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Blind students with white canes waiting to cross Congress Avenue, a busy six lane road.

By Craig Axelrod, former Teacher Trainer, TSBVI, Texas Deafblind Outreach

Abstract: Educators can have more positive, responsive and reciprocal interactions with their students who are deafblind by learning how to modify their own interactive behaviors and adapt the interactive context. High quality interactions contribute to improved educational outcomes for students with deafblindness.

Key Words: programming, blind, deafblind, Jan van Dijk, research-based, interaction, behavior, communication, educator-oriented intervention, instructional strategies, video analysis


"Interaction is defined here as the process by which two individuals mutually influence each other's behavior." (Janssen, Riksen-Walraven & van Dijk, 2003b, p.198).

During a visit to Texas School for the Blind and Visually Impaired (TSBVI), Dr. Jan van Dijk suggested that a team from the school review recent research about interactions with students who are deafblind, then develop a process for sharing the information with other educators and helping them put its principles into practice. This article (which first appeared as a two-part article in the Fall 2004 and Winter 2005 editions of SEE/HEAR) summarizes research-based conclusions about interactions with students who are deafblind, and describes the educator-oriented training process developed at TSBVI that incorporates these findings.

A Summary of Current Research: Interaction Problems and Possibilities

Many in the field of deafblindness intuitively value and try to maintain high quality interactions with students who are deafblind. As research continues to validate the role of interaction in attachment, security, relationships, learning and communication, the need for educators of students with deafblindness to develop their interaction skills becomes more apparent. Appreciating the importance of positive interactions is a step in the process. Improving the quality of one's own interactions with students who are deafblind is a bigger challenge.

Typical development

"It is a universal trait of our species that mothers have the innate skill of mothering. They are able (and it seems that this is similar in all cultures) to provide the newborn child with warmth and security. Mothers feel that the newborn child needs a safe harbor for exploration." (van Dijk, 1999, p.1). "Children who are securely attached to their caregivers have a secure base from which to explore the environment... Children see individuals to whom they are securely attached as available and responsive... Secure attachments are built when caregivers are sensitive and responsive to the infant's communications... Positive interactions occur as the caregiver and the infant respond to each other... The infant sends cues, the caregiver responds, and the infant responds in turn. Each partner learns the rules of turn-taking from the feedback of the dydactic partner." (van Dijk & Nelson, 2001, p. 18). "Given that interaction is the 'vehicle of communication,' it is obvious that harmonious (smooth, balanced and finely attuned) interactions are indispensable to develop high-quality communication." (Janssen, et al., 2003b, p. 198).

"Harmonious interactions and their importance have been characterized in various terms. Attachment theorists emphasize the importance of sensitive responsiveness: A sensitive caregiver is keenly aware of a child's signals, interprets them accurately, and reacts promptly and appropriately so that the child feels understood. During such harmonious interactions, the child learns to trust the caregiver's availability as a source of emotional comfort and support." (Janssen, et al., 2003b, p.198). Dr. van Dijk has referred to this quality of sensitive responsiveness as "IT." This is how he once described IT. "I have been looking all over the place to find a CD-ROM fragment of Suzanne with her mother interacting. Mother wants her to clap her hands, but S. wants her to touch her lips. Mother adjusts her intention to S.'s request. This is IT." (personal communication, October 18, 2002).

"Harmonious caregiver-child interactions have been found to relate to later socioemotional development in various empirical studies... a secure infant-parent attachment relationship - which clearly relates to sensitive parenting - predicts various developmental outcomes for children up to late adolescence... early harmonious interactions influence the development of brain structures and brain functions that mediate the future regulation of emotions, adaptation to changing circumstances, and ability to cope with stress... Particularly, the sharing of high levels of positive affect during interactions appears to have beneficial effects on early brain development." (Janssen, et al., 2003b, pp. 199-200).

The impact of deafblindness

"Children who are deafblind often require considerable time as they establish relationships with others and become comfortable in new environments... The ability of children with severe multiple disabilities to develop secure attachment and turn-taking social interactions may be threatened by multiple factors including: (a) time spent in intensive care units separated from their parents, (b) severe health problems which may have limited physical contact with caregivers, (c) low levels of arousal and an alert state that is not long enough for attachment to occur, (d) extremely elevated levels of arousal that lead to over-stimulation, (e) communicative cues that are atypical and difficult to read, and (f) limited ability to read caregiver cues (e.g., if vision is limited, the young child may not be able to imitate the social cues of his caregiver such as a smile and he may not know when he should take his turn in a social interaction)." (van Dijk & Nelson, 2001, pp. 4, 18-19).

Interactive challenges

"Various studies have indeed shown both deafblind children and their parents to encounter serious difficulties with their interactions. The visual impairments of the children greatly affect quality of the children's interactions with their parents. Eye contact, reading facial expressions, or mutually gazing at the same object are virtually impossible. Lack of responsiveness or over-sensitive reactions such as 'slipping away' in the children may cause feelings of disappointment or frustration in the parents... Auditory stimuli are not well-perceived or processed by deafblind children due to sensory-neural impairment. They may respond very little, not at all, or even negatively to voices and other sounds. Caregivers are therefore dependent on touch and proprioceptive stimulation to keep the interaction going... Rowland (1984) showed the mothers of multiple handicapped visually impaired children to encounter difficulties with the regulation of turn-taking and to inconsistently respond to the vocalizations of the child... Preisler (1996) found deafblind children to elicit contact with their parents by means of body movements, facial expressions, and vocalizations. The children can also take part in joyful interactions, mostly in the form of body games. It is nevertheless difficult to read signals of deafblind children. Their movements and expressions are often very subtle or vague and unfold at a much slower pace when compared to those of sighted and hearing children. Use of idiosyncratic signals and forms of communication by the deafblind can easily lead to misunderstandings." (Janssen, Riksen-Walraven & van Dijk, 2002, pp. 88-89). "The attachment process described by Bowlby (1969), through which the child develops a secure bonding with his primary caregiver allowing him/her to explore and access new opportunities for experience and learning, is endangered in children with multiple disabilities due to the described difficulties in establishing readable signaling systems." (Amaral, 2003, p. 4).

"For educators, the first hampering factor in building harmonious interactions is the lack of natural skills to participate in the deaf-blind world of touch and proximity".

In her study of the communicative interactions between children with multiple disabilities and their teachers, Amaral (2002) concluded that teachers do not spontaneously develop the interaction and communication skills that are necessary for responding to the needs of such children... The educators of deaf-blind children are often not fully aware of the importance of developing harmonious interactions before they focus on understanding the children's message or on further developing communication and language." (Janssen, et al., 2003b, pp. 198, 201). "When the educator of deafblind individuals lacks the insight and skills to understand the world of the deafblind child, one can observe how the individual retreats into himself, avoids touching objects, and attempts to cope with his 'unbalanced organism' by exhibiting stereotypic behaviours." (van Dijk, 1999, p. 2). "Professional educators, such as teachers, classroom-assistants, and the residential staff face the same interaction problems as the parents and sometimes even more serious problems. The educators typically start interacting with the deafblind children at a later age than the parents, which means that many of the children have already developed a number of idiosyncratic and 'difficult' behaviors that can hamper further interaction." (Janssen, et al., 2002, p. 89). "The final factor that is known to hamper harmonious interactions with deaf-blind children holds particularly in institutional settings (schools and residential facilities) and concerns continuous changes. While professional educators regularly rotate from one class, home setting, or group in a residential facility to the next and thus from one deaf-blind child to another, the risk of disharmonious interactions increases with each switch, particularly when the professionals have not been sufficiently introduced in the new work setting and too many staff changes occur at the same time." (Janssen, et al., 2003b, p. 202). "It is obvious that when a child, whose emotional balance is easily disturbed, is provided with many different caregivers, it is hard, if not impossible, for the foundation of security to be laid." (van Dijk, 1999, p. 3). "Given that the principles of individuals' communication and interaction are often not well recorded, the risk of disharmonious interactions following such staff switches increases." (Janssen, et al., 2003b, p. 202).

Adult-dominated interactions

Rick van Dijk and his colleagues noted, "In normal language development, one would expect a parent or a professional teacher to leave the initiative in communication to the child and to respond in a contingent way whenever the parent or teacher felt that it was possible for the child to take the initiative. Only in this manner does the child have the opportunity to explore his or her communicative possibilities... Communication will only lead to language development if the child is enabled to actively take part in communication... we know that parents often have a tendency to control interaction with a deaf child because they cannot fully understand the utterances of the child. Although understandable, this control is in itself detrimental to language development. The more parents try to control the responses of a child, the turn-taking interaction, and especially the topic of conversation, the more slowly language development will proceed. There is solid empirical evidence that use of a less controlling interaction style by parents facilitates not only higher-quality interaction between parents and deaf children but also the process of language development... there is no reason to think that this is not also the case in children who are deafblind." They suggested that "...if one studies interaction and communication, and most certainly if one studies these processes in relation to the facilitation of language development, one will also want to study aspects such as initiation of interaction, contingent and noncontingent reactions of communication partners, and the functions of interactive turns." (Vervloed, van Dijk, R., Knoors & van Dijk, J., 2006, pp. 337, 343).

A study was designed to analyze the interactions between a teacher and his 3-year-old student with congenital deafblindness. The primary research question asked, "...to what extent it would be possible for the teacher to attend to the deafblind child's initiatives and responses and respond appropriately, with contingent interaction patterns thereby resulting... Three target activities that offered many opportunities for close interaction were chosen for the present study... These events were selected because they recurred daily and fit in the schedule of daily routines for this boy. It is widely accepted that such daily routines foster effective interactions and enhance memory processes." Videotaping the observations was considered necessary "...because otherwise it is extremely difficult to notice all the potential communicative signals exhibited by the deafblind child." (Vervloed, et al., 2006, pp. 337, 338).

"Over a period of 4 months, a total of 16 hours of recordings were made during bathing, dressing, and playing... specific events were chosen for video recording in order to capture the most favorable conditions for the elicitation of social interaction and communication.... Three criteria were used to determine if a scene would be included in the study: 1. Both the teacher and the child should be within reach of the camera. 2. The recordings should be of good quality. 3. There should be a period of communicative activity lasting at least several seconds." Of the original recordings, "...less than 2% of the recording time contained prolonged interactions between teacher and child... most of the failures were due to the teacher being too far away from the child to be able to communicate properly or due to the total absence of prolonged communication periods between the two." (Vervloed, et al., 2006, pp. 338, 340). Video fragments that met the criteria were reviewed, and each of the teacher's and student's interactive behaviors were assigned to one of six main observational categories:

  1. The child acts to influence the teacher's behavior
  2. The child reacts to the teacher
  3. The childs actions are not in response to the teachers initiatives, or there is no response
  4. The teacher acts to influence the childs behavior
  5. The teacher reacts to the child
  6. The teachers actions are not in response to the childs initiatives, or there is no response. (Vervloed, et al., 2006, p. 339).

The authors then counted the frequency of these interactive behaviors and analyzed the transitions between them, to learn more about the teacher and childs current interactions, and to predict the nature of their future interactions. If interactive behaviors of the teacher and/or child didn't change, it was likely, with varying degrees of probability, that the characteristics of their interactions would remain the same. They concluded, "The amount of interaction was representative of normal daily interactions between this teacher and deafblind boy... only a limited portion of the time when the teacher and deafblind child were together was devoted to communication and interaction... There existed a true interaction between teacher and child, although each frequently missed the initiatives of the other... Both teacher and child did not respond significantly to each other's responses... the number of teacher initiatives exceeds the number of responses considerably." They also speculated "...that interaction between the partners stopped after one response." From this study, the authors determined that "&it is possible to quantify interaction between teachers and deafblind children and that this can be accomplished in a way that gives insight into the elements of the interaction and communication processes that are important for the development of language." (Vervloed, et al., 2006, pp. 341, 342).

Consequences of disharmonious interactions

"It is likely that the emotional and behavioral problems of deafblind children are at least partially due to the difficulties they experience, from birth on, in their everyday interactions with caregivers. High quality interactions with primary caregivers who sensitively respond to normal children's signals and needs have been found to foster a sense of security and competence in the children and to positively affect both their social and personality development in later years. In contrast, children with insecure attachment relationships reflecting a history of disharmonious interactions with their primary caregivers have been found to be at risk for development of disorders such as problems in self-regulation, depression, and conduct disorders... Given that the interactive signals of deafblind children are often subtle and difficult to interpret, they are frequently missed or misunderstood by caregivers. As a result, children tend to intensify their signals, express frustration via self-abuse or aggressive behaviors or both, and withdraw into stereotypic behaviors or passivity. Such 'inappropriate' behaviors can then elicit inadequate responses from the caregivers, with the risk of both the caregiver and child getting caught in a downward spiral." (Janssen, et al., 2002, pp. 88, 90).

Educator-oriented intervention

Dr. Marleen Janssen and her co-authors designed an educator-oriented intervention program to improve the quality of interactions between deafblind children and their professional educators. To determine the program's effectiveness, their research questions were, "(1) Does the intervention produce an increase of appropriate [educator] responses and a decrease of inappropriate [educator] responses to the interactive behaviors of the children? (2) Does the intervention result in an increase of appropriate interactive behaviors and a decrease of inappropriate interactive behaviors on the part of the children? (3) Is the intervention effective with different educators and in different situations?" (Janssen, et al., 2002, p. 90).

After identifying appropriate and inappropriate child behaviors, and appropriate and inappropriate educator responses, "First, the educators were trained to respond more appropriately to the children's interactive behaviors. Second, the educators were trained to adapt the interactive context to facilitate the occurrence of appropriate interactive child behaviors. Such adaptations were as follows: (1) offering communicative aids [in an] orderly [way], (2) offering choices, (3) removal of distracting stimuli, (4) removal of stimuli not wanted by the child, (5) attuning activities to child's abilities (sensory or motor), and (6) demonstration of appropriate interactive behaviors to the child." (Janssen, et al., 2002, p. 94).

The study concluded that "...it is possible to improve the interactive competence of deafblind children by teaching their educators to respond more appropriately to [the children's] interactive behaviors. In three of the four target children, both an increase in appropriate interactive behaviors and a decrease in inappropriate interactive behaviors were observed. The intervention also proved to be effective for different educators across various situations." (Janssen, et al., 2002, p. 104).

Development of an intervention model

As a continuation of their earlier work, Dr. Janssen and her colleagues developed "a diagnostic intervention model as a guide for designing and conducting interventions to foster harmonious interactions between deaf-blind children and their educators in various settings - The intervention is educator oriented and thus aimed at achieving the goals of intervention for the children who are deaf-blind by changing the behaviors of their educators." (Janssen, et al., 2003b, pp. 197, 208).

In this model, the behaviors of both the child and educator are assigned to one of eight core categories of interactive behavior. "The definitions of the categories are adapted for the purposes of an intervention and are translated into concrete behaviors per individual case." (Janssen, et al., 2003b, p. 207). The eight core categories of behavior "&are as follows:

  1. Initiatives: starting an interaction or raising something new as part of a reaction
  2. Confirmation: clear acknowledgement that an initiative has been noticed and recognized
  3. Answers: positive (approving) or negative (disapproving) reaction to an utterance of the partner
  4. Turns: turn taking, or becoming the actor, and turn giving, or allowing the other to become the actor
  5. Attention: focus on the interaction partner, the content of the interaction, and the people and/or objects within the interaction context
  6. Regulation of intensity of the interaction. For the educator: waiting while the deaf-blind child regulates the intensity of the interaction. For the child: appropriate regulation of intensity by, for example, withdrawing (turning his or her head away) or some other individual signal (such as laying his or her hand on the partner's hand) and apparent processing of information, and inappropriate regulation of intensity by, for example, self-abusive or aggressive behaviors
  7. Affective involvement: mutual sharing of emotions
  8. Independent acting. For the educator: acting with no focus on the child. For the child: executing actions independently (e.g., putting a garment or part of a garment on alone)." (Janssen, et al., 2003b, p. 207).

"On the basis of video analyses, the educators learn to recognize a deaf-blind child's signals, to attune their own interactive behaviors to those of the child, and to adapt the interactive context to promote the occurrence of certain target behaviors... The intervention is evaluated in terms of the intervention aims and the occurrence of particular behaviors before and after intervention." (Janssen, et al., 2003b, p. 208).

A companion study summarizes the successful implementation of the intervention model described above, with six congenitally deafblind children and adolescents, and their teachers, caregivers and parents, in different settings and interactional situations. (Janssen, Riksen-Walraven & van Dijk, 2003a).

Research to Practice: The Interaction Training Process at TSBVI

Based on the research summarized above, and other resources, Kim Conlin, Tish Smith (communication specialists at TSBVI) and I designed a two-day training for TSBVI educational staff. At this time (February, 2008), seven trainings have been facilitated at TSBVI, with four participants in each training. Regional trainings in two other Texas cities have also been held.

When determining who will be invited to participate in interaction training, we consider interested staff who are teaching students with deafblindness and understand the basics of good programming, such as structuring a routine and using a calendar system. They have interactive challenges with their students that we want to address. Staff may also be teaching newer students we want to better understand. The students represent a variety of abilities and needs.

Introduction to the training model

The educator-oriented learning goals of interaction training are to:

  • Understand the role of high quality interactions in early development
  • Understand the challenges to high quality interactions with children who are deafblind
  • Identify student-specific factors that impact interactions
  • Recognize the components of interaction
  • Analyze the interactions between adults and students who are deafblind
  • Identify and implement intervention strategies that improve the quality of those interactions

Several weeks before interaction training, participants are asked to notice and think about the interactions they have with their students, then bring those observations and questions to the first day of training. As the training progresses, and more is understood about the unique characteristics of deafblind children, interactions with deafblind children in general, and with their students in particular, concerns, goals and possible intervention strategies for improving the quality of those interactions become more refined and specific.

On the first morning of training, after introductions and clarification of the learning goals, information is presented about interaction problems and possibilities of students who are deafblind. To help exemplify these ideas, participants view and discuss the videotaped interactions between a student and three adults. The three interactions are clearly very different, and the student's abilities also seem to differ. An Interaction Data form is introduced as a tool to help graphically represent those differences.

Interaction data

The Interaction Data form codes these components of an interaction:

  • Description of Turns: Each interactive turn is briefly described. This enables the people coding to quickly match information seen on the video to its corresponding location on the Interaction Data form.
  • Interactive Turns: Each turn is assigned a letter, A-F, based on the six observational categories identified by Rick van Dijk and his colleagues.
    1. Student Initiates: the student's action is directed at the adult in order to influence the adult's behavior
    2. Student Responds: the student responds to the adult
    3. Student Acts Independently or No Response: the student acts without an intent to influence the adult's behavior, or does not respond to the adult
    4. Adult Initiates: the adult's action is directed at the student in order to influence the student's behavior
    5. Adult Responds: the adult responds to the student
    6. Adult Acts Independently or No Response: the adult acts without an intent to influence the student's behavior, or does not respond to the student
  • Connecting Consecutive Turns: Arrows are drawn between "related" consecutive turns, reflecting the duration of an interaction on a particular topic.
  • Interactive Behaviors: Each turn of the student or adult is then assigned one or more numbers, 1-8, corresponding to behaviors that describe the turn's interactive qualities. These interactive behaviors are adapted from the eight core categories of behavior as defined by Marleen Janssen and her colleagues.
    1. Initiatives: starting an interaction or bringing up something new as part of an answer
    2. Confirmation: clear acknowledgement that a partner's action has been noticed and recognized
    3. Answers: a positive or negative response to the partner
    4. Turn Taking: becoming the actor
    5. Turn Giving: allowing or encouraging the partner to become the actor
    6. Attention: focusing on the partner, the content of the interaction, or the individuals and/or objects within the interactive context
    7. Regulation of Intensity of the Interaction: for the student ' appropriate or inappropriate interaction; for the educator ' waiting while the student regulates intensity, or regulating behaviors that influence the student's intensity (such as proximity to the student [e.g., nearer, further away], pacing [e.g., faster, slower], animation [e.g., facial expression, size of movement], voice [e.g., inflection, volume] and amount or type of touch [e.g., frequency, degree of forcefulness])
    8. Affective Involvement: sharing positive emotions with the partner
    (If during an interactive turn, the student or adult "acts independently or gives "no response," C or F, no interactive behaviors are credited.)

Interaction Data form

Interaction Data form (75k)


Interaction Data

Student's Name:

Date:

Adult's Name:

Topic:

Interactive Turns:

A - Student Initiates; B - Student Responds; C - Student Acts Independently / NR; D - Adult Initiates; E - Adult Responds; F - Adult Acts Independently / NR

Interactive Behaviors:

1 - Initiatives; 2 - Confirmation; 3 - Answers; 4 - Turn Taking; 5 - Turn Giving; 6 - Attention; 7 - Regulating Intensity; 8 - Affective Involvement

Connect "related" consecutive turns with arrows

Interaction Data Form
Description Of Turns

 

 

 

 

 

 

 

Interactive Turns

 

 

 

 

 

 

 

Adult's Interactive Behaviors

 

 

 

 

 

 

 

Student's Interactive Behaviors

 

 

 

 

 

 

 


B is 19 years old and has microcephaly secondary to an encephalocele (a congenital protrusion of the brain through a cranial fissure). He's legally blind with a cortical visual impairment, is suspected of having a hearing loss, and has multiple disabilities that include mental retardation and cerebral palsy.

Coded video fragments from B's three interactions are analyzed, to identify and compare components of the interactions that reflect their different characteristics and result in his varying degrees of interactive competence. This activity also familiarizes participants with the Interaction Data form. Later in the training, they will use the form to code and analyze video fragments of their own interactions.


Interaction Data

Student's Name: B

Date: 5/02

Adult's Name: Teacher

Topic: Physical Therapy - Therapy Ball

Interactive Turns:

A - Student Initiates; B - Student Responds; C - Student Acts Independently / NR; D - Adult Initiates; E - Adult Responds; F- Adult Acts Independently / NR

Interactive Behaviors:

1 - Initiatives; 2 - Confirmation; 3 - Answers; 4 - Turn Taking; 5 - Turn Giving; 6 - Attention; 7 - Regulating Intensity; 8 - Affective Involvement

Connect "related" consecutive turns with arrows

Student B Physical Therapy - Therapy Ball
Description of TurnsTeacher unbuckles seatbelt Teacher takes towel Teacher says "Let's get out of the chair," etc. Teacher stretches B's arm Teacher says "There you go." Teacher stretches B's fingers Teacher picks up B to reposition

Interactive Turns

F

 

F

 

D

 
F
 
D
 
F
 
F

Adult's interactive Behaviors

------

 

-------

 
1
 
------
 

2

 
------
 
------

Student's interactive Behaviors

                         

B and the teacher - stretching on the therapy ball: The teacher talks to B twice in this fragment, but acts independently during the other turns. He prepares to move B, positions him on the therapy ball and stretches parts of his body with no interactive behaviors, no expectation for B to take a turn and no connected turns.


Interaction Data

Student's Name: B

Date: 5/02

Adult's Name: Aide

Topic: Eating

Interactive Turns:

A - Student Initiates; B - Student Responds; C - Student Acts Independently / NR; D - Adult Initiates; E - Adult Responds; F- Adult Acts Independently / NR

Interactive Behaviors:

1 - Initiatives; 2 - Confirmation; 3 - Answers; 4 - Turn Taking; 5 - Turn Giving; 6 - Attention; 7 - Regulating Intensity; 8 - Affective Involvement

Connect "related" consecutive turns with arrows

Student B Eating
Description Of TurnsAide waits, then offers spoon B takes a bite Aide wipes B's mouth B chews and swallows Aide offers spoon B refuses bite Aide puts down spoon and gets milk cup
Interactive Turns
D
image006
B
 
F
 
C
 
D
related to next cell to the right
B
related to next cell to the right
E
Adult's Interactive Behaviors
1, 4, 6, 7
     
------
     
1, 4, 6, 7
     
2, 4, 6
Student's Interactive Behaviors    
3, 4, 6
     
-------
     
3, 4, 6
   

B and the teacher aide - eating lunch: The aide is attentive to B, and waits until he's ready before offering a bite of food. B responds once by accepting the spoon (answering "Yes") and once by rejecting it (answering "No"). When he refuses the food, she confirms his response by putting down the spoon and getting the milk cup. Turns in both of these sequences are connected. She acts independently by wiping his mouth. There is no observed enjoyment (affective involvement) of the interaction.


Interaction Data

Student's Name: B

Date: 5/02

Adult's Name: Visitor

Topic: Conversation

Interactive Turns:

A - Student Initiates; B - Student Responds; C - Student Acts Independently / NR; D - Adult Initiates; E - Adult Responds; F- Adult Acts Independently / NR

Interactive Behaviors:

1 - Initiatives; 2 - Confirmation; 3 - Answers; 4 - Turn Taking; 5 - Turn Giving; 6 - Attention; 7 - Regulating Intensity; 8 - Affective Involvement

Connect "related" consecutive turns with arrows

Student B Conversation
Description Of TurnsB vocalizes Visitor says "What?" B extends finger in lap Visitor says "There goes that finger to the nose." Visitor extends and lifts finger to nose, says "Hey&" B lifts finger to nose Visitor lifts finger to nose and says "Hey&"
Interactive Turns
A
related to next cell to the right
E
related to next cell to the right
B
related to next cell to the right
E
related to next cell to the right
E
related to next cell to the right
B
related to next cell to the right
E
Adult's Interactive Behaviors    
2, 5, 6
     
2, 4, 6, 8
 
1, 2, 4, 6, 8
     
2, 4, 6, 8
Student's Interactive Behaviors
1, 4, 6
     
1, 4, 6
         
4, 6, 8
   

B and a visitor - having a conversation: B initiates the interaction by vocalizing. The visitor responds by asking "What," which confirms B's initiative and gives him a turn. B introduces a new initiative by extending the index finger of a hand in his lap (preparing to touch it to his nose). The visitor takes a turn, and confirms B's initiative, by saying "There goes that finger to the nose." He also shows affective involvement with facial expressions and tone of voice. The visitor then expands on B's initiative by extending his own index finger, positioning it under B's other hand, raising B's hand and saying "Hey" each time he (the visitor) touches it to his own nose. His affective involvement continues. B responds by lifting his finger, touching it to his nose, and smiling. The visitor takes a turn, and confirms B's actions, by laughing, saying "Hey" and touching his own nose again. B and the visitor are attentive and responsive to each other throughout the interaction. All turns are connected.

General Profile

Prior to training, participants develop General Profiles of their students, by compiling information about them that may impact the quality of their interactions. This includes:

  1. Medical/Sensory Information:
    • etiology
    • medication(s)
    • vision (near and distant acuities, fields, and other visual considerations)
    • hearing (functional implications of hearing loss with and without amplification, and recommendations)
    • touch (hand guiding, tactile instruction, mutual tactile attention, tactile signing, etc.)
    • primary and secondary sensory learning channels
  2. A "Communication Assessment [based on the communication model developed at TSBVI for nonsymbolic and early symbolic students with visual and multiple impairments, including deafblindness]:
    • Form: the vehicle for conveying meaning; nonsymbolic to symbolic
    • Social Aspects: these include the social skills and communicative functions which impact the quality of the student's interaction with other people
      • Social Interaction Skills: maintaining joint attention, bonding with primary caregivers, initiating an interaction, turn taking, etc.
      • Functions: requesting, rejecting, commenting, labeling, reporting on past events, etc.
    • Communicative Content: what the student has to talk about
      • Topics: the specific subjects of interaction or conversation which emerge from the student's experiences with varied objects, people and events; swimming, snack, bathing, skating, etc.
      • Meaning Categories: the broad divisions for organizing topical knowledge. They provide a framework for teaching concepts and vocabulary; objects, actions, people, locations, attributes, etc.
      • Context: the situation in which communication occurs; here and now, past or future events, unfamiliar situations, etc." (Hagood, 1997, pp. 6-7).

    The Communication Assessment often includes a description of the student's calendar system, which, among its many benefits, plays "an important role in supporting and expanding students' communication." (Blaha, 2001, p. 10).

  3. Present Levels of Educational Performance, especially in the areas of:
    • Language Arts
    • Social Communicative Interactions
    • Emotional Development
    • Organization - Senses and Motor Skills
    • Basic Concepts
    • Representation/Cognition
    • Other (such as behavior)
  4. Instructional Modifications: Examples include fine task analysis of activities, highly structured routines and learning environment, special materials to structure activities, extended time for processing, increased response time, concrete symbols, tactile symbols and special communication systems.
  5. Appetites/Aversions (Likes/Dislikes): "One sheet is completed for each student. Over a period of time, through observation and listening to stories from others, a list is developed of things the student likes and doesn't like. We all enjoy things that we are good at and that we understand. A student's 'Likes' will be areas of strength and indicate sensory channels that are working. 'Dislikes' will be areas of weakness and indicate sensory channels that may not be working efficiently. The information gathered on this form will suggest underlying themes that can be used for modifications, teaching strategies, topics of communication, and activities. (van Dijk, 1985)." (Blaha, 1996, p. 20).

After the video fragments of B's three interactions are analyzed, participants review their students' General Profiles and summarize them to the group.

Video analysis

Within a few weeks of training, a baseline videotape is made of each participant/student pair engaged in an interaction. (Participants are taped interacting with the same students on the second day of training.) When determining what to videotape, participants are asked to consider these criteria:

  • They are 1:1 with their student
  • Interaction (rather than independence) is a component of the activity
  • The activity is, or has the potential to be, mutually enjoyable and/or satisfying
  • The activity is familiar and occurs at least a few times every week
  • The activity can be repeated during the training

After the General Profile summaries are shared, each baseline video is reviewed in its entirety, to provide an overall sense of the activity, and to identify general participant and student interactive strengths and challenges. A brief fragment from each video highlighting these qualities is selected for coding and analysis. The fragment is coded on the Interaction Data form, then analyzed to identify aspects of the interaction that are successful and those that may be contributing to interactive problems. Based on this analysis, participants discuss ways their interactions might be improved, by changing their own interactive behaviors, and by adapting the interactive context. Changes in student behavior that might indicate improved interactions are also identified. For example:

  • If coding indicates that most interactive turns progress from adult initiations to student responses (D to B), strategies that might encourage more student initiations followed by adult responses (A to E) are identified
  • If few interactive turns are connected by arrows, indicating only brief interactions around topics, increased adult responsiveness to the student's interests could result in more turns on those topics
  • If an adult's interactive behaviors are predominantly initiatives (1) and turn taking (4), attention (6) to a student's actions, confirmation (2) of those actions, turn giving (5), regulating the intensity of the interaction (7), by slowing the pace or pausing, and affective involvement (8) may encourage the student to make more initiatives (1). Additional student interactive behaviors that would reflect a more preferred interaction include attention (6) and affective involvement (8)

On the second day of training, participants are videotaped with their students, as they incorporate new intervention strategies into the same activities that were taped for the baseline. Videos of these interactions are then reviewed, representative fragments are coded and analyzed, and strategies are further refined for future implementation.

At the end of the second day, to conclude interaction training, participants discuss what they've learned. They also describe how they will apply the principles of interaction training, in other situations with the same students and with their other students.

What we learned: 4 case studies

Matt and J

J is 13 years old and deafblind due to prematurity. He is totally blind and has a severe to profound hearing loss, bilaterally (moderate when amplified).

J expresses interest and affection for his primary caregivers by smiling, laughing or hugging. He initiates familiar interaction routines when an adult is nearby. He maintains preferred, turn taking interactions for a long time. In stressful situations, these people can calm him with deep pressure hugs, redirection to a preferred activity, or by reviewing his schedule and giving him more time to process information.

J knows 125 receptive signs, and uses more than 60 expressive signs to request activities, interactions, assistance, and information about the day. These signs are often inexact, but recognized by familiar people. He'll place his hands in the adult's hands, sign "now" to ask about what's happening next, and sign "then" to ask about the day's sequence of activities. He is beginning to comment about past and future events. J recognizes at least 50 tactile symbols that represent activities on his calendar, identify possessions and activity areas, etc. He also uses them to choose between people, food and leisure activities.

J has a daily calendar, with an expansion strip that gives additional information about the "who," "what" and "where" of each activity, and a weekly calendar with a highlighted activity scheduled on each day. It's important to review J's daily schedule with him throughout the day, especially in the morning. J anticipates and completes "next steps" in familiar routines.

J's favorite topics are movement, food, sounds or music, and activities that incorporate these interests. He enjoys knowing what his peers are doing, attends to their actions if they're close and, with support, will pass them materials in structured routines.

J may express frustration about changes in the schedule by refusing conversation, banging his head or crying. He often calms after multiple reviews of the new schedule, along with additional support and reduced demands.

Matt's goal was for J to communicate more spontaneously during his daily calendar discussions. The coded baseline video fragment indicated that Matt had nice interactive behaviors, such as confirmation, turn giving, attention and affective involvement, but he initiated most turn sequences and J primarily responded (D to B). Matt decided to be more responsive to J's initiations (A to E) and initiatives. It was thought that J might initiate more if he was encouraged to get his tactile symbols from the storage bag in the order they interested him, rather than prompted to get them from the slantboard behind his calendar in the order they occurred. After a conversation about each activity, he'd put its symbol on the slantboard. When all of the activities had been discussed, the symbols would be brought from the slantboard and scheduled left to right on J's daily calendar.

These are the strategies Matt introduced in the second taping

  • Encourage J to get his tactile symbols from the storage bag in the order they interest him, rather than prompt him to get them from the slantboard in the order activities occur
  • Respond to J's initiation of touching a tactile symbol (A to E) by touching it with him (confirmation, attention), then identify/label and comment (confirmations, answers) about the activity represented by that symbol before putting it on the slantboard
  • Sign the word "Now" (turn giving) after a response, to emphasize anticipation that J will bring up something new about the activity being discussed (initiative), or get another symbol (initiation)
  • Use a third person standing behind J to help model initiations and initiatives for him

When Matt first implemented these strategies, the new expectations seemed to confuse J a little, but he did initiate more, especially when Matt gave him turns by waiting, signing "Now" or showing him the bag of calendar symbols. J also had more initiatives on topics, and Matt was more responsive to those initiatives. J wasn't always sure what to do with the symbols he selected. The strategy of putting them on the slantboard before they were scheduled on his calendar was confusing, and needed to be further modified. Nevertheless, J continued to initiate and make initiatives on topics that interested him, sometimes with Matt's hands!

After the training, Matt replaced the slantboard with a carpeted tray that is positioned on his lap, between him and Jarvis (adapting the interactive context). He also changed the "Now" sign to an open handed "What?" gesture (turn giving), as encouragement for J to add something new to the current topic (initiative). Using a third person to model initiations and initiatives was awkward, and discontinued.

These new strategies have resulted in even more initiations and initiatives from J. Now he shakes all of his daily symbols onto the tray, and hands Matt symbols in the order they interest him. Matt responds by identifying, labeling and commenting about each activity, and helping J schedule the symbols on his daily calendar. He also gives J turns to make new initiatives on a topic. When all of the symbols have been discussed and scheduled, Matt and J preview the entire calendar sequence.

Laura and L

L is 21 years old and has CHARGE Syndrome. He recently lost all of his vision, and has a profound bilateral hearing loss. L also has a history of perseverative, aggressive, destructive and mildly self-injurious behaviors, which are being treated with medication.

L enjoys interactions, forms bonds with adults and peers, and asks about them when they're not present. He expresses affection toward preferred people and encourages them to communicate with him. Before becoming totally blind, L initiated interactions by sight. He's now learning to get people's attention by tapping their arms or raising his hand, but interactions are usually initiated by others.

L has many topics of conversation, and an expressive vocabulary of approximately 200 signs, which he typically combines in 2-3 word phrases. He initiates conversation, in structured and unstructured situations, to request objects, activities, assistance and people, and to make comments. L also requests information about things that have happened in the past and will (or might) occur in the future.

L participates well in structured routines, has preferences and makes clear choices. L has a daily calendar with the sequence of his daily activities and a monthly calendar for scheduling important events, such as which weekends he's going home or staying on the dorm, when he's going grocery shopping or to a restaurant, etc. Before losing his vision, L used standardized pictures, drawings, photos and some sight words with his calendar, for cooking recipes and other sequences, to label storage areas, etc. Calendar activities are now represented by object symbols and some alternate objects. Tactile symbols are gradually being introduced at the calendar and in a few other situations.

L is able to move about in his classroom without assistance, and has learned to travel many familiar routes independently. He's learning an organizational system for his calendar symbols and other symbols.

Laura's goal was to have a more "connected" interaction with L during his footbath routine, which she knew he enjoyed. In the past, L had often introduced conversational topics unrelated to the activity at hand. After losing his vision, he was constantly asking questions about current and former classmates (what they would be doing in 100 days, whether they were flying home that weekend or riding the bus, etc.). This also occurred during his footbath.

The baseline videotape reflected a chaotic conversation, with Laura and L both initiating on different topics. (Laura communicated about the footbath while L asked about other students.) Only two or three turns were taken on the same topic. One person would initiate, the other would respond then initiate about something else (D to B to A to E to D to B to A to E, etc.).

Laura wanted to increase the number of L's initiations around mutually interesting and less repetitive topics. She also wanted them both to have more turns (initiatives, turn taking, turn giving) around those topics. This would be represented on the coding with more turns connected by arrows, indicating that Laura and L were taking multiple turns on the same topic.

Laura's strategies were to:

  • Make the footbath more mutually interesting (attention, affective involvement) by introducing novelty, such as wearing a toe ring
  • Label the environment to reduce the need for "procedural communication" such as giving directions
  • Share the activity more wholly with L by having her own footbath next to him. This would give her an additional role (besides helping L, answering his questions and following his commands), creating opportunities for them to help each other and comment about their mutual experience
  • Encourage L to have more contact with the objects used in his footbath routine. This would enable him and Laura to increase their interactions around those objects

L smiled and enjoyed himself (affective involvement) during the second videotaped interaction. He and Laura took several turns around the same topic (more arrows!), and she was more responsive (confirmation, attention, affective involvement) to his initiations and initiatives.

Introducing novelty to a topic helps L pay attention to it. Setting up the environment to give tactile procedural information, such as storing materials in consistent places and labeling storage areas (adapting the interactive context), reduces the need to tell him what to do, where to go, etc. He and Laura can then put more emphasis (attention) on mutual enjoyment (affective involvement) of the interaction. Laura will also begin using objects and parts of objects to support L's expanded conversation about other interesting topics (parties, changes in the schedule, etc.), introduce more tactile symbols in the environment, and add tactile symbols of people to his daily calendar.

Hank and S

S was born prematurely and is 9 years old. He has light perception in one eye and a moderate to severe hearing loss. He drinks Pediasure from a bottle and does not eat solid foods.

S will initiate interactions when a partner is near, but most interactions are initiated by others. He recognizes familiar people and initiates interaction games specific to each of them. He encourages (requests) interactions with others by smiling, laughing, signaling, repeating their words, taking and giving turns, saying "Thank you," and giving hugs. He can maintain interactions for up to 10 minutes on topics that incorporate music or movement, and will interact around topics with other sensory aspects (such as inflating and deflating balloons to feel the air, and imitating the sounds they make) for shorter periods of time. Some topics (for example, food and oral stimulation) appear to trigger strong negative reactions that disrupt interaction. He discourages (rejects) these interactions by gently pushing away people or objects. S is drawn to the sensory experience of touching Hank's hair with his palms and face. If those behaviors last longer than 5 seconds, they seem to cause sensory overload, which results in S hitting Hank and biting himself on the arm.

When S does not feel in control, he tries to end an interaction by saying "Finished," or turning away from the activity. He is often less focused and more nervous in new environments or with novel materials. Information is taught within routines, which increases S's sense of security and ability to focus. Novelty is infused into familiar routines to broaden his understanding of concepts and vocabulary. A divided choice board is used to present options within routines.

S understands numerous phrases spoken consistently in his routines and a few signs produced without speech. He can process signs and speech simultaneously. S expressively signals with his body and voice, hand guides adults, gives them objects, and is beginning to request leisure activities with tactile symbols during structured choice times. These symbols are stored in an accessible place so he'll be able to initiate requests. He uses mitigated echolalia (repeating phrases previously heard in appropriate contexts for communicative purpose), and often repeats an adult's spoken words immediately after hearing them.

S's morning or afternoon activities are represented by tactile symbols in a 5-compartment calendar box. Expansion strips are used to pair two tactile symbols in each compartment, introducing the concept that familiar words can be combined in novel ways. Touch prompts remind him to scan left to right. Materials in S's routines are also sequenced in a calendar box, to provide additional structure and give him practice scanning left to right.

Hank was comfortable following S's lead during preferred interactions, such as playing with a balloon. He chose to analyze S's grooming routine because he wanted experience implementing intervention strategies during more outcome-oriented routines. Hank's goals were to feel calm during his interactions with S, be less directing, and follow S's lead more often.

  • Help S stay engaged (attention) without becoming overstimulated (regulation of intensity of the interaction), by slowing the pace, using a quieter voice, focusing on feeling calm, and providing deep pressure to S's arms with lotion
  • Make the routine more conversational, by pausing (turn giving), allowing S to introduce something new (initiatives), observing (attention), and appropriately responding (confirmation, positive answers, turn taking) to those initiatives

During the second interaction, Hank felt calmer, the pace was slower, and the routine was more conversational. He commented and paused more, S had more initiatives, and he was more responsive to those initiatives. Simple, familiar labels spoken in a rhythmic manner ("jaw, jaw, jaw," "chin, chin, chin," "lip, lip, lip") helped S stay organized, focused (attention) and calm (regulation of intensity of the interaction). Hank's sound effects and funny voices also kept S engaged (affective involvement). When Hank modeled toothbrushing, he was able to redirect S from his hair to his face before S became overstimulated (regulation of intensity of the interaction). While deep pressure to S's arms seemed to help calm and organize him, he showed signs of being overwhelmed by the lotion. Hank got a lot of information about how S was feeling by watching his hands (attention). This helped him fine tune his responses.

Hank will keep interactive turns short in situations where S might become overstimulated, and be sensitive to what his hands are "saying" during interactions (attention, regulation of intensity of the interaction). He'll incorporate rhythmic, turn taking vocal games into interactions, to help S stay engaged, focused, organized and calm (attention, regulation of intensity of the interaction, affective involvement). He will continue to give S deep pressure, but no longer use lotion, and ask the OT for additional calming and focusing strategies. Hank will also continue inviting S to introduce initiatives, by commenting then pausing.

Sara and N

N is 9 years old. She had a corpus callosotomy (surgical severing of the corpus callosum, the large fiber bundle that connects the two sides of the brain) at 4 years of age, to control seizure activity that began at 4 months. She has a cortical visual impairment and a suspected mild to moderate hearing loss. Without amplification (which she does not tolerate wearing), "She will at least be able to detect speech at a normal conversational level."

N bonds quickly with her primary caregivers. These relationships are reinforced through resonance-level turn taking interaction routines, in which frequent pauses allow her to signal for continuation of the interaction. N is affectionate with familiar people, seeks them out and allows them to calm her when she becomes upset. Vibration, deep pressure touch and vestibular stimulation help calm N and enable her to attend. N will explore unfamiliar experiences with the people she trusts. Unexpected touching and guiding through movement may overstimulate her.

N receptively understands some object symbols, natural gestures and points. She will move toward, touch, or physically guide people to desired objects, actions and locations. An object symbol placed in a single compartment calendar basket helps N anticipate the "next" activity in her day. She demonstrates recognition of those symbols by performing appropriate actions on the objects or moving toward the correct activity areas. The symbol is placed in a "finished" basket to conclude the activity. N shows a general awareness of the time of day by, for example, going to the breakfast table after arriving at school in the morning, and getting her jacket in the afternoon as she anticipates going home. She recognizes her classroom, calendar area, seat at the table and possessions.

A 3-step sequence box is used in some routines, such as breakfast, to help N anticipate the sequences of steps and to establish clear beginnings and endings. With other routines (for example, hygiene) she chooses the order of steps in the sequence. In general, N is more willing to participate in activities that have become familiar, when high demand activities are followed by those with low demand, and if she is allowed to observe and join in without being forced, then retreat and process the input. She is less distracted in learning environments where visual and auditory clutter is reduced.

Sara's goals were to increase the length, and improve the quality, of her interactions with N during functional routines. She selected a hygiene routine to analyze.

After studying the baseline video, Sara decided to:

  • Put more emphasis on creating and maintaining a positive social atmosphere and less on getting the job done (regulating the intensity of the interaction, affective involvement)
  • Increase the number of turns on N's topics (C to E and A to E)

During the second interaction, Sara was more responsive to N's topics (confirmation, positive answers, turn taking, turn giving, attention, affective involvement), and less focused on completing the routine. When N needed to take a break and process information, Sara let her do this. By allowing these pauses, and providing calming proprioceptive and vestibular input at other times, Sara helped N manage her own biobehavioral state (attention, regulating the intensity of the interaction). The interaction lasted longer, and N stayed in the activity area. There were also more arrows between turns, indicating longer periods of connectedness within the activity, and the turns were often on N's topics (C to E to B to E, etc., or A to E to B to E, etc.). When N signaled a request (initiatives, turn taking), Sara responded (turn taking, positive answers), then gave N another turn (turn giving). During toothbrushing, N let Sara touch the toothbrush (turn giving), which she usually doesn't allow, and was attentive (attention) to Sara's imitation (confirmation, positive answers) of her actions. N and Sara both enjoyed this interaction (affective involvement).

The most effective way to support an interaction on N's topic is to pause (turn giving), observe (attention) her independent or interactive behavior, imitate that action (confirmation, positive answers, turn taking), then pause again (turn giving) so she can take another turn. This verifies to N that her initiative has been acknowledged and approved.

Since the training, N has begun initiating and maintaining interactions from further away (indicating that she seems to be moving into a coactive phase of interaction), and attending for longer periods of time, sometimes for as many as 10 turns. The hygiene routine now goes on for quite a while, and sometimes must end before N is ready, so she can participate in other scheduled activities. When N is allowed to initiate interactions on topics of her choice, even within functional routines, and the adult responds positively to those topics, she more willingly participates on the adult's topics at other times.

Enduring effects

In a recent study, Dr. Marleen Janssen and her colleagues found "...that it is possible to improve the interactive competence of deafblind children by teaching their educators to respond more adequately to the children's signals and to adapt the interactional context." (Janssen, Riksen-Walraven & van Dijk, 2004, p. 88). They also concluded that "...the positive effects of the intervention were retained for two children and diminished but nevertheless remained well above the baseline level for two other children." (Janssen, et al., 2004, p. 89). In addition, these positive effects endured even after staff changes were made following the intervention. This was attributed to training provided by previous staff to new staff, and consisted of "...two components: a) the new staff member observes an educator working with a child and is given information by the educator; b) the new staff member is later coached by the educator while working with a child. While not instructed to do so, the current staff apparently transferred the principles of the intervention to the new staff members via either explicit teaching or having the new staff observe their improved interactions with the deafblind children." (Janssen, et al., 2004, p. 89-90).

At TSBVI, continuity in the implementation of student-specific intervention strategies is maintained with videotapes and written summaries from interaction training, ARD documentation that incorporates information learned during the training (communication assessment recommendations, IEP objectives, instructional modifications, etc.), end-of-the-year videotapes, instructional support staff who provide services to the same students for multiple years (especially communication and behavior specialists), and previous classroom staff, who may be teaching other students on campus but are available to assist new team members. Continuity is also provided by past interaction training participants, who have generalized their understanding and application of interaction principles and intervention strategies.

Participant feedback

"These intensive trainings are extremely useful. Observing and analyzing oneself on video is so important. It always amazes me to see things that I'm not even aware of doing, or not doing. It is also useful to get feedback from a variety of people. Everyone has an opinion about how to make an activity better."

"I was shown how to effectively communicate with my student, as well as how to increase his participation during activities. I liked being able to discuss my student with the other participants, share instructional challenges and frustrations, and brainstorm together. Through our discussions, and the information that was provided, new solutions and strategies were discovered."

"I'll carry away valuable information that will help enhance the quality of my interactions with my students. Being aware of your own interactions, consciously thinking about them, can help improve them."

"I will be more aware of possible initiations by my students, and remember the importance of having both physical and emotional presence during activities. The coding helped me break down interactions, and showed how even a student's most seemingly insignificant gesture may be an attempt at communication."

"I received a lot of helpful information about what a good interaction should look like and feel like; giving and taking turns, etc. I will introduce more novel routines, and label the environment so I can be there to comment, instead of always being the one to provide information. The before and after videos with my student showed me that positive interaction is possible, and that we can both enjoy the activity."

"I will be more aware of my interactions with my students, and mindful about allowing maximum opportunities for student initiation. I really appreciated and valued the opportunity to evaluate my performance, to set goals and to see them being achieved. It helped respark my enthusiasm to try new ideas and see how they benefit my students. It also encouraged me to focus on the positive aspects of my teaching. Sometimes it's easy to see only the negative."

Conclusion

We hope this information has motivated you to take a closer look at your own interactions. Learn more about the unique characteristics that impact your deafblind student's ability to interact. Analyze your interactions. Recognize and celebrate the qualities that are successful, and identify specific ways to improve the interactions, by changing your interactive behaviors and by adapting the interactive context. Remember, you make the difference.

References

Amaral, I. (2003). Analyzing teacher/child interactions: What makes communication successful? Paper presented at the Communication is the Key to Opening Doors Worldwide XIII DbI World Conference. Mississauga, Canada.

Blaha, R. (2001). Calendars for students with multiple impairments including deafblindness. Austin: Texas School for the Blind and Visually Impaired.

Blaha, R. (1996). Thoughts on the Assessment of the Student with the Most Profound Disabilities. SEE/HEAR Newsletter, Fall 1996, Vol. 1, (#4), 13-21.

Hagood, L. (1997). Communication: A guide for teaching students with visual and multiple impairments. Austin: Texas School for the Blind and Visually Impaired.

Janssen, M.J., Riksen-Walraven, J.M., & van Dijk, J.P.M. (2002). Enhancing the quality of interaction between deafblind children and their educators. Journal of Developmental and Physical Disabilities, 14, 87-109.

Janssen, M.J., Riksen-Walraven, J.M., & van Dijk, J.P.M. (2003a). Contact: Effects of an intervention program to foster harmonious interaction between deaf-blind children and their educators. Journal of Visual Impairment & Blindness, 97, 215-228.

Janssen, M.J., Riksen-Walraven, J.M., & van Dijk, J.P.M. (2003b). Toward a diagnostic intervention model for fostering harmonious interactions between deaf-blind children and their educators. Journal of Visual Impairment & Blindness, 97, 197-214.

Janssen, M.J., Riksen-Walraven, J.M., & van Dijk, J.P.M. (2004). Enhancing the interactive competence of deafblind children: Do intervention effects endure? Journal of Developmental and Physical Disabilities, 16, 73-94.

van Dijk, J. (1999). Development through relationships: Entering the social world. Proceedings of the Developing Through Relationships XII DbI World Conference. Estoril, Portugal: Casa Pia de Lisboa.

van Dijk, J., & Nelson, C. (2001). Child-guided strategies for assessing children who are deafblind or have multiple disabilities. Sint-Michielsgestel, the Netherlands: IvD/MTW, AapNootMuis.

Vervloed, M.P.J., van Dijk, R.J.M., Knoors, H, & van Dijk, J.P.M. (2006). Interaction between the teacher and the congenitally deafblind child. American Annals of the Deaf, 151, 336-344.