Increasing the effectiveness of nutrition educators in meeting the needs of individuals with developmental disabilities
Michelle F. Brill
Family and Community Health Sciences Educator
Rutgers, The State University of New Jersey
Kathleen T. Morgan
Department Chair, Family and Community Health Sciences
Rutgers, The State University of New Jersey
Educating individuals with developmental disabilities requires specific knowledge and skills. The high prevalence of obesity and other nutritional concerns due to the limitations to functioning associated with disabilities, sometimes coupled with low income and low literacy, puts this population at high risk for chronic disease. A professional development program was developed to provide an overview of the most common developmental disabilities and their implications for nutrition, behavior, and learning. Effective teaching strategies with an emphasis on the importance of using visual supports were provided and demonstrated. Following training, participants indicated increases in knowledge, ability to adapt teaching strategies, and feelings of effectiveness and confidence in teaching individuals with developmental disabilities. Appropriately trained educators are more likely to create knowledge, attitude, and behavior change in their students. The public value of this program is its contribution to improving the health of communities and furthering the independence of Americans with developmental disabilities.
developmental disabilities, nutrition education, visual supports, obesity prevention
Cooperative Extension professionals, nutrition educators, school personnel, youth development staff, and paraprofessionals endeavor to increase knowledge that will lead to attitude and behavior change with the overarching goal of improving health and preventing disease. In order to accomplish this, the educational content must be communicated in ways that are relevant, comprehensible, user-friendly, and easy to recall. This can be particularly challenging when teaching individuals with developmental disabilities.
The purpose of this paper is to describe the methodology and impacts of a professional development training program for Extension and other educators who teach nutrition and physical activity lessons to learners who have developmental disabilities.
Developmental disabilities and nutrition
Developmental disabilities are a diverse group of severe chronic conditions that are due to mental or physical impairments, or both. People with developmental disabilities have problems with major life activities such as language, mobility, learning, self-help, and independent living. Developmental disabilities begin anytime during development up to 22 years of age and usually last throughout a person’s lifetime (Centers for Disease Control and Prevention 2004). They affect eating behavior, nutritional status, classroom behavior, social inclusion, learning, and academic performance (Williams, Dalrymple, and Neal 2000; McCary 2006; Cross-McClintic et al.1994; Siperstein, Glick, and Parker 2009; The Elizabeth M. Boggs Center on Developmental Disabilities 2000).
An estimated 4.6 million Americans have a developmental or intellectual disability (Larson et al. 2000). The most common disabilities seen in school-age children are learning disabilities, attention deficit disorder with or without hyperactivity, autism spectrum disorders, intellectual disability, and sensory processing disorders. The prevalence of attention deficit hyperactivity disorder (ADHD), the most common neurobehavioral disorder of childhood, has been reported to be 9.5 percent (Centers for Disease Control and Prevention 2010). Due to the limitations to an individual’s functioning associated with these diagnoses, secondary conditions relating to nutrition are prevalent in this population. Researchers have recorded a high prevalence of overweight and obesity in adults with intellectual or developmental disabilities in both institutional and community settings (Bertoli et al. 2006).This puts them at higher risk for conditions such as cardiovascular disease, including elevated blood lipids and hypertension; poor bone health; diabetes; gastrointestinal dysfunction and eating problems; and higher mortality rates (Bertoli et al. 2006, Bazzano et al. 2009). Healthy People 2010 identified nutrition in intellectual or developmental disability as part of the nation’s public health agenda (Office of Disease Prevention and Health Promotion 2000). Compounding the health issues are the prevalence of low income and low literacy among adults with intellectual or developmental disabilities (Yamaki and Fujiura 2002; Nitzke and Voichick 1992; Contento, Randall, and Basch 2002), many of whom participate in the US Department of Agriculture’s community based health education programs. These are the Supplemental Nutrition Assistance Program-Education (SNAP-Ed) and Expanded Food and Nutrition Education Program (EFNEP) programs offered by Cooperative Extension.
Since the 1970s educational and disabilities-related legislation has served to move individuals with intellectual or developmental disabilities from more restrictive environments (i.e., institutions and specialized schools and classes) to less restrictive, more independent and inclusive arrangements in schools and communities. Specifically, the Education for All Handicapped Children Act (1975), the Individuals with Disabilities Education Act (1990, 2004) and No Child Left Behind Act (2001) require that students with intellectual or developmental disabilities be educated in the least restrictive environment. The Developmental Disabilities Assistance and Bill of Rights Act of 2000 Section 109(a)(2) states that the treatment, services, and habitation for an individual with developmental disabilities should be designed to maximize the potential of the individual and should be provided in the setting that is least restrictive of the individual’s personal liberty. These mandates have changed the profile of Extension’s clientele and have created the need for specific training to increase educators’ knowledge of these disabilities and provide them with strategies and materials to improve their teaching effectiveness in both school and community settings. Extension educators generally bring no formal training in teaching individuals with special needs (Brill 2010).
Extension educators are not the only ones who need additional training. A review of the literature found consistent results among studies indicating the need to provide general education teachers with additional and ongoing training in inclusive practices. Buell reports that 78 percent of general education teachers expressed greater training needs, in contrast to 48 percent of special education teachers. The training areas rated more highly included program modification, assessing academic progress, adapting curriculum, managing behavior, developing Individualized Education Programs and using assistive technology. Efforts to increase teachers’ understanding of inclusion and issues surrounding inclusion are likely to engender more confidence in their ability to positively affect students (Buell et al. 1999). Other researchers studying teachers’ perceptions on inclusion found that when teachers were asked to rate their level of concern that staff had not been trained to work with increasingly diverse student needs, 85 percent said they were concerned or very concerned, and 80 percent were concerned or very concerned about the lack of ongoing training with staff (Horne and Timmons 2009).
What is the program?
Teaching Individuals with Developmental Disabilities is a professional development program designed to provide the following:
- an overview of the most common developmental disabilities and how they affect nutrition, behavior, and learning.
- effective teaching strategies with an emphasis on the importance of using visual supports.
Various researchers have found that individuals with autism and other developmental and learning disabilities are strong visual learners (Hodgdon n.d.; University of Florida Center for Autism and Related Disabilities n.d.). Therefore educational programs designed to meet the needs of this population need visual supports to complement oral instruction. The training program placed a heavy emphasis on the theoretical and practical importance of using visual supports.
Tasting strategies were also included in the training because issues such as food selectivity, sensory integration, oral-motor skills, mealtime behavior, and food intolerances have particular significance in nutrition education for this population (Williams, Dalrymple, and Neal 2000; Bandini et al. 2010; Herndon et al. 2009).
The program was provided in one session lasting from one to two hours, depending on the setting. It consisted of a PowerPoint presentation, relevant handouts, and, whenever possible, a small-group interactive component whereby trainees applied the instruction on using visual supports to create a visual learning tool for their students.
What is the program’s purpose?
An initial in-service workshop was developed for Cooperative Extension’s SNAP-Ed and EFNEP paraprofessionals. The workshop was designed to help educators become more knowledgeable about developmental disabilities, better skilled, and more confident and effective in their teaching. The secondary outcome would be that their clients can then use the knowledge and skills they learned to make positive behavior changes.
How does it achieve that purpose?
Background information was collected from the paraprofessionals about the types of developmental disabilities their clients have (if known); their prior knowledge and training in working with this population; reports of challenging teaching encounters; and their knowledge and use of adapted teaching strategies. The first workshop for paraprofessionals was held in September 2009. The format was a structured PowerPoint presentation followed by a question-and-answer period. Immediate evaluations were conducted. Overall instruction and teaching was rated an average of 4.5 on a 5-point scale, and overall program content and presentation was rated an average of 4.46 on a 5-point scale. The educators reported having a better understanding of their clients’ behaviors and needs; increased understanding of learning differences; and having benefitted from the wide variety of teaching strategies offered. Qualitative feedback on what could have been done to make the session more useful included suggestions for additional handouts, requests to include viewing of a video of the behaviors described, and requests for hands-on activities.
Based on the feedback from this workshop, the program was revised to include more instructive handouts, a video segment of teenagers with autism, and a small-group activity designed to encourage brainstorming and development of useful visual tools.
This approach uses the principles of both adult learning and learner centered theories.
How many people has the workshop served?
Over the last two years, various versions of the workshop were designed to match specific audiences that have included Family and Consumer Sciences teachers, nutrition educators, Extension faculty and staff, general education and special education teachers, school nurses, health and physical education teachers, Head Start/Early Head Start teachers, dieticians and disabilities coordinators, and Boys and Girls Club after-school program staff. To date, 407 educators have been trained. Training formats have been both face-to-face and via webinar.
What made the program a success?
The program’s success is evidenced by trainee feedback and follow-up surveys that indicate retention of knowledge gained and incorporation of effective teaching strategies. Evaluations from trainees suggesting an interactive and hands-on component have led to the incorporation of activities based on the software application BoardmakerÒ developed by Mayer-Johnson. Boardmaker offers a graphics database of thousands of picture communication symbols. It is the most widely used graphics database for students with developmental and cognitive delays, and speech impairments. A recent review of research on adding pictures to written and spoken health education materials found that pictures can increase the student’s attention to education materials, their comprehension of health information, their recall of what was explained, and their adherence to health recommendations particularly in individuals with low literacy skills (Houts et al. 2006). Research on program design that uses input from individuals with developmental disabilities supports the use of visual tools (Bazzano et al. 2009).Visual supports are known to improve communication, behavior, socialization, and independence. The training program provides a thorough background on why visual tools are so critical for this population and demonstrates several uses of the tools in games, classroom schedules, class rules, recipes, sequencing activities, learning assessments, and program evaluation.
Teaching Individuals with Developmental Disabilities has been selected to be presented at several state and national professional meetings, which demonstrates its relevance to Extension educators, nutrition professionals, and teachers.
What are the impacts?
Perhaps the most significant impact was the increase in the educators’ knowledge related to the five developmental disabilities. A post/pre evaluation and three-month follow-up survey looked at the nutrition educators’ changes in knowledge of five developmental disabilities, the educators’ ability to adapt teaching strategies, self perceptions of teaching effectiveness, and their confidence levels. Post/pre surveys completed within the first week following the training indicated increases in all areas, and 90 percent of respondents either agreed or strongly agreed that this program added a valuable dimension to their training as a nutrition educator (Table 1).
Table 1. Results of the post/pre survey following the webinar for Cooperative Extension at Penn State University: Teaching Individuals with Developmental Disabilities (n=32)
[Summary: Results of the post/pre survey following the webinar for Cooperative Extension at Penn State University: Teaching Individuals with Developmental Disabilities (n=32)]
Three-month follow-up surveys (Table 2) indicated an increase in knowledge ratings (in the combined Some Knowledge and Knowledgeable categories) as compared to the post-test for all but one of the five developmental disabilities, the exception being sensory processing disorder. This disorder was the most unfamiliar to the participants at the training. It makes sense that more education would be necessary after only one exposure to a topic of which the nutrition educators had little prior knowledge. The respondents’ abilities to adapt their teaching strategies and their feelings of teaching effectiveness and confidence indicated a marked shift in the positive direction. Seventy-five percent of respondents either agreed or strongly agreed that this workshop added a valuable dimension to their training as a nutrition educator.
Table 2. Results of the three-month follow-up survey following the webinar for Cooperative Extension at Penn State University: Teaching Individuals with Developmental Disabilities (n=20)
[Summary: Results of the three-month survey following the webinar for Cooperative Extension at Penn State University: Teaching Individuals with Developmental Disabilities (n=20)]
Following is a sampling of the top three things participants learned from the workshop and examples of how this training made a difference in their teaching, as reported on the three month follow-up surveys:
“I loved the visual aids. I loved the training on teaching each specific disability…that we need to pay attention and try to adjust to each learning style and disability.”
“Clients gain some confidence in my presence.”
“I have a learning-disabled sister and I also love that I can apply this valuable information to how I communicate with her.”
“I now use visual support for every lesson and I have class rules and routines posted.”
“I was uneasy working with this population, but several groups later my confidence has increased and we all seem to enjoy and have fun with the classes.”
“I use the rules! They are great for any group. I also really try to pay attention to new clients that are struggling with literacy and are needing either [sic] special help with paperwork, and try to be sensitive to their needs.”
“I concentrate on visual and auditory learning.”
“I make sure I meet the needs of all of my participants in some way.”
“I am more aware of the group’s actions, if they cannot read, I use a lot of picture examples and always ask if someone needs help filling out the PSNL [Penn State Nutrition Links] program forms; do not take for granted that everyone knows how to read or write.”
“Made me a lot more sensitive to their needs.”
Will other Extension educators want to emulate it?
Extension educators continually update their skills and learn new strategies to better meet the needs of their communities. This training program is being developed into a formal curriculum that can be used throughout and beyond the Extension system. The intended audiences are the educators and supervisory staff of nutrition education programs. These trainees are the “front line” teachers, paraprofessionals, volunteers, and others who conduct programs involving nutrition education for the developmentally disabled. This population may be taught in schools, group homes, day programs, job training centers, and worksites. A research-based curriculum for teaching this population is a welcome addition to Extension resources for educators and others.
Will the intended audience want to attend?
Extension educators are teaching an increasing number of clients with developmental disabilities in schools and community settings such as The Arc. Due to the aforementioned legislation requiring students to be schooled in the least restrictive environment and budget cuts to school districts, many students are remaining in their home district rather than being placed in an out-of-district setting. By and large, Extension educators are trained in content area and teaching strategies for the typical classroom and not the special education or inclusive settings. The same can be said for community settings with adults. Educators with minimal or no training in developmental disabilities face great challenges and are very much in need of this area of professional development. They have expressed the need for ongoing training in this area.
Does the program show the value of Extension to the public?
Extension program teams can readily provide evidence of their programs’ private value, or direct benefits to program participants. They can produce program evaluations showing how individuals, families, or businesses gained from participation. They can share testimonials by people who have had positive experiences with Extension and even demonstrate that some are willing to pay to participate in a program. But Extension also creates public value when its programs induce participants to act in ways that benefit others in the community (Kalambokidis 2011). The public value of this program is its contribution to improving the health of communities and furthering the independence of Americans with intellectual and developmental disabilities, thereby reducing the demand for social service dollars in multiple areas, including the dependence on more costly institutional services. Helping individuals maintain their independence will ultimately lower the costs of health care.
Training those with disabilities aligns with an important Healthy People 2020 goal to “Increase the quality, availability, and effectiveness of educational and community-based programs designed to prevent disease and injury, improve health, and enhance quality of life” (Healthy People 2020). Increasing the number and skill level of community health educators and other auxiliary public health workers to support the achievement of healthier communities has been identified as an emerging issue, and it is one that Extension is well-positioned to address.
This study was reviewed and approved by the Institutional Review Board of Rutgers University.
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