Main content

Alert message

By Kate Moss (Hurst), Education Specialist, Texas Deafblind Outreach

Originally published in the See/Hear Newsletter, Spring 2004 Edition by TSBVI Outreach Programs

Abstract: This article shares information from Dr. Lilli Nielsen’s book, Are You Blind? It focuses on five phases of educational approaches that teachers are to use in working with children if they are using an Active Learning theory approach.

Dr. Lilli Nielsen is the author of many books that look at the way children with visual impairments learn, especially those with other disabilities. Over a period of more than twenty years, she has developed her approach to working with these children that is called Active Learning. This approach is based on the notion that all children learn exclusively by doing until the developmental age of about three. The actions of examining and experimenting with objects using their bodies, is the foundation for the development in cognitive, motor, problem-solving and social skills. She believes that our role in helping children to learn is to create environments that build on skills the child already has, to encourage him to use his body and mind for higher-level tasks. In her book, Are You Blind? She discusses five phases of educational treatment that teachers are to use in working with children. This article will examine these five phases and share some of the highlights of this book.

It is important to note that before beginning to work with any child, a thorough assessment of his/her skills and emotional development is needed, so that you know where to begin. If you start too high you will likely frustrate the child and if you start too low, you run the risk of losing the child’s interest and motivation. Dr. Nielsen has developed a comprehensive assessment tool, the “Functional Scheme” (Nielsen, 2000), and a curriculum to help teachers called the FIELA Curriculum – 730 Environments (Nielsen, 1999).

Phase I: Technique of Offering

Children at this Level

Children at this level of development may seem reluctant to do much. They are often passive or engaged in self-stimulatory behaviors. Their world exists for the most part within the confines of their own bodies. They seldom seek out others for social interactions and may have limited experiences interacting with objects and their environment. This generally occurs because of motor disabilities or health issues that make movement difficult, and/or sensory disabilities that prevent the child from being enticed by the sights and sounds that motivate a typically developing child.

The Role of the Adult

At this stage, Lilli recommends using the technique of offering with the child. First of all the adult will need to set up an environment, such as a Resonance Board with many motivating objects, so that the child can come in contact with them incidentally if he or she makes any movement. The adult will also be with the child, either sitting alongside the child or supporting the child in a sitting position from behind if the child trusts the adult enough for this close contact. If not, the adult needs to respect the child's need for distance and only move in as close as the child seems comfortable with at any time. One of her goals at this level is just to have the child stay in the same room with her.

The adult’s first job is to simply offer the child toys and objects by placing the objects under the child’s hand. The child may touch or grasp the objects when and how he or she pleases. The adult does not talk to the child while the child explores the object in his or her own way. If the child drops or pitches the object, the adult simply offers another object. While offering the objects, the adult also must observe and take note of the objects the child seems to enjoy and those he seems to dislike. What is it about the object that seems to interest the child? What are the actions the child takes on the object? How does the child explore the object and with what physical actions (banging, mouthing, throwing, rolling, etc.)? What distresses the child and how does he show that distress? Does the child show interest in contacting the adult? How does he do that?

Purpose of the Offering Technique:

  • To convince the child that he can trust the adult has no intention of demanding that he does anything at all. Lilli’s only demand is that she wants to play in the same room as the child.
  • To observe the reactions of the child.
  • To learn about the child’s likes and dislikes.
  • To find out what may frighten the child most.
  • To learn about the child’s way of contacting, using this to assess the emotional level of the child.
  • To introduce sound self-activity.
  • To provide the child with the basis for successful introduction to phase II.

Points that Lilli Emphasizes at this Level:

  • Do not move too close to the child too fast — move in a little and watch his reaction.
  • Display an active and positive interest in whatever the child is doing.
  • Some children will not initiate play until they feel certain the adult has left the room. Periodically stop playing for a minute to a minute-and-a-half and just sit silently to see how the child responds. Does his behavior appear to be an invitation for you to continue your activity?
  • Everything the adult does should be done as an “offer.” If the child attempts to initiate an activity, don’t make a big deal about it; act as if he did that every day.

Phase II: Technique of Imitation

Children at this Level

Children at this level are generally somewhat more interested in things outside their own bodies, although they still may exhibit withdrawal, especially with unfamiliar people or people they do not trust. Their interests may also be very limited in scope. They may continue to show a lot of self-stimulatory behaviors, but are more aware of others and can be enticed into interactions with trusted people. They typically don’t initiate many interactions or have limited ways to make contact with others. They are able to play more with objects, but their play with others is more at a level of parallel play rather than interactive play. They also may have only a few actions they perform on objects and have only limited participation in activities. At this point the child may seem unsure of himself in many of his actions.

The Role of the Adult

At this level the adult continues to set up the environment with objects and activities that are highly motivating to the child. For example, if the child likes an object that vibrates, the adult will try to find many different objects that vibrate in differing ways. If the child is particularly fond of a certain color or texture, the adult finds things that seem to expand the child’s experience with other objects that share that quality. One child we know liked banging on and playing with disposable aluminum pie pans. The quality about these objects that seemed to be of most interest to him was the sound they made and that they could be bent to change shapes. He might also have enjoyed that they were lightweight, shiny and cool to the touch. Other things that could be offered to him would include: many sizes and types of metal containers such as individual pot pie pans, turkey roaster, tin cookie canister, metal coffee can; sheets of shiny aluminum foil; wire whisks; metal springs; metal spoons; metal ball bearings or Chinese Mediation balls; and other shiny and/or pliable materials.

In this phase the adult begins by imitating the actions of the child on the objects. For this reason, it is a good idea to have multiple numbers of an object. If the child bangs on the object, so does the adult; simply playing alongside the child at the same level. After a time, the adult can introduce a new action with the object and see if the child will imitate him. If the child does, great! If not, the adult should go back to imitating the action of the child again. This is a conversation of a sort, a turn-taking game. ’“You show me something, and I pay attention and copy you. Now I show you something. Maybe you will pay attention to and copy me. Now it’s your turn again.”

The Purpose of Imitating

  • To increase the child’s interest in activities happening nearby.
  • To increase the child’s ability to take initiatives.
  • To increase the child’s belief in himself.
  • To introduce activities and movements not as yet performed by the child.

Points Lilli Emphasizes at this Level are:

  • Imitation is primarily through auditory and tactile sensory modalities.
  • If the child throws an object, don’t correct him/her! Pick up the object, repeat your play and then place it before the child. It is best to have two of each object — one for child and one for adult.
  • The adult should begin by imitating child, then add some more constructive games (e.g., putting materials together or into one another) briefly before returning to the action the child began.
  • An increase in crying or screaming in a child who was doing that behavior before should be read as a positive “call for attention” from the adult.
  • Your goal is to give the child the opportunity to discover that being with the adult is “pleasant and exciting, and may include new auditory and tactile experiences.”
  • You also want the child to have the opportunity to “discover that he can take initiatives and that doing so leads to the ability to master something in his surroundings.”
  • He learns he has more actions to contribute to the interaction. This provides him with growing self-identity and ability to initiate interactions with other people.

Phase III: Technique of Interaction

Children at this Level

Children at this level are beginning to be interested in more interactive types of games (Lilli calls these “you to me and me to you” games). For example, you might have a bowl with marbles that you both hold on to and take turns pushing and pulling it back and forth between you. You want to see the child attempting to take a turn. The child may not necessarily initiate these games in the beginning at this level, but can be more easily engaged with others. He may, at times, want to take time out for his own exploration of an object, but will come back to the adult to share his interest after a time. This is the child that is interested in his environment and the actions of others and so is ready to begin learning that he can help others. This is a child who may also need support to transition from an enjoyable, interactive activity to a new activity without the adult. Some children at this level may fuss when an interaction comes to an end. It is as if the child were saying, “I want you to stay” and signals an emerging self-identity. The child begins more and more to attempt to make contact with others as he progress at this level.

The Role of the Adult

The adult sets up situations and environments that will foster interactive games. It is important for the adult to be patient and wait for the child to take his turn without trying to persuade him to act. Simply be quiet and still. If the child is trying to complete a motor skill that he has not yet mastered but matches his motor development, the adult can say, “You can help me.” If the child will use his hands, the adult needs to provide every opportunity for the child to familiarize himself with the activity and participate, and to complete the moment when he wants to do it. If the child will not use his hands, the adult can model the activity as close to the child’s hands as the child will allow. This allows the child to have control of his hands, and he can withdraw them when he needs a break. Lilli also cautions us to stop playing the game with the child while the play is still enjoyable. If it goes on longer than the child enjoys, the child may be unwilling to continue to interact with us. Another point Lilli makes is about the adult giving the child “presents.” Say “I put milk in your cup,” instead of “There is milk in your cup.” The whole notion of “yours versus mine” helps promote the child’s self-identity. Use a phrase like, “Your toys are on your shelf and my toys are on my shelf.” The adult also prepares the child when it is almost time for the interaction to come to an end so that the child does not see the adult as rejecting him.


  • To help the child to learn sound dependency on one or several people.
  • To help the child to initiate interactions.
  • To enhance the child’s development of self-identity.
  • To give the child the basis for social development.

Points Lilli Emphasizes at this Level:

  • Focus in on “you to me and me to you” games.
  • If the child becomes interested in something he wants to explore on his own, this should be respected. Wait patiently for a blind child to use his fingers to “look” at the object.
  • It is important always to wait for the child to initiate his part of the game.
  • Complete an action that may be too complex for the child to do, but at the same time tell the child he can “help” with the action.
  • Move at a slow pace. Know when the child “has enough to consider for a while.”
  • Tell the child before you come to the end of the activity that you will be leaving and that you are going on to a new activity. He may continue to play on his own if he chooses to.
  • If the child begins to say “more” or “again,” names the adults, or seeks out adult attention, he is ready for Phase IV while continuing with Phases I-III.

Phase IV: Technique of Sharing the Work

Children at this Level

The purpose of using the techniques of phase I, II, and III focuses on the child’s emotional development. It is done by establishing “an exchange and balance between periods of interaction and sound self-activity, between dependence and independence.” In the next phase, the child is at a place where he is ready to learn that taking action and interacting with others does not mean that he has to do everything or do it perfectly. The child exhibits confidence in performing some actions or activities. He has some beginning understanding of time and a sequence of events. He may appear threatened when familiar activities are changed slightly.

The Role of the Adult

Set up environments and activities that give the child tasks to do that are based on the things the child has experienced success in doing. In the beginning the tasks can be completed in a few seconds up to a few minutes without any consideration for how perfectly the child can complete them. The adult needs to let the child know which part of the tasks he will complete and which part the adult will complete. If the child is reluctant to do the task after being asked several times, the adult can suggest they do it together. The adult must make sure to give the child plenty of time to complete the task, but if he still won't do it, consider if the task is too hard. In complex tasks the adult may need to use various techniques (e.g. offering, imitation, etc.) for different parts. Let the child know how long the task will last and what will follow. This is when you can begin to teach time concepts like yesterday, today, tomorrow, now and next. It is important to have an established schedule.


  • To increase the child's experience of success.
  • To involve the child in new social relationships.
  • To increase the child's interest in acquiring new abilities.

Points Lilli emphasizes at this level:

  • Help the child learn that to be the one who does something does not necessarily mean that one has to do everything or do it perfectly.
  • The abilities the child has been successful with in previous phases form the basis for deciding which activities can be used for the technique of sharing work.
  • Keep tasks short (few seconds or minutes) initially, accept whatever the child does as correct.
  • Explain each time which parts of the activity the adult will perform and what the child will do.
  • Give plenty of time for the child to initiate the task and wait silently and calmly — be neutral.
  • Let the child know how long the activity is supposed to last.
  • Try to keep the environment the same or only make gradual changes.
  • Before going to more complicated and longer lasting activities the choice of technique for every part of the activity should be given careful consideration.

Phase V: Technique of Consequence

Children at this Level

Before using techniques at this level the child needs to have an emotional age of two years. This is when the child is ready to learn that his own actions have consequences. The child must show some confidence in what he can do and feel secure interacting with others generally. He may still have some difficulty initially in handling changes, but begins to show more coping skills at this level.

The Role of the Adult

The adult needs to model how consequences work for the child through a discussion of the adult’s actions. By this I mean things like saying, “I have to stop playing and cook dinner, or you will not have anything to eat.” Or, “I need to ask you to wait; I need to find a clean shirt for you.” Then after a time the adult begins to set up situations where the child can experience the consequences of his actions. For example, “If you want me to pour more milk, you must put your glass on the table.” The adult may accept a less than perfect response from the child, and may need to offer encouragement either through prompting or modeling. For example, “See you can put your glass here.” The child begins to understand choice-making.


  • To help the child to endure meeting demands.
  • To help the child to endure changes in life.
  • To help the child to feel self-confident, which is fundamental to the ability to make decisions about his own life.
  • To establish the basis for the sense of responsibility.

Points Lilli Emphasizes at this Level:

  • When the child feels secure and confident in performing different activities and has received information about the consequences involved in activities, it should be possible to let the child experience consequences. BUT only through activities the child is able to perform.
  • As the child is able to fulfill more and more requests he may demand more attention — don’t overly praise but rather act as if it is the most natural thing in the world that he can do something.
  • As independence increases the child may be able to tolerate that he sometimes is unable to succeed in what he intends to do. He will become better able emotionally to accept significant changes in his life. As he moves higher, he will be able to make friends with other people, decide when faced with situations that he has a choice.


Are You Blind? is a book that offers a great deal of guidance in working with a child who is at an emotional developmental age under age three for a typical child. By using the five phases of educational treatment Dr. Nielsen outlines in this book, we can help the child grow emotionally. When the child reaches the emotional age of three, then new approaches to learning may be available to him. We can begin to consider incorporating other more traditional ways of teaching into our plans with these children beyond simply learning by doing.

By Kate Moss and Stacy Shafer, Education Specialists, TSBVI Outreach

Abstract: This article focuses on Phase IV and V of Lilli Nielsen's five educational phases of educational treatment outlined in her book, Are You Blind?, and how the Active Learning principles can be incorporated into activity routines.

Key Words: programming, blind, deafblind, visually impaired, Active Learning, Lilli Nielsen, activity routines

In Dr. Lilli Nielsen's book Are You Blind? she outlines the five phases of educational treatment we can use to help the child with blindness or deafblindness grow emotionally and develop cognitively. The purpose of using the techniques of the first three phases is to establish "an exchange and balance between periods of interaction and sound self-activity, between dependence and independence." In Phase IV, which Dr. Nielsen calls "sharing the work", she describes a child who is at a place where he is ready to learn that taking action and interacting with others is within his capabilities.

If we think about the child at each of these educational phases we can see the progression:

Phase I - The child is very inwardly focused, engaging in self-stimulation, with very limited experiences with objects in the environment, and who is very reluctant to engage with others except the most trusted adult (usually a caregiver).

Phase II - The child is somewhat more interested in his environment and others and can be engaged in brief interactions around high-interest objects or actions or "start-stop-start" games such as patting, swinging, bouncing, rocking, etc. He is still somewhat withdrawn, has limited interests, has limited ways to make contact with others, and has limited things he can do with objects. He can "play" along side the adult and show some interest in what the adult is doing, but does not try to imitate the adult.

Phase III - The child is interested in more interactive types of games (sometimes referred to as "you to me and me to you" ) where he can take a turn, although he may not be able to initiate these games. Many of these games have imitative elements. The child may take time out from the game to process the experience or explore independently, but will come back to the adult to continue the game. He is interested in his environment and other adults and may fuss when the activity comes to an end.

Phase IV - The child is ready to learn that taking action and interacting with others does not mean he has to do everything or do it perfectly. He has confidence in some of his actions or activities. He is beginning to understand time and a sequence of events and will often become upset or act threatened when familiar activities are changed.

Phase V - The child is ready to learn that his own actions have consequences. He generally feels secure interacting with others and though he still may have difficulty initially handling change, he is showing more coping skills. He should have an emotional age of two years before attempting to work with him at this phase. (Nielsen, 1990)

Dr. Jan van Dijk, in his approach to working with deafblind multiply disabled children, also emphasizes the importance of establishing a relationship and learning to read the child's subtle communication as a first step. Similarly he uses co-active movement following the child's lead to engage the child in interaction. He develops anticipation through building structured activities and routines; then slightly changes something in the routine to introduce novelty and learning. All along his goal is to build the child's self-esteem and confidence in his abilities to do for himself and to interact with others. Specific communication skills are tied to these experiences as concepts are developed through experiential learning. (van Dijk, 2001)

Best practices teach us that throughout the child's development in these early stages, routines and turn-taking interactions play a critical role. For example, all children participate in basic care-giving activities such as bathing, diapering, and feeding. Through these care-giving activities that occur daily, the child begins to establish a memory and can anticipate events. Later on, through participation in simple turn-taking games that are done in a routine way, the child is able to cause the adult do something pleasurable by taking an action of his own. Still later in his development, the child is able to take part in a simple series of actions that result in some desired outcome through more structured routines. Finally the child develops independence in completing the steps of the routine he has spent time "helping" the adult to complete.

Phase IV - Sharing the Work or Level I Routines

In her book, Communication: A guide for teaching students with visual and multiple disabilities, Linda Hagood describes three levels of routines, and the child at Phase IV is just at Level I. In the Level I routine she describes an activity that:

Uses short, easy, predictable steps.Has a consistent beginning and end.Occurs at a consistent place and time with consistent objects and person.Is based upon the interests of the child.Is done with the adult in close proximity.Focuses on relationship building.Does not have the expectation of the child completing the activity on his or her own.Uses non-language forms such as objects, vocalizations, touch cues, etc.Views non-communicative behaviors as having communicative intent.

When a child is engaged in an Active Learning approach, it is at Phase IV when we begin using activity routines to supplement his independent exploration activities and simple interaction times with an adult.

At this phase the child should exhibit confidence in performing some actions or activities and have some beginning understanding of time and a sequence of events. When the child is demonstrating these traits, you can begin to include some routines where you expect the child to play an active part into a portion of each day. For example, he might show some anticipation of a familiar set of steps used in making his breakfast by trying to help pour the milk in his cup when the milk carton is opened. He may also become upset when he discovers that the carton contains orange juice and not milk.

Select a Motivating Activity

So how do you begin? As a first step, try to select activities that are motivating to the child. Think about the things (the objects) the child most enjoys playing with in independent exploration or in times when you are interacting with him. Are there activities you can design that will incorporate these materials? For example, if the child is interested in wire whisks, could you use a whisk to make instant pudding? Also consider the kinds of actions the child finds interesting. Can some of these actions be included in the routine you design? If the child likes to bang the whisk on another object can you have him bang the whisk from the finished pudding on the side of the bowl?

Pick an activity that is simple, one without a lot of complicated steps. Some of the payoff for participating in the routine needs to be apparent to the child from the beginning — "I get to play with the object I like." Additional perks for hanging in there until the end of the activity should also be included along the way — "I really like chocolate. I like banging the whisk on the side of a bowl with my teacher. I like to tear open cartons."

Organize the Materials

Participating in a routine with a child requires your undivided attention so you can respond to him emotionally and not miss any of his comments or reactions. Make sure you have all the materials you will need collected before you begin the activity. Think about the space where you will do the routine. Is this a space where the child feels comfortable and is not distracted by events or people? Is the area set up so that you can be at the child's level, even if that means sitting on the floor? If the child can't or won't sit, can he physically access all the materials and complete an action? This might mean covering the floor with a protective cloth if the activity is likely to get messy. Will the child help you collect some of the materials or is that too much to ask of him at this point? Get everything ready before you ask the child to come "play".

Provide Time to Explore

Give the child time to explore the space and the materials you will be using during the routine. Be sure to let him explore it in his own way and not the way you think he should explore it. If possible, let the child experience his own exploration of the objects outside the routine before introducing it into a structured routine.

Share in his exploration by having a duplicate set of materials for you to use or by giving joint attention to the object. For the visually impaired child this is often demonstrated through a shared tactile experience using a hand-under-hand approach (Barbara Miles, 1999). For example, if he bangs the wire whisk on the table, have one you can bang along side him. If he puts his hand in the water, put your hand in there with his so that he knows you are aware of what he is doing. Don't hurry him in his exploration — this means you need to allow plenty of time for the routine.

Set up the Sequence

It is necessary to the child to provide a clear sequence of steps in the activity. Using a slotted box like the ones typically used for a daily object calendar works well. Place an object you will use in each step in sequential slots of the box. Organize them from left to right so the child can find his way to the next step easily as each step is completed. Provide a finish basket or box to discard the object after you have completed the step. After he becomes more familiar with the routine the child may be able to help you load the objects into the slots after he has thoroughly explored each one. If not you may quickly review each one that you have pre-loaded into the slotted box so he knows where each object and action occurs in the sequence.

Complete the Steps

As you introduce each step, give the child a little time to re-explore the object before asking him to "help" complete the step. Then you can give him the word or sign for the object and model what you are going to do such as pour, stir, throw, tear open, etc. In the beginning the tasks you are asking him to complete can be completed in a few seconds up to a few minutes without any consideration for how perfectly the child can complete them. Be sure he understands which parts you are asking him to complete and which parts you will do. Most importantly, give him plenty of time to attempt to do the step before helping him complete it.

Modeling using a hand-under-hand approach during the routine, allows him to access what you are doing without making demands upon his hands to do all the work. If the child wants to explore the object a bit more after you use it, let him, but finish each step by helping to place the object in the finished box. Going back to the left-most slot and feeling for the next object can be beneficial in encouraging the child to look for the next "step" in the routine. (This is the perfect time to begin to introduce the concept and language of "next".) Eventually (after many times helping you do the action) the object should prompt the child to take the action independently. Wait silently and patiently!

Be Mindful of Pacing

Though you don't want to rush the child through the activity, you also don't want to lose him by dragging things out too long. This is where your teaching becomes an art; you have to be a keen observer of the child's emotional state. You know the child and can read his signs of boredom, anxiety, or pleasure. Allow more time for his "fun" parts and move more quickly through steps that are less pleasurable.

Clean Up and Put Away

To whatever degree the child is capable have him help you collect materials and clean up the space. At first this might simply mean helping you get a key item from its place or put the object representing the activity in the finished basket. If he can carry dirty materials to a sink or throw a water toy into the bucket, get him to do that much. Over time, he should be able to take on greater responsibility for collecting and putting away the materials.

After the Activity is Completed

Take a few moments after the activity is done to "talk" about how the child helped. Don't overly praise him, just comment on his successes and what you did together. If the child is using a calendar system at an anticipation level (at least), you may be able to reflect on the activity before you place the representing symbol in the finished box or basket.

Throw a Curve Once the Routine is Well-Established

When the routine has been completed a number of times and the child is definitely familiar with both the materials and the steps, it may be time to throw him a curve. For example, change the container that holds the milk, put bubble bath into the water, get a very large wire whisk or a very small one. Don't change too much too quickly. You will likely see some surprise or even anxiety when he encounters the change. This surprise will provide a great topic for conversation. It also will expand the child's knowledge of objects and /or actions based on a very familiar, understood event. This is the way we all learn the best, not too much new to take in at one time.


Using routines is an invaluable tool when working with children who are developmentally delayed. A well-designed routine provides a great structure for learning. Incorporating Active Learning principles into the routine is also helpful. Just remember some of the points Dr. Nielsen mentions:

Help the child learn that to be the one who does something does not necessarily mean that one has to do everything or do it perfectly.The abilities the child has been successful with in previous educational phases form the basis for deciding which activities can be used for the technique of sharing work.Keep tasks short (few seconds or minutes) initially, accept whatever the child does as correct.Explain each time which parts of the activity the adult will perform and what the child will do.Give plenty of time for the child to initiate the task and wait silently and calmly — be neutral.Let the child know how long the activity is supposed to last.Try to keep the environment the same or only make gradual changes.Before going to more complicated and longer lasting activities the choice of technique for every part of the activity should be given careful consideration.


  • Hagood, Linda. Communication: A Guide for Teaching Students with Visual and Multiple Disabilities. Texas School for the Blind and Visually Impaired, 1997.
  • Miles, Barbara and McLetchie, Barbara. Developing Concepts with Children who are Deaf-Blind. DB-Link, 2004.
  • Miles, Barbara. Talking the Language of Hands to Hands. DB-Link, 2003.
  • Moss, Kate. "Five Phases of Educational Treatment Used in Active Learning Based on Excerpts from Are You Blind? by Dr. Lilli Nielsen." Texas School for the Blind & Visually Impaired, See/Hear, Volume 9, No. 2, Spring, 2004.
  • Nielsen, Lilli. Are You Blind?, SIKON, 1990.
  • Van Dijk, Jan. Development Through Relationships. DB-Link, 2001.
  • Van Dijk, Jan. An Educational Curriculum for Deaf-Blind Multi-Handicapped Persons, DB-Link, 2001.

By Stacy Shafer, Early Childhood Specialist, and Ann Adkins, Education Specialist- TSBVI Outreach Programs

Abstract: This article describes some of the techniques of Dr. Lilli Nielsen's Active Learning Theory.

Key Words: blind, deafblind, Active Learning, Lilli Nielsen, real objects, Little Room, resonance board, position board, play

Editors Note: In a previous edition of See/Hear, we printed "An Introduction to Dr. Lilli Nielsen's Active Learning" and promised to provide additional information on active learning in each issue this year. In this issue, we'd like to examine some of Dr. Nielsen's learning strategies and the importance of using real objects. We would also like to hear from others who have used active learning, and encourage you to contact Ann Adkins at , Sara Kitchen at , Scott Baltisberger at , or Chris Montgomery at to share your experiences.



Visually impaired children learn by exploring and manipulating the objects in their environment and by comparing new objects to familiar ones. They need as many experiences as possible with real objects and textures. Hands-on experiences with a variety of objects, made out of as many different materials as possible, allow students to work on a variety of skills and learn about their environment. Concrete experiences with real objects also facilitate concept development. It is important to give students ways to actively impact their environment and teach them to be active participants in their world instead of passive recipients of stimulation from adults. The active learning techniques developed by Dr. Lilli Nielsen provide excellent opportunities for visually impaired students to gather information through the exploration and manipulation of real objects. Dr. Nielsen's approach encourages children to be active learners, and helps them discover that they can control events in their lives.


Some of the active learning equipment and materials that we have observed include:

The Little Room

The Little Room is described in detail in Dr. Nielsen's book, Space and Self, and in the article in the last edition of See/Hear. It is a piece of equipment that provides students with a safe environment for independent play and exploration. Many children are more willing to tactually explore objects when they are in control of an activity and can anticipate what might happen. The objects in the Little Room are attached with elastic and go back to their original positions when the child lets go of them, enabling him to find them again and repeat an action as quickly and as often as he wants. It gives students the opportunity to work on object exploration and manipulation, object comparison, object permanence, cause and effect, spatial concept development, problem solving, independent play, recognition, anticipation, sensory integration, and spatial memory. The Little Room also provides the opportunity to learn about the different materials from which objects are made (paper, leather, wood, metal, etc.) and the different attributes of objects (size, weight, temperature, etc.). As students experience these different objects and learn about their specific characteristics, they will discover that some objects are better for some activities than others. They will learn that some objects make better sounds when batted at than others, some are better for mouthing, some are more interesting to touch, etc. Although the Little Room is an independent activity, it MUST be supervised at all times.

The Position Board

This is a piece of pegboard to which objects are attached with pieces of elastic and is also described in Space and Self. It may be used as an independent activity if the position board is placed so it will remain stationary, or it may be used with an adult. It can be attached to a student's wheelchair tray, attached to a wall, or placed on the floor or table. Like the Little Room, objects should remain in the same position to encourage the development of object permanence, and the elastic attached to the objects needs to be long enough for students to be able to bring the objects to their mouths. Be sure to include objects with different weights and textures.

The Scratching Board

This is a piece of wood with different textures attached to it. These textured squares are approximately 3" X 3". Examples of textures to include are: leather, carpet, cork, shiny wrapping paper, packing "bubble" sheets (if there is not a danger of the student tearing off a piece and getting it in his mouth), corrugated paper from a box of chocolate candy, shiny ribbon, suede, etc. Fine screening, like tea strainers or cooking strainers, can also be used if the edges are covered to prevent injury. The scratching board can be attached to a student's tray or positioned so that it can be used while the student is lying on the floor, with either his hands or feet. The Scratching Board can be stabilized so it is an independent activity.

The Tipping Board

This is a board that is fixed in an upright position. Hang objects from the top of the board so that students can receive sensory feedback by batting at them. Again, it can be positioned so that a student can use both his hands and feet. Some objects to consider using include: shiny bead necklaces, strings of interestingly shaped beads, chains (such as those used in the 70's as belts and necklaces), bells, a plastic or metal slinky, wooden spools strung on cord, etc. Inexpensive necklaces can be restrung with nylon fishing cord or dental floss to prevent breakage. The Tipping Board is an activity that students can do independently, with supervision, if the board is stabilized.

Vest with Objects

The Vest is like a cummerbund with Velcro. Objects and interesting textures are attached to it for students to explore independently. Headliner fabric may be used instead of Velcro to reduce the possibility of abrasions.

The Resonance Board

Playing on a resonance board can be a very rewarding activity for students, providing them with sensory input from the vibrations created by their play. Position the student on the resonance board with several interesting objects around him to encourage him to explore his immediate environment. Playing on the resonance board can be an independent activity, or it is an activity that could be shared with an adult or another student. The child should be on the Resonance Board when using a Little Room.

All of the activities described above encourage students to use their hands to explore their environments. Visually impaired students need repeated opportunities to tactually explore and examine real objects every day. They need a variety of experiences that require active responses. Additional information on active learning can be found in Dr. Nielsen's books, Space and Self and Are You Blind? These books also include information on suggested objects to use with the activities. The student's educational team should work together to choose appropriate objects. Objects should be pleasurable, graspable, and have tactile, auditory, and visual qualities. Real objects from everyday experiences and daily activities are recommended because they can provide more meaningful and rewarding experiences than toys. Toys and commercially available objects are often made of plastic, and plastic provides little information that is tactually meaningful for visually impaired students. Objects should also be presented in such quantities that the child will have the opportunity to choose, compare, and play counting and sequencing games. They should also vary in weight and texture. Caution is advised because some objects are not appropriate for use with all students. Teams should ensure that all materials and boards used in active learning activities are splinter free, that rough edges are covered with heavy layers of masking or packing tape (especially pegboard), and that any paint, acrylic, or finishing agents used are nontoxic. Even though these are independent activities, they MUST be supervised at ALL times.


  • Nielsen, Lilli. Space and Self, SIKON, 1992.
  • Nielsen, Lilli. Are You Blind?, SIKON, 1990.
  • SEE/HEAR Winter 2004

Last Update: 4/12/2017 AKL

(Originally published in in the June 1995 edition of VISIONS)

Summer 99 Table of Contents
Versión Español de este artículo (Spanish Version)

By Stacy Shafer, Early Childhood Specialist, TSBVI, VI Outreach

Dr. Lilli Nielsen has worked as special education adviser at Refsnaesskolen, National Institute to Blind and Partially Sighted Children and Youth in Denmark since 1967. She was trained as a preschool teacher and psychologist. She has performed research in the area of spatial relations with infants who are congenitally blind and has written several books and articles about educating children with visual impairments and multiple disabilities. Dr. Nielsen's approach is called Active Learning. She has presented week-long training sessions on developing the full potential of young children with visual impairments and multiple disabilities in countries around the world. We were very fortunate that she presented in Dallas, Texas, May 1994. I was asked to write about some of the information she has shared with us.

All young children learn through play. They need to be encouraged to explore their environment and objects in their environment. Dr. Nielsen believes that all very young children learn by being active, rather than passive recipients of stimulation. We need to observe typical children to see how they learn to move their own bodies (raising their heads, reaching for objects, sitting up, etc.); use their bodies to explore their surroundings (including any and all objects within their surroundings); and actively participate in interactions with other people. A visual impairment prohibits a child from having enough opportunities to develop these abilities and have these experiences without intervention. She encourages adults to set up the child's environment so that s/he can do this.

Here are a few of Dr. Nielsen's recommendations when developing the child's environment:

  • Observe the child. It is imperative that we know what the child can do, what activities s/he enjoys, what type of objects s/he likes, etc. Assessing the child's existing skills and preferences is the first step in programming. Observation will help you note the child's current developmental skills. A child's preferences are indicators of the underlying strengths of his system. These preferences can guide you in the selection of objects and activities. You need to know a child's repertoíre so you can notice change and improvement.
  • Provide the child with more activities and objects that are similar to those he enjoys. This will encourage the child to explore and experience new things and broaden his knowledge base. Young children with visual impairments need to be encouraged to explore, not only toys from the toy store, but also everyday objects around the house.
  • Give the child opportunities to practice and/or to compare. As adults, we are often tempted to remove materials as soon as the child shows that s/he can use them. We all relate new information to things we already know. For example: The first time you successfully drove a car around the block, you still needed lots more experiences driving in different environments. For example, you needed to drive on different types of roads and highways, different vehicles, different times of the day and night, in different types of traffic, with the radio on and off, with friends in the car, and so forth, before you really mastered all the skills and concepts about driving. When a child begins to bang one object on another one, he needs to be given the opportunity to bang lots of different objects on lots of different surfaces. (The sound produced when banging a metal spoon on the couch is much different than banging it on the coffee table or a metal mixing bowl.) Children need to be able to repeat an action many, many times in order to learn.
  • Provide a few materials and activities that are at a slightly higher developmental level. This will provide a challenge for the child, so he doesn't become bored. You only model these activities for the child. You do not expect him to imitate.
  • Do not interrupt a child by talking when s/he is actively engaged in play. Most of us have had the experience of talking to an infant who is busily kicking her legs and having the child stop kicking to listen to our voice. We need to refrain from talking to a child who is exploring or playing with an object or practicing a new movement. We should wait until the child turns to us to share her/his experience or at least until s/he takes a little break in the activity before commenting. This does not mean that we need to stop talking to our young children with visual impairments, just that we need to pick our moments.
  • Slow down when interacting with a child. We must be willing to wait and give the child time to take a turn in the interaction. When playing with a child, Dr. Nielsen tells us to give the child time to explore an object alone, rather than jumping in and showing her/him how to use it. At a conference during a child demonstration, Dr. Nielsen offered a battery operated facial brush to a child. She let him explore the brush in his own way. He held the brush against various body parts, moved it from hand to hand, turned it over, put it on a tray, moved it against other objects on the tray, picked it back up, put it to his lips, and did many other things with it. Then he turned to Dr. Nielsen to share the experience. That was the moment she talked with him about the facial brush and the things he had done while playing with it.
  • Let the child have control of her/his own hands. Dr. Nielsen feels that when we are interacting with a child who has a visual impairment, it is important not to take her/his hand and bring it to the materials. Instead, we need to develop alternate strategies for presenting objects to the child (e.g. gently touching the toy to the child's arm or leg to alert her/him of the object's presence, making noise with the object to arouse her/his curiosity and encourage her/him to reach out, placing several objects near or touching the child's body, so any movements s/he might make will bring her/his body in contact with an object, etc.).
  • Provide opportunities for the children to actively participate with their environment. One of these "special environments" is the "Little Room". The "Little Room" consists of a metal frame supporting three side panels and a Plexiglas ceiling from which a variety of objects are suspended. These objects should be ones that the child finds interesting and enjoyable. This gives the child the opportunity to experience the properties of objects, to compare different objects, and to try out different things with the objects on her/his own without adults interpreting that experience for her/him. Since the objects are stable (secured to ceiling and walls), the child is able to repeat her/his actions with an object as many times as s/he needs to, at one to two second intervals, without dropping and losing them. The immediate repetition enables the child to store the information gained from the experiences in her/his memory.

Dr. Nielsen has given us lots of information about ways to encourage a child with a visual impairment to learn and develop. For more information about Dr. Nielsen's Active Learning, contact the Consultant for the Visually Impaired at your Education Service Center (You can find a map of Texas Education Service Centers at or call Outreach Services at Texas School for the Blind and Visually Impaired at 512.206.9268).


Here are some of the books and articles written by Lilli Nielsen.

  • Environmental intervention for visually impaired preschool children with additional disabilities, VIP Newsletter, Vol. 8, No. 3.
  • The blind child's ability to listen, VIP Newsletter, Vol. 10, No. 3.
  • Active learning, VIP Newsletter, Vol. 10, No. 1.
  • Space and Self, SIKON, 1992.
  • Early Learning Step by Step, SIKON, 1993.
  • Are You Blind?, SIKON, 1990.
  • Notes taken from lectures given by Dr. Lilli Nielsen at conferences in Albuquerque, New Mexico, in September 1992, in Milwaukee, Wisconsin in October 1993, and Dallas, Texas, in May 1994.

Video of student in the HOPSA dress

When a student is visually impaired or deafblind with significant cognitive and physical disabilities (especially if the condition is congenital) unique instructional strategies must be used to systematically teach what other children learn incidentally. One of these strategies is known as Active Learning, an approach developed by Dr. Lilli Nielsen. This approach uses specific equipment and techniques to help students from birth thru high school age functioning developmentally at ages younger than 4 years or 48 months. This approach focuses on creating environments for the learner to develop foundational concepts and skills in all areas. It can be used to provide instruction at an appropriate learning level in both the standard curriculum and the expanded core curriculum for these students with the most profound disabilities.

Some teachers and administrators have questioned the use of Active Learning because it looks very different from typical instructional approaches used in most educational settings. It looks like “play” to many people. However, very specific learning goals and prerequisite skills are the focus of a true Active Learning approach.

In a guidance letter from Office of Special Education and Rehabilitation Services, Department of Education (November, 2015) the appropriateness of a focus on prerequisite skills aligned to the standard (or general) curriculum was discussed. Below are pertinent excerpts from this document related to these students:

Based on the interpretation of “general education curriculum” set forth in this letter, we expect annual IEP goals to be aligned with State academic content standards for the grade in which a child is enrolled. This alignment, however, must guide but not replace the individualized decision-making required in the IEP process.5 In fact, the IDEA’s focus on the individual needs of each child with a disability is an essential consideration when IEP Teams are writing annual goals that are aligned with State academic content standards for the grade in which a child is enrolled so that the child can advance appropriately toward attaining those goals during the annual period covered by the IEP.

The Department recognizes that there is a very small number of children with the most significant cognitive disabilities whose performance must be measured against alternate academic achievement standards, as permitted in 34 CFR §200.1(d) and §300.160(c). ….The standards must be clearly related to grade-level content, although they may be restricted in scope or complexity or take the form of introductory or pre-requisite skills.

Excerpt from Pages 4-5 of a guidance document from OSERS on alignment to the standard curriculum, November 2015

Texas School for the Blind & Visually Impaired Outreach Programs has developed a process for aligning instruction for these special learners that utilizes Texas Early Learning Pathways, Pre-K Guidelines, Essence Statements, and Texas Essential Knowledge and Skills. This is done by utilizing the Functional Scheme assessment and other assessment tools to determine the learner’s current developmental levels prior to developing the PLAAFP and setting priority areas goals and objectives. For learners at this level, many if not all of these goals are focused on pre-requisite skills.

We invite you to learn more about Active Learning and utilizing this approach at Active Learning Space (, a special website developed by Penrickton Center for Blind Children, Perkins School for the Blind and Texas School for the Blind and Visually Impaired. You may also want to view a webinar about Active Learning, alignment and instruction which can be found at

Object Calendars can be used to help facilitate communication. Calendars also help children transition from one activity to another. The team chooses a few activities that the child does on a daily basis. They then choose an object from each activity to represent that activity. The chosen activities should include several that the child enjoys. The object that is used to represent an activity needs to be meaningful to the child. The team slowly keeps adding to the number of activities in the child's day that are represented in her calendar. You can work on joint attention, social interactions, anticipation, sequencing, object exploration, choice-making, turn-taking, etc. There are many different types of calendar systems you can use with a student. The first level of calendar system is described below:

  • The team chooses a few fun activities (4-6) that the child does on a daily basis (playing with the tent, sit-and-spin, water play, jumping on a rebounder, going for a walk outside, eating a snack, etc.). Then choose an object from each activity to represent that activity. (You will have 4-6 different objects.) The object that is used to represent an activity needs to be meaningful to the child and needs to be used during the activity.
  • Cue the child that an activity is about to occur by presenting the object associated with that activity to her. Allow her to handle the object and explore it as she wishes, then IMMEDIATELY take her to the area the activity is going to occur, preferably while she's still holding the object, and engage in the activity.
  • Cue the child that the activity is finished by presenting a distinctive basket that is unlike any other basket in her daily life. This will be her "finished basket". For example: When it is time to end the activity, present the finished basket to her, let her tactually explore the basket, then help her take the object that represents that activity and place it in the finished basket. Then IMMEDIATELY pick up the materials or move her out of the area.
  • At least once a day, present a different basket containing all 4-6 object symbols to the child and let her explore with it. When she picks up one object symbol and begins to play with it, go do that activity with her.
  • When the child begins to search for the object symbol for her favorite activity, this is the beginning of pre-symbolic object-based communication and she will be ready for the next level. (Or when she places the object symbol for an activity that she doesn't like into the finished basket as soon as it is given to her.)
  • The team slowly keeps adding to the number of activities in the child's day that are represented in her calendar.

The next step will be to set-up a permanent location in the classroom for the calendar system. Instead of taking the object to the child, you bring the child over to the calendar. Then while the child explores the next object in her calendar, you have a short discussion with the child about the up-coming activity, then the child takes the object with her, goes and does the activity, brings the object back to the calendar and puts it in the finished basket.

Developed by Stacy Shafer

For additional information please contact Sara Kitchen

A wonderful resource book about Calendars is now available!!

Robbie Blaha's, Calendars for Students with Multiple Impairments Including Deafblindness is available from the Curriculum Department at the Texas School for the Blind and Visually Impaired.

Photo of hands reading braille.

The current English Braille American Edition (EBAE) code will be changing beginning January 2016. Students across the United States will start learning Unified English Braille (UEB), a new code to facilitate braille compatibility with new and emerging literacy needs and current technology.

Spring 2017

  • Provide STAAR tests as per plan developed in 2016-2017 school year.
  • Continue data collection for research studies regarding the use of Nemeth Code.
  • Explore the addition of an innovative course in UEB Technical Code to TEA’s list of approved state elective course.

Fall 2016

  • Start teaching UEB at Texas Tech University.
  • Start teaching UEB to elementary students and older students who are new to braille.
  • Begin to collect data for research studies regarding the use of Nemeth Code vs. UEB Technical Code, focusing on Math and Science.
  • Make Braille TExES in UEB available and continue to offer Braille TExES in EBAE for two more years.
  • Facilitate the Braille Challenge in UEB format.

Summer 2016

  • Start teaching UEB at Stephen F. Austin State University.
  • Continue preparation for 2016-2017 UEB implementation for teaching students with visual impairments.
  • Continue the implementation of Nemeth Code training for transcribers and teachers of students with visual impairments.
  • Release plan for STAAR testing.

Spring 2016

  • Statewide celebration of National UEB implementation on Louis Braille’s birthday (January 4 th).
  • Continue preparation for 2016-2017 UEB implementation for students with visual impairments.
  • Continue the implementation of Nemeth Code training for transcribers and teachers of students with visual impairments.

Fall 2015

  • Continue to develop training plans for braille transcribers and teachers of students with visual impairments.
  • Implement Nemeth Code training for transcribers and teachers of students with visual impairments.
  • Develop a plan to transition STAAR to UEB code with TEA and test developer.
  • Send survey to braille transcribers to determine UEB knowledge and skills and level of certification.
  • Continue public relations regarding UEB with districts and ESCs.
  • Continue braille curriculum transition to UEB code.

Summer 2015

  • Plan training for braille transcribers and current teachers of students with visual impairments for 2015-2016 school year with ESCs and TSBVI.
  • Continue to develop Nemeth Code training plans for transcribers and teachers of students with visual impairments.
  • Continue to develop university UEB braille courses.
  • Add UEB code information to the 2015 Guidelines and Standards for Educating Students with Visual Impairments in Texas.
  • Begin transition of current braille curriculum (Braille FUNdamentals, APH programs) to UEB.

Spring 2015

  • Begin State of Texas Assessments of Academic Readiness (STAAR) transition development with TEA and the STAAR test developer.
  • Advertise National Braille Association training in April, 2015 in Austin, Texas.
  • Present UEB overview to conferences: Texas Council of Administrators of Special Education (TCASE), Deafblind Symposium, Low Incidence Disability (LID) network, and Texas Association of Education and Rehabilitation of the Blind and Visually Impaired (TAER).
  • Post Unified English Braille overview items on state and regional websites.
  • Continue to develop training plans for braille transcribers and teachers of students with visual impairments via ESCs and TSBVI.
  • Begin face-to-face and online trainings for braille transcribers and teachers of students with visual impairments.
  • Begin exposing teachers and students to UEB recreational readings.
  • Develop university UEB braille courses.
  • The decision to retain the Nemeth Braille Code for mathematics and science was made by the Braille Authority of North America (BANA) in November, 2012; BANA will provide provisional guidance on how to transcribe the Nemeth Code within UEB contexts.
  • Work with teacher certification test developer and TEA to plan UEB Braille TExES development timeline.
  • Plan the transition for state-adopted instructional materials to the UEB code with TEA Instructional Materials Division.
  • Provide public relations UEB awareness campaign with school district administrators.
  • Evaluate access to UEB via technology for students with visual impairments.
  • Facilitate the continued use of the Nemeth Code by creating a Nemeth Code Handbook.
  • Facilitate the continued use of the Nemeth Code by developing training plans for transcribers and teachers of students with visual impairments.

Fall 2014

  • Explore available options for training for braille transcribers and current teachers of students with visual impairments.
  • Develop resource document of available references on rules, resources, and training.
  • Advertise National Braille Association (NBA) training on April 16-18, 2015 in Austin Texas.
  • Develop UEB training plans for braille transcribers and teachers of students with visual impairments throughout the state in conjunction with Education Service Centers (ESC) and Texas School for the Blind and Visually Impaired (TSBVI).
  • The Texas Education Agency (TEA) will collaborate with the teacher certification test developer for transition to UEB on the Braille Texas Examinations of Educator Standards (TExES).
  • Explore opportunities for funding for teacher and transcriber attendance at the National Braille Association UEB training in April 2015 in Austin, Texas.

Compiled by Texas UEB Stakeholder Group - November 5, 2014; Revised August 20, 2015

Here is a collection of resources for gaming. There are 2 sections. First, is magazines dedicated to the gamer with visual impairments. Second, is a list of sites where you can download and/or purchase games.


  • How To Play a Text Adventure, Part 1
  • QuestML - What is QML? QML, the Quest Markup Language, is a free XML-based Choose-Your-Own-Adventure game system by. Adventures can have images, sound, states to check, random events and much more. You can have them be played on any browser, even make them accessible by text-to-speech clients.

Accessible Games

By Robbie Blaha, Education Specialist, TSBVI Deafblind Outreach with help from Stacy Shafer, Millie Smith and Kate Moss, TSBVI Outreach

Since it’s inception of laws providing for the free and appropriate education for all students in this country our schools have seen a steady increase in the population of students who are considered to have the most profound disabilities. Although our willingness to serve these children is evident, our understanding of these students’ educational needs, assessment and programming is still very much in its infancy. It is easy to feel we do not know what to do with these students. Developmental checklists and assessment tools used with other populations are not often sensitive enough to provide usable information to those charged with the instruction of this type of student.

The purpose of this article is to: (1) present basic user friendly assessment questions and background information which relates to this particular population, (2) acknowledge the individuality of each of these children by building a personal picture of how they learn, and (3) provide useful information with which to develop programming. This is not intended to be a comprehensive assessment process but rather some questions and background information to consider when planning for this particular population.

What Can Be Done To Gain And Hold This Child’s Attention?

Attending And Biobehavioral States

A typical nervous system exhibits a range of levels of arousal. In all of us there is a structure in the brain stem that controls levels of arousal (biobehavioral states). Some examples of these levels of arousal states are deep sleep, drowsiness, alertness, anxiousness, and agitation. (Guess, 1988). If our nervous systems are n the normal range, we spend our day shifting across the states in a typical manner. We sleep at night, are alert and absorbed in a good book and drowsy after a big noon meal We may become very agitated when paying our bills or it a stray dog digs up the garden.

We are able to consciously control some of these arousal states. For example, if we find we are getting sleepy behind the wheel of a car, we stop to get a cup of coffee. We are calmer in a stressful situation if we bring along a friend or wear a favorite outfit. If something agitates or makes us anxious, we may engage in “self talk” as a form of state management. For example, to calm down we might think to ourselves, “I’m not going to worry about it. It’s not that big of a deal. If worse comes to worse I’ll just…”

For all of us, the only time we can learn new information is when we are able to achieve and maintain an alert state. This is why, after something traumatic throws you into an extremely agitated state, it is sometimes impossible to remember things that were said or to reconstruct a particular sequence of events. You may also find that, after a big lunch in a warm room, you become incredibly sleepy and have trouble reading a long memo from your boss. The ability to attain and maintain an alert state is essential for understanding and learning.

Children with profound disabilities may not exhibit the typical range of states. This is a characteristic of a number of students with profound disabilities. One student may always seem to be sleeping or drowsy. Another is chronically irritable or anxious, leaving adults fearful of interacting with her lest they “set the child off.” Many of these children may have brief cyclical periods of alertness, but seem unable to maintain this state long enough for typical instructional activities. Slightly over-stimulating this child can cause him / her to “shut down” to a sleep state.

Often these children have difficulty achieving and / or maintaining alert states. They may experience health setbacks that bring incredible drains on their energies and effectively prevent them from being able to respond to any environmental demands outside their bodies. In some students with deafblindness the lack of normal stimulation due to an extensive sensory loss causes them to spend much of their time in other than alert states. The key to instructing these children is to understand the internal influences on the child’s ability to attend to instruction.

There is a growing interest in the possibility that external factors can have impact on biobehavioral states in these children. During the assessments, we want to learn things about children that might help them develop better control of their states and maintain alert states for longer periods of time. The more adept they become to attending, the more opportunity they have for learning. Therefore assessment should help determine the child’s current profile of states and what adaptations to the environment may assist the child in achieving and maintaining an alert state.

The questions related to biobehavioral states that should be answered during assessments are:

  • What are the range of states the child exhibits across the day or week?
  • What are the child’s most common states?
  • Is this child able to reach the quiet alert or active alert state?
  • Can he maintain it?
  • What problems does the child have in shifting and maintaining states?
  • What variables appear to effect state in the child (especially attending)?

There are a number of tools that can help in obtaining this information. These include:

  • Assessment of Biobehavioral States and Analysis of Related Influences
  • Appetite / Aversion Form or Likes and Dislikes from the APH Sensory Learning Kit 
  • Assessment of Voluntary Movement Component
  • Carolina Record of Individual Behavior (CRIB)
  • Analyzing Behavior State and Learning Environments Profile (ABLE).
  • The Key to Attending: The Orienting Reflex

People have a subconscious monitoring system that is working at all times. If this system detects something that needs our immediate attention, it pulls us to attention with the powerful orienting reflex. The orienting reflex is just that: a reflexive alerting to: significant things. It tells us when to pay strict attention so that we may make a decision whether or not to defend ourselves or to get more information. It alerts the senses to the fact that they need to pay attention, so that survival matters and novel things can be handled. (Silverrain, 1991)

All of us have orienting reflexes throughout the day. As an example, say that you are driving along listening to the afternoon news. The words roll by you until suddenly you hear your street address being said over the air. You snap to attention, lean forward, and turn up the dial to take in every word. You reflexively oriented to something that is important to you. The orienting reflex is powerful because it is the prerequisite to the alert state in the array of biobehavioral states. (Rainforth, 1982) It pulls you to an alert state from another state. Parents use this reflex all the time. If you have a fussy (agitated state) child in the grocery store, you try to distract her so she will calm down. (“Do you see that man with the funny hat? What do you think his name is?”). What you are actually doing is trying to trigger the orienting reflex in the child so she will shift from an agitated state to a calm state.

In the area of attending, a critical component in both assessment and instruction is the orienting reflex. (van Dijk, 1985) It is important to consider because the orienting reflex can potentially be used to help the child who is usually in “other than alert states” shift into attending. The hope is that you can capture their attention on a reflexive level; then provide instruction. (See “associative learning” discussion.)

If the child shows an orienting reflex in response to a change in position, a particular scent, or colored lights, these materials or strategies can be embedded in the lessons to try to gain the child’s attention and help him shift to an alert state. Once he makes that shift, you have a brief window of opportunity to provide further information and to attempt to extend the amount of time that he attends.

An important thing to note: There is a difference between the orienting reflex and a defensive startle. Overhearing your name in a conversation produces an orienting reflex. “The orienting reflex readies the nervous system for further learning.” (Silverrain, 1991) The blare of a fire alarm typically produces a defensive startle. A startle indicates an overload of the nervous system, which is aversive rather than appealing. The result is not “attending,” but rather physical agitation and / or disorientation and / or withdrawal. The child who experiences a defensive startle during an interaction with his instructors or his environment feels under assault rather than invited to participate.

If the stimulus is perceived as aversive, you are less likely to attend and more likely to spend your energies trying to get away from the stimulus. Children who cannot physically get away from an aversive stimulus may literally shut down into sleep to escape. That is why it is critical to determine what the child tolerates or is attracted to (appetite) versus what repels the child (aversion). (van Dijk, 1985)

Families as well as other members of the child’s team often have valuable pieces of information related to the things that seem to catch his attention or deeply bothers him. In the assessment process you need to identify things that elicit an orienting reflex so that you can embed those in your lesson to help the child maintain attending. You also need to assess what things are aversive to the child so you do NOT inadvertently include these things in lessons or social interactions with him and take away his ability to attend.

The questions related to orienting reflex that must be answered during assessment are:

  • What does the orienting reflex look like in this child?
  • What elicits an orienting reflex in this child?
  • What does the defensive startle look like in this child?
  • What elicits a defensive startle in this child?

There are a number of tools that can help in obtaining this information. These include:

  • Assessment of Biobehavioral States and Analysis of Related Influences,
  • Appetite / Aversion Form,
  • Assessment of Voluntary Movement Component

How Does The Child Take In Information?

Preferred Sensory Modalities

We all use our senses to gather information from our environment. These senses include: visual, auditory, vestibular (related to movement and spatial orientation sensed through muscles, tendons, joints, and the inner ear) kinesthetic (related to bodily position, weight, or movement sensed through the muscles, tendons, and joints, olfactory (smell), and gustatory (taste).

We also have preferred senses for taking in information which impacts how we best learn. Some of us learn new material best by listening, others prefer to read the information, and others may need to write new information down. It is important to determine which sensory channel (s) the child with profound disabilities prefers to use and then provide instructional activities and information through those preferred channels. For example, a child may alert to a change in lighting. She may attend longer if there is some music involved in the lesson. She will accept certain types of tactual input in the palm of the hands but never on her mouth. Looking at the self-stimulatory behaviors (i.e. rocking, flicking, etc.) can also give you some information about which sensory systems have value to the child. (Moss & Blaha, 1993)

It is helpful to systematically test across all sensory channels with tools like Every Move Counts and to compile and analyze anecdotal information from families and staff who have daily interactions with the child. These observations contain clues about sensory things involving water. You observe that the one sound that seems to “tune him up” (bring him to attending) is the sound of water running from a faucet. That piece of information tells you that the child recognizes a consistent and a distinct auditory cue and associates it with something that he really enjoys.

The strategy of “multi-sensory approach” is sometimes recommended for this population. There seem to be different working definitions for this term. This approach is sometimes perceived as stimulating all the child’s senses at the same time with the same level of intensity. This version of multi-sensory approach assumes a couple of things:

  1. All senses are triggered in pleasant ways. This may not be true for these children. A child may orient to music through the auditory channel but find tactile information through his hands frightening. Combining these with equal intensity in a lesson may throw the child for a loop.
  2. The child can combine completely different sensory input into a meaningful whole. This may not be possible for all children. For example, some students may need to focus on one channel at a time to understand what is happening. It may be better to pace the lesson so the child can have a longer time to look at or touch something before you start talking about it. You can relate to this need if you think of the times you have turned off your radio when you were looking for a freeway exit in a large unfamiliar city.

The questions that should be considered in assessment related to sensory channelsare:

  • What sensory channels are most effective for gaining the child’s attention?
  • What sensory channels are important for conveying reliable information to the child?
  • What degree of sensory information or pacing of presentation of information helps the child shift his state to attending?
  • What channels are associated with orienting reflexes?

Assessment tools that help to provide this information include:

  • Learning Media Assessment (LMA),
  • Every Move Counts,
  • Appetite / Aversion Form,
  • Inventory of Self-Stimulatory Behaviors.

Does The Child Remember And Learn?

Any type of learning has to do with memory. The following are indicators that a child is remembering specific sensory information.

Habituation As An Indicator Of Memory

When I first moved to Austin I rented a home near the airport. It was a great house but unfortunately stood under the flight path. Incoming flights woke me up at night and interrupted phone conversations for the first few days. After a time, however, I tuned it out and stopped noticing the noise. When my sister came for a visit she asked me, “How can you stand it?” I honestly had no idea what she was talking about. I had gotten used to the sounds and had stopped hearing them. This is an example of habituation. Our minds unconsciously sort through incoming information. Habituation is an indication of memory because you only get used to things that your system is able to remember. Habituation decides what we should ignore or notice and is characterized by a lack of response. This is very important as it allows the nervous system to focus on relevant events and not be overwhelmed by all the trivial types of stimulation occurring around us all the time.

Watching for signs of habituation in a child is important because it tells you he is remembering. Many times you hear comments like, “He used to really jump when the intercom came on, but now he doesn’t seem to notice it. I don’t know if he can still hear it.” Or “This used to be her favorite tape, but now she doesn’t seem to respond to it.” These could be indicators of habituation which signifies that the child views the information as “old news.”

Building Associations As An Indicator Of Memory

Building associations between two events is a type of learning and remembering. Linking a new fact with a familiar one (associative learning) is one way we grow to understand the things around us. Before we talk about ourselves, however, let’s talk about less complex life forms and what they have shown us about associative learning.

“Snails, believe it or not, demonstrate simple associative learning. Recent studies show the effects of learning on the nervous systems of snails. Large groups of sea snails are given a fast spin (simulating the roll of a wave) which makes them contract. Each spin is preceded by a burst of bright light. Bursts of bright light alone have no effect on snails. After a while, the snails will contract when the light is shone on them, as if a spin were imminent. Researchers have shown that during this learning, new nerve connections have grown that did not exist before. The snails began to react or anticipate the spin simply by association with the burst of light.”

“You might find it interesting to know that new born human infants have also shown the ability to associate a preceding event with one that follows. A hungry, crying baby will become quiet when she hears her parent’s footsteps approaching in the night because she anticipates the bottle. We know that the human nervous system is capable of making associations between two events when the final event in the chain relates to basic survival or pleasure needs.” (Silverrain, 1991)

A child who dearly loves the taste of pudding initially shows no recognition of a spoon. However, over time, you may see him develop the same level of enthusiasm for a spoon as the pudding because you the repeatedly paired the spoon with the pleasure of eating pudding. The ability to make an association between the spoon and the pudding is an example of associative learning. (Note: We have learned from early studies that present the spoon immediately before he tastes the pudding is the way to help the child make the connection.) By building these meaningful pairs in a child’s life you are expanding his understanding of the world. Noting any associations that child may have already is important assessment information.

Anticipation As An Indicator Of Memory

Anticipation should be considered an indication of learning and memory. When a child feels his bib go about his neck and begins to open and close his mouth, he is anticipating the next step. He is showing us that he remembers. Unlike habituation that is characterized by a lack of response, anticipation is characterized by a “tuning up” of the system and some action on the part of the child that says “Oh yeah, I remember this!” Anticipation tells you that you have been successful in developing associative learning. You have built an association between bib and eating.

Anticipation of an upcoming event can “rev you up” to maintain an attending state. For example, a person is on a road trip and knows that the exit he must take will be a few miles past a factory on the left. This guy may drive along lost in his own thoughts for thirty minutes or so until suddenly, the factory appears on the left and triggers an orienting reflex. He shifs into the alert state and begins to anticipated the exit. Because he anticipates the exit, he stays alert for a short period of time and looks closely for the sign. Using cues with children helps them anticipate and pull to attending so they can learn.

Surprise As An Indicator Of Memory

Building in a surprise or what has been called a mismatch of expectations (van Dijk, 1985) is a test for memory and learning. A mismatch occurs for the child when he anticipates his mother picking him up and playing a particular swinging game, but is treated to this same game by this father. The child registers his surprise by fluttering his eye lids and breathing more rapidly. The surprise elicits an intense alert state in which associations previously learned are reviewed and compared with the new experience important learning has taken place for him. A child responds to a mismatch of expectations only because he remembers what should have happened.

Questions to ask related to assessing cognition (habituation, anticipation) include:

  • Are there things the child used to orient and respond to that he now seems to notice?
  • Does he stop responding after 2-3 times?
  • Does he seem to pair things, events, and/or people together?
  • Does the child show anticipation of what is about to happen?
  • Does the child register surprise when there is a change in a familiar routine?
  • Does the child seem to know familiar versus unfamiliar people?

As assessment tool that helps to provide this information is Every Move Counts.

What Can This Child Do To Impact His Environment?

Since learning is something the child does with you and not something you do to him, it is critical to determine the easiest way for the child to respond so that he is able to successfully participate. Possible responses that these children might make are changes in affect, vocalizations, gaze shift, and body movements. (Korsten, 1993) Even if these responses are not intentional, you should identify a particular response he gives and try to shape it into a purposeful response. Systematically testing for these responses is an important part of assessment.

Systematic Inventory Of Voluntary Movements

It is important to systematically observe the child in all the positions typically used with him and inventory the voluntary movements he can make. Some of these children are said to have no voluntary movements to use for instructional purposes. Typically this is not the case. When a child is observed in a variety of positions he may show a surprising number of movements. From this inventory of voluntary movements, the team can target a particular response(s) which will allow the child to participate in an activity.

Many children can make a particular movement easily in one position but not in another. Some positions are more stimulating or relaxing for a child and this effects their ability to attend. (“As soon as we put him in side-lying, he stops fussing.”).

Additionally, some children, when moved from one position to another, experience a significant change in their biobehavioral state. They may find the experience frightening and need a period of time to recover before they can attend. These children could benefit from strategies to make the transition less aversive (e.g., touch cues which signal that they are about to be taken from their travel chair or slowing down the pace of the transition). Other children may be at their most alert following a change in position. It is an individual things.

Questions related to voluntary movement that can be addressed in assessment include

  • What specific voluntary movements does the child exhibit across positions?
  • How do different positions affect the child’s level of arousal or biohehavorial states?
  • Does transition from on position to another cause a significant change in the child’s biobehavioral state?.

Assessment tools that help to provide this information include:

  • Every Move Counts
  • Assessment of Voluntary Movement Component
  • Physical Therapy Assessment
  • Occupational Therapy Assessment

Using The Assessment Information In Developing Programming

Programming Strategies

Once this assessment information has been compiled the educational team should be able to draw on it in developing their program. Ann Silerrain suggested some strategies to follow in her 1991 article. These include:

  1. Use assessment data to determine learning media that provides the appropriate level of stimulation---enough to be alert and not enough to cause withdrawal. We must forget about stimulation for the sake of stimulation. “Tolerating stimulation: is not an appropriate goal. Damaged nervous systems need the appropriate type and amount of stimulation; they do not need to be bombarded.
  2. Develop activity routines which have a predictable sequence of steps, objects, or actions that evoke the orienting reflex to reengage the child throughout the activity and provide opportunities for the child to respond or take a turn. Remember pacing is critical in getting child response.
  3. Use familiar objects and people in daily routines as a basis for instruction. Evaluate anticipatory responses to sensory cues to determine the appropriateness of the materials or actions used for cuing. As you cue the child, look for orienting reflexes to occur. Remember that you want to get an orienting reflex, follow with an activity of high interest or one that comforts or meets a basic need as a way of rewarding the child’s response. Over time we should begin to see the child show signs of anticipation. All things we want the child to respond to should be real things or actions that are used by or with the child in everyday routines.
  4. Design a daily schedule of predictable and pleasurable events or routines. With any activity, if we want to see an anticipatory response (evidence that the child remembers) the activity must have a strong emotional appeal for the child.
  5. When we see the child anticipate events and show some awareness of the functional use of objects, then primitive communication choice systems can be used. When a child does such things as gaze at a preferred item then at you; tactually explores two objects and picks the relevant one in context; pushes an object toward you; pulls or pushes your body in a way that says “I want you to do this with me,: then you are beginning to move into the realm of intentional conversation.
  6. When the child is consistently anticipating a particular object or action in a routine, toss in a mismatch to test awareness and communication. This check can only occur within the context of a stable routine. For example, the child is routinely expecting to have you present her red bib before meal time, but instead you put a hairbrush in front of her and her bib off to one side. Will she realize there is a problem and try to communicate that to you? Will she try to get your assistance in resolving the problem? These are indicators of a readiness for more complex learning.


As the family and the other members of the educational team work together they become more able to recognize and respect the skills and strong personal preferences that children with the most profound disabilities show us. All the children have ways of showing us what they want more of and what they would like to avoid. It is our responsibility to develop the assessment expertise needed to be aware of those messages and to use them to build better learning environments for the child.

References And Resources

Guess, D., Mulligan-Ault, M., Roberts, S., Struth, J., Siegal-Causey, E., Thompson, B., Bronicki, G.J., & Guy, G. (1988). Implications of biobehavioral states for the education and treatment of students with the most handicapping conditions. JASH, 13 (3), 163 - 174.

Korsten, J.E., Dunn, D.K., Foss, T.V., and Francke, M.K., (1993), Every move counts. Tucson, AZ: Therapy Skill Builders

Moss, K. and Blaha, R. (1993), Looking at self-stimulation in pursuit of leisure or I’m okay, you have a mannerism. P.S. NEWS!!!, July 1993, pp 10-14.

Rainforth, B. (1982). Biobehavioral State and Orienting: Implications for Educating Profoundly Retarded Students. TASH Journal, Vol. 6, Winter, 1982 (33-37).

Silverrain, A. (1991). An informal paper: teaching the profoundly handicapped child. San Antonio: ESC Region 20.

Simeonsson, R. J., Huntington, G.S., Short, R.J., & Ware, W. B. (1988). The Carolina record of individual behavior (CRIB): Characteristics of handicapped infants and children. Chapel Hill: Frank Porter Graham Child Development Center, University of North Carolina at Chapel Hill.

Smith, M., Levack, N., & MaGee, B. (1996). Teaching Students with visual and multiple impairments: a resource guide. Austin: Texas School for the Blind and Visually Impaired.

Van Dijk, J. (1985). Personal notes from a seminar.

SEE/HEAR Editor’s Note: This article first appeared in the Fall 1996 edition of SEE/HEAR newsletter published by Texas School for the Blind and Visually Impaired and Texas Commission for the Blind. It was developed in response to requests we have had from teachers who are working with children who have the most profound disabilities. Typical assessment information provided little for the teachers to use in developing programming for this type of child.

(P.S. NEWS!, Vol. IV, No. 3, July 1991, pages 10-12.)

by Robbie Blaha, Teacher Trainer and Kate Moss (Hurst), Family Training Coordinator

En Espanol

There are few events in our day to day lives that do not become routines. Whether it is brushing our teeth, putting gas in our cars, or going bowling there exists in our minds a series of predictable steps and specific objects associated with those steps. Often we move through these familiar activities with little notice. However, there are aspects of these routine activities that deserve a second look. A well organized routine can have a powerful effect on a child with severe disabilities. Children with severe disabilities have been shown to benefit from learning through routines.

If you consider your child's day, you probably have already established a variety of routines. Think about changing a diaper, eating a meal, bath time, etc. These events happen daily and generally in a predictable or routine way. Here are some things that these routines are providing your child.


You may notice during these activities your child seems to communicate a great deal with you. His subtle or sometimes not so subtle responses during these events might "tell" you, "I'm not hungry," "I'm ready to get out of the tub," etc. You understand and respond to these communications by skipping to dessert or pulling the plug on the tub and wrapping the child in a towel.


Routines feel comfortable and the child uses his energy and attention more efficiently. When a person who is not familiar with your routine way of doing an activity, attempts to feed or bathe your child, the child might become anxious or uncooperative. Yet if you direct that person to do it your way the child will often calm and respond better. He's familiar with the routine. That helps him to better anticipate and participate in the activity.


Routines develop a sense of a beginning, middle and an end to an activity. They also help weave a cluster of people, actions, objects and locations into a meaningful whole. Routines make use of natural cues, i.e. one step acts as a cue for the next step. This type of cueing does not require another person to always prompt the child because the objects used in the activity serve as the prompts. In addition routines can help a child anticipate an end to an undesired activity or recognize the beginning of a desired activity.


Routines build a memory foundation for other learning. Paul Carreiro and Sue Townsend (Routines: Understanding Their Power) note that the development of a sophisticated memory is dependent on a core memory system referred to as "procedural memory." Procedural memory is defined as "the ability to retain a simple everyday 'low attentional' understanding of how things work." If a child does not have an organized experience he can not understand. If he can not understand an experience he will not learn from it.


When a child has an internal picture of an activity he can recognize when something changes. He is alerted to attend and learn the new part. He can become aware of specific bits of information that impact him and is more likely to tune in to that particular concept. For example, if a child has a routine for making pudding, you can introduce a new flavor. The child will tune in to the flavor being different because everything else in the activity has stayed the same. The difference in flavor can be "spotlighted."

Using routines at home can reinforce learning, improve communication between the child and family, and reduce frustration for everyone. The information that follows will help you formalize your existing home routines. If you do not use routines, you might want to consider developing some. As you develop routines, share them with school personnel. If your school is not using routines currently with your child, you might encourage them to become familiar with the concept of using routines in learning.


Before you set up your routines it is important to decide which of your child's daily activities you want to formalize into routines. The following tips will help you in this process:

1. Map out a typical week day and weekend day for your child. (Figure 1)

2. Begin by picking obvious activities where routines are likely to exist already such as eating, toileting. Give special consideration to those activities that will be most beneficial to the child's mental and physical health. Next look at those activities that adults must do for the child. Would these activities be made easier if your child could participate partially? For example, it would be helpful if the older child could anticipate when you need to slide a diaper under him and participate by raising his bottom rather than requiring you to have to lift him. Finally look at those activities that could be done as vocational activities.

Figure 1 - Mapping out a typical week day and weekend schedule helps to identify existing routines which can be formalized. It can also help to identify times when routines might be helpful to the child and family.
6:30 a.m. wake up 7:30 a.m. wake up
6:40 a.m. bathroom 7:40 a.m. bathroom
6:50 a.m. breakfast & medications 7:45 a.m. help dad cook pancakes
7:15 a.m. brush teeth 8:30 a.m. breakfast & medications
7:30 a.m. dress 9:00 a.m. brush teeth
8:00 a.m. catch bus 9:15 a.m. dress
AT SCHOOL 9:45 a.m. free time
10:45 a.m. family activity
3:30 p.m. return home 1:00 p.m. lunch time
3:45 p.m. bathroom 2:45 p.m. continue family activity
3:50 p.m. snack 4:00 p.m. snack
4:15 p.m. freetime 4:15 p.m. freetime
6:00 p.m. dinner 6:00 p.m. dinner
7:00 p.m. plays with dad 7:00 p.m. plays with dad
8:00 p.m. bath 8:00 p.m. bath
8:30 p.m. bedtime 8:30 p.m. bedtime


After you have identified activities for routines it will be helpful to write these routines out. List all the steps in the activity in the order in which they occur. The amount of detail in each step will depend on the expectations you have for your child. You might have the staff at your child's school review these routines and decide which specific IEP objectives could be worked on during the routine. These objectives could be written into your routine script. One objective might be included in several different routines. (Figure 2.)


  1. Walk to dining table (Trail wall from hall to dining room)
  2. Find chair and sit down
  3. Wait for mom/dad to put on bib
  4. Look for spoon when tapped on table and pick it up (Use visions to explore space and locate objects. Grasp object)
  5. Allow mom/dad to help scoop and carry spoon to mouth (hand over hand)
  6. Set down spoon and reach for cup when drink is offered, or set down cup and reach for dessert (Indicate choice by reaching for preferred item)
  7. Help move plate away when meal is finished
  8. Allow mom/dad to wipe off hands and face
  9. Drink medication from medicine cup
  10. Remove bib (Remove clothing independently)
  11. Get down from chair

Figure 2 - A mealtime routine might include steps in which IEP objectives can be imbedded. The objectives appear in italics.

You might enjoy tracking your child's success in carrying out the routine. A nice way to do that is by making periodic video tapes of the activity or keeping a log that you share with school. You may even come up with some other method to note the changes. It is important to remember that this type of information can and should be shared with the ARD committee when assessment data is being reviewed.


Family life is subject to unexpected events and unplanned for crises. Given that, set up a schedule that is reasonable for you. Don't plan to take on too many new routines until you feel comfortable with the existing routines. When a routine becomes formalized, it may take longer to do especially if you expect your child to participate more in the activity. Allow for more time to complete the activity, or if that is not possible, opt to reduce the level of the child's expected participation. For example, family meal times may prove to be too hectic for encouraging the child to try emerging self feeding skills; however, snack time might be more relaxed. Instead of writing out a meal routine that includes using new self feeding skills, you might focus on these during the snack activity.

Once you have identified some routines that exist in your day write out a schedule. You may not be able to follow it exactly everyday, but if you have a schedule and everyone knows it, you will be more likely to follow it. Post the schedule on the refrigerator. Tape up the individual routines near the area where the activity will take place. Share this schedule and the routines with those individuals who may fill in for you such as grandparents, baby sitters, and siblings. It is especially important to share these routines with the educational staff who work with your child. This will help the staff to design their routines to be consistent with the routines that take place at home.

Editor's Notes: There is much more to learn about routines and their uses with children who are deaf-blind. Look for future P.S. NEWS !!! articles to cover this material. If you have questions about this article please contact Robbie at or Kate at . This article is based on two articles by Paul Carreiro and Sue Townsend who are communicative disorder consultants with Student Services in Edmonton Public Schools in Alberta, Canada. The articles are titled Routines: Understanding Their Power and Implementing the Routine Model.