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Winter 2002 Table of Contents
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Visual Stimulation: A Personal Reflection on Its Role and Benefit

By Millie Smith, Educational Consultant, Austin, Texas

Sometimes new knowledge shows me that something I have been doing is even more helpful than I thought it was. That has turned out to be the case with vision stimulation for infants and toddlers, and students with the most profound disabilities at any age. When I first began doing visual stimulation activities with students, I was very focused on increasing their visual efficiency. I wanted them to get in the habit of using whatever vision they had to, as best they could, interact with people and objects in their environments. I still want that, but I know now that something much bigger is happening as a result of these sensory experiences. In this article, I want to share some of the most important things I have learned about this, and give a couple of examples of how I have used this information with students.


Children around one year of age or younger, either chronologically or developmentally, are what Jean Piaget called sensory-motor learners. What he meant by that is that they learn about their worlds by sensing it and acting on it. The sensory part is seeing, touching, hearing, tasting, smelling, and moving (vestibular). The motor part is using muscles to respond to the sensory source by exploring it, by trying to make it do something, or by stopping it. A sensory-motor experience includes both a sensory event and a motor response. The very best learning takes place when these two things happen together --- when a sensory event is taken in, and muscles are used in response to it. This tends to happen in two phases. For example, a baby sees something it likes, maybe the glasses on your face. She gazes at the glasses. This is the passive phase. Then, she is likely to try to grab these miraculous light-reflecting glasses. If she can get them in her mouth to explore them, she will. This is the active phase. Together they make up a sensory-motor experience. The result is high quality learning. Our knowledge of our world is made up of the accumulation, interpretation, and organization of thousands of these kinds of experiences. If there is a sufficient ground of experience at this level, the child can begin to know that objects continue to exist when they are not immediately part of the sensory-motor experience. This is called object permanence. Now the child is beginning to be what Piaget called a preoperational thinker. This kind of thinking opens up the world of symbols, imitation, and imagining (Furth, 1970).

The science of neurobiology, through use of technologies like PET scans and MRIs, has added much to our understanding of sensory-motor learning. At birth, the brain is the most immature of all our organs. It continues to grow and develop during the first years of life. In normally developing infants, its size actually doubles in the very first year of life (Kotulak, 1996). We know now that brain growth occurs as a result of the building-up of thousands of neurological connections between brain cells. These connections, or pathways, are established as children participate in sensory-motor experiences. When these experiences are repeated, connections strengthen. This is practice. You play the piano better after years of practice because neurological pathways related to the playing of a specific piece of music are very well established. A baby brings his hands together at midline better after he has practiced that action hundreds of times. A neurological groove is in place. These grooves make things easier and more efficient (Greenough, 1985).

This growth and refinement is highly dependent upon the infant's early sensory experiences. Experiences in all the senses are important, but early visual experiences play a particularly important role no matter what the quality of vision may be. A huge portion of the brain is dedicated at birth to visual processing. This may be because vision is the first sensory channel an infant uses intentionally to access information about his world. The eyes and head move voluntarily, and with more refinement, much sooner than any other part of the body. Gradually, portions of the cortex available for processing visual information begin to be used for processing other kinds of sensory information, if the quality of that information is significantly better. The only way this process can unfold as it should, is by providing in infancy sensory experiences in all channels, including vision (Kolb, 1998).

Children deprived of rich and frequent sensory experiences develop brains 20% to 30% smaller than normal for their age. They suffer corresponding decreases in cognitive ability. This effect has generally been studied in children from impoverished backgrounds (Campbell and Ramey, 1994). Children with significant sensory impairment at birth are also at risk in the area of cognitive development because, without intervention, the quantity and quality of their sensory experiences may be significantly diminished. They cannot access many of the ordinary sensory events in their environments. If a visually impaired child has a mobile over her crib that is too far away, or has objects on it that are too hard to see, it is the same as if it were not there (Barraga, 1976). The children most at risk are those with visual impairments, hearing impairments, severe motor impairments, and especially those with some combination of these impairments. The quality of intervention we provide will determine whether or not children and students with these challenges have adequate sensory experiences for cognitive growth.

Now, it is time for a big caution. If sensory-motor experiences aren't provided in just the right way, they may be harmful. For the last several years there has been a lot of material in neurology, child development, and behavioral journals about the relationship of stress hormones to learning. It seems that stress hormones inhibit memory function, and prolonged stress can actually break down neurological pathways in parts of the brain. Young children with multiple and severe impairments are constantly stressed as a result of having limited or no control over when, how, and what kinds of sensory input they might be subjected to. In addition, when interactions with others around these sensory events are associated with demands, stress levels are even higher. As demands increase, so does stress (Gunnar, 1996).

Quality sensory events must have a level of intensity that is accessible to the sensory impaired learner. The only way to provide those quality events without producing stress is to choose events we think the child will enjoy, and to make sure the child knows that we will respond to his signals to continue or to stop the event. The only way to invite motor responses to events without creating stress is by following the child's actions. We must join, not demand. We do this by watching to see what the child is doing and then gently beginning to do it with him, matching his pace and level of intensity. After a while we might pause, and wait to see if the child does something that invites us to "go again." When a bond of trust is established, we can expand on the initial child initiated response and invite a new behavior (van Dijk, 2000). An instructional strategy called "routines" is a very good way to structure sensory-motor learning experiences that avoid stress.

When children have severe motor impairments, the motor part of sensory-motor learning is very challenging. What is motor learning for these students who can move very little? Most of us were taught to facilitate their participation by moving their hands for them. This was called hand-over-hand instruction. There is something obviously problematic about this approach. How does the child learn anything if somebody else's brain is doing all the planning and somebody else's muscles are doing all the work? Event-related brain potential research indicates that a motor event isn't what most of us always thought it was. It turns out that there are several phases to every motor event. The electrical activity in the brain can be measured during each phase. A motor event begins with a preparation phase during which the person plans and gets ready. The electrical activity in the brain is very high during this phase. Next is the initiation phase, beginning to move, which is also accompanied by very high cortical activity. The execution phase, the carrying out of the activity, is next. Surprisingly, brain activity levels drop significantly. Finally, there is a termination phase, with relatively quiet levels of brain activity (Deecke, 1996). This is such good news. The two most important phases are preparation and initiation. They are the two phases that all children, no matter how severe their motor impairments, can participate in independently. All children can prepare if they know two things --- what is happening next and some body will wait for them to do their part. All children can initiate if they can tense a muscle, blink an eye, open or close a mouth or hand, lean a head forward or backward, or extend an arm or leg a tiny bit. Then we can go ahead and facilitate the execution phase by helping their hands, preferably with a hand-under-hand technique whenever possible. Again, structuring experiences using the instructional strategy of "routines" helps ensure that these elements will be in place.



I met Julie several years ago when she was three years old. Her teacher was at a loss. Julie didn't seem to respond to any of the lights, colors, textures, or sounds that were part of her educational environment. Julie was drowsy most of the time and seemed to actually go to sleep when the teacher put her on the mat to work with her. The teacher and I did an arousal state baseline and found out that Julie was alert only 15% of the time she spent at school. Alert states were about forty-five seconds in duration and happened most often as a result of being moved or touched. Julie's drowsiness was largely a result of under-stimulation. The things available to her weren't in the sensory channels she was ready to use or they did not have the levels of intensity she needed. Some of her experiences with sensory events were too stressful. She didn't know what was going to happen to her, and she didn't like some of it. Julie's "going to sleep" when her teacher tried to work with her was really withdrawal brought on by stress.

Our first goal was to begin building up Julie's cognitive stamina by increasing the amount of time she was alert. A state of alertness is necessary for learning. We began by doing a sensory response assessment to determine what kind of sensory input Julie enjoyed most. Julie's team spent several days carefully trying different sensory events in each sensory channel, with lots of recovery time between each one. They paced each of these events to allow time for Julie's sensory-neural system to process the information they provided. They avoided startle responses, and repeated events only if Julie showed a positive response. Julie's mom had to come in to help them interpret her responses. Mom showed them how to watch for muscle tone, skin color, and breathing changes. She told them that tightening of the muscles around Julie's lips was smiling, and flushing was mad. Brief light breathing was excited. If it went on for more than a few seconds, though, it was scared. After about a week, they had an appetite list for Julie. These were the things she liked. They also had an aversion list. These were the things she didn't like.

We took items from the appetite (like) list and made routines. For a student like Julie, routines tend to be basic.

  1. Find out what's going to happen.
  2. Transition to the place where it is going to happen.
  3. Do it.
  4. Ask to do it again.
  5. Find out it's finished.

Each step is critical, but none is more critical than the first. Cueing students to let them know what is about to happen sets the stage for learning. It lowers stress and enables them to focus cognitive energy on the activity. Unfortunately, it is also the step most often left out. We have to change that.

The first routine we wrote for Julie was swinging on the platform swing. Tim, the teacher, did this routine with Julie.

  1. Tim told Julie what was going to happen by presenting her object cue for the activity. Object cues will be different for each activity and for each student. They should be an object from the event that is very important to the student. Julie's swing had a sheet of bubble wrap over a foam wedge placed on the platform. She loved the wrap. So, Tim cued her for swing time by first letting her hear the bubble wrap as he scrunched it up near her ear, then touching it to her arm, then her cheek. He had to be very careful not to startle Julie. By talking to her as he approached with one of the cues that helped her prepare for the presentation, Tim taught Julie to trust him.
  2. Tim pushed her travel chair to the swing, lifted her, placed her supine on the wedge, and then rolled her to prone. He did all of this exactly as the physical therapist trained him to do it. He waited a couple of minutes to allow Julie to get used to her new position.
  3. Tim began gently swinging Julie. He sat on the floor by Julie's head so he could watch her face while she was swinging. Her eyes opened wider, her lips stretched a bit into what we had learned to recognize as her smile, and the muscles in her neck and shoulders tensed. The latter is what the physical therapist was hoping for. At first, Tim just did the swinging until Julie began to poop out. When her stamina increased to about two minutes, he began to do step four.
  4. Tim would stop the swing and wait. He treated the first thing Julie did during the wait as a signal to start again. The first time he stopped and waited, she blinked her eyes several times; he started. The next time, she moved her head a little; he started. After many days of this, she began to understand that if she did something, the swinging would start. Blinking became her favorite signal. When this was pretty consistent, Tim waited for the blink. That whole process took about two months.
  5. Tim told Julie that swinging was finished by rolling her over and removing the bubble wrap from under her as she was turned. He gave her about fifteen seconds to process this information and to notice the absence of bubble wrap. Then he lifted her from the swing.

Some of Julie's other favorite routines included:

Exciting things happened in each routine. She gave the team her first vocalizations with the stereo speaker routine and the first voluntary movement of her hands and feet with the water routine. They began by moving the water themselves. Then, much to their surprise, Julie began moving her own hands and feet a little bit when they stopped and waited. They kept her aversion (dislike) list and reintroduced some of the things she hadn't seemed to mind too much. Some of these became appetites. If she responded negatively, staff never repeated them without a long break. They didn't ever repeat the ones that got strong negative responses. After three months, Julie was alert for 40% of her time at school and the duration of each alert episode was about three minutes. After six months, she was alert 70% of the time and the duration was six minutes. By now, she was able to orient and stay alert when she was on her own. For instance, she had never responded to colored lights, which had only been presented as colored filters on a flashlight. At this point in her progress, though, a color wheel was tried. The combination of light and movement worked. Julie would watch it for about five minutes, smiling her Julie smile. This type of passive stimulation is not good for learning, but it will, at least, help maintain alertness when a teacher can't be present or when the student needs a break. That is important. During the times somebody was with Julie, she worked on lots of cognitive, communication and motor skills that were targeted in her routines.


I met Zap when he was twelve years old. Zap's teacher, Sue, asked for help because she couldn't get Zap to do anything with objects. If she tried to put something in his hands, he dropped it or threw it. He spent most of his time watching his waving hands in front of light sources like ceiling lights, windows and doors. Our first goals were to give Zap the sensory input he was craving in more appropriate ways and get him to hold objects. We knew he liked creating visual displays and that he needed a lot of contrast and some movement to do this. We knew that he did not like the tactual characteristics of the objects he was being given, particularly in his hand. We also suspected that Zap did not like being acted upon by another person. Part of what he liked about his self-stimulatory behavior (watching his hand wave in front of light sources) was that he was in charge of it. Part of what he didn't like about objects was that somebody else put them in his hands. In fact, this avoidance had generalized to a dangerous level. Zap moved away when people approached. He sometimes pushed, or hit out if they persisted in being close to him. He was stressed by the very prospect of something being imposed on him.

The team began by trying to lower Zap's stress level. They wanted to join him and build trust. For instance, when Zap would scoot over to the window and begin waving his hand in front of his face, Sue sat near him and waved her hand in front of her own face. When Zap got used to this, Sue would reach over every once in a while and wave her hand in front of his face. Zap looked intensely at her whenever she did this. At least he was interested and didn't move away. Then, Sue started saying, "Here comes my hand," in a voice with a kind of singing quality, and slowly moved her hand toward Zap. After a while, Zap would look at Sue and smile when he heard the words. Now, Sue always waited for Zap's look before moving her hand. Zap learned that he was in charge. He learned that his look was a signal he could use to control his teacher's behavior. He learned that his teacher would always honor his signal and, therefore, could be trusted.

We turned this into a routine that gradually grew over time as steps were added. It started with these steps.

  1. Go to window and sit down. (This was Zap's cue to his teacher to start the routine.)
  2. Begin to wave hand.
  3. Look at teacher to request her part.
  4. Repeat as desired.
  5. Stop looking at teacher to end routine.

Sue elaborated on the game. She started putting different things in her hand. She would say, "Here comes the shoe," and wave the shoe in front of Zap's face. They built up quite a repertOíre of objects --- a shoe, a plate, a piece of chain, a wind chime, a mirror, a towel, a glove, a wiggle pen, etc. Sue put all these things in a basket so Zap could hear her getting the objects out of the basket and putting them back in. When Zap ended the routine, Sue left the basket and walked away. She hoped that Zap would reach in there and start exploring the objects. Eventually, he did. If Zap wanted the piece of chain, he would dig around in the basket until he found it and then wave it. Sue added more things to the basket. He always chose the heaviest and smoothest objects - a barbell, the glass pitcher part of a blender, a weighted spoon, a horseshoe, etc. He was now holding and exploring many objects.

After a good trusting bond was established, Sue tried to expand to new environments. Zap's parents were very disappointed that he would not work at a desk like other students his age. Sue put a mirror against the wall next to the window. She waved the object in front of Zap's face as he sat on the floor and then wave the object in front of the mirror. That became a new step in the routine. She already knew Zap liked the mirror. Sure enough, he was very interested in this addition. When the routine ended, he would dig in the basket for his favorite objects and wave them alternately in front of the window and in front of the mirror. Next, Sue put the mirror on a low desk. Things proceeded as usual. Zap gradually lost interest in the window. Sue began to raise the desk legs so he had to stretch to see the mirror. She introduced a chair and Zap accepted it. Mom and dad were very proud the first time they walked into Zap's classroom and saw him sitting in a chair at a desk, picking up various objects to inspect in front of his mirror.

The team went on to develop routines with many of Zap's favorite objects. They made a horseshoe game routine packed with social, communication, and motor skills. They used the blender in a smoothie making routine. Zap used his barbells in a mainstreamed P.E. class.


Not all interventions I have been involved with have been so dramatic. I can honestly say, however, that I have never seen these principles applied correctly without good results of some kind. It takes information and training to provide this kind of programming. One of the reasons so much skill is required is that each intervention is unique. No two sensory-neural systems are alike. Experiences and behaviors are different. Everything must be taken into account to design the right combination of cognitive, social, behavioral, sensory, and motor elements. Usually, to pull this off, a team must work together. A very good book to start with is Essential Elements in Early Intervention by Deborah Chen. Almost all the regional education service centers have workshops on routines. Some are also beginning to offer workshops on using sensory experiences to manage arousal states. You can request these workshops by getting in touch with the person in charge of training for low incidence populations at your region's education service center. Technical assistance for individual children and students is available from most education service centers, and from the Outreach Program at the Texas School for the Blind and Visually Impaired.

My experience confirms my belief that, with the proper attention to sensory-motor learning, all children and students can be active learners with the possibility of realizing their full potential, regardless of their age or ability or the complexity of their challenges.


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