Introduction
Children who have a combination of severe disabilities are called “Multiply Disabled”. Caring for multiply and severely disabled children is never easy and they need an enormous amount of time, patience and love.
Realising the need for promotion of services for children with multiple disabilities, an autonomous organization of the Ministry of Social Justice and Empowerment, Government of India, was set up under the “National Trust for the Welfare of Persons with Autism, Cerebral Palsy, Mental Retardation and Multiple Disabilities” Act (Act 44 of 1999).The National Trust was set up to find an answer to the worries of parents of such children.
DEFINITION OF MULTIPLE DISABILITIES
Multiple disabilities - “concomitant impairments (such as mental retardation-blindness, mental retardation-orthopedic impairment, etc.) the combination which causes such severe educational needs that they cannot be accommodated in programs solely for one disability. (IDEA)
According to the act “Multiple Disabilities” means a combination of two or more disabilities as defined in clause (i) of section 2 of the Persons with Disabilities (Equal Opportunities, Protection of Rights and Full Participation) Act, 1995 (1 of 1996). Disabilities under the National Trust Act are in fact Developmental Disabilities caused due to insult to the brain and damage to the central nervous system. These disabilities are Autism, Cerebral Palsy, Mental Retardation and Multiple Disabilities. These are neither diseases nor contagious nor progressive. They cannot be cured by drugs or surgery. But early detection and training improve outcome. This is done using the services of Physio-Occupational and Speech Therapists, Community Based Rehabilitation Workers and Special Educators.
The combination of disabilities and degree of severity is different in each child. The time at which the disability occurs in the child, what is known as the ‘age of onset’, may also range from birth to a few days after birth, from early childhood till late teens. Sometimes children are born with one disability but acquire the second or third disabling conditions during childhood. The characteristics and the needs of the children depend on the nature of combination of the disabilities, the age of onset and the opportunities that have been available to a child in his environment.
Multiple Disability refers to: a combination of two or more disabling conditions that have a combined effect on the child’s communication, mobility and performance of day-to-day tasks.
We can say that just as every child is different, similarly every child with MD is different. However there are some things that this group of children have in common.
· It affects the all-round development of the child
· Communication with the world around is most severely affected
· Opportunities to interact with the environment becomes very limited
· Ability to move around in the environment is restricted
· Need regular help in simple day-to-day activities such as wearing a shirt, opening a door,
· Finding a chair to sit down and so on.
· A highly structured educational / rehabilitation programme helps in their training.
CHARACTERISTICS OF CHILDREN WITH MULTIPLE DISABILITIES
Children with MD show some of the following characteristics:
Vision Problems: As children grow, some of them appear to always squeeze their eyes together to look at something closely, or keep looking at their moving fingers/paper, bump into things while walking, complain of too much light all the time. Their eyes may also look different from ‘normal’ eyes.
Hearing Problems: A child with a hearing problem may respond to only particular sounds. They may take a long time and repeated training to develop speech. And mostly they may only repeat what they hear. They may also learn to adapt to their routine environment by ‘guessing’ the conversations going around, but may actually face a lot of difficulty in a new place with unknown
people. Sometimes deaf children also show difficulty in balancing their body or walking in a straight line.
Learning Problems: Due to the combined loss of two or more disabilities, the rate and speed of learning of the children is very slow. Learning often becomes repetitive and meaningless, unless special care is taken to make the child feel safe about exploring the world around him. Multi handicapped children also have very limited ideas to play with toys or things around them.
Communication: Communication is probably the one area that is most significantly affected in children with multiple disabilities. The children are unable to see or hear or follow the different ways in which their brother and sister play with each other, elders are greeted, standing in a line to get a ticket or passing a bottle of water around a dining table.
Posture and Mobility: Our sight, hearing and body movements help us to move around, without bumping into things, remember the way to reach places or even to use our own hands to hold and look at things. Presence of Cerebral Palsy, locomotor disabilities and balance difficulties makes it hard for the child to manage his own body movements sometimes and so it becomes very difficult to use his body to move from one place to another.
Odd Behaviours: Most children with multiple disabilities show strange behaviours that are called ‘self-stimulating’ behaviours. Some of these are moving one’s body repeatedly, shaking head side to side, moving fingers in front of eyes, hitting or slapping the ears, swinging in one place and so on. The children mostly do this due to lack of anything else to do. Sometimes it is important for them to continue doing it from time to time as it helps them get some information about the world around them in their own special way. Sometimes these children also show disturbed sleep patterns.
Medical Conditions: Most multi-handicapped children also suffer from other medical conditions such as epilepsy, frequent eye and ear infections, respiratory disorders, muscular degeneration frequent surgeries and so on. Such medical conditions lead to frequent hospitalizations and the child again misses out on a lot of exposure and learning from the environment.
Prevalence: The percentage of students having severe multiple disabilities is very low.
Approximately 0.1 to 1 percent of the general school-age population and approximately 2 percent of the total population of school age students have severe and multiple disabilities. It is not likely that more than one student with severe multiple disabilities would be enrolled in a general classroom at any given time.
CAUSES AND TYPES OF MULTIPLE DISABILITIES
There are several factors that cause severe and multiple disabilities & can be divided as follows:
Prenatal causes which include:
· Chromosomal abnormalities
· Viral infections
· Drug and Alcohol use during pregnancy
· Mother’s malnutrition
· Physical trauma to the mother
Perinatal causes which include:
· Lack of oxygen supply to the baby’s brain
· Physical injury to the baby’s brain at birth
· Contracted infections during birth
Postnatal causes which include:
· Childhood infections such as meningitis & encephalitis
· Traumatic brain injury from an accident or abuse
· Lead poisoning
· Reactions to medication
· Exposure to toxins or other environmental conditions
As with other disabilities, the severity and complexity of the disability depends on the genetic
abnormality, the amount of damage to the brain and the environment in which the child is raised.
VARIOUS COMBINATIONS OF MULTIPLE DISABILITIES
Impairments can be associated in various ways. Their functional impact varies according to the child development, and the primary disability risk may be aggravated to become secondary disabilities, which are predominant in the prognosis and for which several treatments are available.
Mental retardation
Defined by an IQ around 50, mental retardation in children leads to:
However, the ability to express feelings is often preserved, as well as contact with the environment, and gain in independence are achieved by children receiving proper treatment based on skills rather than defects/deficiencies.
Behavior disorders are sometimes a significant part of the child's condition: stereotypies, self-aggressiveness, withdrawal psychosis. Issues pertaining to boundaries between multiple disabilities and some very regressive forms of disabling psychosis are often addressed.
Specific studies have shown how rare are the features that allow differentiating autism and mental retardation in young children. Signs that influence diagnosis can be observed around 18 months of age. Using assessment scales such as ECAN (échelle de comportement autistique du nourrisson) [Infant Autistic Behavior Scale] clarifies the nature of these signs as well as their progression. Border cases are very common, and in genuine mental retardation, autism-like signs may be observed, which are reduced with proper treatment.
The presence of specific syndromes, in which psychotic manifestations and severe disabilities are reunited or alternating, truly shows the complexity of the problem: this is the case of Rett syndrome, a progressive disease with an unknown cause, affecting boys only. Children show indifference at first and lose their hand function, and then they experience seizures that progress into quadriplegia and spasticity. This is also the case for some forms of epileptic encephalopathies (West syndrome) with autistic-like traits and behavior disorders.
Motor impairments are nearly permanent. Motor impairments and their functional impact will be described below.
Cerebral palsy
A distinction is still made between individuals with cerebral palsy whose intelligence level is poor, and individuals with motor impairments whose intellectual potential is preserved despite verbal expression difficulty. At the neurological level, however, problems are identical, such as the impaired control of muscle by nerve centers, leading to spasticity with exaggeration of the stretch reflex, stiffness comparable to what is observed in adults with Parkinson's disease, and athetosis in which lack of reciprocal inhibition and abnormal movements are predominant.
When children are young, only poor motricity, impaired postural tone and stiffness of the limbs can be observed. Then as children develop and gain motor control, they may sustain quadriplegia, hemiplegia, paraplegia, and more complex disorders of a dystonic nature. Postural defects are permanent and affect head and trunk postures, as well as seating and standing positions.
Severe hypotonia
Severe tone abnormality in posture and limbs is observed in some forms of brain deformities (lissencephaly). Diagnosing peripheral or muscle lesions is not always easy, and moreover, central, peripheral and muscular lesions coexist in some forms of progressive diseases affecting the nervous system.
In addition, rare forms of myopathies are combined with mental retardation, which produce a clinical picture close to multiple disabilities.
Motor control disorders
These are very specific motor defects mainly observed in subjects with early epileptic encephalopathy (West or Lennox syndrome).
There is no actual paralysis present, but severe central hypotonia is at least observed in young children. As a result, a slow recovery of motor activity takes place that may lead children to resume gait, which remains risky. There are unawareness of the body's position in space, balance disorders, robot-like gait, neglecting obstacles. Falls are also commonly observed. Severe motor regression sometimes follows a convulsive state or repetitive absence seizures (form of epileptic seizure during which the subject seems awake, but is 'absent' and does not react or communicate. This regression is usually temporary, but causes motor function to be impaired in a very random fashion.
Slightly different motor control disorders may also affect subjects with encephalopathy due to malformation or some chromosomal aberrations. For instance in Angelman syndrome, individuals can hardly use their lower limbs. Congenital joint and peri-articular lesions may also be associated.
Secondary motor impairments
They are resulting from the impact of spasticity, abnormal postures or motor stereotypies on joints. Hip dislocations, progressive scoliosis in adolescence, as well as limb deformities cause limitations in motor performance and capacity of mobility, and are a source of pain. All the efforts put in early motor training and orthopedic equipment focus on the prevention of these secondary impairments and must be undertaken at a very young age.
At the functional level
Regardless of the motor impairment concerned, current methods used by the individual with multiple disabilities to achieve highly varying degrees of motor independence, from walking in a more or less stable manner without any aids to significant disabilities of dependent quadriplegia.
Personal use of manual or powered wheelchairs is limited by the level of intellectual and spatial orientation, but has to be attempted. In any case, the term 'bedridden' should not be relevant anymore, as there are methods used in most of cases to 'verticalize' individuals with multiple disabilities, at least in the seating position. This is important in terms of life expectancy, for mortality rates are positively related to the degree of motor dependence and to the severity of orthopedic deformities hindering vertical station.
The buccolinguofacial impact of motor impairments and the associated mandible disorders play a significant role in the prognosis due to swallowing disorders and false passages.
Epilepsy
It affects 40 to 50% of subjects with multiple disabilities, and in one case out of 4 or 5 these seizures are difficult to control. The severe epileptic and disabling form with multiple seizures and highly polymorphous typically follows the diagnosis of West or Lennox syndrome in early childhood. There may be absence seizures, brief tonic seizures, and sometimes falls caused by epilepsy with unpredictable seizures, which lead to repetitive traumatic injuries, mainly to the face of the walking subject, with tooth fractures, and deformities becoming real secondary impairments. Behavior disorders may also be following repeated seizures (drowsiness alternating with hyperactivity episodes, and sometimes aggressiveness or self-destructive behaviors).
At the functional level, these highly disabling but fortunately rare forms are a sign of poor prognosis, especially at the level of life expectancy. In contrast, episodic seizures are more easily treatable with the treatments currently available, and affect the daily life of these individuals to a lesser extent.
Sensory impairments
They are very often part of the disabling problems experienced by the individual with multiple disabilities, especially with ageing.
Audiological assessment is not easy to perform, as it requires that the individual can understand what the tester asks of him in order to be properly assessed. Deafness is relatively rare and involves adjustment and tolerance problems to hearing aids. However, middle-ear deafness due to infection or malformation is also observed.
Vision impairments are very common and account for 40% of persons with multiple disabilities. Ametropia (myopia, astigmatism), congenital or acquired cataracts, eye deformities or retinal lesions validated by ophthalmologic examinations, sometimes performed under general anaesthesia.
Emphasis has recently been placed on the frequency of visual processing disorders (cortical blindness or central visual disorders). These disorders cannot be measured with traditional examination methods as vision becomes tedious and random, with difficult perception of depth, background contrast versus object, and sensitivity to visual clutter. These individuals perceive moving objects better because the image is formed on the peripheral retina, as opposed to macular or central vision; hence the use of very peculiar visual stimulation methods involving the overall structures of the head and neck.
With ageing, it is important to detect the new sensory disorders that may appear. Intolerance to noise and tendency to isolation could be signs of hearing loss. Visual hallucinations or false perceptions may be observed in subjects with altered vision. Cataracts and retinal detachment may also occur with ageing.
Combined visual and auditory sensory disorders are currently scarce ever since the prevention of congenital rubella syndrome. However, they engage specific issues of rehabilitation and communication, especially as personality and behavior disorders may be also present.
Somatic disorders
Individuals with multiple disabilities are fragile. Mortality rates are ten times higher than in normal individuals of the same age. The most frequent and severe problems are described below.
In contrast, boulimia and obesity phenomena can be observed, but they are not as frequent. In Willi Prader syndrome, obesity and orthopedic disorders may lead to severe multiple disabilities, event though their severity is not as significant as the profound mental retardation.
Gastroesophageal reflux is very common and causes pain, anemia and sometimes vomiting.
The health status of individuals with multiple disabilities is directly related to the daily care they receive, and is particularly sensitive to any modifications in their lifestyle and environment. It has been shown that 25% of mortalities occur within three months following lifestyle modifications.
Leprosy cured
Leprosy is an infectious disease that causes severe, disfiguring skin sores and nerve damage in the arms and legs. The disease has been around since ancient times, often surrounded by terrifying, negative stigmas and tales of leprosy patients being shunned as outcasts. Outbreaks of leprosy have affected, and panicked, people on every continent. The oldest civilizations of China, Egypt, and India feared leprosy was an incurable, mutilating, and contagious disease.
However, leprosy is actually not that contagious. You can catch it only if you come into close and repeated contact with nose and mouth droplets from someone with untreated leprosy. Children are more likely to get leprosy than adults.
Leprosy is caused by a slow-growing type of bacteria called Mycobacterium leprae (M. leprae). Leprosy is also known as Hansen's disease, after the scientist who discovered M. leprae in 1873.
Tuberous sclerosis (TWO-bur-uhs skluh-ROH-sis), also called tuberous sclerosis complex, is a rare genetic disease that causes noncancerous (benign) tumors to grow in many parts of the body. The signs and symptoms of tuberous sclerosis vary widely, depending on where the tumors develop and how severely a person is affected.
Tuberous sclerosis is often detected during infancy or childhood. Some people with tuberous sclerosis have such mild signs and symptoms that the condition isn't diagnosed until adulthood, or it goes undiagnosed. Others experience serious disabilities.
Although there's no cure for tuberous sclerosis, treatments are being studied. The course or severity of the disease can't be predicted, but with appropriate care, many people who have tuberous sclerosis lead full, productive lives.
Tuberous sclerosis is a genetic disease caused by mutations in the TSC1 or TSC2 gene. Normally, these genes are thought to prevent cells from growing too fast or in an uncontrolled manner. Mutations in either of these genes can cause cells to divide excessively, which leads to numerous lesions throughout the body.
Multiple sclerosis
Multiple sclerosis (MS) is a potentially disabling disease of the brain and spinal cord (central nervous system).
In MS, the immune system attacks the protective sheath (myelin) that covers nerve fibers and causes communication problems between your brain and the rest of your body. Eventually, the disease can cause the nerves themselves to deteriorate or become permanently damaged.
Signs and symptoms of MS vary widely and depend on the amount of nerve damage and which nerves are affected. Some people with severe MS may lose the ability to walk independently or at all, while others may experience long periods of remission without any new symptoms.
There's no cure for multiple sclerosis. However, treatments can help speed recovery from attacks, modify the course of the disease and manage symptoms.
The cause of multiple sclerosis is unknown. It's considered an autoimmune disease in which the body's immune system attacks its own tissues. In the case of MS, this immune system malfunction destroys myelin (the fatty substance that coats and protects nerve fibers in the brain and spinal cord).
Myelin can be compared to the insulation coating on electrical wires. When the protective myelin is damaged and nerve fiber is exposed, the messages that travel along that nerve may be slowed or blocked. The nerve may also become damaged itself. It isn't clear why MS develops in some people and not others. A combination of genetics and environmental factors appears to be responsible.
EARLY INTERVENTION
The earlier children with or at risk of disabilities receive assistance and the sooner their families receive support towards their children’s development, the farther they will go in life.
The following Early Intervention Steps may be needed to help the child with multiple disabilities to reach its maximum independence in getting ready for school.
· Assisting technology devices and services - equipment and services that are used to improve or maintain the abilities of a child to participate in such activities as playing, communication, eating or moving.
· Audiology - identifying and providing services for children with hearing loss and prevention of hearing loss.
· Family Training - services provided by qualified personnel to assist the family in understanding the special needs of the child and in promoting the child’s development.
· Medical Services - only for diagnostic or evaluation purposes.
· Nutrition Services - services that help address the nutritional needs of children that include identifying feeding skills, feeding problems, food habits and food preferences.
· Occupational Therapy - services that relate to self-help skills, adaptive behaviour and play and sensory, motor and postural development.
· Physical Therapy - services to prevent or lessen movement difficulties and related functional problems.
· Psychological Services - administering and interpreting psychological tests and information about a child’s behaviour and child and family conditions related to learning, mental health and development as well as planning services including counselling, consultation, parent training and education programs.
· Rehab worker/Special teacher/Community worker - someone who works in partnership with the family by providing assistance and services that help the family to coordinate and obtain their rights as well as in preparing an assessment of the social and emotional strengths and needs of a child and family and providing individual or group services such as counselling or family training.
· Special Instruction - includes designing learning environments and activities that promote the child’s development, providing families with information, skills, and support to enhance the child’s development.
· Speech-language Pathology - services for children with delay in communication skills or with motor skills such as weakness of muscles around the mouth or swallowing.
· Vision Services - identification of children with visual disorders or delays and providing services and training to those children.
· Health Services - health-related services necessary to enable a child to benefit from other early intervention services.
PLANNING FOR NEEDS-BASED EDUCATIONAL SUPPORTIVE SERVICE
Educational Placement: As far as possible, every child with special needs should be placed in regular schools, with needed support services.
Aids and Appliances: All children requiring assistive devices should be provided with aids and appliances, obtained as far as possible through convergence with the Ministry of Social Justice
and Empowerment, State Welfare Departments, National Institutions or NGOs.
Support Services: Support services like physical access, resource rooms at cluster level, special equipment, reading material, special educational techniques, remedial teaching, curricular adaptation or adapted teaching strategies could be provided.
Teacher Training: Intensive teacher training should be undertaken to sensitize regular teachers on effective classroom management of children with special needs. This training should be recurrent at block/cluster levels and integrated with the on-going in-service teacher training schedules in SSA. All training modules at SCERT, DIET and BRC level should include a suitable component on education of children with special needs.
Resource Support: Resource support could be given by teachers working in special schools.
Where necessary, specially trained resource teachers should be appointed, particularly for teaching special skills to children with special needs. Wherever this option is not feasible, long term training of regular teachers should be undertaken.
There are two primary focuses in the orthopedic management strategy for individuals with multiple disabilities: mobility and positioning. Both these goals, of which some aspects may be opposed to one another, are the foundation of the functional and orthopedic prevention measures intending to avoid secondary impairments, deformities and the progressive limitation of motor capacity.
At a young age, various motor training methods are undertaken by a kinesitherapist and a psychomotor therapist, who are relayed by the child's family whenever possible. Generally, they are global methods based on levels of motor development in children (Le Métayer) or on relaxation positions (Bobath) using every moment of the child's daily life as an opportunity to foster mobility and help him find his own motor strategies through the coaching of body movements and playful stimulation. Postures and other more segmental methods may be necessary as the child grows. Special attention should be paid to the training of muscles of the mouth and face aimed at addressing or preventing the eating difficulty that may be present.
Progress in motor control is usually possible and as such, it is critical to preserve the mere motor capacity throughout the child's growth. However, this may become more difficult to achieve with the child growing and getting heavier.
Some children may achieve a more or less balanced spastic gait (stiff legs), and many of them may be able to achieve independent ambulation, yet with some limitations (hesitant or tiring gait, mobility on the ground); others present limited mobility, but are capable of standing for a while with some assistance. This is particularly important when it comes to dressing and transfers. Finally, some children may be able to walk a few steps assisted by an adult.
Manual capacity varies in the same way: clumsy grasp yet still usable, ability to use upper limbs during transfers, weight bearing and positioning in wheelchair, or no ability to grasp, whether this is due to neurological disturbances or lack of propensity to engage in motor activity, or hand stereotypies typical of Rett syndrome. It is thus important to perform a simple functional assessment for each individual regularly that not only takes their weaknesses into consideration, but also their capacities.
Positioning and bracing have two objectives:
The main orientation to be achieved is verticalization, which is the positioning of the individual in a standing or seating position with more or less assistance. This vertical position improves the digestive function and is an attempt to prevent rarefaction of bone (as bone structure cannot be maintained without pressure influencing the blood flow that feeds joints). This position also has an impact on the gaze direction, and thus on the individual's contact with the environment. Various methods are used: to achieve the desired positioning. When it is impossible for the individual to actively achieve the standing position, various standing aids may be used: stand-in tables, static standing frames, molded hip-knee-ankle orthoses (plaster or polypropylene). The former Phelps is no longer in usedl'ancien appareil de Phelps étant de moins en moins prescrit.
Shoe fitting is very important (molded soles, wide opening on the top of the foot, good fitting techniques).
In seating position, the aim is to achieve balance of the pelvis and symmetrical hip abduction in order to help the growth of the hip joint and prevent dislocations and scoliosis. Wide arrays of customized plaster or polypropylene molded seats are used, with or without headrest, and with various support devices. However, these devices are often adjusted too tightly and even when appropriately used, they limit mobility, which leads to their use at various times during the day, alternating assisted and unassisted mobility.
Spinal deformities (scoliosis) occur mainly from the pubertal growth spurt and lead to the use of braces for control—often times bivalve braces with excellent padding of various types. Precautionary measures taken prior to brace fitting and monitoring of the condition of the skin under the brace will increase the individual's tolerance and prevent pressure sores at the brace-skin interface.
Surgery is sometimes needed to prevent deformities. It focuses either on soft tissues (tenotomy, neurotomy) or bones— more or less invasive osteotomies of the femur or pelvis; arthrodesis involving the foot; spinal fusion when the curvature can no longer be controlled by bracing. The latter surgery is risky and requires both psychological and somatic preparation for the individual, the participation of his family and educational team, and rigorous monitoring of the surgical outcomes and of the result achieved compared to recommended indications. No surgical intervention should be considered without a clear justification of the objectives, expected results, risk factors, and care required following surgery.
Aids and assistive devices are the supporting devices used by persons with disabilities in improving their quality of life in terms of mobility, communication and for performing their daily activities. There is a wide range of assistive devices available to meet the needs of person with disabilities. By use of these Aids & assistive devices, people with disabilities becomes independent and their participation in the society increases.
Following are some examples of aids & assistive devices given below:
Aids for Daily Living: Which covers self help aids for use in activities such as eating, bathing, cooking, dressing, toileting, home maintenance, etc. These include modified eating utensils, adapted books, pencil holders, page turners, dressing aids, adapted personal hygiene aids.
Mobility Aids: Devices that help people move within their environment, electric or manual wheelchairs, modifications of vehicles for travel, scooters, crutches, canes and walkers.
Home/workplace modifications: structural adaptations that remove or reduce physical barriers such as ramps, lifts, modification in the bathroom to make it accessible, automatic door openers and expanded doorways etc.
Seating and Positioning: Adapted seating, cushions, standing tables, positioning belts, braces and wedges to maintain posture, and devices that provide body support to help people perform a range of daily tasks.
Alternative and augmentative communication devices (AAC): These devices help people with speech impairments or person having low vocal volume to communicate such as speech generating devices, voice amplification aids and communication software. For visually impaired person, devices as magnifier, Braille or speech output devices, large print screens, closed circuit television for magnifying documents, etc.
Prosthetics and Orthotics: Replacement or augmentation of body parts with artificial limbs or other orthotic aids such as splints or braces. There are also prosthetics to assist with cognitive limitations or deficits, including audio tapes or pagers (that function as s or reminders).
Vehicle Modifications: Adaptive driving aids, hand controls, wheelchair and other lifts, modified vans, or other motor vehicles used for personal transportation.
Sensory aids for vision/hearing impaired: such as magnifiers, large print screens, hearing aids, visualing systems, Braille and speech/telecommunication output devices;
Computer Access Aids: Headsticks, light pointers, modified or alternate keyboards, switches activated by pressure, sound or voice, touch screens, special software, voice to text software that enable persons with disabilities to use a computer. This category includes speech recognition software.
Recreational aids to enable participation in social/cultural events and sports: Devices to enable participation in sports, social, cultural events which includes audio deign for movies, adaptive controls for video games etc
Environmental Controls: Electronic systems that help people control various appliances, switches for telephone, TV, or other appliances which are activated by pressure, eyebrows or breath.
The National Trust has already established a National Resource Centre for display of available assistive devices called ‘Sambhav’ at AADI (a registered organisation of the National Trust), New Delhi to demonstrate the possibility of independent or assisted living for persons with developmental disabilities through the use of aids & assistive devices and technologies.