Article

Remedial and Special Education

Examining the Effectiveness of 32(4) 309321

2011 Hammill Institute on Disabilities
Reprints and permission: http://www.
TouchMath With Students With sagepub.com/journalsPermissions.nav
DOI: 10.1177/0741932510362198

Physical Disabilities http://rase.sagepub.com

Mary Jane Thompson Avant1 and Kathryn Wolff Heller1

Abstract
One of the most fundamental math skills for students to learn is basic computational skills. Students who have difficulty
learning math skills may benefit from representational approaches, such as TouchMath. A multiprobe, multiple baseline, across-
participants design was used in this study to investigate the use of TouchMath with students with physical disabilities. The study
was designed to determine the effectiveness of this strategy on the students ability to solve basic addition problems with sums
to 20. All students were successful in reaching the criterion, with high percentages of correct responses using the TouchMath
strategy to answer simple addition problems. Data were analyzed by graphic visual analysis and calculation of the percentage
of nonoverlapping data. Generalization and maintenance data supported the effectiveness of this strategy.

Keywords
mathematics instruction, orthopedic impairments, single-participant design

One of the most fundamental math skills for students to learn
is basic computational skills. Besides being a functional skill
that is used in everyday activities, it also serves as a foundation
for more advanced math skills (Dev, Doyle, & Valente, 2002;
Fuchs et al., 2006; Simon & Hanrahan, 2004). Many students
receiving special education services or remedial instruction
have difficulty learning computational skills. Students with
physical disabilities are also at risk of not performing well in
this area of instruction (Duris, 2002; French, 1995; Heller &
Garrett, 2009). However, there has been a paucity of research
examining the effectiveness of strategies used to promote
computational skills with this population of students. One
promising strategy that warrants further investigation is the use
of TouchMath. TouchMath may be appropriate for use with
students who have physical disabilities because of its represen-
tational approach of teaching computational skills and the
adaptability of the approach to meet the unique characteristics
of students with physical disabilities.
Students with physical disabilities often have several
unique characteristics that may interfere with mastery of
computational skills. Some of these factors may include poor
motor skills, communication impairments, fatigue, health
factors, psychosocial issues, and cognitive impairments.
Poor motor skills make it difficult for students with physical
disabilities to manipulate objects, write, and maintain ade-
quate sitting balance for the length of a typical classroom
activity (Heller, 2009). Communication problems, including
semantic difficulties and articulation disorders, can affect
learning because of an inability to accurately ask questions or
respond in class. Fatigue is also a factor in students ability to
perform in a consistent manner throughout the typical school
day. Health factors such as medication side effects and high
absentee rates also affect performance. Psychosocial issues,
such as poor motivation and depression, can affect perfor-
mance as with any population of students. Students with
physical disabilities may also have mental retardation, learn-
ing disabilities, or any number of information processing
issues (Barnes et al., 2006; Heller, 2009; Lantz & Meyers,
2008; Pueyo, Junqu, & Vendrell, 2003; Sankar & Mundkur,
2005). The precise cognitive issues are best examined given
the specific type of physical disability. Three types of physi-
cal disabilities that often have additional cognitive issues are
spina bifida, cerebral palsy, and stroke.
Cognitive and Math Abilities of Students With
Physical Disabilities
Many students with myelomeningocele spina bifida exhibit
deficits in math abilities, and there is a higher incidence of
1
Georgia State University, Atlanta
Corresponding Author:
Kathryn Wolff Heller, Georgia State University, Department of
Educational Psychology and Special Education, PO Box 3979, Atlanta,
GA 30302-3979
Email: kheller@gsu.edu
310 Remedial and Special Education 32(4)
math processing problems found in children with spina
bifida than in the general population (Barnes et al., 2006;
Dennis & Barnes, 2002; French, 1995). In this condition,
the embryonic neural tube fails to close, resulting in a spinal
defect and conditions such as hydrocephalus, which can
cause deficits in cognitive abilities. Processing skill deficits
are often present, in such areas as attention, memory, recall,
motor reaction times, visual-perception skills, and organi-
zational skills (Houliston, Taguri, Dutton, Hajivassiliou, &
Young, 1999; Iddon, Morgan, Loveday, Sahakian, & Pickard,
2004). In addition, the majority of children with myelome-
ningocele spina bifida typically fall into the low average
range of intelligence (Jacobs, Northam, & Anderson, 2001).
The math profile of children with spina bifida is somewhat
similar to that of children with specific math disability, with
deficits in accuracy, speed, and strategy use (Barnes et al.,
2006; Dennis & Barnes, 2002).
Students with cerebral palsy are at high risk for deficits in
math abilities. In this condition, there is damage to the brain
before, during, or soon after birth, resulting in motor difficul-
ties, and typically additional disabilities, such as specific
learning disabilities, visual perceptual problems, and/or
impairments in executive functioning (Hoon, 2005; Rosen-
baum, 2003; White & Christ, 2005). Intellectual disabilities
often occur, with approximately 60% of individuals with cere-
bral palsy having intellectual disabilities (Sankar & Mundkur,
2005). In one study examining addition and subtraction accu-
racy, differences in performance between students with
cerebral palsy and a control group were attributed to deficits in
working memory, early numeracy skills, intelligence, and, in
some cases, less instructional time (Jenks et al., 2007).
Stroke is another example of a physical disability that can
result in deficits in arithmetic skills. Depending on the charac-
teristics of the stroke, deficits may occur in motor, behavior,
and cognition, including deficits in the areas of processing
speed, auditory short-term memory, arithmetic skills, visuo-
spatial skills, attention, and motor skills including hemiparesis
and ataxia (Everts et al., 2008; Ganesh, Deenadayalan,
Janakiraman, & Viswanathan, 2006). Also, stroke is often
associated with intellectual disabilities, with one study, by
Sreenan, Bhargava, and Robertson (2000), identifying 71% of
participants functioning in the intellectually disabled range.
Several of the learning deficits found in many students
with physical disabilities may be present in students in other
disability categories. Because of this overlap of learning
characteristics between disability categories and the paucity
of research in physical disabilities, an examination of math
interventions with other populations of students is needed.
Strategies for Teaching Computational Skills
Basic computational skills may be taught using (a) con-
crete instruction (e.g., manipulatives, finger counting),
(b) representational (semiconcrete) instruction (e.g.,
pictures or drawings that represent items), or (c) abstract
instruction (e.g., numbers or symbols). This graduated
instructional sequence is often referred to as the concrete
representationalabstract (CRA) sequence (or concrete
semiconcreteabstract sequence; Maccini, Mulcahy, &
Wilson, 2007). Students start with concrete items and are
able to gradually progress to abstract items.
Concrete approaches of instruction are commonly used
for beginning computational skills to ensure that the student
understands the underlying concept. Research has sup-
ported the use of manipulatives for teaching math concepts
(Furner, Yahya, & Duffy, 2005). Finger counting is also
used by students who require concrete displays or who lack
automaticity in basic addition facts. For example, finger
counting was successfully used with students with learning
disabilities as part of a strategy approach of finding the
smaller number in simple addition problems and counting
on their fingers to arrive at the correct answer (Tournaki,
2003). However, students with physical disabilities often
have difficulty manipulating concrete objects or accurately
moving their fingers to count because of their disability.
When concrete items are not required for conceptual under-
standing of the underlying math concept but are needed to
assist with counting, more accessible strategies are required.
Several abstract strategies have been used for teaching
calculation skills such as drill and practice, computer-
assisted instruction (CAI), self-instruction, and peer
instruction. The drill and practice approach has been used
for more than 20 years as a method of teaching basic math
facts and achieving automaticity (which is the ability to
execute the fact without conscious monitoring). This has
been found to be an effective strategy in teaching students
basic math facts, including those with learning disabilities
(Tournaki, 2003). Drill and practice software has also been
developed as part of CAI. For example, Fuchs et al. (2006)
investigated the use of CAI on number combination skill
and found that it was an effective intervention for improv-
ing scores on addition number combinations. Abstract
strategies can also be supported with the use of self-instruction
or peer tutoring for the remediation of math skill deficits
(Calhoon & Fuchs, 2003; Kroesbergen & Van Luit, 2003;
Uberti, Mastropieri, & Scruggs, 2004).
Although abstract strategies can be very effective, some
students with physical disabilities may not be ready for
abstract approaches or have difficulty remembering compu-
tational facts (e.g., addition facts) because of cognitive
deficits or other factors. Several representational strategies
may be used to support basic computational skills such as
using pictures or line drawings, a number line, and dot nota-
tion. Pictures and line drawings have long been used on the
CRA continuum (Babbitt & Miller, 1996; Case & Harris,
1992), although this may not be age appropriate when other
Avant and Heller 311
strategies are available. Griffin and Case (1997) discussed
the use of a number line to teach students to construct
number sense and included the movement of chips along
the number line as part of the strategy. However, students
with physical disabilities often have difficulty manipulating
chips or touching a number line or have difficulty under-
standing the direction to move on the number line. The use
of dot notation is another strategy that has been successfully
used for instruction in basic math concepts (Scott, 1993;
Simon & Hanrahan, 2004; Wisniewski & Smith, 2002).
The TouchMath Approach
One representational approach using dot notation is Touch-
Math. TouchMath uses a multisensory approach that takes
into account the individual learning differences of students
and lends itself to modifications to fit the needs of a variety
of students. This may be particularly beneficial to students
with physical disabilities. Students are taught a dot notation
for the numerals 1 through 9 in which they touch dots on the
numerals as they count (see Figure 1). They are then taught
specific steps in the use of the dot notation to complete addi-
tion problems. This may involve either consecutively
counting all of the dots on the two numbers being added in
the count all method or stating the larger of the two num-
bers, then continuing counting the dots on the second number
to arrive at the total in the count on method. Over time, the
dots are faded and students are taught to point with their
pencil to the positions where the dots were located. In this
way students are able to use this technique on standard, unal-
tered numerals. This is an unobtrusive method (i.e., other
students are not aware that the student is using the Touch-
Math strategy, as they would be if students were holding up
their fingers and counting) that allows learners who have dif-
ficulty with fact recall to solve math problems.
Few studies have been conducted on the use of
TouchMath with students with disabilities, including mild
intellectual disabilities and learning disabilities. Scott
(1993) instructed 3 fourth-grade students with mild intel-
lectual disabilities or learning disabilities (based on state of
Georgia criteria for identification) in the use of TouchMath
in solving addition and subtraction problems, with and
without regrouping. Baseline scores on all target areas were
measured at 0% accuracy (using worksheets with all types
of math problems targeted for each student). These scores
rose to between 89% and 100% following intervention.
Wisniewski and Smith (2002) replicated the study by Scott
(1993). A total of 4 third and fourth grade students with
mild intellectual disabilities, learning disabilities, or other
health impairments participated in the study. The students
were instructed in the use of TouchMath over a period of
14 weeks. The students were taught to use TouchMath to
complete simple addition facts and two-digit addition facts
Figure 1. TouchMath dot notation system
with and without regrouping. Students were timed on Math
Mad Minute Addition worksheets weekly to assess their
performance. Results indicated that all students academic
achievement scores improved. A third study by Simon and
Hanrahan (2004) replicated the previous studies. Three
10-year-old students with learning disabilities participated
in the study. Students were taught the dot notation system
and then taught to solve nine progressively more difficult
types of addition problems. All students successfully
learned the dot notation and consistently used it to solve all
levels of problems.
In a study by Cihak and Foust (2008), the use of number
lines and touch points was compared with students with
autism. Three elementary students were taught to use either
a number line or touch points to solve single addition prob-
lems in an alternating-treatments design. Baseline scores
for the three students averaged 0.7%. These scores rose to
72% accuracy using touch points and 17% using a number
line. These results indicated that overall the use of touch
points was more successful than the use of a number line to
solve single-addition problems.
Duris (2002) discussed the use of TouchMath with stu-
dents with physical disabilities but did not provide any
empirical evidence to support its use. She did note the need
for adaptations for use with students with physical disabili-
ties and that TouchMath is easy to adapt to address a variety
of student needs. In particular, she noted the fine motor dif-
ficulties that these students often exhibit but cautioned that
the use of TouchMath for some students in this population
may require that an assistant initially touch the dots for
them as they count in their heads until they learn to do so
independently.
Using a representational strategy such as TouchMath
seems promising for students with physical disabilities
who need support in performing basic computational skills,
but research is needed with this population of students.
The purpose of this study was to investigate the use of
312 Remedial and Special Education 32(4)

Table 1. Participants With Physical Disabilities and Adaptations

Name Age Grade Disability Math Scoresa Adaptations

Amy 8 2nd Spina bifida NOK:8 Enlarged font

MRK:3 Avoid right side
Color cues and arrows
Bob 9 3rd Cerebral palsy NO1:2 Enlarged font
MRK:9
Connor 7 1st Stroke NOK:5 Enlarged font
MR1:2 Color cues
Tapped numerals in air
Note: NO = numerical operations; MR = math reasoning.
a. Wechsler Individual Achievement Test, Second Edition.

TouchMath with students with physical disabilities to solve
basic addition problems. The research questions addressed
were as follows: (a) Is TouchMath an effective strategy for
students with physical disabilities for solving basic addition
problems with sums to 20? (b) Will students be able to gen-
eralize the use of TouchMath from a one-to-one setting to
their regular math class?
Method
Participants
Three elementary grade students who had physical disabili-
ties were selected for this study (see Table 1). To qualify for
the study, they had to meet several criteria. First, the stu-
dents had to have a physical disability and qualify for
services under orthopedic impairments (IO) or other health
impairments (if the health impairment included a physical
disability). Unlike many states definitions, Georgia requires
that cognitive functioning be no lower than in the mildly
intellectually disabled range (IQ 5570; Georgia Depart-
ment of Education, 2007). Additional selection criteria for
this study included (a) receiving services by a teacher certi-
fied in physical and health disabilities, (b) having no
comorbid sensory impairment requiring the services of a
teacher certified in visual impairments or deaf or hard of
hearing, (c) having reliable communication skills that
permit the student to ask questions and provide answers
accurately, either verbally or through the use of an augmen-
tative communication device, (d) having math objectives on
the individualized education program (IEP), and (e) scoring
lower than 70% on baseline assessment math sheets.
Only three students met the criteria for this study from
the targeted elementary school in a large metropolitan area.
These students exhibited varying levels of impairment;
however, all were able to write using standard tools. All
three students attempted to use their fingers to assist with
calculations (finger counting), but they were unable to
accurately isolate finger movements as a result of their
physical disabilities and would often miscount. In addition,
the students were all weak in the area of mathematics and
had IEP goals and objectives in this area.
Amy was a second grade student with a diagnosis of
spina bifida (myelomeningocele type) who had repeated
kindergarten. Her physical disability affected her fine motor
skills, stamina, mobility, peripheral vision, spatial and per-
ceptual skills, visual-motor integration skills, and school
attendance. Fine motor skill deficits resulted in poor hand-
writing, so a computer was often needed. A lack of stamina
and fatigue issues affected her ability to complete class-
room tasks and sometimes resulted in her falling asleep in
class. She had a peripheral vision loss in her right eye, so
materials were not presented to her right, and sometimes
items needed to be enlarged. Her academic performance
was compromised by having frequently missed school
because of repeated doctor appointments, illness, and sev-
eral surgeries. Because of her spina bifida and classroom
performance, she was suspected of having information pro-
cessing skill deficits. In the area of mathematics, she
exhibited a variety of avoidance behaviors (e.g., refusing to
work, asking other students for answers) and often stated
she did not like math. Amy typically tried to use her fingers
to complete addition problems or simply guessed at an
answer. If cued, she would attempt to use a number line but
often became confused about the direction to move on the
number line to complete problems. She initially received
math instruction in the second grade classroom, using drill
and practice, number lines, manipulatives, and the standard
text. She was unable to keep up with the pace of instruction,
and was not successful using the standard classroom strate-
gies. Her instruction was switched to the OI classroom.
Bob was a third grade student with a diagnosis of cere-
bral palsy, spastic diplegia type (spasticity primarily
affecting his legs) who had repeated kindergarten. His
physical disability primarily affected his stamina and
mobility, with milder impairment of his fine motor skills.
Bob also exhibited a receptive and expressive language dis-
order that caused difficulties with academics, particularly in
Avant and Heller 313
the area of math. His handwriting was legible most of the
time, but he quickly fatigued, and modifications were in
place to reduce the length of his assignments and number of
problems. In the area of mathematics, Bob typically tried to
use his fingers to complete simple addition problems, often
hiding his fingers under his desk while trying to figure out
the answer. Bob performed almost 2 full years below grade
level at the beginning of the school year. He received spe-
cialized instruction in math using drill and practice
techniques, which took place in the OI classroom. He
received all other instruction in his regular third grade
classroom.
Connor was a first grade student who had a stroke as
the result of an arteriovenous malformation when he was
5 years old that resulted in the need to repeat first grade.
The stroke resulted in fine motor skills deficits, tremors,
balance problems, mobility issues because of ataxia (a type
of motor disorder affecting walking), fatigue, language def-
icits, and depressed cognitive functioning. He was able to
write, although it was a very difficult, slow process in which
he had trouble controlling the size of his letters and diffi-
culty making certain strokes. He also had tremors that
sometimes affected legibility (e.g., writing on a line, align-
ing numbers, or using manipulatives). He often sat slumped
over at his desk, leaning on his arms, as his trunk was not
stable or strong enough for him to maintain an upright sit-
ting position for the duration of the class. In terms of
language deficits and depressed cognitive functioning,
Connor exhibited deficits in verbal memory, executive func-
tioning skills (e.g., attention, working memory, sequencing),
word finding, inattention, following directions, expressive
language, and articulation (because of impaired breath sup-
port). In the area of mathematics, Connor was very dependent
on manipulatives to be successful. However, when he tried
to use counting blocks or cubes he often ended up knocking
them onto the floor. He also used a number line, although his
tremors made it difficult for him to accurately touch the
numbers and count up or back along the line. Connor rarely
used any particular strategy for completing addition prob-
lems; he would sometimes attempt to use his fingers to
count, at other times would try the number line, and would
sometimes simply guess at an answer. These strategies were
unsuccessful, and he became increasingly frustrated when
attempting any math activity.
Materials and Setting
The material used in this study was the TouchMath Number
Concepts Kit (4th ed.) manufactured by Innovative Learn-
ing Concepts (Bullock, 1991). The kit contains several
activities for teaching the dot notation system for each
numeral 1 through 9, along with corresponding sets of line
drawings. For teaching addition, the program begins by
presenting four addition problems per page with corre-
sponding line drawings for the students to use as they
add. The worksheets progress through addition facts, begin-
ning with adding 1 to numerals, then 2, then 3, and so on
up to adding 9. The next set of addition activities presents
12 problems per page, with no line drawings. All the numer-
als on the addition sheets display the dot notation system.
Dot notation instruction involves teaching the student
the pattern of dots for each numeral 1 through 9. Instruction
is provided on teaching each numeral, including where to
begin counting and the order in which the dots should be
counted. On numerals 1 through 5, single dots are spaced
out along the numeral. Beginning with numeral 6, a system
of double dots is implemented. A solid dot is drawn within
a larger, open dot. The students are then taught to double
count on each of these double dots, again following a spe-
cific pattern (see Figure 1). Once students learn the patterns
for the numerals, explicit instruction is provided on how
this system is used to complete addition, subtraction, multi-
plication, and division as well as other math functions. For
this study, only addition was taught using the dot notation
system.
All instruction on the use of the dot notation system and
its use for addition was conducted during one-on-one
instructional sessions conducted by the researcher, who is a
special education teacher with 30 years of experience in
math instruction. Instruction occurred in the OI classroom.
Once students met mastery criterion for the use of Touch-
Math, the strategy was generalized to their daily math
instruction. Two students received daily math instruction in
the OI classroom; the third student received daily math
instruction in the regular education classroom. The instruc-
tion they received during their regular math classroom did
not conflict with the intervention because it dealt with other
math concepts (e.g., time).
Procedure
Preintervention training: Dot notation system. Prior to the
beginning of the intervention, students were instructed on
the dot notation system. Teaching the TouchMath dot nota-
tion system consisted of teaching each student the system of
dots that corresponded to the numerals 1 through 9. The
students were taught the system of dots and asked to touch
the dots as they counted aloud. The numerals were taught in
isolation. Each numeral was presented on an enlarged flash-
card. The numerals were roughly 3.5 4.5. For example,
there are three dots on the numeral 3. Students were
instructed to begin at the top of the numeral, and touch each
dot while counting, One, two, three. This was repeated
for each numeral. The numerals were taught in sequential
order. Once the students were taught the system, they were
quizzed on all the numerals, which were presented to the
314 Remedial and Special Education 32(4)
students in random order. They were required to obtain
100% accuracy on using the dot notation system before
beginning intervention.
Preintervention training: Using dot notation for addition.
Each student was instructed in the use of TouchMath to
complete simple addition problems. Two versions of addi-
tion were demonstrated for each student; count all and
count on (also called continuance counting). For count all,
the student was instructed to begin counting at the top of the
column of numbers, touching and counting each dot, work-
ing straight down the column of numbers. For example, to
add 5 + 4, the student would begin with the numeral 5 and
touch and count, One, two, three, four, five, then move to
the numeral 4 and touch and count, Six, seven, eight,
nine. The student was then instructed to write the answer: 9.
For count on or continuance counting, the student was
instructed to touch the largest number, say its name, and
then continue counting on the next numeral. For example,
to add 6 + 3, the student would touch and say, Six, then
move to the three and continue touching and counting,
Seven, eight, nine. The student was then instructed to
write the answer: 9. Intervention began once the student
reached 100% on the preintervention training for addition
using either the count all or the count on method.
Intervention. At the beginning of each session, the
researcher conducted a quick review of the dot notation
system by asking the student to touch and count for each of
the numerals 1 through 9. The enlarged flash cards were
used for this part of the intervention. Following this review,
the student was asked to verbalize how he or she was going
to add the numerals together. A correctaccepted response
included a step-by-step explanation of the strategy the stu-
dent would use or the name of the strategy (count all or
count on method).
Once the student had indicated the strategy to be used,
he or she was presented with a worksheet containing addi-
tion problems. The initial worksheets contained four
problems, each with line drawings to support the addition.
For example, the problem 3 + 2 would have the numerals
with the dots, along with three fish next to the numeral 3
and two fish next to the numeral 2. Because the worksheets
progressed through addition facts and two worksheets cov-
ered each set of addition facts, the two worksheets were
presented together in a single session. The student was
asked to complete both sheets in the session, using the strat-
egy the student had selected. The researcher observed the
student to verify that the student was using the strategy cor-
rectly. If the student became confused, the researcher would
remind the student how to perform it. Four to five sessions
consisted of the students completing two worksheets with
four problems per page. Once the students had progressed
through the four-item worksheets, they moved to work-
sheets containing a mixture of addition problems, 12 to a
page. The numerals still had the dots, but the pictures were
no longer a part of the worksheet. Problems accurately
solved using the TouchMath strategy were recorded as cor-
rect. Problems that were solved inaccurately, or problems
solved with a verbal reminder about how to use the strategy,
were recorded as incorrect. The percentage of correct
responses was then calculated for each session. Once the
student reached criterion for mastery of addition (85%
accuracy or greater for two out of three sessions for a mini-
mum of four sessions), he or she moved to the generalization
phase.
Generalization to daily math class instruction and mainte-
nance. During the generalization phase, the students were
encouraged to use the TouchMath strategy in their daily
math class. Each student was provided with a TouchMath
cue card to keep at his or her desk (which consisted of a
card with the numbers 1 through 9 in order, with the dots).
The TouchMath cue card could be used as a reference
because the math problems in their daily math class did not
show the dots on the numerals, and the students would need
to remember to point to the position where the dots were
located. The researcher observed and initially reminded the
students that they could use the TouchMath. This verbal
cueing was faded as the students became more comfortable
with knowing when to use the strategy. Follow-up observa-
tions were conducted approximately 5 months after the
completion of the study. Permanent products and anecdotal
reports were used to collect data for each student.
Adaptations to accommodate physical disabilities. Students
standard adaptations were put in place at the beginning
of the study, and students were constantly monitored for
adaptations to accommodate their physical disabilities
throughout the study. Positioning was a critical issue for all
three students, as fatigue played a factor in their ability to
maintain appropriate positioning and attention to task. Each
student utilized specific strategies and/or materials (e.g.,
wheelchair desk, foot rest) to assist with his or her unique
positioning needs.
It was expected that fine motor issues would result in
some difficulty in counting the dots on the numerals and
either the material would need to be altered or the students
would need to be taught an alternative method of counting
the dots. Alterations of the material included enlargement
of some of the worksheets (once the worksheets progressed
to 12 problems per page, it was more difficult to see and
count the dots). Amy required the worksheets to be blown
up to 150% because she was not able to accurately touch the
points unless they were enlarged. In addition, peripheral
vision loss in her right eye made it important to present
materials slightly to the left of center to ensure that the
material was completely in her visual field. All three stu-
dents needed the enlarged numerals on the cue cards as an
aid when solving addition problems during their daily math
Avant and Heller 315
instruction to accommodate for their fine motor problems.
Conner required an alternative method for counting the dots
because he had significant hand tremors that prevented him
from directly tapping the numbers. Instead, he held his
pencil slightly above and near the number and traced the
taps in the air.
Typically there are activities in which students are
required to draw dots onto numerals themselves. Because
of the previously mentioned fine motor issues for these stu-
dents, this step was not instituted because they were not
able to accurately draw the dots.
Adaptations to accommodate learning. To provide addi-
tional assistance in learning the system, color cues were
implemented as needed. For each numeral, the initial dot
to be counted was colored green. Arrows were drawn to
assist with the sequence to be followed. Amy required
color cues and arrows to remember where to start count-
ing and how to count all the dots without double counting
or skipping any dots. The arrows were eventually faded,
but she continued to need the color cues. Connor used
the color cues but did not need the arrows. Bob indicated
that he did not need these aids and was successful with-
out them. During training, initial attempts were made to
have the students follow the dot pattern as described in
the TouchMath program. However, two of the students
(Amy and Connor) changed the pattern on the larger
numbers. They were allowed to do so once it was clear
that they always followed the same pattern without
making a mistake.
Design
The study used a multiprobe, multiple baseline, across-
participants design (Kazdin, 1982; Kennedy, 2005) to
determine if the students accuracy improved in solving
addition problems using TouchMath instruction. The ben-
efit of using a multiple baseline design is that it allows for
the introduction of an intervention that cannot be reversed,
as is typical for an academic intervention. The independent
variable was TouchMath, and the dependent variable was
the students accuracy in solving simple addition problems
with sums to 20.
Baseline data were taken on the percentage of addition
problems correctly solved by each participant. During this
time, no instruction was given on the use of TouchMath,
and no aids were used (e.g., counting on fingers, cue card).
Baseline consisted of a minimum of three sessions.
After each students baseline phase was complete, the
students participated in pretraining on the dot notation
system. As discussed in the procedure section, students
were systematically taught to use the dot notation system
and then taught to add using the system. Students were
allowed to select their preferred method, either count all or
count on. After reaching 100% on this pretraining, the stu-
dents could begin the intervention phase.
The intervention phase consisted of using the Touch-
Math procedure to complete addition worksheets supplied
with the TouchMath kit. Data were taken on the percentage
of correct responses on addition problems with sums less
than 20. The criterion was reached on achieving 85% accu-
racy or above for two out of three sessions. Once the first
student reached the criterion of 85% accuracy for two out
of three sessions, the second student would start the train-
ing phase. The third participant would begin the training
phase once the second participant reached criterion. Inter-
vention was continued for all three students until all had
reached the criterion. In addition, no students intervention
phase could be shorter than four sessions to help promote
generalization.
The generalization phase consisted of taking probe data
over two sessions on the students use of the TouchMath
procedure during their daily math instruction. Once all
three students had reached criterion, the generalization
phase began. Probes were taken during this phase for two
sessions to document use of TouchMath during the stu-
dents regular class sessions. Data were taken in the same
fashion as the intervention phase, including documenting
the use of the TouchMath strategy.
Follow-up observations were taken 5 months after inter-
vention ended. Anecdotal data were taken in descriptive
format as to whether or not the student used the strategy
independently, needed verbal cues to use it but was then
able to use the strategy successfully, or needed to be retaught
the strategy.
Reliability, Procedural Fidelity, and Social Validity
The percentage of problems solved correctly using the
TouchMath system was calculated using permanent prod-
ucts as the data collection method. Only those problems on
which the student used TouchMath were used to calculate
accuracy. A second trained observer also calculated the per-
centage of problems correctly solved using the TouchMath
system. Permanent product agreement using the point-by-
point approach was used to calculate reliability (Kazdin,
1982). Agreements of the observers for each problem were
divided by the number of agreements by disagreements for
each problem and multiplied by 100.
Procedural fidelity was assessed during the instruction
of the TouchMath dot notation system and during instruc-
tion in the use of TouchMath to complete addition problems.
A checklist for each student was developed that detailed
how each student used the system. The checklist incorpo-
rated the steps detailed in the TouchMath kit for instruction
in the use of TouchMath. Observers used the checklist to
judge whether each step was correctly implemented during
316 Remedial and Special Education 32(4)
Figure 2. Percentage of correct responses for addition
problems across three students
the dot notation phase and again during the addition phase
for each student.
Sustainability was used to assess the social validity of
TouchMath as an intervention strategy. Following comple-
tion of the study, probes were conducted to determine if
students continued to use TouchMath as an aid when
completing addition problems. They were not required to
continue the use of TouchMath, so independent continued
use was considered an indication of social validity.
Results
A multiprobe multiple baseline design was used to investi-
gate the effectiveness of using TouchMath to complete
simple addition problems with sums to 20 for students with
physical disabilities. Data included performance during
baseline, intervention, and generalization phases and were
graphed for the three students (see Figure 2). Data were
analyzed through visual analysis of the graph as well as cal-
culation of the percentage of nonoverlapping data (PND).
PND for an intervention that is intended to increase the
target behavior is calculated by determining the percentage
of data points that are higher than the highest baseline data
point. Anecdotal information was also collected 5 months
after the study was completed.
Amy
During baseline, the percentage of correct responses ranged
from 33% to 67%. Although Amy reached the minimal
number of sessions for baseline, the researcher wanted to
continue to achieve a more stable baseline. However, Amy
refused and complained that she hated math and could not
do it. Preintervention training was implemented at that time
to prevent further student distress. During preintervention
training, Amy was able to master the dot notation system
after two sessions. Instruction was then provided on the use
of the dot notation system to complete simple addition
problems. Amy utilized the count all method, and mastered
the strategy after one session of instruction.
Amy reached criterion after the first two sessions of the
intervention phase, with 88% and 100% accuracy. Inspec-
tion of the graphed data shows a rapid immediacy of effect
following intervention. The performance score of 33%
correct responses of addition problems at the end of the
baseline phase shifted to 88% immediately following the
implementation of the intervention, then rose to 100%.
The intervention quickly altered the pattern of the data,
indicating a strong functional relation. However, Amy did
display some variability after reaching criterion. A PND
score was calculated based on procedures described by
Scruggs, Mastropieri, and Castro (1987). A score of 89%
was calculated, indicating a moderate effect size for the
intervention for Amy.
During the generalization phase, Amy achieved 100%
accuracy for both probe sessions. Anecdotal records taken
during this time indicate that Amy generalized the use of
TouchMath when working on addition problems during
daily math instruction. She kept the TouchMath cue card
(a card with the numbers 1 through 9 in order, with the dots)
on her desk and would pull it out to use for addition prob-
lems. She moved between the cue card and the math sheet,
putting one finger on the number on her sheet and then
Avant and Heller 317
using the other hand to touch the points and count on the
cue card. She was able to complete addition problems with
100% accuracy using this method. Five-month follow-up
data were not collected because Amy had moved out of
state by that time.
Bob
During baseline, Bob showed stability in his performance
(five sessions, M = 47%, range = 42%58%). Bob was able
to master the dot notation system after two sessions of pre-
intervention training. Instruction was then provided on the
use of the dot notation system to complete simple addition
problems. Bob utilized the count on strategy and mastered
the strategy after one session of instruction.
Bob reached criterion within the first three intervention
sessions, with accuracy at 63% in the first session following
intervention, followed by 100% accuracy in the next two
sessions. Visual analysis of Bobs data shows a rapid imme-
diacy of effect following implementation of the intervention.
This was the first replication in the study and indicates a
functional relation between the use of TouchMath and the
successful completion of addition problems. The perfor-
mance score of 42% correct responses of addition problems
at the end of the baseline phase shifted to 63% immediately
following the implementation of the intervention. A PND
score of 100% was calculated, indicating a large effect size
for the intervention for Bob.
During the generalization phase, Bob achieved 100%
accuracy during the two probe sessions in his daily math
class. Bob was observed independently using the cue card
to complete addition problems. He was observed touching
the numbers on his worksheets following the dot pattern he
had been taught, and he only glanced at the cue card to
remember the dot patterns for the larger numbers. Further
anecdotal data indicate that he eventually discarded the cue
card, stating that he did not need it anymore.
Five months after the completion of the study, anecdotal
data indicated that Bob continued to use TouchMath on a
regular basis. He was observed using the strategy during
addition of two-digit numerals with and without regroup-
ing. He also asked if TouchMath could be used to help him
learn about multiplication. He was successful in using a cue
card to help him calculate simple multiplication problems
using the concept that 4 5 means count by 4 five times. He
then tapped each dot on the numeral 5 as he counted, Four,
eight, twelve, sixteen, twenty."
Connor
During baseline, Connor showed stability in his performance,
with probes used for the final two data points (M = 21%,
range = 17%33%). He was able to master the dot notation
system after three preintervention sessions. Instruction was
then provided on the use of the dot notation system to com-
plete simple addition problems. Connor utilized the count all
strategy and mastered the strategy after one session of
instruction.
Connor reached criterion within the first three inter-
vention sessions, with 100% accuracy in each session.
Visual analysis of Connors data shows a rapid immedi-
acy of effect following implementation of the intervention.
This was the second replication in the study and indicates
a functional relation between the use of TouchMath and
the successful completion of addition problems. The per-
formance score of 17% at the end of the baseline phase
shifted to 100% immediately following the implemen-
tation of the intervention. A PND score of 100% was
calculated, indicating a large effect size for the intervention
for Connor.
During the generalization phase, Conner achieved 100%
and 86% accuracy during the two probe sessions in his
daily math class. During this time, Connor asked for the cue
card to be taped on his desk. He would sometimes need
reminders to use it but readily complied and always remem-
bered how to add using the dot system. He moved between
his math sheet and the cue card just as Amy did.
Five months after intervention was completed, anecdotal
data indicated that Connor still needed occasional reminders
about when to use TouchMath. Once reminded, he readily
used it during regular class sessions as well as during test-
ing. No reteaching was required for Connor to successfully
use TouchMath.
Reliability, Procedural Fidelity, and Social Validity
Results
Reliability was assessed using permanent product agree-
ment. Agreement was 100% across all three students for
all worksheets completed using TouchMath. Procedural
fidelity was assessed for the instruction on the dot notation
system and the use of the system to complete simple
addition problems to 20. For both instructional phases,
procedural fidelity was 100% across all students.
The social validity of this intervention is based on its
sustainability. Amy had moved out of state immediately fol-
lowing completion of the study, so no sustainability data
were collected. However, sustainability data collected
through anecdotal records showed that Bob continued to use
TouchMath and asked to be taught how to use it for subtrac-
tion and for multiplication. Connor would use TouchMath
when he had difficulty with a problem and was reminded
that he had a strategy to use that would help him. The
continued use of TouchMath by these two students was
considered an indication of the social validity of this inter-
vention for this population of students.
318 Remedial and Special Education 32(4)
Discussion
The purpose of this study was to investigate the use of
TouchMath as an intervention strategy for students with
physical disabilities who also have math deficits. Specifi-
cally, the study looked at the effectiveness of this strategy
for increasing the students ability to solve basic addition
problems with sums to 20. All three students were able
to learn the dot notation and addition strategies and suc-
cessfully use them in their math classes. This research
demonstrated the effectiveness of a strategy for improving
math skills for students who struggle in the area of addition.
As such, it adds to a small but growing body of knowledge
on effective strategies for students who have difficulty
learning math (Calhoon & Fuchs, 2003; Fuchs et al., 2006;
Kroesbergen & Van Luit, 2003; Uberti et al., 2004).
This study has replicated the previous findings of studies
investigating the effectiveness of the TouchMath program
(Scott, 1993; Simon & Hanrahan, 2004; Wisniewski &
Smith, 2002) but has also extended the previous research by
adapting the strategy for use by students with physical dis-
abilities. Adaptations included the use of an enlarged font,
the use of color coding, and alteration of the counting pat-
terns on the dots. One of the students, Connor, was not able
to actually touch the dots because of tremors in his hands.
Instead, he moved his pencil just above the dots to count
them. In addition, the TouchMath curriculum was slightly
changed to accommodate the fine motor issues encountered
by the students. They were not asked to draw the dots on
numerals but instead used the TouchMath cue card to com-
plete the addition problems. By making simple adaptations,
students with mild physical disabilities were able to suc-
cessfully use TouchMath in their daily math work.
The use of TouchMath proved to be an effective strategy
for increasing the accuracy of student responses when solv-
ing addition problems with sums to 20. All three students
learned the dot notation system and the method for addition
within four sessions. There was an immediate improvement
in their accuracy following the training sessions. After
reaching criterion, there was some variability of the data for
Amy and Connor, which is thought to be attributed to out-
side factors (e.g., Amy learning she was moving out of state
and Connor having surgery). In Amys case, during Ses-
sions 6, 7, and 10, her accuracy dropped to 75%, 50%, and
67%, respectively, although she maintained 100% accuracy
during the other sessions. During this time frame, Amy was
told that her family would be moving after Thanksgiving.
She was very upset and began refusing to work in all her
classes. After speaking with the counselor and with her
teachers, she began to participate in class, although she still
required a lot of encouragement to work. In Conners case,
there was a decrease to 75% in Session 12. This was thought
to be because of residual effects from gamma knife
radiation surgery, which caused fluctuations in his aca-
demic, motor, and speech abilities and performance.
In the area of generalization, all three students were able
to generalize the use of the TouchMath strategy across
settings. All students were able to successfully use the strat-
egy to complete addition problems during their regular
math instruction with 85% to 100% accuracy on two con-
current sessions. In addition, Bob generalized using the
approach to complete his homework and was very eager to
know if he got 100% correct. The students were able to use
the strategy with addition problems that did not have dots
embedded in the numerals. A cue card depicting the numer-
als with the dot notation was all that was needed for
reference. The ability to use the strategy without the dots
being present on the math problems themselves makes this
a very useful strategy and allows the typical class material
to be presented without having to modify the numerals
(unless there is a visual or motoric issue).
The students demonstrated sustained use of the strategy
over time, an indication of the social validity of this strat-
egy. Bob and Conner were effectively using the strategy
5 months after the study ended. After the generalization
phase, Amy and Bob asked to be taught to use the Touch-
Math strategy with subtraction and were successful using it
with simple subtraction problems. Bob asked to be taught
how to use TouchMath to help him with multiplication.
Connor continued to use the strategy and appeared to value
it because he requested that the cue card be taped to his desk
in his first grade classroom. The students found the strategy
useful and were very accepting of it, given their continued
use of the strategy and enthusiasm to use it with different
applications and additional environments. Also, noticeable
improvement in their attitude toward math was observed in
all three students, along with improvement in the use of
basic math problem solving abilities by each student.
Further studies are needed to replicate the findings of this
study. Although the study showed TouchMath to be effec-
tive, more students with more diverse physical disabilities
are needed to determine overall effectiveness for this popu-
lation of students. For example, students with more severe
physical disabilities who are unable to move their hands or
arms in a meaningful manner would need an alternate strat-
egy to count the dots. For those students who use software
programs (e.g., MathPad, IntelliMathics) to complete addi-
tion problems, it would be important to develop strategies
that would allow them to use TouchMath in conjunction
with the software. Possible strategies could include instruc-
tion in the use of eye gaze to track the dots and use of the
computer pointer to touch the dots as they add. Further
research on appropriate adaptations for students with more
severe physical disabilities, especially those utilizing assis-
tive technology to complete their class work, would be an
important contribution to this body of knowledge.
Avant and Heller 319
Longitudinal studies are needed to determine how
students utilize this strategy over a period of years. It would
be important to determine if they continue to count the dots
or if they begin to learn addition facts (or other computation
facts) and eventually do not need to use the strategy.
Also, this study was limited to the acquisition of basic addi-
tion with sums to 20 and does not address how effective
TouchMath would be in assisting students with physical
disabilities in solving more complex computations. Further
research is needed to evaluate the effectiveness of this strat-
egy with more diverse computational skills.
Implications for Teachers
This study indicates that TouchMath is an effective strategy
for solving addition problems to sums to 20 for students
with physical disabilities. The students in this study were
able to quickly master the strategy and apply it to math
problems in the TouchMath kit as well as to problems in
their regular math class. This study adds to the growing
body of research supporting the TouchMath strategy across
different populations of students. Teachers may want to
consider this strategy for their students who struggle with
computational skills. However, because the literature is still
limited in its evaluation of this strategy, teachers will want
to closely monitor their students progress to determine if it
is effective for them.
When using the TouchMath system, teachers are cau-
tioned to carefully look for any needed adaptations to the
method, whether there is a physical disability or not. Not
only did the students in this study require adaptations to
address their physical disabilities, but also adaptations were
needed to promote learning. For example, color cues were
added to assist the students when learning the dot notation.
For some of the students, arrows were added while they
learned to follow the pattern of dots. If the students altered
the pattern but were consistent in following the altered pat-
tern, they were allowed to continue. This did not have a
negative effect on their use of the strategy as a whole. These
adaptations are easy to implement and can be faded as the
students become more familiar with the patterns and the
strategy itself. A thorough assessment of needed adapta-
tions should occur prior to introducing the strategy as well
as ongoing assessment as the students progress through the
TouchMath steps for learning the dot patterns and while
learning how to use them to add.
The teachers attitude in introducing a new strategy can
affect the students attitude toward the strategy. In this
study, the students were eager to learn the new strategy. The
teachers enthusiasm and positive attitude contributed
toward the students willingness to learn and use the strat-
egy. Once they saw their success in the training sessions,
they quickly asked to use it during their daily math classes.
As time progressed, the students also asked if the dots could
help them in other areas (e.g., subtraction, multiplication).
Although only anecdotal data were taken on the teach-
ers and paraprofessionals opinions of using this approach,
their evaluation of it was favorable. The program was easy
to follow, and students were able to easily move from
having the dots on the numerals to unaltered numerals with
a cue card for reference. This is a simple strategy that can be
implemented in conjunction with any math curriculum. Its
ease of implementation and effectiveness of use should
make this a successful intervention for students who are
struggling to acquire basic math concepts.
In summary, this study investigated the use of Touch-
Math for students with physical disabilities. The students
were successful in using the strategy to solve simple addi-
tion problems with sums to 20. This study extended previous
research involving students with mild intellectual disabili-
ties and mild learning disabilities to a new population of
students, those with physical disabilities. As such, it has
contributed new information to a small but growing body of
literature focused on math interventions for students with
disabilities. It is hoped that this study will be the first in a
line of research directed at developing further strategies that
examine effective interventions for promoting computa-
tional skills for use with students with more severe physical
disabilities.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interests with respect
to the authorship and/or publication of this article.
Financial Disclosure/Funding
The authors received no financial support for the research and/or
authorship of this article.
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About the Authors
Mary Jane Thompson Avant, MEd, is a doctoral student in the
Department of Educational Psychology and Special Education at
Georgia State University in Atlanta, GA.
Kathryn Wolff Heller, PhD, is a professor of special education at
Georgia State University in Atlanta, GA.