The definition of children with PMLD

Children with profound multiple learning disabilities (PMLD) experience barriers to communication and interaction which prevent them having the full opportunity to an appropriate education. It is essential to remember that as they 'share the same general aims as other children in school'(Ref), that is, they need to progress to the best of their ability. In Saudi Arabia there are very few centers that provide a successful curriculum for children with PMLD (Rectory Paddock School, 1981)Be careful - this looks as if Rectory Paddock school is expressing a view about education in Saudi Arabia and it didn't.). Moreover, all/some/many teachers are inexperienced and lack the ability to develop the full potential of children with PMLD. This confirms that I need to establish a greater knowledge of services in the UK and identify the positive aspects. In the past, PMLD in the UK received only rehabilitation programs that included providing basic necessities such as medical treatment and food. Recently, this practice has changed to providing a successful curriculum that focuses on the needs and abilities of the individuals (Lacey & Ouvry, 1998). This essay will therefore provide suggestions on how to achieve a successful curriculum for children with PMLD, helping to understand the wider concepts involved and how these children can eventually reach sufficient independence by identifying their individual needs.

This essay will present the definition of children with PMLD, followed by the children's primary needs including their physical, sensory and communication needs. It will then go on to look at the way of organize the classroom and then it is going to explain some of the teaching approach.

The definition of children with PMLD

Complicated terminology is used to refer to children who have the greatest difficulties with learning e.g. PMLD, severe learning disabilities (SLD), profound learning disabilities (PLD) and severe disabilities. To understand how to educate the children, it is necessary to address more than one of the associated issues which are related with ill defined terms, variables and unstable definitions.

The official terms used for dealing with PMLD may be different in various countries. In America the term 'severe' is used for individuals with an IQ of 20/25 to 35/40 and 'moderate' for those with IQ 35/40 to 50/55. In contrast, United Kingdom refers to children with IQ below 50 as having SLD (Porter, 2009). In Saudi Arabia 'multiple disabilities' is a common term used to refer to presence of more than one disability in a child which leads to severe educational problems which includes multiple intellectual disorder, multi-sensory disabilities, multiplicity of disability associated with severe behavioral disorders and severe disabilities

(General Directorate of Special education , 2001)

). The term 'learning disabilities' used in the UK should not be confused with - terms used in other countries where they have the same meaning as mental retardation or intellectual disabilities. UK calls problems such as dyslexia - 'specific learning difficulties' or 'specific learning disabilities' (Rennie, 2007).

Another problem which arises is that many believe that SLD and PMLD are synonymous terms. There is a lack of differentiation between profound learning disabilities and multiple disabilities as the two terms have similar needs and come under the same heading of Severe Learning Disabilities (Evans and Ware 1987). Some writers, such as (Aird, 2001) continue dealing with these two terms as synonymous. On the other hand, Swift(2005) defines the two terms differently. He says that SLD refers to children who have emotional needs, some students may use signs and symbols to support their communication and/or sensory impairments in addition general cognitive difficulties and mobility difficulty. On the other hand, PMLD regards to children who present physical disabilities, sensory impairment or severe medical condition. Although there are similarities in the definitions, it is preferred to use PMLD as it is widely accepted in Britain (Ware, 2009). Furthermore, some children with profound learning disabilities are described as PMLD whereas there are few people with profound learning disabilities who have no other severe impairments (Ware& Healey,1994).

To become more aware of this group of children, it is necessary to identify their characteristics. Children with PMLD have profound intellectual impairment and other multiple disabilities including sensory, physical or autism (Lacy & Ouvry 1998. To illustrate that, I will use the example of Rett Autism Syndrome displaying an inability to performer motor functional actions including eye gaze and speech and slowed brain function (Pierangelo & Giuliani, 2008). However, they are described as not a homogenous group (SCAA, 1996). In my professional practice, I have dealt with children who had severe physical or visual disabilities but did not necessarily have profound learning disabilities and some who had profound learning disabilities with good motor ability, learning, motor and sensory skills and thus needs differed from child to child. Another approach to a definition suggests that children with PMLD are in the first four stages of Piaget's Sensory motor development (What is this??_ (Clark, 1991). However, from my experience the pre-process stage, which says that the child in this stage can combining attributes samples of common objects and classifying them. Children with PMLD may have the ability to recognize visual word (MAKTON) system and classify the thing that he/she wants to do as an activity. In relation to PMLD symptoms children may have behavior disorders which are challenging for teachers (SCAA, 1996). The association between behavior and physical disability may or may not be a casual one. For example, disability may lead to depression which further increases the level of disability (Marten, 1980). From my experience, behavior is not only influenced by genetic and neurological factors but is due to the negative interaction and relationships between the child and the society.

Another approach to categories concentrates on the IQ in classified the person with PMLD whose has IQ level below 20. Recently the World Health Organization adapted a more social model of disability which classify on the individual strength and the social barriers that may compound a disability. Internationally three criteria are regarded as requiring to be met before learning disabilities can be identified: intellectual impairment, social dysfunction and early onset (The World Health Organization WHO, 2001(. On the other hand people with PMLD function equal to or less than one fifth of their chronological age (Sebba, 1988). This is a rather old referenceSome prefer to down play IQ on terms of the students' curricular needs; they call someone with severe learning difficulties if he/she attends an SLD or school. It can also consider what happens to children when they leave school, or we may distinguish pupils with moderate and severe learning difficulties by reflecting on the age at which their problems were first identified (Farrell, 1997).

(Quite a lot of this section uses some dated material - is this because you can see similarities between those debates and the ones now happening in your country.)

Criteria for placing pupils into categories have changed over the time. Children who may have had PMLD in the past may be now regarded as having multiple disabilities but not PLD (Ouvry & Saunders, 2001). This last consideration is of enormous importance when considering learning with PMLD: children with PMLD are now classified to be more intellectually able. The current percentage of children with PMLD has increased as a result of high level of health care provided (Lacey & Ouvry, 1998) where the number of adults with PMLD will raise from 78 in 2009 to 105 in 2026, as in average 3 in 2009 to 5 in 2026 (centre for Disabilities Research CeDR, 2009).

The definition has changed over time linked with the changing of the education system from segregation to inclusion. I will illustrate this by references to curriculum access. Around 1971, children with the most profound disabilities in the UK were excluded from education, cared for in wards as they were considered unable to follow the standard curriculum (Clark, 1991; Lacy & Ouvry, 1998). However, after this point, some children who attended schools for pupils with LD also had severe physical disabilities require specialized facilities but which would possible to provide in Educational Sub Normal ESN(S) classes (Rectory Paddock School, 1981)., Historically some writers assume that Special Care Units (SCUs) remain the only setting specifically able to provided for children with PLD and additional disabilities in schools catering for severe learning disabilities (Evans & Ware, 1987) In contrast, terms "special care" is not acceptable as the provision provide for PMLD are varied (Sebba, 1988).

In the UK, the curriculum needs have given more attention to other educational aspects (Cline & Frederickson, 2009). Children with PMLD may work with P1-P4 in the national curriculum where P scales provide small, achievable steps to monitor progress (Swift, 2005). Some children may even work at P levels 1-3 for the majority or all of their school life (Ware, 2009).

It is hard to reach a clear definition which would be used to describe a group of children who share common characteristics with other categories. However, in my view, supported by this evidence, a child with PMLD has multi-disabilities: learning disability and other disabilities. The most important aspect in planning education is to focus on the children's requirements and needs no matter how this group of learners is defined..

Children with PMLD primary needs which affect their ability to learn

Children with multiple disabilities face many problems which challenge adults who work with them. A careful analysis to their needs is required to understand exactly what is preventing progress (Stone, 1995). There is a wide spectrum of special educational needs that are frequently inter-related. They may fall into at least one of four areas: communication and interaction, cognition and learning, behavior, emotional and social development and sensory and/or physical (The Code of Practice, 2001).

Physical needs:

There is some physical impairment that can be diagnosed from birth: cerebral palsy, spin bifida, congenital abnormalities of the skeleton and other rare neuromuscular diseases (Hogg & Sebba, 1986a). PMLD has a lack of independent, muscle spasm, abnormal reflex activity, inability to control bladder or bowels and congenital abnormalities of skeleton which make people feel uncomfortable and cause other problems (Clark, 1991; Hogg & Sebba 1986).

Physical impairment affects other parts of the child's life: being unable to move well may be at risk of developing distortions of body shape over a period of time (Rennie, 2007; Fulford & Brown, 1976). The teacher needs to understand these problems and focus on basic physical therapy in a curriculum plan (Clark, 1991), with a holistic approach (Rennie, 2007) and lifelong commitment which influences the majority of the individual's time at school and home rather than an ineffective ritual (Lacy & Ouvry, 1998). Yet this as I believe does not necessarily mean therapy used in traditional ways. Many creative methods a physiotherapist can use in cooperation with the teacher in the classroom in children's mobility curriculum and teaching methods. Traditional ways should not be taught in the same order (Stone, 1995)What do you mean?. I would suggest using things from everyday environment would be more suitable for physical therapy, merging skills training for recognizing colour and rolling to train muscles by placing the child on a mat between a green and a red ball and asking them to move in the direction of either ball. This way the child learns colour recognition, exercises and s the game. Children learn more quickly if they enjoy themselves.

As a child with PMLD spends most of his time at home, therapy can be successful when the parents have major roles in planning and implementing (Lacy & Ouvry, 1998). The best way is to raise parents' awareness and to make fully participate in the therapy which lead to greater improvement in the child.

Sensory needs

Children with PMLD?? often experience sensory problems. There are a number of different needs arising from sensory impairment, one arising directly from the impairment such as visual or auditory impairment (Lacey & Ouvey, 1998) which have adverse effects on linguistic development, behaviour, and emotional adjustment, socially isolated and the general quality of a person's life (Clark, 1991; Ellis, 1992). Other problems are often environmental. Parents and teachers can lose interest in interacting meaningfully with their child who does not provide cues or rewards in the form of a smile. From my experience, children with PMLD are often ignored by their peers and teachers who interact with children who communicate more.

Hearing impairment and learning disabilities are not clearly separated (Kropka & Williams, 1986) and cannot be underestimated as the hearing impairment is not as obvious to an observer as some other impairments (Sebba,1988). In this matter it is primary aim of managing sensory impairments is to try to allow children to have access to the same quality of life and experiences by using whatever hearing and sight they have to the best of their ability or by helping them to make use of their other senses such as touch and smell (Sebba, 1988).

Communication needs

When I was in the early phases of my training, I remember there was a teacher who sang to a child with PMLD. I wondered why this teacher was choosing to do so when the child could not hear. The child smiled and laughed at the teacher and reacted positively in her presence. It became clear to me that the child needed to have interaction and could communicate in a specific way as he could interpret some sensory information.

If communication fails, then other social activities go away ???as well. Children with profound learning disabilities show massive delays in communication, which makes it hard to communicate, convey ideas and experiences with other people. (Hogg & Sebba, 1986) Despite that in fact every child is a unique case, speech is not the only means of communication (Hogg & Sebba 1986). Some children who are described as not having the ability to traditionally communicate are able to show preferences when they are given a choice (Glenn? & O'Brien 1994). This is confirmed by my experience which shows that these children have a lot of stored energy which just needs continuous attention and time to be displayed or disabilities are likely to deteriorate. The code of practice mentions that most children with special educational needs have strengths and difficulties in one, some, or all of the areas of communication. Children will need to continue developing their linguistic competences (Code of Practice, 2001).

With the knowledge that there is no cure(This takes us right into the medical model - is that your intention> for these needs, there are many ways to help these children get the best possible outcome for growth and development, to perform any tasks that are necessary in their daily lives to remaining integration in society. Thus we need to build an appropriate program for children with PMLD on an individual basis to meet individual needs, where in the last ten years there has been a big change in the ways of dealing with children with PMLD and schools are now receiving children who have several needs (Lacy & Ouvry, 1998).

Teaching and learning is complex. Within this discussion, little attention will be given to curriculum content for two reasons. First, the lack of compatibility between the curriculum in Saudi Arabia and England. Second, because for this group of learners focus on effectiveteaching and learning including accede to several different teaching methods is of prome concern. Even if there are good teaching practices put in place, they will not work if the environment is not suitable for learning (Sebba, 1988). Therefore it will focus on how to organize the learning environment where children should be more familiar with the classroom, and anticipate the activities (Ouvry & Saunders, 2001). You have introduced t/l first and then the envornment. Is it logical to write the sections in the same order or to re-order these comments?

How to organize the learning environment

Children will need to overcome classroom obstacles before they are able to start to learn, this can be handled by the establishment of an appropriate learning environment .There are numerous necessary measures to build and maintain an appropriate environment for children with PMLD it is vital that this environment is well organized to suit their needs. Regardless of whether children with PMLD are educated in a specialist environment or in mainstream school, (Ware, 1994) suggests three core principles in the organization of a classroom: the organization of time, people and material in an environment which can all overlap.

The physical environment organization

The physical environment plays a role in raising children's motivation to work. Teachers should define each area of classroom and ensure that the environment is not distracting to help the child to learn easily (Byers, 1998) for example, the work area should not include visual distraction which can confuse and have a negative effect on the learning process (Porter, 2002).

In addition the size of the room must be considered, if the room is too large or open this can distraction the child (Nind et al, 2001). From my experience I remember that also the small room encourages unsuitable behaviour, teachers was putting the pupils' standers behind the door because the room was very smallwhich can make movement in and out of the room difficult; this subsequently upsets the children and made him react in an unsuitable manner.

Another matter is organizing the classroom based on the child's needs. For example, it is often a good idea to place children with the most profound physical needs in easily accessible points in the classroom so they can move more freely (Algozzine & Ysseldyke, 2006). For children with visual impairments, strip lighting is unsuitable as it does not provide good distinction between different objects, and so spot lighting, colored bulbs or dark areas should be used to show different areas as well as different textures.

Furthermore, I have found that it is beneficial for children with PMLD to have a designated seat in the classroom as this promotes confidence and a sense of familiarity (Nind et, al 2001). But which position are the best for seating. A study found that children who functioned at a lower level worked well in a prone position (Park et al, 2005). Other study suggests that position is not simply a matter of optimizing attention, but the impact on other functions, such as hand use and spinal extension (McEwen, 2002).

The position of the teacher and the other staff is significant. They should be able to assess the child and their emotions, so that they can help the child sufficiently. If they are behind the child or to the side, they may not be able to see the Children may need help with their medication if they have to take it through the school day (Algozzine & Ysseldyke, 2006).

The social environment organization

Knowledge of the child is very important in the social environment organization, knowing what they like, dislike, how they interact and communicate; education should happen co-actively (Cartwright & Wind-cowie, 2005).

Teacher also should not become dominant in the relationship; rather, they should help the child learn in their specific way. There are three main models for the teacher/pupil relationship: the teacher dominating, the pupil dominating or a two way dialogue. The third is the hardest, but if successful, the best (Lacy & Ouvry, 1998). The final model requires very strict planning and organization in order that it works well.

Rewards are also positive in order to build a good social environment. The teacher should understand that some children with PMLD will find standard encouragement techniques, such as cheering, very discouraging and distracting. Therefore, the teacher should observe signals from the child to discern what they like and do not like (Sebba, 1988).

Another matter which is very important in the social aspect is that teachers should understand how the child would react to failure, in this way they can prepare for it. (Corker, 1992) suggests that children should be encouraged to see failure not as a result of inability but because of lack of effort or dedication. In this way, they are empowered to change it and succeed in the future.

The time organization

The most difficult balance to maintain is how to organize time inside the classroom with regards to the curriculum and the ways of teaching. There should be an appropriate division of time between national curriculum, non-national curriculum based activities and therapy (Ware, 1994). I remember from my experience that children have their own schedule divided between the child needs. Expand

Another matter, which is widely discussed, is the way of teaching children. Which way of teaching a child with PMLD is more beneficial? Children with PMLD would benefit from being taught in a group. If the children with PMLD are placed together they may become more perceptive and have a greater interest in what they are doing (Hogg & Sebba, 1986). Although group work can be effective, in reality can be deceptive. A child who appears to be working in a group may in fact actually be working alone (Bennet & Cass, 1988). Some specialists infer that in teaching children with PMLD, there should be group work involved and also individual work this is seen as the most beneficial practice (Ware, 1994). From my experiences whilst the teacher worked with the class as a whole, the teaching assistant would remove a child from the group in order to provide individual focus to that child. This enables effective and beneficial learning for the children as it advantageous for the child's learning to have individual attention.

The grouping learning a raises the question of how much time should the teacher spend with an individual child compared to how much time spent with the entire class. I think group work is imperative and therefore time should be devoted to this, particularly because children should be encouraged to develop awareness of their peers, this is realized through group work (Cartwright & Wind-Cowie, 2005). However, I realize from my experience the specific method influences the way of teaching; whether individually or in a group. (Ware, 1994) mention some examples for effective grouping are suggested, Scripted or Jigsawing which are used with heterogeneous group without losing the benefits of individual work.

In addition, there are also issues about whether the same activities should take place at the same time each day or not. There should be a clear routine established and a consistent timetable, especially at the beginning of the day with registration; so that the child knows what is happening and so therefore is not anxious (Corker, 1992 ; Ware, 1994). However, this can sometimes be problematic because it must be accepted that some activities will take longer for children with PMLD to carry out, in these cases certain allowances must be made. (Orelove et al, 2001).

There are other issues related to the timetable of the children's learning, there is no evidence that children will learn best in the morning. There is evidence that children with PMLD may be best taught if they have therapy in the morning so that they are calm for the other activities. Moreover, there is the issue of medicinal side effects and how this can cause problems with learning (Ware, 1994). All this must be taken into account when time planning to keep the attention focused and to help the child to learn.

Teaching approaches

The special education literature now focuses more on the teaching methods than the curriculum content. I will mention some of the teaching methods which are used. Task analysis in which a task is broken down into manageable pieces with clear objectives, making it easier for the child to learn (Sebba, 1988). Errorless learning, an exercise in which examples are given to the children yet only require only one possible solution, thus increasing the opportunity of reward for the child. Do you agree with errorless learning??Recording, where all the practices are planned and recalled so they are then assessed (Hogg & Sebba, 1986). Next is the use of ICT to help with communication and with social interaction. Also to aid choice making as it will help with life skills and requires a lot of concentration (Ware, 2009). Using pictures to communicate choice and show correlation between different pictures and objects has often been effective with the use of commands (Porter & Ashdown, 2002). There are also three main types of holistic approach: conductive education, patterning and coactive intervention (Hogg & Sebba, 1986). Acoustic bells can be used to create an intense sound environment to encourage learning and concentration (Mednick, 2007).

It is now necessary to evaluate two teaching approaches, intensive interaction and multisensory approach. Because these two methods focus on the children with PMLD which I mention them previously. I will be used as illustrative examples to examine the techniques that can be employed to optimize the learning experience for the child with PMLD.

Intensive interaction

Teaching children with PMLD is often focused on communication (Ware, 2009) which is fundamental and makes child learn about themselves and others (Hewett & Nind, 1998). However, sometimes children with PMLD are taught a way of communication which they cannot understand or which may be limited and therefore unsatisfactory. In my experience, teaching that solely focuses on the core curriculum was only effective for a number of children, leaving others unresponsive to the teacher. During the activity the teacher would help the child physically whilst using different way of communicating, for instance by photo cards, however this may not be beneficial every time. From my reading I have established that these children were entitled to communicate in their own way; they should not have to be taught a standardized way of communication, at least in the initial stages. By using our body language and gaining feedback by watching others' reactions (Caldwell, 2008) this makes communication easier as the child will understand that the teacher can understand their emotions.

The standard ways of 'Intensive interaction' refers to when the adult working one to one to with the child to mimics any communication behaviour of the learner of by using the child's own method (Watson, 1994) to makes teaching and learning easier (Hewett & Nind, 1998), and to develop sociability, communication, cognitive abilities, emotional well-being, constructive interaction with immediate environment and self awareness (Nind & Hewett ,1994). I think this is practical and reality, if we see how the mother contact and communicate with her child, we don't compare between children with PMLD with the infant, What I want to highlight, is how the baby feel happy with his/her mother imitations and his reaction and how he continue in communication.

The Strategies:

There are two studies which say that intensive interaction is a very good way of developing communication and social skills. It must be employed systematically and used efficiently in order for it to be effective (Watson & Fisher, 1997; Kellett, 2003).

The focus must be on the quality of the interaction sociability and communication and not the outcome (Hewett & Nind, 1998).

Records must be kept of all interaction so that any changes, even if minute, can be remembered. It is often difficult to do this without records as the changes can be very small (Irvine, 1998).

There must be a limiting of numbers of staff and volunteers so that there is routine and the people can all be fully trained to their abilities (Ware, 1996).

Intensity, sensitivity and reflection are key in implementing this method. The method encourages awareness of those around the learner, and ignores ideas about tasks and correct or incorrect ideas, and so puts the precedence on the learning process. (Hewett & Nind, 1998).

Intensive interaction should be used within a group environment to make it more standard and to ensure that abuse allegations do not occur (Nind & Hewett, 1994).

The process of intensive interaction is included in this. An advantage to adopting this approach is its simplicity; it does not require materials and therefore can be used in the home. What makes this approach more significant is that it can be used easily at home (Irvine, 1998).

There are some problems encountered in this methods, the abilities to make a response is sometimes weak. The adult may be tired or the child may anxious (Kellett & Nind, 2008) the child may want to continue to interact when no one is available (Irvine, 1998) so it is necessary for the adults to learn to tolerate a delay (Maggs & Samuel 1998). Another problematic issue is that Intensive interaction works for some people but not all. So although there are some overriding principles for using intensive interaction, the approach must be changeable and flexible so that the child can achieve the most possible. (Kellett & Nind, 2008). However, for those it does work for, it is still very difficult to prove that intensive interaction is the only cause for improvement (Irvine, 1998).

The multisensory approach

Some children, who have sensory ability such as sight, may not understand how to use it or how to interpret what they see. Thus teachers should help children to use all the senses to enable good learning.

One of the ways of the using multisensory approach is the sensory room. This can be described as a reactive environment (Mednick, 2007). There are two ways to define the sensory room or 'snoezelen' () : the actual space and the impact on the child. The space can be characterized by the physical attributes, size and complexity, size of the room is very important so the child does not feel overwhelmed by the space or out of control. The same is for ideas about complexity; there should not be a sensory overload. There is no set list of things which are including in a sensory space, which can include simple materials or complex interactive electronic equipment (Stephenson, 2002). Other physical aspect are the different type of sensory room, there are six primary kinds of rooms: white room, dark room, sound room, interactive room, water room, soft play rooms finally there are outdoor spaces in the gardens each room have aims and goals (Pagliano, 1999). Although the only limitations on these spaces is imagination, the child's likes and dislikes are the primary influence as some might not like a white room but may love a water experience. If the child can exert control over their environment, they will develop control and autonomy and greater self confidence (Stephenson, 2002).

The other aspect of the definition is the impact on the child's ability, which includes good communication, movement, cognitive ability, emotions, behavioral changes, life skills and good expressive arts (Longhorn, 1988). This makes it one of the most effective methods to teach a child with PMLD because it makes learning easier (Fowler, 2008) and fun for