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Devising and Assessing an Intervention to Help Extend the Attention Span of a Child with Cerebral Palsy

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Devising and Assessing an Intervention to Help Extend the Attention Span of a Child with Cerebral Palsy Devising and Assessing an Intervention to help Extend the Attention Span of a Child with Cerebral Palsy Marie-Louise Yvette Carter A thesis submitted in partial fulfilment of the requirements of the Institute of Education, University College London for the degree of Doctor in Education 27 September 2019 1 Declaration and word count I hereby declare that, except where explicit attribution is made, the work presented in this thesis is entirely my own. Word count (exclusive of appendices and the list of references but including footnotes, figures and tables) 49,293 words. M L Y Carter 2 Abstract Literature suggests that children with developmental impairment of motor skills may have an increased risk of disorders of learning, including attentional and working memory (WM) difficulties, which may remain undetected. Whilst there are many clinical studies which focus on limb function and movement, very few studies have explored the cognitive difficulties of children with cerebral palsy (CP). Among cognitive difficulties, working memory (WM) and attention seemed particularly important. In the present research, an extensive pilot focusing on working memory identified insuperable methodological difficulties. The study therefore focused instead on sustaining attention (readily identifiable from observed behaviours) and on testing the ability of an intervention to increase attention. The research consisted of close observation of a single individual with CP in a single-case study design. The present study, within the action research paradigm, incorporates some features of single case methodology; specifically, of the ABA withdrawal design. The design consisted of three phases: A no-intervention baseline phase (A), an intervention phase (B), and a no-intervention withdrawal phase, followed by return to a (new) baseline (A). The initial baseline assessment involved a series of observations during unstructured play sessions. This was to establish typical movement patterns for the participant with CP so that these could be distinguished from later movement patterns associated with the interventions. The idea of ‘pattern’ was the central concept chosen for the intervention because it is central to mathematical understanding and is part of the school curriculum. Activities were planned which were not being taught or practised at other times. Sustained improvement in attention in successive baselines would suggest the intervention programme was successful in effecting a stable change. Results demonstrate the intervention was successful in supporting a child with cerebral palsy to develop his attentional ability. This was evidenced through increased time on-task across the intervention. The child was able to choose what to pay attention to and what to ignore when undertaking adult-led learning tasks. 3 Impact Statement Findings of The Deployment and Impact of Support Staff (DISS) Project, conducted between 2003 and 2009, highlighted that more support from Teaching Assistants did not lead to better progress made by children. Despite these findings, children often remain overly supported, leading to possible dependency and poor educational outcomes. The present research study supports the findings of the DISS project and provides an opportunity for stakeholders to consider the implementation of policies that target effective support for children with special educational needs and disabilities. The allocation of funding which supports inclusive practice through cost effective programmes of targeted intervention will make better use of limited resources, at a time when education, health and social care services are over- stretched. The potential impact will be better use of resources and public money to improve outcomes. This research has the potential to contribute to further research that considers effective educational approaches to supporting associated attentional difficulties of children with some types of cerebral palsy. This could lead to evidence- based interventions which improve attentional control and increase educational outcomes for the child. Through increased engagement children learn to be actively involved in activities, to think about what they are doing and to develop the skills needed to be independent life-long learners. Improved educational outcomes contribute to the child’s sense of self-worth, emotional wellbeing and mental health. This research has provided a valuable opportunity to gain insights through increased understanding of the difficulties and approach needed to support a child with cerebral palsy within a mainstream setting. The impact on Bob, the child in the main study, has been improved engagement in activities, which was systematically measured and evidenced through increased time on-task. The teaching assistant involved with Bob benefitted. Involvement in the intervention through observation provided an opportunity to observe a different 4 approach that effectively supported Bob’s engagement with activities and enabled progress. This research has the potential to increase awareness amongst both stakeholders and practitioners of the potential of children like Bob, to make educational progress with targeted intervention. It challenges the current model of mainstream practice whereby all children follow a curriculum devised for typically developing children, with an expectation that they make age-related progress measured against national norms. This research highlights the need for a new pedagogical approach to meet the complex needs of children like Bob, attending mainstream schools. This research has impacted my practice as a specialist advisory teacher. I would argue that, regardless of medical diagnosis, an understanding of the child’s cognition is essential. This awareness has been raised amongst other practitioners in the researcher’s team. The impact has been developing more holistic assessment of children’s learning needs, instead of a focus on the physical access arrangements and environmental adjustments required. When meeting with stakeholders I endeavour to implement decisions through increasing awareness of the problems facing mainstream schools in meeting the needs of children like Bob, and by highlighting how an alternative approach is needed, which endorses the findings of the present study. 5 Acknowledgements I feel privileged to have been able to work with so many children over the years, especially children with disabilities. They have been a source of inspiration in the way they face their daily challenges with persistence and determination. Without knowing, they have provided the motivation to keep going despite the many difficulties encountered during these studies. I owe my sincere thanks to my supervisor, Dr Yvonne Reynolds, who supported me throughout my thesis journey with guidance, patience and kindness. I would like to acknowledge the substantial support and advice provided by Dr Karl Wall over the last few years, especially with the data. I hope this thesis adequately reflects the time and patience so generously offered. I appreciate the schools and staff that supported my work and interventions with the children. Finally, I am sincerely grateful to the parents and child who made this study possible and for the many insights provided. 6 Table of Contents Reflective Statement 13 Chapter 1: Introduction 1.1 Overview of the study 19 1.2 Context for the study and professional background 19 1.3 Institution-focused study 19 1.4 My work in mainstream schools 20 1.5 Focus of the current study 21 1.6 The problem this research addresses 22 1.7 Rationale and aims of the study 23 1.8 Special Educational Needs and Disabilities 23 1.9 Summary 24 Chapter 2: A Review of Literature 2.1 Introduction 26 2.2 Search Strategy 27 2.3 Key terms used in this thesis 28 2.4 Learning difficulties associated with Cerebral Palsy 31 2.5 Current understanding of attentional difficulties in Cerebral Palsy 32 2.6 Memory difficulties in Cerebral Palsy 33 2.7 The relationship between working memory and attention 33 2.8 Assessment of attention and working memory difficulties in children 34 2.9 Studies undertaken in atypical populations 38 2.10 Mathematical difficulties in children with Cerebral Palsy 40 2.11 Rationale for the focus on ‘pattern’ in the present study 42 2.12 Other factors that can affect learning in children with CP 43 2.13 Associated medical difficulties which may disrupt learning 44 2.14 What perspectives and insights do present-day practitioners have? 48 2.15 The importance of the present study 51 2.16 Summary 51 2.17 Plan of the remainder of the thesis 52 Chapter 3 Method 3.1 Introduction 53 3.2 Advantages and disadvantages of action research and single-case 53 study (SC) approach in answering the research questions of the present study 3.3 The ABA withdrawal design (or ABAB (reversal) design) 55 3.4 Single-case methodology 57 3.5 Rationale for a single-case study 58 3.6 Method and overall design 59 3.7 Organisation of the pre-intervention assessments 62 3.8 The Intervention 66 7 3.9 Intervention: session defined 66 3.10 Intervention: overview of sessions 67 3.11 Intervention: assessment defined 68 3.12 Intervention: overview 68 3.13 Sample 69 3.14 Setting 69 3.15 Instruments and materials 73 3.16 The researcher 76 3.17 Data analysis 77 3.18 Events 80 3.19 Ethical considerations 84 3.20 Validity 86 3.21 Dissemination of findings 87 Chapter 4: Pre-intervention assessments 4.1 Introduction 89 4.2 Case history 89 4.3 Assessment of mathematical understanding 91 4.4 Typography of movement 92 4.5 Pre-intervention
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