way your student will control the amount of touch he or she desires.
Autistic children may be very sensitive to tight clothing. Even a small crease in a sock may cause a great discomfort. Make sure that snowsport clothing is not causing any discomfort.
When putting on the helmet on your student, stretch the helmet as far as possible by pulling apart the earflaps. Then put the helmet on your student's head and gently snap the helmet in place.
When in lift line, protect your student from crowds, touching, pushing and sensory overload. If necessary, use your ski pole in horizontal position to create a safe space around your student.
If possible, explain to the ski area management that you may need to use the exclusive ski school line (or patroller's line) when with an autistic student. Since autism may be invisible to others in the lift line, you'll need to explain to the area management that your student with cognitive disability may need to "cut-in" more than students with visible physical disabilities.

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