Main content

Alert message

Originally published in Texas SenseAbilities Fall 2008
Versión Español de este artículo (Spanish Version)

Lisa Ricketts, OTR, Texas School for the Blind and Visually Impaired

Abstract: This article discusses the impact of visual impairment on sensory integration, and how sensory integration disorder manifests in students with blindness and visual impairments.  Treatment approaches and educational interventions are also described.

Keywords: sensory integration, blindness, visual impairment, motor development, tactile skills.


As an Occupational Therapist at TSBVI, I am inspired to learn all I can about the theory of sensory integration by Dr. A. Jean Ayres. As a specialist for children with visual impairment and multiple disabilities, I am studying the impact of vision loss on the other senses and overall developmental progression. I also work at a sensory integration clinic here in Austin for the treatment of autism and sensory processing disorders.

I am lucky to be surrounded by expert teachers, therapists, school psychologists, and, most importantly, by my students, whom I learn from every day.  My purpose here is to share terminology, explanations, and problem solving ideas with students, parents, and teachers.

Sensory Integration and Motor Control

The author and initial researcher of the Sensory Integration Theory used in Occupational Therapy is Dr. A. Jean Ayers.  Her work presents an expansive theory describing how the brain and the body processes, organizes, and integrates the sensations received through sight, sound, touch, taste, smell, body position, and movement.

Students with visual impairment rely on hearing, touch, body position and movement sensations for everyday activities.  Normally these activities are directed by vision. Sensory Integration theory provides a framework to help emphasize and explain the role of all our sensory systems.


The tactile system processes touch experiences felt through the skin as light touch, firm touch or pressure, static touch, moving touch, temperature, pain, and comfort. There are two primary functions of the tactile system. One is protection and the other is discrimination.

The protective touch function is neurologically bound to the limbic system of the brain.  This system is described as the emotional control center with direct connections to the primal flight or fight responses. The protective function of the skin is reflexive and primarily unconscious with touch sensations automatically categorized into calming, soothing, familiar sensations, or into danger reactions.

The discrimination functions of the skin are conscious, cognitive tasks that are learned through experience.  These include touch localization, recognition, and stereognosis. Localization refers to knowing where on the body one is being touched. Tactile recognition is required to learn characteristics of objects such as size, shape, texture, and the weight of items.  Stereognosis is object recognition through touch.

Signs of tactile system imbalance:

  • Reacts negatively to touch, does not like being picked up or hugged.
  • Does not like being touched and may rub or press on his or her skin after being touched.
  • Startles easily.
  • Inability to feel touch immediately and responses are delayed.
  • Extraordinarily high or low tolerance for pain.
  • Does not like certain clothing or tags in clothes, and wears clothes for the wrong season.
  • Does not like band-aids or stickers on skin.
  • Uncomfortable wearing shoes or socks, or unwilling to walk barefoot.
  • Does not like brushing hair or teeth, or cleaning and trimming nails.
  • Avoids certain foods because of texture, or does not chew food well.
  • Rejects touching messy materials and will not handle clay, mud, shaving cream.
  • Washes or wipes hands often.
  • Uses fingertips instead of the entire hand.
  • Has a hard time sitting still.
  • Is poorly coordinated, is a heavy walker, or walks on toes.
  • Craves touch and may over-touch others or objects.
  • Doesn’t notice when hands or face are messy.
  • Doesn’t notice when clothes are twisted, or when feet are not well placed in shoes.


Body Position

Proprioception refers to body position sensation and is required to regulate movement and posture. This system allows us to feel the position of our limbs for motor control and to determine the amount of strength needed for specific actions, or graded force. It is an unconscious feedback system between the muscles & joints of the body and the brain. The receptor stimuli is the bending, straightening, pulling, and compressing of the body’s joints between the bones. Proprioception is neurologically connected to both the tactile and the vestibular systems.

Signs of proprioceptive system imbalance:

  • Has difficulty planning and executing motor tasks for gross or fine motor activities such as getting on or off a bike or riding toy, climbing on/off playground equipment, buttoning clothes, turning on/off a faucet, pouring, etc…
  • Has a high need for jumping.
  • Enjoys hanging by the arms.
  • Tends to lean on or hang on people or furniture.
  • Enjoys falling down.
  • Assumes odd body positions.
  • Is clumsy and plays roughly.
  • Breaks toys often.
  • Grips a pen or pencil too loosely or too tightly.
  • Has difficulty with fine motor skills for picking up small objects.
  • Did not crawl much during early development.
  • Difficulty grading muscle force—muscle exertion is either too much or too little to manipulate objects and perform tasks.
  • Puts non-food items in the mouth, chews on clothes, or grinds teeth.
  • May hit, pinch, or bite self or others.


Vestibular processing refers to movement and balance sensations.  These are the combined functions of the semicircular canals of the inner ear, basal ganglia, cerebellum and the cerebral motor cortex. This system regulates the feelings of motion such as balance, acceleration, deceleration, starts and stops, direction, rhythm, and creates and stores patterns of movement. The hair cells inside the semicircular canals are activated according to position and movement of the head in relation to gravity. Vestibular processing is likely to be impacted by auditory impairment.

Signs of vestibular system imbalance:

  • Difficulty maintaining balance and controlling the speed and direction of movement.
  • Poor balance reactions such as protective extension or righting responses.
  • Poor spatial orientation and is easily confused by directions.
  • Fears being upside down or tipped sideways.
  • Is anxious when feet are not touching the ground.
  • Is anxious about walking up or down inclines.
  • Is anxious walking up or down stairs.
  • Rejects unfamiliar movement activities and is afraid to move backwards.
  • Is afraid of movement, or is gravitationally insecure.
  • Gets motion sickness easily.
  • Is anxious about swimming.
  • Seeks out gross motor movement and may have a very high tolerance to spinning.
  • Possible extraneous or non-purposeful movements.
  • Can’t sit still—craves movement.
  • Likes to fall without regard of safety.
  • Difficulty with self regulation.
  • Needs to be moving but this may interfere with listening and interacting.
  • Needs to be moving in order to listen or be attentive.
  • Needs to jump or spin.
  • Likes inverted upside down position.
  • High or low muscle tone­—the vestibular system combines with the proprioceptive system to regulate muscle tone.


Impact of Sensory Integrative Dysfunction

Sensory integration is the organization of sensation for use.  Countless bits of sensory information enter our brain at every moment, not only from our eyes and ears, but also from every place in our body.  Sensations are food for the brain that provide energy and knowledge needed to direct our body and mind.  The greatest development of sensory integration occurs during an adapted response; this is a purposeful, goal directed response to a sensory experience.  In an adaptive response, we master a challenge and learn something new.  At the same time, the information of an adapted response helps the brain to develop and organize itself.  The first seven years of life our brain is a sensory processing machine nourished by having fun through play and movement.  The child who learns to organize play is more likely to organize activities of daily living.

If the brain does a poor job of integrating sensations, this will interfere with many things in life.  The brain is not processing or organizing the flow of sensory impulses in a manner that gives good, precise information about the body or the world.  Learning is difficult and a child often feels uncomfortable and cannot easily cope with demands and stress.  If a child is blind or visually impaired this difficulty is compounded when attempting to make sense of his or her world.

Complex medical problems associated with many syndromes at birth may result in delayed sensory integration development.  This delay may be due to either neurological disorders or medical issues creating limitations to sensory experiences that nourish the brain.  Symptoms of irregular sensory processing in the brain are different for each child.  There are three basic sensory systems that impact how a child learns and behaves in the environment. They are the tactile, vestibular, and proprioceptive systems.  The following outline is a brief description of symptoms observed in each of the three systems when dysfunction of sensory processing is present:


The Tactile System (Discriminative versus protective touch)

Dysfunction in the discriminative system may result in:

  • Difficulty with fine motor skills impacting daily living skills.
  • Problems articulating sounds due to inadequate information from touch receptors in and around the face and mouth.
  • Difficulty with accurate tactual perception and basic concepts.
  • Impaired awareness of body scheme.
  • Inefficiency in how one tactually explores an object or the environment in order to gain additional cues which give meaning about the object and about the environment
  • Contributes to somato dyspraxia – a specific disorder in motor planning

Dysfunction in the protective system may result in:

  • Interpreting ordinary contact as threatening
  • May be frequently in a state of Red Alert
  • May react with flight/fright/or fight, either physically or verbally.
  • Being labeled tactually defensive
  • Some children feel too much and feel too little.  Some may have a high tolerance for pain because they do not accurately feel what is happening to them.
  • They may not react to being too cold or too hot because they are unaware of temperature.

Proprioceptive System

The proprioceptive system is our unconscious awareness of muscles and joint positions that constantly send information to the brain to tell us our body position and posture.

Dysfunction in proprioception results in: Slower body movements.

  • Clumsier movements.
  • Movements involve more effort.
  • Difficulty grading muscle force—muscle exertion is either too much or not enough when manipulating objects or performing activities.
  • Difficulty feeling the weight of objects
  • Difficulty planning body movements while performing gross or fine motor activities (getting on or off a riding toy, buttoning clothes, turning on a faucet, etc.)

Vestibular System

The vestibular system responds to the position of the head in relation to gravity and accelerating or decelerating movement, and linear or rotary movement. Vestibular receptors are the most sensitive of all sense organs and are major organizers of sensations to all other sensory channels.

The location of the vestibular system is in the inner ear called the “labyrinth.”  Abnormalities of the ears and hearing loss are common features in many syndromes, the influence of this system plays a major role in the developmental milestones of sensory processing and gross and fine motor skills.

Influence of vestibular system on eye and neck muscles:

  • Ability to visually follow objects.
  • Ability to move eyes from one spot to another.
  • Ability to interpret—is it an object, our head, or our whole body that is moving?
  • Ability to interpret—is our head moving or tilted?
  • Ability to maintain a stable visual field.

Influence of vestibular system on muscles of the body:

  • Generates muscle tone.
  • Helps us to move smoothly, accurately, and with proper timing.

Influence of vestibular system on postural and equilibrium responses:

  • Maintains balance.
  • Controls spontaneous body adjustments.
  • Facilitates co-contraction of muscles.
  • Elicits protective extension and other balance reactions.

Other areas influenced by the vestibular system:

  • Reticular Interactions – responsible for arousal of nervous system (calming effects vs. arousal effects); the vestibular system keeps the levels of arousal balanced.
  • Relation to Space – perception of space; position and orientation within that space.
  • Auditory Processes – helps the brain process what is being heard; vestibular disorders slow down speech development.
  • Emotional Development / Behavior – for emotions to be balanced the limbic system, which generates emotionally based behavior, must receive well modulated input from the vestibular system.


Two types of vestibular disorders


Under-reactive vestibular system:

  • Child may tolerate an enormous amount of movement (merry-go-round, swinging, spinning) without getting dizzy or nauseous.
  • Has poor integration of the two sides of the body.
  • Is easily confused by directions or instructions.
  • Hands and feet do not work well together. Poor bilateral coordination and upper/lower body coordination.

Over-reactive vestibular system:

Child is hypersensitive to vestibular input resulting in:

  • Gravitational insecurity – a feeling of anxiety or stress when assuming a new position, or when someone else tries to control movement or body position; swings, merry-go-rounds, and other playthings that move the body in non-ordinary ways may feel terrifying.
  • Intolerance to movement – discomfort during rapid movement; the child is not necessarily threatened by movement, but it causes  uncomfortable, or possibly nauseous feelings.

Evaluation and Intervention

If there is suspicion that a child has dysfunction with sensory motor processing, an evaluation can be conducted by either an occupational therapist or physical therapist.  Evaluation consists of both standardized testing and structured observations of responses to sensory stimulation, posture, balance, coordination, and eye movements.  The therapist who conducts the testing may also informally observe spontaneous play, and may ask the parents to provide information about their child’s development and typical behavior patterns.  A report will follow the evaluation that provides test results and interpretation of what the results indicate.  The therapist will then make recommendations regarding the appropriateness of therapy using a sensory integrative approach.

Providing intervention based on the principles of sensory integration theory requires that the therapist be able to combine a working knowledge of sensory integration theory with an intuitive ability to gain a child’s trust and create the “just right” challenge.  Therapy will involve activities that provide vestibular, proprioceptive, and tactile stimulation, and are designed to meet a child’s specific needs for development.

Activities will also be designed to gradually increase the demands upon a child to make an organized, more mature response.  Emphasis is placed on automatic sensory processes in the course of a goal-directed activity, rather than instruction on how to respond.  Parent or teacher involvement is crucial to the success of a child’s development and improved sensory processing.  The therapist may make suggestions to the parent and teacher about how to help a child in the home and school environment.

Sensory Integration and Sensory Motor Activities

Tactile Play Activities

Try the following ideas for tactile stimulation. If your child or student will not touch materials with their hands and fingers, don’t push.  Try letting them touch with a spoon or fork or straw, or try wearing dish or other gloves to get started. Keep soft cloths and water ready for clean up.  Provide wash cloths for frequent hand wiping as needed. If touching bath foam or finger paint is too stressful, put a small amount into a zip lock bag and hold and squeeze the bag. Begin play with dry textures if wet, messy materials are too stressful.

  • Try water play outside of demanding situations such as bathing and tooth-brushing. Use various textures of washcloths, sponges, water toys, squirters, water guns. Water plants with a spray bottle.  Clean and wipe tables or floors with sponges and a bucket of water.  Play with cool and warm temperatures.  Help wash dishes in warm water and rinse in cool.
  • Fill large storage bins with dry beans or rice, encourage play in the bin with hands and feet.  Hide small toys for searching, use cups and coffee cans for pouring, stir with large spoons, play with funnels and other kitchen toys.  Pour beans or other textured material outside on the sidewalk and try to walk across.
  • Use lotion for firm touch massage.  Teach self massage.  Remember that firm, deep touch is calming and organizing.
  • Consult an OT or PT familiar with skin brushing and joint compressions.  This is a technique recommended to help reduce tactile defensiveness with frequent, structured tactile and propriooceptive input.
  • Art activities: finger paint, modeling clay, glue and glitter, glue and sand.  Make art with pasta and glue or string and glue.  Glue designs on paper.
  • Create feely boxes or bags with a variety of textured materials and various textured toys.  Fill with fabric swatches to discriminate, label or match.  Fill with items to identify and describe, like wooden puzzle shapes, beads, etc.
  • For hand fidgets, keep a fanny pack available with a variety of textured items inside.  For squeezing try stress balls, thera-band, thera-tube, and stretch toys.  Use noisy squeeze toys for play.
  • Cooking activities – mixing and stirring cookie dough, pushing cookie dough into cookie cutters.  Measuring and pouring ingredients.  Make pudding and jello. Sift flour.
  • Carefully introduce various textures for exploration and play.  Place materials on a cooking sheet or plastic placemat – shaving cream, bath foam, lotion, play dough, silly putty, toy slime (gak).  Introduce toys for ideas such as a “bath foam or shaving cream car wash.”  Drive toy car through shaving cream or draw shapes and write designs with fingers.
  • Play dough – use rolling pin, cut dough with safe/dull scissors, practice cutting with knife and fork, use cookie cutters and molds, hide items to search for (coins, marbles, pebbles, or small toys).
  • Sand play – use cookie sheet, cover table with plastic, or play outside.  Use clean dry sand and a spray bottle with water for added moisture.  Play with cookie cutters or toys, such as plastic dinosaurs or cars.  Write in sand, or build shapes or a sand castle.
  • Fabric and texture play – use carpet squares for walking on; space out squares to find with toes.  Use swatches of various types of fabric (corduroy, satin, velvet, fake fur).  Play and walk on egg crate foam; also use foam to roll up inside “taco or hot dog game”
  • Trace raised lines of tactile maps.
  • Any pushing through the hands will help.  Such as on the tummy over a yoga ball holding body weight through arms and hands.  This “prone weight bearing” is very helpful for tactile tolerance, general strength, postural control, and proprioceptive/vestibular input.
  • Theraputty is a resistive exercise material used by therapists.  Colors vary according to resistive strength.  Hide toys, coins, or buttons inside for tactile searching.  Keep in a sealed container and be careful not to get on clothes or carpet. (It will stain and stick!)
  • Try vibration with massagers or vibrating mats or toys, squiggly pens, or electric toothbrushes.

Proprioceptive Play Activities:

  • Move as much as possible!  Jump on a trampoline or a mini-tramp. Bounce on yoga balls. Outside play on all kinds of equipment for supervised climbing and up and down a slide.
  • Prone weight bearing – such as four-point crawling or on the stomach over a therapy ball holding weight through arms and upper body.  If strong enough, try “wheel barrel walking.”  (Prone weight bearing is very important for postural strength, upper body and arm/hand strengthening, and reflex inhibition).
  • Scooter board activities: for small size scooter boards sit cross-legged and propel with hands.  Ideally have long size scooter boards available for riding on the tummy to propel with arms.  Add wrist weights for increased proprioceptive and pressure sensation. Try all directions, forward backward turning full circles left to right.  Push off from a wall to propel backward.  Crash into cardboard brick walls or stacked boxes.  Ride scooter board down a ramp to crash into toy bowling pins or crash into a large pillow.  Ride a scooter board short distances to search for and pick up toys or bean bags and return.  Try prone on a scooter board with a large rope to pull forward for hand over hand reach.
  • Add weights to items for more feedback.  For example add weight to a cane or pre-cane to help keep it in the correct position and to provide greater pressure feedback.  Small size wrist and ankle weights are available – these can be worn for extra proprioceptive feedback and can also be added to other items.  Ask OT/PT if a weighted vest might be helpful.  Weighted blankets are available or try heavy quilts.  Neck and shoulder wraps are available in drug stores sometimes designed to go in the microwave for heat – these can be used without heating around the neck or held in the lap.  Weighted sweatshirts can be made easily by sewing seams shut after filling with dry beans or rice or sand.  Wear loosely over the shoulder and back or on the lap.
  • Hang from a trapeze bar or chin up bar – if this is too scary have a step stool to stand on and feel the pull through the arms and hands without having to support full weight.
  • Teach simple isometric exercises such as wall push-ups and chair push-ups.  Teach modified push-ups and sit-ups.
  • Practice pouring over the sink or outside from heavy containers – gallon and ½ gallon jugs.  Practice pouring with pitchers filled with sand or other dry materials.
  • Use squeeze horns such as a bike horn. Have a variety of stress balls—there are many different types and interesting toys for squeezing. Wring water from sponges and cloths.  Squeeze bottle glue and squeeze bottle puff paints for art. Use spray bottles to water plants or keep spray bottles at sinks or in tubs for play.
  • Zoomball game” is a toy with a plastic ball strung on two ropes.  The ropes have handles on both ends and the object is to pull arms apart quickly to send the ball to your partner.  Arms are spread quickly and closed quickly for a successful pass.
  • Try using tools with supervision – hammer, screwdriver, pliers, or sanding wood. Use dull/safe scissors to cut heavy paper or cardstock.
  • Pull with a partner for tug-o-war games.  Pull a friend in a wagon or push/pull a laundry cart.
  • Roll in foam pad or quilt for deep pressure games—“the hot dog”, the “burrito”, or the “enchilada.”  Use rhythmical touch with hands or roll over with a therapy ball.  Try weighted balls such as a medicine ball (weighted PE ball).
  • Climb and lie under large pillows, bean bags, mattresses, or cushions.  If other students are available have them try to crawl across and then take turns being underneath.
  • Throw balls against a wall.  Throw to the left and right sides, forward and backward and overhead.
  • Vestibular Play Activities:
  • Sit and bounce on yoga balls.  Try prone (on the tummy positions) and supine (lying on the back).  Give support to lie back and stretch the back and hang the head backward.
  • Stationary bike and treadmill exercise.  Ride tandem bikes.  Help a younger child ride tricycles and bikes with training wheels for left/right integration and reciprocal control.
  • Ride stand up scooters (with handle bars) and support. Roller skate with hand hold support or put a large belt around the body to hold on to.
  • Bouncy shoes or “moon shoes”—these are large toy shoes that fit over regular shoes to bounce, jump, and walk with.
  • Try as many types of swings as possible—standard playground swings, platform swings, bolster swings, pogo swings (a bouncy and rotational swing) and hammock swings.
  • Use rocker boards and spin boards. Both are low to the ground and the rocker board can be used in sitting or standing with support. Try four point position (crawling position) or tall kneel position with support. The spin board is only used in sitting!
  • Try a T-stool.  Try to keep balance while throwing a ball against the wall.
  • Rolling games or races; rolling down or up hills outside. (Rolling is terrific for tactile, proprioceptive, & vestibular input and reflex inhibition).
  • Practice balancing on one foot.  Hop with feet together and hop on one foot.  Jump one foot to the other.  Practice marching, running, or stomping in place.
  • Try very low balance beams or tandem walking in a straight line (heel toe, heel toe).  Use hand hold support, hold onto a hula hoop, or dowel – add a bean bag to balance on the head for greater challenge.  Place a ladder on the floor and try to step across separate rungs.
  • Use an inner tube to step or hop inside and walk around the edges for balance.
  • Balance in tall kneel position or half kneel.  Toss a ball against the wall while holding balance or keep a bean bag on the head.
  • For smaller feet, place feet in shoe boxes to slide along the floor.  Try walking with swim fins.
  • Directional movement practice – use a heavy wooden chair for sit/stand commands, in front/behind move to the left/right sides, circle the chair, three steps forward/backward from chair.  Add music, slow and fast movements.  Combine with Simon Says and Red Light Green Light games.  Practice directional controls for facing the front of the room, the back, & either wall.  Practice facing north, south, east, and west.  Try quick change games for moving from sitting to standing to four point to stand on one foot, etc.  Practice turning toward sound.
  • Parachute games for up/down arm movements and shaking.  If a group is available try having kids crawl under to the other side.  Add a light weight ball and bounce the parachute to toss the ball over the side.

Heavy Work Activities:

Heavy work tasks are any activities that require whole body movement and resistance such as carrying heavy objects or carrying large size boxes; pushing through heavy doors; pushing a grocery or work cart; pushing a laundry basket; pulling a friend in a wagon; helping to move furniture; vacuuming—any activity that requires resistance with movement.

Heavy work activities are thought to provide the longest sensory effect with combined benefits of proprioceptive and vestibular stimulation (heavy work routines potentially have a calming effect on the nervous system for 4-6 hours).


Terese Pawletko, Ph.D
reprinted from: FOCAL Points, Fall 2002 Volume 1, Issue 2
The journal concerning Optic Nerve Hypoplasia & Septo Optic Dysplasia

As a former teacher of the visually impaired I was struck by the fact that a subgroup of children with whom I worked did not respond to typical interventions used in early intervention with children with significant visual impairment – for instance, multi-sensory approaches, narrating everything that was going on around the child, hand-overhand presentation. In fact, several of these children appeared to “retreat” and/or become distressed (e.g., might engage in stereotypic behaviors, “appear to be deaf”). Literature in the vision field did not provide an adequate explanation as to the cause for these behaviors aside from labeling the mannerisms as “blindisms” and calling them “autistic-like” – the belief being that some of these behaviors were related to the child’s sensory impairment and lack of opportunities to engage in more typical social exchanges. Rarely was the following question raised: “could this child also be autistic?” At the end of this brief introductory article, I hope that you will have a general understanding of the definition of autism and why it is possible for a child to have both a significant visual impairment and autism.

1. What is autism?

Autism is a biological developmental disorder of the brain that impairs communication and the ability to relate to others. It is often referred to as a spectrum disorder given its presentation ranges from mild to severe in any of its features.

2. What causes autism? How is it diagnosed?

Autism is not etiology specific – that is, it has many possible causes including genetics, environmental toxins, metabolic dysfunction, etc. The commonality among all the causes is that it is a brain-based disorder.

Autism is diagnosed by the presence of certain behavioral features – it cannot be diagnosed by a specific blood test or scan. The defining features include: impairments in reciprocal social interaction that is sustained (e.g., impairment in use of nonverbal behaviors; with young children may fail to develop peer relationships appropriate to developmental level; may lack spontaneous seeking to share enjoyment and interests with someone; may prefer solitary activities; limited to no concept of needs of others); impairments in communication marked and sustained affecting spoken language and nonverbal skills (e.g., delay in or lack of development of spoken language; or may have impairment in ability to sustain conversation; or may show repetitive use of language or idiosyncratic language). For those with speech present, may have unusual pitch, intonation, rate, or rhythm to speech.

Grammar may be immature and include stereotyped use of language (e.g., repeating phrases; repeating commercials). Child may have difficulty understanding simple questions or commands. There may be a lack of varied, spontaneous make-believe or social imitative play commensurate with developmental level. Individuals on the autism spectrum also have restricted, repetitive, stereotyped patterns of behavior, interests (e.g., intense preoccupation with dates, phone numbers; electronic equipment; perhaps with parts of objects), and activities; inflexible adherence to nonfunctional routines or rituals; stereotyped/repetitive motor mannerisms, etc. They may insist on sameness and show resistance and/or anxiety over small changes. There may be stereotyped body movements (e.g., flapping, rocking, toe walking, hand posturing).

Finally, these delays or abnormal functioning in one or more of the above areas must be present before the age of three. While not a defining feature, a number of children and adults on the spectrum have hypo or hypersensitive responses to various stimuli (e.g., certain sounds; certain textures including clothing or food; smells).

3. I’ve read about autism but my child does not have every feature exactly as described in the article. Does that mean he/she doesn’t have autism?

Several issues need to be considered here. First and foremost, autism (and its related disorders, including Aspergers, PDD/NOS, for instance) is defined by the presence of the cluster of behaviors – the presence of any one behavior (e.g., flapping) does not mean that a child is autistic. In addition, it is developmental in nature and as a result, it will change somewhat in presentation as a result of the maturational process. What is important is that the cluster of behaviors be present prior to the age of 3. Finally, given it is a spectrum disorder (e.g., child’s level of function can vary on all dimensions including cognitive ability, behavioral presentation, sensory sensitivities, language/communicative abilities, social relatedness) it is highly unlikely that any individual will fit any one description to a “T.”

4. Can a child with a visual impairment be autistic too? I heard that they have “autistic-like tendencies” but not autism. Is that true?

Children with visual impairments can be on the autism spectrum as well. Remember, it is a brain-based disorder so those children with neurological vulnerabilities (e.g., seizure disorders, septo-optic dysplasia, Prematurity associated with bleeds, agenesis of the corpus callosum, congenital rubella syndrome, etc.) may be at increased risk. The literature in the field of visual impairment needs to be more cautious in its use of the terminology “autistic-like” in that it can result in missed diagnosis and/or delay in procuring appropriate services for those children who are on the autism spectrum. Strategies useful for children who are visually impaired and autistic vary considerably from those effective for children who are just visually impaired.

5. Why are we hearing so much about autism now?

Autism is not as rare as was once thought. According to Dr. Marie Bristol-Powers (1999) National Institute of Child Health and Human Development, autism spectrum disorder is not rare as was once thought. Current estimates suggest that 1 in 1,000 individuals fit the definition of "classic" autism and that 1 in 200 individuals fall within the Autism Spectrum, including Pervasive Developmental Disorder and Asperger's Syndrome.

Why the increase?

We now have clearer diagnostic criteria, increased public awareness and “acceptance”, broader definition of autism as a spectrum disorder, more children, tinier and neurologically more vulnerable children are surviving prematurity; and we have the presence of environmental toxins as potential contributors.

6. Is the notion of autism co-occurring in a child with visual impairment new?

Dr. Stella Chess - her observations of children with Rubella noted “…the difference between the autistic and nonautistic rubella children with sensory defects is the use they make of alternative…modes of experiencing. Nonautistic youngsters … are very alert to their surroundings through their other senses, especially exhibiting visual alertness and appropriate responsiveness... also through seeking of affectionate bodily contact. Some are shy, some slow to warm up, some perhaps wary; but one is impressed by their readiness to respond to appropriately selected and carefully timed overtures. …the autistic children neither explore alternative sensory modalities nor manifest appropriated responsiveness. They form a distinct group whose distance from people cannot be adequately explained by the degree or combination of visual and auditory loss, nor by the degree of retardation where this also exists. … whether retarded or not, their affective behaviors do not resemble those of children of their obtained mental age – in fact, there is no mental age for which the behaviors are appropriate.” Chess... P. 116 - 117

Why the controversy? Why the ongoing debate? Confusion in literature

  • Treated symptoms in isolation (e.g., mannerisms)
  • Viewed as indicative of emotional and behavioral problems (e.g., self-stimulatory behaviors; problems of hyperactivity, inattention, impulsivity; disruptive behaviors such as oppositional; problems of social interaction; problems of mood, affect)
  • Viewed as being totally associated with sensory deprivation (e.g., turn inward for stimulation)
  • Viewed as related to mother-child attachment (e.g., in incubators longer; lack of eye contact so hard to read cues; maternal depression further limiting her involvement w/child)

Examples of some of the eye conditions where Autism Spectrum Disorder has been documented

  • Anophthalmia (may occur at critical periods in brain development and yield higher co-morbidity)
  • Lebers Congenital Amaurosis
  • Peters Anomaly
  • Retinopathy of Prematurity
  • Septo-optic dysplasia
  • Congenital Rubella Syndrome

Key thing to remember: autism is a brain related disorder; that estimated that 50% of blind children have LD and 56% of those with severe LD or IQ<50 have autism (Steinberg et al., 2002)

7. What do we do about it?

It is important to begin to advocate for appropriate diagnosis for your children through collaborative efforts between autism diagnostic centers and teachers of the visually impaired, and by advocating with your primary care providers. Cooperative efforts between vision and autism programs will be critical as most of the strategies used for children with autism rely on vision – not always an option for our children and students. For more information you can go to:

and others…

About the author:

Dr. Terese Pawletko has worked with children since 1976, first as a teacher of the visually impaired, then as school and pediatric psychologist. Starting in 1989, after completing a postdoctoral fellowship in Pediatric Psychology at UNC-Chapel Hill, she worked at UNC School of Medicine with chronically ill children, and with autistic students, their parents, and related service providers. In 1997 she joined the staff of the Maryland School for the Blind where she worked with multiply handicapped children with a variety of disabilities including visual impairment, autism spectrum disorders, cerebral palsy, mental retardation, and learning disabilities, as well as training staff to work with these students. While at MSB, Dr. Pawletko and her colleagues developed the first program in the country for children with visual impairment and autism. She is considered a national expert in this area and has presented at regional, national, and international conferences, conducted evaluations of children suspected of dual diagnosis, and provided consultation to and training of parents and service providers.

Terese's contact information:
Snail mail:
Terese Pawletko, Ph.D.
33 Johnson Lane, Eliot, Maine  03903

Joseph's Coat: People Teaming in Transdisciplinary Ways

Originally published in Spring 1998 SEE/HEAR newsletter, from TSBVI Outreach Programs
Versión Español de este artículo (Spanish Version)

by Millie Smith, Educational Specialist, TSBVI VI Outreach

In the last five years I have been working with staff and families to support their efforts to team more effectively using the transdisciplinary model. I have not seen or created any perfect transdisciplinary teams during that time. I have seen staff and parents use bits and pieces of the model very effectively to improve programs for students. I am more convinced than ever that transdisciplinary teaming is the best of the service delivery models available to us at the present time. I am equally convinced that the best chance we have of increasing its use is to assure staff and parents that partial implementation is not only realistic, but probably as effective as a more idealistic whole cloth application. The product may be a patchwork conglomeration of pieces supplied by different people at different times, but a coat nevertheless.

The most powerful aspect of the transdisciplinary model, in my opinion, is its emphasis on plugging the expertise of specialists into the day-to-day instruction of students with severe multiple impairments. In this model specialists work in classrooms. They may provide direct instruction or therapy to the student during a regular activity or they may model, coach, and monitor interventions implemented by others. Often they do a combination of both.

Another powerful aspect of the model is that, whenever possible, specialists, instructors, and family members collaborate by meeting together to design instructional activities. More often, they collaborate by leaving each other notes, sharing video tapes, and calling each other on the phone. By collaborating, an effort is made to provide as much consistency in programming as possible across settings and people.

The best approach for implementing transdisciplinary teaming strategies may be to treat the total model like a menu of options. Teams can choose to concentrate their efforts on assessment, IEP development, or instruction. They can do some transdisciplinary work in each category without doing everything that category offers. In order to make informed decisions about where to concentrate efforts, a global understanding of the model is helpful.

Why is transdisciplinary teaming important?

Students with severe impairments receive instruction and services from a variety of different people. Instructors include teachers, teaching assistants, and family members. Special services may include speech, occupational therapy, physical therapy, vision, hearing, and others. Teaming allows specialists, teachers, and families to work together to teach skills in natural contexts where there is more opportunity for frequent practice.

Many specialists have changed the way they serve students with severe impairments in the last ten years. The professional organizations to which most specialists belong have endorsed a service delivery model that emphasizes integration of special services. Integration of special services benefits students with severe impairments in two ways: skills are worked on in natural contexts so that students don't have to try to generalize skills learned in a special setting, and skills are worked on every time the opportunity occurs, whether the specialist is present or not, so that practice is frequent.

In an integrated service delivery model, specialists assess needs, do diagnostic teaching to try out techniques and strategies, model techniques and strategies for other staff and family members, and monitor effectiveness and progress. When the integrated model is transdisciplinary, information is shared among specialists, instructors, and family members. This type of service is intense and dynamic, and highly effective.

How can specialists provide natural contexts and frequent practice?

The traditional service delivery choice for specialists has been direct or consult. For students with severe impairments a wider range of choices is necessary.

Direct Pull-out Always one-to-one. Special equipment. Infrequent practice. Context not natural.
Integrated Direct One-to-one or small group. Natural context. Infrequent practice.
Traditional Consult General information shared. Contact very limited
Collaborative Consult Specific information shared with team. Accountability  tied to progress in instructional activities. Requires more time.

Each of these models has a place in transdisciplinary teaming. For instance, direct pull-out may be appropriate for post trauma students or for a student learning a new communication device. Usually, this service is provided for as short a time as possible and a very structured transition period follows pull-out in order to transfer skills to natural contexts. That transition period might be integrated direct service. Integrated direct service is often used by speech/language pathologists teaching communication skills in natural contexts and by OT's and PT's teaching motor skills in natural contexts. Consult is usually provided in conjunction with direct service. Sometimes consult is the only service provided.

What type of consultation tends to be most effective?

Most consultation is general. Specialists write recommendations in their assessment reports. When specialists consult with teachers, they talk to them about their recommendations. Information is shared at a general level. For example: "This student has CVI. Most CVI students like the color red. If you want the student to look at something, try using red. Moving the object slightly in the peripheral field might also help."

Many teachers will remember the student might like red and they will probably make an attempt to select red materials when they can. When the VI teacher checks back with the teacher after this kind of consult, she may hear something like, "Well, I don't notice that red really makes that much difference."

Specific consultation tends to be more effective. In this type of consultation the specialist assesses, recommends, demonstrates in a natural context, and evaluates results. For example: "This student has CVI. CVI students tend to like red. Let's use a red scoop dish at mealtime instead of the cream colored cafeteria tray. If he can see the bowl, it may be easier to get him to scoop. We may need to position the bowl slightly to the left and move it a little at first. When he looks at the bowl, we'll give him a touch prompt to move his hand to the bowl. I'd like to come in at lunch time and try this a few times. Let's keep data on this for two weeks and see if there are more independent attempts to scoop. We may need to do something with the spoon as well."

Traditional consult by itself puts a very heavy burden on classroom teachers and family members to come up with activities and specific modifications for students with extremely intense needs. Transdisciplinary teams use a more dynamic kind of consultation. When consultation is specific and collaborative, it is a highly effective type of service. It also requires more time than traditional consultation. Students with severe multiple impairments tend to be chronically underserved. The average amount of service in Texas for traditional consult appears to me to be about thirty minutes a month. In many places it is less. A more reasonable average for collaborative consultation would be between two and four hours a month. Time demands are more intense when a team is starting a new program. Once the program is established, less time is needed for monitoring and maintenance.

What are the components of transdisciplinary teaming?

Collaborative Assessment

Collaborative assessment occurs when team members identify strengths and needs through shared observations and discussion. One type of collaborative assessment is an arena assessment. Team members meet together to observe a child as one team member (frequently the parent) interacts with the child. Collaborative assessment can also occur during team meetings designed to share and interpret information gathered by individual team members in one-on-one assessments with the child.

Integrated IEP

A team IEP is a document containing goals and objectives developed collaboratively by all team members. Based on family priorities, the group establishes an integrated set of goals (four to six) and two to three objectives per goal (eight to twelve objectives total for the IEP). If an objective relates to a particular related service, that related service provider is identified as responsible for insuring that instruction addressing the objective is implemented and that documentation is collected.

Natural and Frequent Instruction

IEP goals and objectives are taught in activities which occur naturally and frequently at home, in school, and in the community. A team member, usually a classroom teacher, parent, or teaching assistant, is identified as the direct implementor of instruction for a specified activity which may have several IEP objectives imbedded in it. The related service team member responsible for developing a given IEP objective either integrates direct service or consults with the direct implementor of instruction.

Role Release

Team members share knowledge and skills in their particular areas of expertise by role releasing. This is a systematic process whereby one team member trains another to use specific procedures and techniques. The team member who has received this training may then implement a procedure or technique in a given activity when the trainer is not present. The person with specific knowledge is responsible for ensuring that these procedures and techniques are used effectively and appropriately with a given child.  


Information is gathered for the purpose of evaluating and refining instruction, reporting student progress on objectives, and sharing information with families and team members.

What assessments are important and how does the team use them?

Students with severe impairments are sensory-motor learners. Assessments of sensory and motor skills are extremely important. Cognition and communication are also important areas. Information about skills in each of these areas may be obtained by specialists in their individual assessments done as part of the Comprehensive Individualized Assessment. Assessment of biobehavioral states of arousal may be very helpful for students with the most profound impairments.

In transdisciplinary teams, specialists collaborate to plan their assessments, to carry out their assessments, and to interpret their assessments. Sometimes arena assessments are done. In this type assessment, one person interacts with the student while other team members observe and ask questions guided by the use of protocols specific to their disciplines. The advantage to this assessment approach is that the student interacts with the persons most familiar with him or her. Performance is likely to be more typical under these conditions. The disadvantage to this approach is that, although total assessment time tends to be less overall, assembling all team members in the same place at the same time can be difficult.

After teams assess, they must share information and come up with program priorities. Instruction is sometimes ineffective for students with severe impairments because too many needs are addressed. Instruction is much more effective if instruction is very focused on four or five priorities. These priorities become goals. Specific needs in each goal area are then identified. These become objectives.

What should a good transdisciplinary IEP contain?


The team uses assessments to select four to six priorities for the school year. Each of these becomes an annual goal. Some teams write very broad goals; some write more specific goals. Each annual goal should be a statement of what the team believes the child can accomplish within a school year. A broad goal would be: "Student will improve his expressive and receptive communication skills." A more specific annual goal would be: "Student will use ten expressive signs in appropriate contexts." Specific goals work best for students with severe impairments.


Objectives are the steps between the child's current level of performance and the annual goal. They state one specific task the child will do, at what level, by when, and what criteria will be used to measure progress. For a broad goal, the team might write: "Student will use five expressive signs during meal time and snacks, independently, eighty percent of the time, measured by teacher observation." For a more specific goal, the team might write: "Student will use name sign to greet nurse when he gets meds, independently, eighty percent of the time, measured by teacher observation." Specific objectives work best for students with severe impairments.


A skill is the behavior to be learned. The phrase following the word "will" in the objective is usually the skill. In a transdisciplinary IEP, specific discipline skills are imbedded in objectives. An objective might be that a student will assist during meals by opening his mouth for bites. The VI teacher might add that the student will open his mouth for bites when a brightly colored spoon is moved slightly in the right peripheral field of the right eye from a distance of six inches.


An activity is the context in which the skill will be used. The phrase following the word "during" in the objective is usually an activity. Teams include information about context in objectives to make measurement more meaningful.


These are the techniques, technology, and strategies which are necessary to ensure the highest level of participation for the student in the activities of his school day. Federal law requires that these be specified in the IEP. Most school districts include a generic modification page in the ARD papers. Some of these may be useful, but teams have to come up with more specific modifications in order for progress on objectives to occur. A general modification for a special education student might be "shorten assignments." A specific modification for a student with severe impairments might be "use adapted spoon."

Some teams continue to write traditional IEP's in which each team member comes up with his or her own set of goals and objectives. Students with severe impairments can't usually learn as many things as team members can come up with to try to teach them. Also, when team members are trying to teach too many things, they tend to scatter their energy and not teach any one thing very intensely. Teams tend to be more accountable when they focus their attention by writing one collaborative IEP. In this approach special skills are integrated into short-term objectives.

Student: Catherine 
Date Accepted by ARD Committee: 5/1/95 
Annual Goal: Will improve functional use of objects*

Short-Term ObjectivesEval. Method
Observation Formal testing
(Accuracy Level)
TargetedPresent  CompetenciesMet  Y/N
1. Will visually locate a desired object in an adapted environment during rec/leisure time. 
Direct Implementor(s): Classroom Teacher/TA 
Support Staff Responsible: VI Teacher 
Begin Date: 8/95 End Date: 5/96
Observation Independent Frequent physicalmanipulation  
2. Will look at an object presented by a caregiver to request continuation of an activity during grooming activities. 
Direct Implementor(s): Teaching Asst./Mother 
Support Staff Responsible: VI Teacher 
Begin Date: 8/95 End Date: 5/96
Observation 90% 20%  

* Sensory skills are integrated in short-term objects.

Sometimes a column for modifications is added. The example given in objective number one might include: Modifications: Den/Little Room

How is instruction provided in natural contexts by the whole team?

routine is a teaching strategy that focuses the team's efforts on specific activities that occur with high frequency in the student's schedule. Routines are designed to teach specific special skills to students who require consistency and repetition in order to learn. As skills are learned, the student's level of participation in activities increases. Any activity can be developed into a routine when team members plan what they will teach and adapt for a given student. An activity is not a routine unless it meets the following criteria:

  • There is a clear signal to the student that the activity is starting.
  • The steps of the activity occur in the same sequence every time.
  • Each step is done in the same way each time (same materials, same person, same place).
  • Modifications and techniques provided by specialists are implemented exactly as directed.
  • The minimum amount of assistance is provided in order to allow students to do as much as they possibly can.
  • The pacing of instruction is precisely maintained until the activity is finished (no side conversations, going off to get something you forgot, or adding new or different steps that won't happen the next time the activity is done).
  • There is a clear signal to the student that the activity is finished.

Why are routines worth the trouble?

The power of a routine is the precise planning of what the student will do and how he will do it on each step of the routine. Many students are able to learn new skills and participate at higher levels when this strategy is used because they need the following things that routines provide:

  • Predictability: "I know what is going to happen from start to finish."
  • Consistency: "I know what I am supposed to do."
  • Anticipation: "When you do that, I know what to get ready for."
  • Practice: "I remember what I did last time and I can try to do more this time."

Students with severe impairments rarely do every step of a routine independently, but they are afforded the dignity of doing everything that they are cognitively and physically capable of doing.

What do routines look like?

Mealtime is a good activity to develop into a routine because it usually happens three times a day. Practice opportunities are frequent. The team's plan might look something like this:

  1. Get spoon from calendar box to begin activity. 
    Target skill: Tactual exploration of objects in calendar to recognize spoon. 
    Person responsible: VI teacher. 
    Strategy: VI teacher demonstrates shadowing technique to TA to decrease student's aversion to hand over hand manipulation.
  2. Take spoon to eating area. 
    Target skill: Maintain grasp, intentional release. 
    Person responsible: OT 
    Strategy: OT demonstrates use of "buncher" for grasp and pressure point technique for release to T.A. who will implement instruction.
  3. Give spoon to adult to request meal. 
    Target skill: Use object to request. 
    Person responsible: Speech/Language Pathologist (SLP) 
    Strategy: SLP demonstrates touch cueing technique to TA who will implement instruction.
  4. Eat. 
    Target skill: Manipulate spoon for scooping. 
    Person responsible: OT 
    Strategy: OT provides adaptive equipment and demonstrates technique to TA who will implement instruction.
  5. Put spoon in washtub at dish window to end activity. 
    Target skill: Maintain grasp, intentional placement. 
    Person responsible: OT and VI teacher. 
    Strategy: OT demonstrates arm support technique to TA who will implement instruction. VI teacher provides visual enhancement of target.

How do specialists help other team members address needs in their areas?

Transdisciplinary teams use a procedure called role release. Any team member having special skills may train any other team member needing those skills. The need for a team member to have certain skills is usually dictated by scheduling. Specialists cannot always be present when a skill needs to be taught in a natural context. Specialists have certain responsibilities. They cannot release their role to another until that person demonstrates that she can perform without prompts. The specialist must then monitor the activity to ensure that the released procedure is performed as taught.

The role release process usually consists of the following steps:

  • The specialist and other team members share information related to the need.
  • The specialist teaches the designated person(s) a specific procedure to address the need.
  • The specialist supervises the implementation of the procedure and makes adjustments as needed.

Communication among team members is essential in the role release process. Members must be able to ask questions, seek help, and respond quickly. Here are some tips for increasing and maintaining contact:

  • Schedule time to observe activities.
  • Review videotapes of activities between observations.
  • Attend team meetings.
  • Post notes to team members on a special bulletin board.
  • Keep documentation in an area where all team members can access it.
  • Keep a school/home notebook.

How do teams document student progress?

There are two things to remember about documentation:

  • It is important because team members have to know what's working and what isn't working
    Students with severe impairments don't fail to make progress, but teams may fail to provide the necessary level of support in order for progress to occur.
  • It must be easy to gather so that it does not take time away from teaching and attention away from the student.

Different kinds of documentation are appropriate in different situations. Here are some common types:

  • Frequency Tally Method: A mark is entered each time the designated behavior occurs. The event may be a student behavior (signed "more") or the event may be a teacher behavior (touch prompt given).
  • Annotation: The teacher may write a comment describing the student's performance on a given trial.
  • Plus/Minus: The target skill occurred or did not occur.
  • Level of Prompt: A letter is entered to indicate the highest level of prompting given during the trial (hand-over-hand, touch prompt, verbal prompt, independent).

Be consistent. Decide which method fits best for a given situation and stick with that method. The whole team must use the same methods in the same situations.

Routine and data sheet sample.

An example of a routine with annotative documentation is included on page thirteen (Routine and Data Sheet). Notice that documentation is kept only if the step is one in which an IEP objective is addressed. If there is no number in the IEP column, no documentation is kept.

How do specialists document service time?

Parents typically do not demonstrate a high degree of confidence in consultative services. Some demand direct service because they fear that their children's needs will not be addressed adequately in a consultative model. This can be counterproductive for students with severe impairments who need frequent intervention in natural contexts. One way to assure parents and other team members that real help is being provided is to share documentation.

Most specialists are used to keeping records of some sort for their supervisors. These may consist of student contact logs or observation summary forms. An example of a contact sheet which emphasizes the team approach is shown on page fourteen (Sample of a Collaborative Service Delivery Contact Sheet).

Routine and Data Sheet 
Routine: Hair Care Time 
Implementor: Classroom Teacher, TA 
Time: 9:00 a.m. 
Location: Classroom

Routine StepsAdaptation/ModificationIEPComments/Data
1. Travel to hair drying area. Chair pushed to hair drying area. Looks at caregiver to signal readiness.    
2. Visually locate hair dryer. Caregiver wears dark-colored smock against which bright yellow hair dryer is held. Use object lighting, if necessary. #1 Looked at hair dryer on third  of three presentations after light enhancement provided.
3. Turn desired part of head/ face to airflow as caregiver holds dryer.      
4. Visually locate hair dryer each time care-giver turns it off to request continuation of activity. See #2 #1 Looked at hair dryer on second and fourth - presentations no light.
5. Visually locate hair-brush held by teacher. Caregiver holds bright red  hairbrush against smock. Use object lighting, if necessary. #1 Did not respond, four presenta tions with light (contrast may not be adequate, try different  colored brush.)
6. Cooperate while hair is brushed by caregiver.      
7. Travel to area of next activity. Looks at caregiver to signal  readiness for lift. Chair is pushed to next area.    

Documentation Date: 10/7/95 Documentor's Signature: (VI Teacher)

Sample of a Collaborative Service Delivery Contact Sheet

Student: Catherine 
Service Provider: M. Smith, VI Teacher

DateTime InTime OutStaff PresentService Delivered
2/7 9:30  10:00 T. Johnson, Linda Evaluated visual responses (JVE)
2/11 2:00 2:30 Linda Evaluated visual responses (JVE)
2/18 3:00 3:30 T. Johnson, Linda & Parent Wrote activity routine
2/22 9:30 10:00 Linda Role release hair dryer procedure
3/12 9:30 10:00 Linda Observed & modified hair routine

Administrator's Signature: _______________________


Remember Joseph's coat. It was made a piece at a time. It might be a good idea to remember that Joseph probably wore some other garments as well. If your team ends up with a vest or a really good pair of socks, success is just as sweet. Good luck!

What a Concept!

(First Published in Spring 2000 SEE/HERE Newsletter)

Versión Español de este artículo (Spanish Version)

By Jim Durkel, CCC-SPL/A and Statewide Staff Development Coordinator (with help from Kate Moss (Hurst), Stacy Shafer and Debra Sewell) Texas School for the Blind and Visually Impaired Outreach

Communication has three parts. The most noticeable part is the "form." Form is how the communication happens. It is the behavior used to communicate. Speech is one communication form. Sign language is another. Crying, using objects, using pictures, even falling asleep - all of these are behaviors we do, forms we use, to communicate.

"Use" is another part of communication. What is the purpose? Is it to share information, direct attention, request something, ask or answer a question? All of these are reasons why we communicate.

The third part of communication is called "content." Content is the part of communication that deals with meaning. It is noon. I am hungry. I walk up to you, look at you and say, "Lunch?" My voice rises at the end of the word, and I raise my eyebrows when I say it. Those are the ways I communicate, my forms (we usually use several at once). I am using these forms to ask you if you want to have lunch with me. That is why I say that word to you in that way. It is the reason I am doing this. But what does "lunch" mean? What is the content? Am I asking if you want to go eat and drink somewhere for 2 hours, or am I asking you if you want to go to McDonald's and be finished in 30 minutes? Am I asking you to cook this noon meal for me as you have for the last 20 years, or am I offering to cook it for you? You and I probably have a shared idea of what "lunch" in this context means. We understand that other people may or may not use it as we do. The shared idea is the "content" part of communication.

This content develops as a result of several things. First, you and I have decided what the word means to each of us. This was not taught to us. We "figured out" the meaning. We heard it used at the same time everyday. We did something the same way as we heard it (or very shortly after we heard it). More than likely, there were actions, smells, tastes, sights, sounds, objects and maybe other people involved in what we did when we heard the word.

We developed our own meaning or concept for "lunch" based on our personal experiences. Even if we did not hear the word "lunch" used, we still developed an understanding of what happens at a noon meal. We discovered how it was the same as other meals (we sat at a table, we ate food) and how it was different. (We did not eat cereal like at the morning meal, and we usually did not eat as much as at the evening meal.) We developed a concept of lunch.

Once we had the concept, we paid attention to the form ("lunch"). We heard the word "lunch" every time we had our noon meal. Next, we figured out if that form referred to the same concept for all people. Some folks eat "dinner" at noon! Last, we figured out how to use that form in certain ways to get people to fix us lunch or eat lunch with us.

Children with visual impairments, including deafblindness and children with multiple impairments, have difficulty developing concepts. They have difficulty understanding how the world works, how parts of the world relate to other parts, how these parts are the same and how they are different. What makes the communication of children with a loss of vision really different from the communication of other children, is that many of these children often use communication forms without having the content or meaning or concept firmly in mind. Often, children with a vision loss are good at hearing, remembering, and using words without having a real "gut" sense of what they are saying. I do the same thing whenever I try to talk about football. I know the talk, but I can't walk the walk. I know labels ("tight end," "Hail Mary Pass"), but I did not have the experience of playing football. I do not really have concepts for these words.

Many people think of concepts as things like "right," "left," "top," and "bottom." These are a particular type of concept having to do with positions in space. But "tree" is a concept, as is "dog," "house," "push," and "work." There is the concept of "book" and of "reading." Concepts can also be about events, such as "going shopping" or "visiting Grandma." The story of "Snow White" is a concept. And so on. All the words we know, all the language we speak and read, have underlying concepts. Some concepts are expressed in one word, like "lunch." Other concepts are expressed only by using several words in a specific way, "After I run some errands, I will eat lunch."

Impaired concept development will impact learning later in life. For example, most teaching after second grade is not "hands on." Students are expected to read about and/or listen to the teacher talk about something. For students who have good experience-based concepts, this kind of learning is OK. So what if you have never been in an igloo. You understand houses, and you understand how various kinds of houses are different and how they are the same. You understand that not everyone lives in Central Texas, where ice outside is a rare thing. You understand ice and how it can look like a brick. You can read about an igloo and relate what you read to what you know. If those basic concepts are shaky, your understanding of what you read will be shaky too. Even if you can say all the words, read all the print, or read all the Braille.

When I say concepts, many people think, "label." They think we should always be talking to children with visual impairments. They think the underlying problem is that children "just need the words." But this is not really true. Concept development is delayed because vision is what drives the typically developing infant to move and interact with objects. When vision is impaired, often this drive is also impaired. Babies with visual impairments do not handle objects in the same way that babies with no vision loss do. They do not explore the environment the same way. They also do not see the actions of others well or at all. They cannot rely on vision to give them information to the same extent that babies with no visual impairment can. Vision also allows one to see how one piece of the world relates to several other pieces of the world. Children with visual impairments have to view their world piece by piece; then put it all together into the big picture. Children with no visual impairment can see the big picture first; then look at the pieces; then go back to the big picture. For example, a child with no vision loss will see that I am holding a rattle. She will look at the rattle and at me, and she gets the picture that the rattle is "attached" to me. A child with a visual impairment will hear the rattle, maybe see it, but may not understand that the rattle is "attached" to me. For that child, objects appear to float in space, unless we help her get the big picture. All of these things happen during an early time of learning called the sensorimotor period.

The sensorimotor period was named by Jean Piaget, a French psychologist. He studied how children developed concepts and made sense out of the world. He believed that children "constructed" these concepts through active exploration and interaction with the environment. Most of this exploration and interaction took place during play. Piaget said that the sensorimotor period in most children lasted from birth to the age of 2 years. During this time, children learn about their bodies, their own actions and the actions of others. Children also learn about the properties of objects and how objects are used. Children begin this learning by accident, then through their own deliberate movement, then by watching others. This is a time of developing concepts about how the world works through the use of sensory and motor (sensorimotor) skills.

Jan van Dijk, a Dutch psychologist who works with children with deafblindness, says that all we know can be traced back to our actions. He gives the example of asking us to define a castle. We say, "It is where the queen lives." He responds, "Yes, tell me more." We say, "It has towers and big gates." If he keeps asking questions, eventually we say it is where people eat and sleep and play. And, that eating, sleeping, and playing means using certain objects in certain ways. We have used these objects and performed these actions. These are concepts that we usually develop during the sensorimotor period.

Our experiences can give us concepts that are very unique to us. You probably heard the story of the woman who called her mother to ask about how to make a roast. Mother told her to get the roast, cut off the end, rub it with oil and pepper, put it in a pan, and bake it in the oven for a period of time. The roast was great, and later Daughter asked Mother why she had to cut off the end of the roast. Mother said she did not know but that was how her mother did it. When they asked Grandmother why they had to cut off the end of the roast, Grandmother said she did that because otherwise a roast would not fit into her pan.

We all have our unique ideas about the world around us. If you use chairs as something to hold on to and push around the room to help you walk, your concept of "chairness" may be different than mine (I think they are to put my legs on when I sit on the table). Children with visual impairments are not incapable of learning the concept of "tree." But their concept may be very different than mine because we rely upon different senses and have different experiences of "treeness." A 2-year-old with a visual impairment may know all about rustling leaves, a piece of treeness I did not learn until much later in life!

Kurt Fisher, an American psychologist, says that we put together basic concepts into bigger and bigger "chunks." For example, we learn about how one object can be stood up on top of one another. Another time, we learn that if we push a ball, it will roll. Another time, we learn that a rolling ball can knock over things. We put all these things together when we set bowling pins upright on the floor and aim a bowling ball at them in order to knock them down. Sensorimotor concepts that we can use as adults!

Some people call these bigger chunks of basic concepts, "scripts." A script usually involves a series of actions. We have a script for going to the grocery store. We get our cart, walk up and down the aisles, put food in the cart, and then pay for that food. Some of us may have parts in our scripts where we eat the free samples, some of us don't! We learn how a script for buying food at a Walmart superstore is different from buying food at a convenience store.

We also develop more abstract and more complex concepts, as we grow older. We learn about the physical world in science classes. We start by dividing the world into things that move and eat and things that don't. We don't stop categorizing until well after we are discussing bacteria and plankton and chemical compounds. We learn about our own bodies and our lives; then learn about our friends' lives; and then we are discussing Arab-Jewish relations in Israel. We learn about in and out and on and off; and then we are booting up computers, putting in our floppies and typing away. But all these concepts start with what we learn in the sensorimotor period. They start with our own experiences, not what we have been told about another person's experiences.

How do we help a child with visual impairments develop a solid base of concept development? The key is not to so much tell the child about the world around them, as it is to provide the child with experiences that allow them create these concepts for themselves. For example, telling a child who has no vision about you washing dishes is not as good as having the child right there with you. She needs to learn about dish washing as she feels the suds, experiences the dirty dish going into the water, notices the difference between the wash water and the rinse water, and touches the dishes in the dish rack. You can use words to describe what the child is experiencing, but don't use words without the experience.

Another way to help the child develop these concepts is to give them opportunities for exploration and play. The OT, PT, Orientation and Mobility Specialist, and Teacher for Students with Visual Impairments all need to work with families to help children develop motor skills they can use to explore the world. Sometimes this means that children need "help" to move independently. Sometimes it means that children need toys that sound interesting to encourage exploration or toys that feel interesting, or toys that we know the child can see and will enjoy examining.

A child with visual impairments needs to have routines in order to learn how pieces of the world are connected. We need to provide an environment that is predictable. How is eating different than bathing? Each happens in a predictable place, with distinct objects and actions, and at certain times during the day.

A predictable environment is also one where I can find things easily. During the first part of the sensorimotor period, children without a vision loss "forget" about things they can't see. Gradually the child learns that objects do continue to exist, even when they are out of sight. This is a harder concept for children with visual impairments to learn. Anything these children can't touch or hear is gone. We can help these children learn about the permanence of objects by creating a situation where objects are easy to find and where objects don't get lost quite so easily. We can do this by attaching toys to a frame with string or by putting the baby in a play pen with her toys velcroed to the same place on the floor or to the slats every time. We can make sure a toddler's toys are always in the same place, and that the toddler has lots of landmarks to use to find those toys. We can look for toys that make sounds, so the child can hear them even if he can't see or touch them (We need to remember that reaching to a sound happens later in the infant's life than reaching for an object he can see).

Children need toys that help them make comparisons. If we give a child blocks to play with, we should give her all types of blocks. She needs LEGOs and wooden blocks and big blocks and small blocks; so that she can compare and discover for herself what makes a block a block. Some important comparisons are materials (wooden spoons vs. metal spoons), size (big spoons vs. small spoons), shape (a plain spoon vs. a spoon with Bugs Bunny for the handle), number (one spoon vs. many spoons) or the objects themselves (spoons vs. forks).

Toys and objects should respond to the child's actions. The child needs to have things that she can squeeze, rattle, open, close, stack, turn, pull apart, and put together. The child also needs things that get warm when she holds them, things that move when she pushes, and things that make sounds when she blows through them.

Provide the child with real, every day objects. Pots and pans, cups, plates, forks, blankets, brooms, TV remotes, toilet paper, towels, and sponges.

We need to provide experiences. We need to take the child with us to the store, post office, and dry cleaners. We need to explore parks and malls. We need to have the child with us while we wash dishes, make beds, prepare meals, put gas in the car, shine shoes, fold clothes, and plant flowers.

Hooking new learning on to old concepts is one way to help the child learn more about her world in a meaningful way. It allows the child to try new things and change her ideas about the things she already knows. New things should not be totally new. We need to introduce new things to our children in a way that does not scare them. Some part of the new thing should be familiar to the child. If we are introducing a new object, is there some way the new object is like something the child already enjoys? Is it the same size, the same color, the same shape? Can the child try familiar actions such as banging or opening or rolling on the new object? Does the new object make the same noise a familiar object makes?

Children need lots of time to try something over and over in order to make sense of it. Let your child play. Let your child direct the play. You can join in and play with your child, but do what she is doing before you try to show the child something new. Let the child know that she can have interests of her own, and then that you can show her new ways of doing things.

Concept learning and teaching should be fun for both adult and child. It is exciting to see children discover the world. It is thrilling to see children having new ideas. It is a joy to be part of that discovery and learning.

Woman driving a car using bioptics.

Many individuals with low vision are eligible to become drivers using bioptics, a small telescopic lens mounted on the frame(s) of glasses.  Each state has its own laws governing the use of bioptics when driving and most states have certified driving instructors who can provide driver's education for these individuals.  Considering whether or not to become a driver using a bioptic is a complex decision.

A good place to start considering whether bioptic driving is to practice Passenger-in-Car Skills.  With your parent(s) or other licensed drivers, grab the front passenger seat and go for a drive using your monocular or bioptic.  Practice refines the essential skill of rapidly moving your focus into and out of the bioptic. These activities will focus on the following skills:

  • Distance viewing
  • Bioptic usage
  • Hazard perception

5 Keys to Safe Space Cushion Driving

There are 5 key things to remember that will keep you at a safe distance from hazards while driving.  These are:

  • Aim high in steering
  • Keep your eyes moving
  • Get the big picture
  • Leave yourself an out
  • Use lights, horn and signals properly

(Source: Smith System Driver Improvement Institute, Arlington, TX) 

When we talk of aiming high in steering, it means looking down the road as far as possible when traveling.  It is important to understand that as speed goes up, you must look further ahead to have time to respond to traffic and hazards.  Though you are looking forward using your bioptic as necessary to spot targets when driving, you also have to be scanning so you can get the big picture.  This allows you to use to always have “an out” for yourself while in traffic or when an unsafe condition occurs.  That way you can use your lights, horn, signals, and brakes properly to keep you and others safe when you are behind the wheel.

About the Bioptic Driving Exercises

The Bioptic Driving Exercises 1-3 that accompany this introduction are developed by Chuck Huss, COMS, Driver Rehabilitation Specialist with the West Virginia Bioptic Driving Program and are meant to be activities that prospective bioptic drivers can utilize to improve their use of a bioptic before actually getting behind the wheel.  Done with the support of a parent or other licensed driver they can help the aspiring driver identify skills that they need to work on and provide practice to improve these skills.  They can also help parents understand better what their child is able to see from the front seat of a car before deciding if their child should get behind the wheel.

The exercises that follow were developed by TSBVI Outreach Programs based on materials from Chuck Huss, COMS, Driver Rehabilitation Specialist with the West Virginia Bioptic Driving Program in 2015 for the In the Driver's Seat workshop.

Exercise 1

Exercise 2

Exercise 3



In the Driver's Seat: Low Vision Specialist, Dr. Laura Miller

Description: In the Driver's Seat. A conversation with Low Vision Specialis Dr. Laura S. Miller, O.D. about bioptic designs, and the visual acuity & fields necsssary to pursue a Texas Driver's License.

Downloads: Transcript (txt) Audio (mp3)

In the Driver's Seat: Pre-Driver Readiness Skills - Part 1

Description: In the Drivers' Seat Interview with Rehabilitation Specialist, Chuck Huss, about pros and cons of hand-held and head-borne telescopes, specialized training for drivers with low vision, and common restrictions for drivers with low vision.

In the Driver's Seat: Pre-Driver Readiness Skills - Part 1
Downloads: Transcript (txt) Audio (mp3)

In the Driver's Seat: Pre-Driver Readiness Skills - Part 2

Description: In the Drivers' Seat Part two of an interview with Rehabilitation Specialist, Chuck Huss, about pre-requisite skills that any person needs to learn to drive safely; i.e. learning how, where and what to look for when traveling.

In the Driver's Seat: Pre-Driver Readiness Skills - Part 2
Downloads: Transcript (txt) Audio (mp3)

In the Driver's Seat: From the Parent's Perspective

Description: In the Drivers' Seat An interview with Rehabilitation Specialist, Chuck Huss, about how parents can build the prerequisite skills needed to be a safe traveler, and how to help their child explore whether or not bioptic driving is for them.

In the Driver's Seat: From the Parent's Perspective
Downloads: Transcript (txt) Audio (mp3)

In the Driver's Seat: From the COMS Perspective

Description: In the Drivers' Seat An interview with Rehabilitation Specialist, Chuck Huss, about how Certified Orientation & Mobility Specialists and help in teaching the prerequisite skills needed to become a bioptic driver.

In the Driver's Seat: From the COMS Perspective
Downloads: Transcript (txt) Audio (mp3)

  • National DeafBlind Child Count, NCDB"The term, 'children with deafblindness,' means children and youth having auditory and visual impairments, the combination of which creates such severe communication and other developmental and learning needs that they cannot be appropriately educated without special education and related services, beyond those that would be provided solely for children with hearing impairments, visual impairments, or severe disabilities to address their educational needs due to these concurrent disabilities."  
  • This is the definition and the ways that a student may meet IDEA eligibility as DeafBlind in Texas. Texas Education Agency, TEA, Chapter 89, Subchapter AA:

(2) Deaf-blindness. A student with deaf-blindness is one who has been determined to meet the criteria for deaf-blindness as stated in 34 CFR, §300.7(c)(2). In meeting the criteria stated in 34 CFR, §300.7(c)(2), a student with deaf-blindness is one who, based on the evaluations specified in subsections (c)(3) and (c)(12) of this section:

(A) meets the eligibility criteria for auditory impairment specified in subsection (c)(3) of this section and visual impairment specified in subsection (c)(12) of this section;

(B) meets the eligibility criteria for a student with a visual impairment and has a suspected hearing loss that cannot be demonstrated conclusively, but a speech/language therapist, a certified speech and language therapist, or a licensed speech language pathologist indicates there is no speech at an age when speech would normally be expected;

(C) has documented hearing and visual losses that, if considered individually, may not meet the requirements for auditory impairment or visual impairment, but the combination of such losses adversely affects the student's educational performance; or

(D) has a documented medical diagnosis of a progressive medical condition that will result in concomitant hearing and visual losses that, without special education intervention, will adversely affect the student's educational performance.

Meeting eligibility in one of these ways requires both hearing and vision professionals at least attend ARD meetings.

The majority of students reported on the Deafblind Census will fall into one of the 4 categories above.

Examples of (A) could include

  • a child with Usher Syndrome 1, where the hearing loss is well documented and the vision loss has resulted in visual field loss.
  • a child with hearing loss and vision result of prenatal exposure to CMV as the cause of both hearing and vision loss.

An example of (B) could include students with suspected hearing loss and the team needs one year to confirm or deny the presence of the hearing loss. It was not intended that these students maintain this form of eligibility for longer than one year. 

A examples of (C) could include the student with Down Syndrome who has high myopia and a mild fluctuating conductive hearing loss.  Alone, these losses may not impact education.  However, given the presence of Down Syndrome together with these mild losses, the educational impact of the combined losses may be greater than anticipated.  This could be confirmed by a functional vision and functional hearing assessment.

A example of (D) would include students with Usher type 2 where the hearing loss is present from birth but the vision loss is slow to develop.  These students may not show any vision loss until very late in their high school years but there may be value working on a transition plan for them.  There may be value in connecting the to other students and families with Usher type 2.

There may be students who could be placed on the Deafblind Census that an ARD committee has decided do not meet the above criteria.  These could include:

  • A student in general education who does not need special education and yet has a combined hearing and vision loss (including progressive losses).  An example would include a student with Usher type 2 for whom the hearing loss is not creating educational need and the vision loss has not progressed to the point of educational need either.  A student like this may or may not be receiving 504 services.
  • A student who meets eligibility but the ARD committee has decided to not consider one or another of the sensory categories, usually for social/emotional reasons.  An example of this would be the student with Usher type 1 who has grown up profoundly deaf, uses visual communication and is considered too emotionally fragile at this time to receive the additional label of visually impaired.
  • Students suspected of being deafblind but more assessment is needed.  These students can remain on the census for year as assessment data is being collected. Assessment could include functional vision and functional hearing testing in the absence of good eye medical or audiological information.  This might include the student who is so medically fragile that trips outside the home to get this kind of medical information are not easily possible.


 AI Teacher

 VI Teacher

SPED Teacher

 Teacher of DB

Informal assessment and/or formal evaluation

 Contribute to assessment of communication skills and determination of primary mode of communication. Contribute to physical portion (otological and audiological information,) social/emotional, cognition, and achievement as it relates to AI

 Functional Vision Evaluation Learning Media Assessment Eye report VI Registration Consent form DB Census Consent form


 Functional Communication assessment (communication Matrix, ADAMLS, JvD’s Child guided Assess, ISA, SLK)

Contribution at ARD Meetings

 Contribute to AI Supplement (in ARD document), interpretation of otological and audiological reports; PLAAFP of communication skills

 VI Supplement (interpretation  of parts A&B, as they pertain to FVE/LMA); Contribute to PLAAFP on  use of vision; interpretation of eye report, recommendations from FVE/LMA


 DB Supplement (interpretation of AI/VI supplement as it pertains to DB implications)

Ongoing Data Collection

 Participate in ongoing data collection  and progress monitoring

 Participate in ongoing data collection  and progress monitoring

Data collection and progress monitoring

 Data collection and progress monitoring

Contribution at ARD Meetings Annual Goals and Objectives

Update Annual Goals and Obj’s  as they relate to AI (this may include communication, academics, and/or social emotional/behavior)

Annual Goals and Obj’s as they relate to VI

Annual Goals and Obj’s

Annual Goals and Obj’s – As they relate to DB

Contribution at ARD Meetings

Contribute to accommodation page as related to AI

Contribute to accommodation page as related to VI

Contribute to accommodation page

Contribute to accommodation page

Contribution at ARD Meetings

Provide parent information packet annually for A.I. (should include TSD and any other resources)

Parent information packet for VI (Annual ARD) Must include information on TSBVI; include Benefits of Braille if student is functionally blind; Benefits of O&M and any other resources and supportive agencies


Parent information packet for DB (Annual ARD)

By Jim Durkel, CCC SPL/A and Statewide Staff Development Coordinator, TSBVI OutreachWith help from Jenny Lace, Gigi Newton, and Kate Moss, TSBVI Texas Deafblind Outreach

Originally published in the Fall 2003 See/Hear Newsletter

Abstract: This article discusses the importance of including auditory training in curriculum for students who are deafblind. It also offers some suggestions for activities and resources related to providing auditory training.

Key Words: deafblind, auditory training, auditory assessment, hearing aid, cochlear implant

Children who are deafblind need to develop skills in using auditory information. Children who are deafblind need to learn to use whatever residual hearing they may have for a variety of reasons including travel safety, identifying people, literacy, communication, and so forth. They also need to learn how to use adaptive devices and equipment such as cochlear implants, hearing aids, and voice output devices. Auditory skills development, just like visual skills development, requires well-thought-out instruction that is provided regularly and consistently throughout the child's school career. Learning to listen, a skill we all need help with, is a skill that is critical for these children.

Steps in Providing Auditory Training

For children with visual impairment or deafblindness the first step in auditory training is to provide access to as much auditory information as possible. If there is a hearing problem, this starts with the use of hearing aids or a cochlear implant. Key to the use of these devices is good behavioral audiological assessment. This is because the best hearing aid or implant fit can't be obtained without behavioral testing.

Any child who is unable to participate in pure tone conventional screening, may need the educational team to compile information about his functional use of hearing before going to the audiologist. Some of the same activities that teach listening can be used to check hearing. By including listening activities at a level appropriate to the child, the child will learn to respond better in more formal hearing assessment situations. The team that knows exactly what behaviors indicate a child with limited communication skills has heard something can be very helpful to the audiologist who may not know what to look for as a response.

The next step is getting consistent use of the device (implant, hearing aid) if the child needs one. A hearing aid or implant is of no help to the child if the child doesn't wear it regularly.

The third step (if the child has some type of device) is to establish a system of daily checks of the hearing aid or implant to make sure it is working properly. Wearing a broken device is an additional impairment to whatever residual hearing the child might otherwise have available to use.

It is important to understand that, even though a child consistently wears an appropriate device in good working condition, he may still not have the same access to auditory information as another child. Each child will have a unique blend of abilities in the areas of hearing, vision, thinking and communication. Some children can become very sophisticated users of a wide range of auditory information while other children may be able to learn to use some, but not as much, auditory information. However, any child will benefit from learning to use any and all auditory information they can.

After the hearing aid or implant, then what?

Auditory training does not end with putting on a hearing aid or implant. The child needs help to learn how to use the device and the information the device allows him to hear. The goal of auditory training is to help a student discriminate sound (in increasingly fine steps from gross sounds to speech) in order to gain meaning from the sounds he hears.

Goals at the highest level of auditory training focus on helping a child use speech. Using speech well requires a person to make very fine discriminations of pitch, loudness, and timing. When we hear a child give an appropriate verbal response to another person's spoken word or phrase (verbal stimulus), we know that he is making those fine discriminations. For most children the social benefits of responding to others' verbal communication is enough reinforcement that they learn quite naturally to make these discriminations and responses. For example, a baby eagerly says "bye-bye" again and again, just to trigger his grandmother's delight and keep her interacting when she announces it's time to go home.

Remember that auditory training is about helping a child make finer and finer discriminations. A gross discrimination is being able to recognize absolute quiet from a very loud sound. The sound is there or not there. A fine discrimination is the difference between the sound "s" like the first sound in "sun" and "f" like the first sound in "fun." Even people who are hearing have trouble hearing the difference between these sounds (especially over telephones!)

Moving from a gross discrimination like the presence or absence of sound, one step towards a finer discrimination would be to hear the difference between a loud sound and a quiet sound. The next step from there is to hear the difference between a loud sound, a medium sound, and a quiet sound.

Now, it is not just enough to be able to hear these differences. We want our to children to recognize why these differences are important. We want our children to respond in a way that demonstrates that sounds have meaning. For example, a car horn honking is important to pay attention to; it signals danger. A loud knock at the door or the sound of a doorbell lets you know that someone is outside and wants to come in for a visit. The telephone ringing, the sound of the alarm clock ring, and many other sounds have meaning in our world. Think of other situations where the presence or absence of a sound means something; all of these sounds can be used in auditory training and can be tied to real-life, functional activities for the child.

Of course, it is not fair to ask a child to make discriminations or responses that are beyond their ability. It would be like asking someone without eyes to read print (braille might be ok!) or asking a 6-year-old to play basketball like Michael Jordan. That's why it is important to start with gross discriminations, utilizing sounds you know that the child really can hear. You want the child to have success at each step in learning to use his hearing. When listening becomes too difficult or aversive, the child is likely to shut down. Listening should be a rewarding experience for the child.

Fitting Auditory Training Into the Child's Day

It is important to do a quick check of a child's auditory skills every day to make sure his or her hearing aid, cochlear implant, or assistive listening device is working. Doing this type of activity when the student arrives at school can catch problems with technology, but it also serves as a good time to tune the child into listening for voice. A quick way to do this is to use the Ling Six Sound Test. The Six Sound Test is used to determine the student's ability to detect and/or discriminate speech sounds. The six sounds are used because they cover the speech range from low frequency to high frequency. The six sounds are "a" as in "baaaa", "u" as in mooo, `e' as in we, "sh" as in shoe, "s" as in sun, and "m" as in mom. This test is given live every day voiced by the adult with the student's own hearing aids, cochlear implant, and/or assistive listening device.

First, check the student's amplification as you normally would. Then, as the student wears the amplification, say the six sounds either from behind or in front with your mouth hidden from view. Ask the student to respond in some way to the sounds such as clapping, raising his/her hand, jumping up and down, etc. This is done to test for detection. If you ask the student to repeat the sound you can test discrimination. It is important to be consistent. Always say the sounds at the same volume and distance from the student. However, vary the order in which you say the sounds every day.

If, all of a sudden, you notice the child not responding as well as they have been, it may be that the child's amplification is not working or the child's hearing has changed. (As might happen if the child has an ear infection.)

It often works best to have a regularly scheduled time to work on auditory training, especially if you are introducing a new activity. Sometimes this can be scheduled as a small group activity or can be done with an individual child. It is easy to turn listening into a fun experience or a game. A child with very little hearing can sit on the floor near the door and listen for you to knock. He can open the door and pretend to be surprised to see you. She can put the baby doll in a bed "to sleep" and make the baby wake up when the alarm goes off. A group of children can dance to the music and freeze when it stops.

Practice, throughout the day, on listening skills learned in more formal lessons helps the child generalize the skills. For example, the student can listen for the teacher to call his or her name to come line up. For the child with very beginning discrimination skills, the student can listen for a drum sound (off/on environmental sounds). Another child might be asked to listen for his name as you target the skill of off/on awareness of voices. For the child a little farther along, you might ask her to discriminate between names that are very different in length and vowel/consonant structure such as "John" and "Latisha." Another student might be asked to discriminate between a normal voice and a whisper or between two very similar names such as "Bill" and "Will." Letting the child play teacher and have the other children listen can also reinforce their interest in tuning into sounds.

Every lesson in school or every activity at home has potential for working on auditory skills. Have the child listen for a timer to go off to let you know that his oatmeal is ready. Ask the bus driver to honk his horn when he stops out front. Listen for the sound of Dad's truck when he comes home in the evening. (With the help of a cell phone you can even keep the wait short if he gives you a call when he is just down the street.)

Schools have bells and alarms of all kinds; practice listening for the bell to ring before you go to lunch. When the principal makes an announcement over the intercom, encourage the child who hears it first to alert his classmates. As you read "Three Billy Goats Gruff" have one child pretend to be the troll who hides under the bridge and listens for the sound of the goats tramping on the bridge. Have another child listen for the phrase, "Who's that tramping on my bridge?" before responding vocally. Point out sounds as you take a walk and tie them to the objects and events that make that sound such as a loud air conditioner, a noisy cart in the cafeteria, or the sound of a ball bouncing on the floor in the gym.

There is no limit to the number of activities that teach and reinforce listening skills. Every child with a visual impairment, even those without an identified hearing loss, needs to develop good auditory skills. These play a critical role in developing other skills related to literacy, problem solving, following directions, orientation and mobility, and socialization. The auditory channel is a critical sense for learning for a child with deafblindness.

A child may initially only be able to discriminate gross differences between sounds, but with a lot of auditory training he may learn to discriminate very slight sound differences, even with profound hearing losses. Without training, a child with a very mild hearing loss may have difficulty making sense of what he hears.

What Parents Should Discuss With Their Teams About Auditory Training

Both teachers of students with visual impairments and teachers of the deaf and hard of hearing know the importance of listening skills. If your son or daughter is visually impaired or deafblind you should think about how well the child is able to use hearing for learning. Many children should have auditory training goals included in the IEP. As parents, you may need to get some help in determining where to begin with your child.

Ask your team about how your child uses his hearing in the school setting.Observe situations at home or in the community where your child responds well to sounds or seems to have problems and share that information with your team.If he has not had a hearing check recently, you may want to consider having one done as soon as possible.


There are a number of great resources for teaching auditory training, if you and your team are ready to get started. Check with your school's speech therapist or teacher of the deaf and hard of hearing about materials they may have on hand to assess listening skills and ideas for auditory training activities. Here are a few resources that you may want to consider:


ASIPS _ Auditory Skills Instructional Planning SystemForeworksPost Office Box 82289Portland, OR 97282Phone: 503-653-2614

CASLLS - Cottage Acquisition Scales for Listening, Language & SpeechSunshine Cottage103 Tuleta DriveSan Antonio, TX 78212Phone: 210-824-0579 ext. 244 or TTY/ 824-5563

CHATS, the Miami Cochlear Implant, Auditory & Tactile Skills CurriculumIntelligent Hearing Systems7356 S.W. 48th StreetMiami, FL 33155Toll free: 800-447-9783Phone: 305-668-6102

DASL II _ Developmental Approach to Successful Listening IICochlear Corporation400 Inverness Drive South, Suite 400Englewood Colorado 80112Toll free: 800-523-5798Phone: 303-790-9010

SPICE _ Speech Perception Instructional Curriculum and EvaluationCID Publications4560 Clayton AvenueSt. Louis, MO 63110Toll free: 877-444-4574 (ext. 133)

Computer related

Visi-Pitch IIIKay Elemetrics Corp.2 Bridgewater LaneLincoln Park, NJ 07035Phone: 973-628-6200

This device is only good for use with children who have useable vision. This is a device that provides visual feedback to sounds the child produces, but it can aid the child in paying attention to speech sounds.

Earobics Software (Home version and Specialist/Clinician versions)Cognitive Concepts990 Grove StreetEvanston, IL 60201Toll free: 888-328-8199

This device is only good for use with children who have useable vision. This software has games and activities to work on higher level auditory training skills.

Reader RabbitRiverdeep - The Learning Company, Inc.399 Boylston StreetBoston, MA 02116Phone: 617-778-7600

This device is only good for use with children who have useable vision. This software has games and activities to work on higher level auditory training skills.


Last Revision: September 1, 2010

  1. Obtain pre-service coursework in DeafBlindness that is aligned with professional standards.  
  2. Stay current in the field by:
  • Maintaining a sustained focus on state and national efforts in product development, research, political efforts and resources.      
  • Participating in ongoing in-service to increase skills in the area of DeafBlindness.
  • Joining and participating in organizations that focus on DeafBlindness.  
  • Maintaining a resource library on pertinent information on DeafBlindness

3.  Contribute to the field of DeafBlindness by:

  • Participating in the ongoing development of appropriate assessment and instructional methods and materials for children with DeafBlindness
  • Building a body of research that supports appropriate programming for this population.
  • Increasing local capacity by working with administrators and families to identify and access in-service training in this unique area of special education
  • Mentoring new itinerant TDBs through the Texas School for the Blind and Visually Impaired Teacher of DeafBlind Mentor Program
  • Participating in local, regional and state comprehensive planning activities system improvement with the Educational Service Center’s DeafBlind Specialist and the Texas DeafBlind Project  

4. In local district, serve as part of the group of qualified professionals in determining if a child meets federal and state eligibility for DeafBlindness.   

5. During the FIE process, assist other professionals with the use of appropriate evaluation tools for students with DeafBlindness. Provide input into the evaluation results as they relate to DeafBlindness and develop appropriate programming recommendations.            

  • Participate in Functional Behavioral Assessments          
  • Provide information regarding the impact of the child’s etiology on learning style and behavior          
  • Evaluate the impact of the child’s vision loss on the acquisition and use of preferred mode of communication

6. Participate in all IEP or IFSP meetings to insure appropriate programming and services specific to DeafBlindness.          

  • Accommodations for state mandated testing          
  • Behavior Intervention Plans          
  • Provide the families with information regarding services for students with DeafBlindness from state agencies  

7. Provide direct, indirect and consult services to the child with DeafBlindness, educational teams and families.   

8. Support the intervener model in the district by:

  • Providing the team and administrators with information about the model
  • Determining the need for an intervener
  • Providing in-class support to the intervener  


9. Assist local district in child-find activities for students with DeafBlindness and in the completion of the annual TEA Deafblind Census.  


From 2012-2013 Texas Deafblind Project TDB Committee

TDB Flowchart download   

By Craig Axelrod, 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, deafblindness, Jan van Dijk, research-based, interaction, behavior, communication, educator-oriented intervention, instructional strategies, video analysis

Part One of this article, which first appeared in the Fall 2004 edition of SEE/HEAR, summarizes research-based conclusions about the importance of high quality interactions with students who are deafblind. From that research, and other resources, Kim Conlin, Tish Smith (communication specialists at TSBVI) and I designed a two-day training for TSBVI educational staff. In Part Two, this educator-oriented training process is described. When it was originally published, in the Winter 2005 edition of SEE/HEAR, four trainings had been facilitated, with four participants in each training. At the time of this revision (February, 2008), seven trainings have been facilitated at TSBVI, and regional trainings in two other Texas cities have also been held.


The Interaction Training Process at TSBVI

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 (as described in Part One). 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



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.



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.


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.