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Introduction

Communication skills are essential for children to be able to interact with other people. Visual impairments may directly affect communication by altering the ways in which children communicate, and indirectly through possible delays in other areas of development that are important for communication. The purpose of this session is to provide basic knowledge and skills about typical communication development and the impact of visual impairments on communication development.

Objectives

After completing this session, participants will

  1. describe seven levels of communicative competence.
  2. describe the development of communication and language in typically developing children from birth through 36 months.
  3. define language and describe five elements of language.
  4. explain the importance of caregiver responsiveness in parent-child attachment and communication. 
  5. describe the importance of concept development for communication and why children with visual impairments may develop concepts differently.
  6. describe six modes of nonlinguistic/prelinguistic communication, and explain how visual impairments may prevent children from engaging in typical nonlinguistic/prelinguistic communicative behaviors.
  7. describe the potential impact of visual impairments on nonlinguistic/prelinguistic communication, including the development of idiosyncratic communicative behaviors of children with visual impairments and additional disabilities.
  8. describe the potential impact of visual impairments, with and without additional disabilities, on language development.

Major Points

A. Seven levels of communicative competence

Children move through seven levels of communicative competence as they develop the ability to communicate (Rowland & Stremel-Campbell, 1987). Children first engage in behaviors that are interpreted as communication by their caregivers (Levels I and II). Next they engage in presymbolic communication (Levels III and IV). Finally, children move on to symbolic communication (Levels V, VI, and VII). Each level is described below (see Handout B).

By understanding these levels, professionals can support families as they scaffold their children’s learning to move to the next level of communication competence. Scaffolding is providing responsive support to children that helps them acquire skills at the next developmental level.  

Level I, preintentional behaviors. Preintentional behaviors are reflexive responses to the child’s internal state. For example, when newborns are hungry or uncomfortable, they will cry. Caregivers’ interpretation of the behaviors and responses to them result in communication. Gurgling, cooing, head/limb movements, postural changes, and facial expressions are other behaviors that occur at the preintentional behavior level.

Level II, intentional behaviors.  At this level, children intentionally engage in behaviors, such as moving their bodies, without the intent to communicate a message. Caregivers’ interpretation of these behaviors and responses to them result in communication. For example, when infants smile, they are not intentionally trying to share the smile with another person. Caregivers, however, will respond to the smile with words, gestures, and facial expressions. In addition to smiling, babies at Level II will fuss, regard objects, avert head, and reach.

Level III, nonconventional presymbolic communication.As children move into presymbolic communication, they use intentional nonconventional gestures to affect caregivers’ behavior. Laughter, nonspeech sounds, reaching, pushing, tugging, smiling, approaching, and moving away are nonconventional behaviors used to communicate messages such as requesting more, rejecting, protesting, confirming, etc.  

Level IV, conventional presymbolic communication. At this level, children develop conventional gestures, such as pointing, waving, kissing, and nodding to affect caregivers’ behavior. Children also begin to use intonated sound patterns to express their needs.

Level V, concrete symbolic communication. At the concrete symbolic communication level, children begin to pair concrete symbolic representations with specific referents in the environment, such as making the sound of an object (“vroom, vroom” for “car”) and depictive gestures (i.e., gestures that look like what they mean, such as those for “mine,” “come,” “sit,” etc.). The symbols are termed concrete because they share features with their referent.

Level VI, abstract symbolic communication. At the abstract symbolic communication level, children use few abstract symbols or one-word utterances to represent entities in the environment. Symbols are used primarily one at a time. For example, a child may say “Hot” when he feels the heat blowing out of a floor air vent.

Level VII, formal symbolic communication. At this level, children begin to understand the semantic and syntactic rules of formal language. They combine two or more words to communicate and rearrange the words to change meaning.

B. Communication and language development

As typically-developing children progress through the levels of communicative competence, they usually acquire skills in a relatively uniform sequence. The attainment of important developmental skills, such as the first meaningful word or walking independently, are called developmental milestones. Children with disabilities, and with visual impairments in particular, are highly diverse. Some may attain communication and language milestones in the same sequence and at a similar rate as that of children without disabilities; however, others will not.

When considering the communication and language skills of young children with disabilities, we should be more concerned about helping them to acquire skills at the next level of communication competence than whether or not they are achieving milestones at the same rate as typically developing children. By identifying the level of communication competence at which children are currently functioning and by being aware of what comes next, we can scaffold children’s experiences to help them acquire that next level of competence.

Scaffolding is specialized support by an adult to a child that helps children link objects, actions, and categories to one another. An example of scaffolding could include relating an object, activity, or topic in which the child is engaged to a previous experience. Scaffolding is used to help children acquire new skills in a developmentally appropriate manner. Therefore, the age levels associated with the acquisition of communication and language milestones in this session should be used as a rough reference point and should be used very cautiously with young children with disabilities.

For any child, some skills will emerge earlier and others later. The information in this section should be viewed as a general guide to the sequence and rate at which children develop communication, not as target goals for communication development. If a child has multiple disabilities, communication development may be affected by the additional disabilities. See Major Points H and J for more information about children with multiple disabilities.

When infants who are only a few hours old begin to cry, they do not intend to communicate hunger. They are simply responding to hunger the only way they can. Adults respond to children’s behaviors often without even being aware that children are communicating. Adults’ responses reinforce children’s behavior, and children’s responses reinforce adults’ behavior. For instance, if a newborn infant cries (i.e., engages in nonintentional communication), the caregiver knows something is wrong but has to guess what it is. Is it a dirty diaper, hunger, or pain? Through the process of elimination, the caregiver identifies the problem and responds, causing the child to stop crying. Infants soon learn that if they cry, someone will come and take care of them. In this way infants’ expressive communication (i.e., cries) become intentional even though they are still nonsymbolic.

Again, throughout this section, all age ranges are provided as general guidelines and should not be viewed as absolute developmental milestones or targets.

Children and parents communicate in many ways during the first 6 months of life (Adamson, 1996; Gard, Gilman, & Gorman, 1993; Sachs, 1997). Of a newborn’s repertoire of expressive communication strategies, one of the most frequently used is crying; by 3 months most infants have differentiated cries to communicate different needs (e.g., hunger, exhaustion, pain). During the first 3 months, children begin to coo and gurgle. Soon they begin to make vowel sounds, first at the front of the mouth, then at the back of the mouth. As children get older, they add consonant sounds to their repertoire and begin to produce consonant-vowel combinations. From 3 to 6 months, children increase their babbling; sound production increases, with a variety of consonant-vowel combinations, followed by duplicated syllables such as mama and baba with changes in pitch and inflection. They also begin to babble to other people and objects as well as while alone. At the same time, most infants begin to laugh and chuckle, vocalize pleasure and displeasure, and occasionally vocalize in response to an adult’s speech.

Receptively, infants respond to communication from adults during the first 6 months (Adamson, 1996; Gard et al., 1993; Sachs, 1997). Beginning in the first 3 months, newborns will attend to voices and become excited when a parent or caregiver approaches. They will smile in response to smiles and coos from an adult; they will quiet when picked up. From 3 to 6 months, infants begin to smile at faces and to stop vocalizing when an adult approaches. Children also begin to respond to their names by 6 months.

As children develop, they learn that their actions have an effect on others. In Table 1 and Handout C, Rowland and Schweigert (2000) describe communicative behaviors and communicative intent for each of  the seven levels of communication competence. Children learn to use many nonsymbolic methods of communication, including vocalizations (e.g., babbling, crying), gestures, facial expressions, social referencing (i.e., looking at an adult to determine how to respond to a novel situation), joint visual attention (i.e., looking at the same object an adult looks at), and responsiveness to a communicative partner (Adamson, 1996). Some of these communications are used to gain an adult’s attention. For example, when children babble in response to parents’ voices, parents are more likely to continue talking to them. Other communications are to express a need or desire. Children may cry when their diapers are wet, or they may look at the bottle when they are hungry. Slowly children learn to engage in certain behaviors to elicit adult responses (i.e., engage in nonsymbolic intentional communication). In typically developing children, most communication is nonintentional from birth to around 6 to 8 months (Owens, 2001).

Table 1 Development of Communicative Intent
Level of communicationPragmatic Features

Level I

Preintentional (reactive) behavior

States expressed by behaviors (as interpreted by caregivers)

  • discomfort
  • comfort
  • interest/excitement
  • startle

Level II

Intentional (proactive) behavior

Functions that behaviors serve (as interpreted by caregivers)

  • protest/reject
  • continue pleasurable action
  • obtain more of something
  • attract attention

Level III

Nonconventional presymbolic communication

Intents for which behaviors are used by child

  • refuse/reject
  • request more of an action
  • request a new action
  • request more of an object
  • request a new object
  • request attention
  • show affection

Level IV

Conventional presymbolic communication

All of above intents and

  • greetings
  • offer/share
  • direct attention to something
  • confirm/negate
  • ask questions

Level V

Concrete symbolic communication

All of the above intents and

  • request an absent object
  • label

Level VI

Abstract symbolic communication

All of the above intents and

  • comment

Level VII

Formal symbolic communication (language)

All of the above intents

Note. Rowland, C., & Schweigert, P. (2000). Presymbolic communication: Key elements of individualized instruction. In Communication development and teaching strategies for children with severe and multiple disabilities: Presymbolic communication and tangible symbol systems (p. 8). Portland: Oregon Health and ScienceUniversity Design to Learn Projects. Used by permission of Oregon Health and ScienceUniversity.

Between 6 and 18 months, most children increase their intentional expressive communication (Adamson, 1996; Gard et al., 1993; Sachs, 1997). From 6 to 9 months, they attempt to imitate gestures and familiar sounds made by their parents. They initiate vocalizations with other people and have distinctly different vocalizations for different states (e.g., anger, contentment, hunger). By 9 months, children cry when their parents leave them. From 9 to 12 months, children can gesture and vocalize to indicate their wants and needs. Children begin to shake their heads no, wave good-bye, and raise their arms to be picked up. Children will also repeat actions that elicit laughs from others.

Receptively, children understand many more adult communications between 6 and 12 months (Adamson, 1996; Gard et al., 1993; Sachs, 1997). Between 6 to 9 months, they begin to comprehend some gestures from their parents. They will look at a common object or person when named. They comprehend “no,” even if they don’t always respond to it. Beginning around 9 to 12 months, children also understand “hot.” They can follow simple commands and look at an object when asked. A summary of the stages of nonlinguistic/prelinguistic communication is included in Table 2 and Handout D. Again, children with and without disabilities vary considerably in the ages at which they acquire communication skills, and so the ages provided in the table should be viewed cautiously.

Table 2 Stages of Nonlinguistic/Prelinguistic Communication Development
Approximate age rangesExpressive communicationReceptive communication

Birth to 3 months

  • undifferentiated cries
  • cooing
  • begin to make single vowel sounds

 

  • attend to voices
  • become excited when hear parent’s voice
  • smile in response to smiles and coos from parents
  • quit crying when picked up
 

3 to 6 months

  • increase babbling and include double syllables, changes in pitch/inflection
  • babble to people and objects
  • laugh
  • vocalize to express pleasure

  • smile at faces
  • stop vocalizing to attend when parent approaches
  • begin to respond to their names
 
 

6 to 9 months

  • attempt to imitate gestures and sounds
  • initiate vocalizations
  • distinctly different vocalizations based on state (e.g., anger, contentment)

  • comprehend some of their parents gestures
  • look at common object or person when named
  • comprehend “no” even if they don’t always respond to “no”
 
 

9 to 12 months

  • gesture and vocalize to express wants and needs
  • begin to shake head “no”
  • begin to wave “bye”
  • raise arms to be picked up
  • repeat actions that elicit laughter from others

  • understand “hot”
  • begin to follow simple commands
  • look at toy or object when asked to
 
 

Over time, infants develop a greater understanding of expressive language (Gard et al., 1993; Pan & Gleason, 1997; Tager-Flusberg, 1997). Somewhere between 10 and 18 months, most children use their first true word, meaning they relate the symbol to the concept it represents. Children also begin to point at objects and use a word approximation simultaneously. Between 12 and 18 months, children begin first to imitate words and then develop a vocabulary of 3 to 20 words. They also learn several stock phrases such as “All gone,” “What this?” and “My turn,” and frequently use ritual words such as “Hi,” “Bye,” “Please,” and “Thank you.” Between 12 and 18 months, 50% of utterances are nouns. Between 18 and 24 months, children begin using more verbs and adjectives, and they develop verbal yes/no responses. An abbreviated sequence of typical language development is provided in Table 3 and Handout E.

Table 3 Abbreviated Sequence of Typical Language Development
Approximate age rangesExpressive communicationReceptive communication

10 to 18 months

  • develop first true words
 

12 to 18 months

  • imitate words
  • develop vocabulary of 3 to 20 words
  • use phrases (e.g., “All gone,” “What’s this?”)
  • use ritual words (“Hi,” “Bye,” “Please”)
  • 50% of utterances are nouns

  • follow simple one-step commands
  • point to one to three body parts
  • identify one of two objects from a group
 

18 to 24 months

  • use more verbs and adjectives
  • develop verbal yes/no response
  • 65% of speech is intelligible
  • have vocabulary of 50 recognizable words 
  • comprehend around 300 words
  • begin to be interested in listening to stories
 

By 30 months

  • 70% of speech is intelligible
  • have vocabulary of around 200 words
  • can answer what and where questions
  • use two-word phrases including negation (“No milk”), possessives (“Daddy chair”), and pronouns (“Me Philip”)

  • comprehend 500 words
  • listen to 5-10 minute story
  • carry out two related commands (e.g., “get your coat and bring it to me”)
 

By 36 months

  • 80% of speech is intelligible
  • have vocabulary of around 500 words
  • ask simple questions
  • repeat simple sentences
  • begin to use articles (“a,” “an,” “the”)
  • begin using contractions
  • begin using -ing endings
  • 25% of utterances are nouns and 25% are verbs

  • comprehend 900 words
  • know concepts such as big/little and in/on
 

Expressive communication development continues throughout the early years (Gard et al., 1993; Pan & Gleason, 1997; Tager-Flusberg, 1997). By 2 years of age, approximately 65% of children’s speech is intelligible, with about 50 recognizable words. By 2.5 years, 70% of children’s speech is intelligible, and they have about 200 words in their vocabulary. Children are now able to answer simple questions like “Where?” “What (are you/am I) doing?” and “What do you hear?” Children begin using two-word phrases including negation (“No bed”), possessives (“Mommy car”), and pronouns (“Me Janey”). By 3 years, 80% of speech is intelligible, and children have a vocabulary of about 500 words. Children can ask simple questions and repeat sentences. Children begin using articles such as “a” and “the” as well as contractions and gerunds (–ing endings). By 3 years, 25% of utterances are nouns and 25% are verbs.

Receptively, children also make tremendous progress from 12 to 36 months (Gard et al., 1993; Pan & Gleason, 1997; Tager-Flusberg, 1997). Children between 12 and 18 months are able to follow simple one-step commands, point to one to three body parts, and identify one or two objects from a group of objects. Between 18 and 24 months, children comprehend around 300 words, and most children now become interested in listening to stories. By 2.5 years, most children comprehend 500 words and can listen to 5 to 10 minutes of a story. They can also carry out two related commands. By 3 years of age, most children comprehend 900 words and know concept words such as “in/on” and “big/little.” For a list of resources written specifically for families to explain typical communication and language development, see Handout F.

C. Elements of language

Language refers to any complex system that represents concepts through arbitrary symbols governed by rules. Language therefore includes speaking and listening, and reading and writing. Consisting of semantics, syntax, morphology, phonology, and pragmatics, language slowly and naturally evolves into more refined and complex systems as the typically developing child progresses through childhood. Similarly, language develops through childhood for most children with visual impairments.

In typically developing children, meaningful language begins to emerge at around 12 months, but there is great variability in the timing of children’s first words and subsequent vocabulary development (Owens, 2001; Wetherby, Warren, & Reichle, 1998). Language is frequently divided into five components (Owens, 2001):

  • phonology,
  • morphology,
  • semantics,
  • syntax, and
  • pragmatics

Phonology refers to the rules that govern the use of speech sounds. For example, English includes certain side by side consonant sounds in the same syllable (e.g., g and r), while other consonants are never beside each other in the same syllable (e.g., k and m).

Morphology refers to the rules that determine the internal organization of words. The rules determining which word can have an –ing attached is an example of morphology.

Syntax refers to the rules that govern the form and structure of sentences. For example, in English adjectives usually precede nouns, as in “the blue dress.”

Semantics refers to the rules that determine the meaning of words and word combinations. For example, you may create a syntactically correct sentence that has no meaning (“The fiddle slept a loud picture”); semantics refers to the need for language to make sense.

Pragmatics refers to the rules that governs how a given language is used in different social contexts and environments. Pragmatics includes communicative acts such as turn taking, facial expression, and pointing.

Language can be used expressively—to send a message to someone else—and receptively—to understand someone else’s message.

D. Attachment

Child-caregiver attachment provides the foundation for early development, including communication and language development. Attachment refers to the emotional connections between people in intimate relationships such as parent and child (Zeanah & Boris, 2000).

Many of a child’s familiar behaviors, such as smiling, crying, and crawling toward or clinging to the parent, encourage attachment. Some of these behaviors may be delayed in children with visual impairments (Tröster & Brambring, 1993; Warren & Hatton, 2003). Other behaviors, such as glancing at parents to judge their reaction to novel events or people, occur less frequently or with less clarity in children with visual impairments (Als, Tronick, & Brazelton, 1980; Baird, Mayfield, & Baker, 1997; Rogers & Puchalski, 1984; Rowland, 1984).

Caregiver responsiveness is the most important factor in encouraging attachment and communication of children with visual impairments (Fazzi & Klein, 2002; Warren & Hatton, 2003). Responsiveness includes reading children’s signals to know when they want to interact, when they are tired or overstimulated, and what interests them. For example, an infant who is blind may become very still when a parent begins talking to her. This could be attentive stillness, in which the child is staying still to better attend to the parent’s interaction. Attentive stillness is not a behavior frequently observed in children with normal vision, and parents have to learn to recognize and respond to their children’s subtle cues (Als et al., 1980). Ferrell (1985) recommends several strategies that parents can use to help bond with their child:

  • Talk to the child before picking him or her up.
  • Give the child a few seconds to adjust to new situations (e.g., being picked up).
  • Respond contingently to subtle, nonverbal communication such as changes in breathing, or opening and closing hands.
  • Let the baby touch their faces, beard or moustache, and hair to learn to recognize them.
  • Carry the baby with them as they work around the home or go out into the community.

E. Concept development

For communication to be meaningful, people must have something about which to communicate. A concept is an abstract or generic idea generalized from particular instances. For concept development to occur, children must have repeated experiences with specific examples of the concept.

A newborn infant has had very few experiences; first experiences are largely internal, such as feeling hungry, tired, cold, and so on. Within a few weeks, infants are able to develop concepts about the things they experience. They learn that hunger is satiated with milk and that discomfort is assuaged when they are held and rocked. Their initial, reflexive cries become intentional communications to gain attention from caregivers. As infants grow and gain new experiences, they develop more concepts about themselves, their world, and other people. These new concepts provide them with more things about which to communicate.

For example, for children to develop a concept of a chair, they must experience many different types of chairs, including different sizes, different styles, different materials, etc. Children must also have some way to connect all of these objects under the general category of chair. More abstract concepts are developed in the same way. For example, children learn the meaning of under through repeated experiences with under (e.g., being under an umbrella, putting a doll under a blanket). Through these experiences children begin to develop a concept of under, and adults help children to develop the vocabulary word “under” as a label for this concept. Children must understand the concepts about which they and their parents are communicating or else the communication has little meaning to them (Fazzi & Klein, 2002).

Children with visual impairments often experience delays in concept development compared to typically sighted children (Warren & Hatton, 2003). Additionally, children with visual impairments often develop motor skills, especially self-initiated movement, at later ages than do typically sighted peers (Warren & Hatton, 2003). Delays in motor skills may further limit children’s ability to explore their world and learn about objects and concepts. Even limited vision can provide opportunities to perceive and interact with the world in ways that total blindness precludes (Preisler, 1991). Given appropriate hands-on, relevant experiences, children with visual impairments can develop appropriate concepts about their world.

Naomi pulled herself up on the coffee table in the living room. She slid her hand out across the surface to determine if anything was there. She found a peach in a fruit bowl in the center of the table. Holding the peach, she sat down by the table. She smelled the fruit and rubbed its fuzzy surface on her hands, then put it into her mouth and licked the peel. Her two teeth left slight indentations on the surface of the peach. As she turned it in her hands, she felt the bruises left by her teeth and poked her finger on the soft spot. Her finger broke through the surface and found the firm, sticky pulp on the inside of the peach. She licked her finger and liked the sweet taste. She pushed her finger further in the hole and a little of the fruit stuck to her finger. She brought the fruit to her mouth again and tasted the hole that she had made. She smiled broadly, because the peach tasted so good.

Her mother, who had been watching Naomi the entire time, smiled too. She sat down on the floor by Naomi and said, “You found a peach. Does it taste good?” She talked to Naomi about the feel, taste, and smell of the peach as Naomi continued to taste and play with the fruit.

As children develop more concepts, they are able to communicate about more things. Naomi is starting to develop many concepts about peaches. They are fuzzy, they are round, the inside is wet and sticky, and they taste and smell sweet. The next time she smells a peach, she may want to let her mother know she would like some. Her mother is helping her learn the vocabulary to describe these characteristics, but until Naomi learns to speak, she will need nonlinguistic ways to communicate about the peach, such as holding it out for her mother to peel for her.

F. Six modes of nonlinguistic/prelinguistic communication

Because most nonlinguistic communication relies directly or indirectly on visual information, visual impairments often prevent children from engaging in some typical nonlinguistic communicative behaviors. Ziajka (1981) described six modes of communication: proxemic, kinesic, gestural, ocular, tactile-kinesthetic, and vocal. When children have typical vision, mother-child dyads use visual information in each mode of communication.

The proxemic mode includes the child’s movement toward or away from a caregiver. Vision can be a strong motivator for the child to explore the environment, either in moving away from the mother to reach a toy or toward the mother for comfort.

In the kinesic mode (i.e., involving facial expressions), vision is necessary for the child to know that the mother is smiling unless the child touches the mother’s face.

In the gestural mode (e.g., the child reaching toward the caregiver), vision provides important information about where to gesture.

Obviously, the ocular mode (i.e., seeing) requires vision in order for children to look at their caregivers or to know that the caregiver is looking at them.

The tactile-kinesthetic mode (i.e., physical contact between the infant and caregiver) benefits from visual input to provide information to the child about the location of the caregiver’s body.

The vocal mode includes vocalizations from the infant to the caregiver and from the caregiver to the infant. In typically developing infants, vocal communication uses cross-modal processing that involves hearing and sight (Kuhl & Meltzoff, 1984; Kuhl, Williams, & Meltzoff, 1991). Children with visual impairments may be limited in their access to the visual cues involved in vocal communication (e.g., facial movements during speech).

With the possible exception of the tactile-kinesthetic mode, all of Ziajka’s (1981) modes of nonlinguistic communication rely partly or entirely on visual input. For children with visual impairments, the visual information they receive is limited or absent, resulting in differences in communication. This does not mean that children with visual impairments do not communicate in many of these ways, just that their visual impairments limit or alter most modes. For example, visual impairments affect children’s ability to use intentional eye gaze that has traditionally been associated with mutual gaze, joint attention, and social referencing, three important components of communication for children with typical sight. Obviously, children who are blind cannot visually fixate on a person or object. Children who have low vision may also experience difficulty with using eye gaze. They may be unable to fixate due to nystagmus or other conditions. When children experience damage to the central portion of the retina, they may use eccentric fixation, making it difficult for caregivers to know where they are looking. Additionally, children with conditions such as severe myopia may not be able to see objects clearly that are more than a few feet away, so they are unable to direct their gaze toward these objects.

By definition, very young nonlinguistic children communicate through methods that do not involve speech. Even after language develops, many aspects of communication still involve nonverbal cues, such as turn taking, facial expression, initiation (i.e., making the first communication in an exchange), responsivity (i.e., responding linguistically or nonlinguistically to someone else’s communication), etc. Typically developing children learn to interpret and use socially appropriate nonverbal communication through communicative social interactions with adults and children (Hala, 1997).

G. Visual impairments and nonlinguistic/prelinguistic communication

The inability to use vision to identify objects, persons, and events in the environment affects other aspects of communication. To communicate, children must have something to communicate about and must be able to identify the topic for their communicative partner; this is why concept development is so important.

Sapp (2001) reported that children with visual impairments communicate as frequently as sighted children about egocentric topics (e.g., hunger) but less frequently about environmental topics (e.g., a toy a few feet away). She found that an inability to see items in the environment results in fewer communicative initiations about objects in the environment.

Children also use movement within their environments to communicate. Crawling toward a toy communicates the child’s interest in it (Ziajka, 1981). Children with visual impairments are delayed in their development of gross motor skills such as crawling and walking (Adelson & Fraiberg, 1974; Palazesi, 1986; Tröster & Brambring, 1993); furthermore, visual impairments tend to reduce exploration of the environment (Jan, Sykanda, & Groenveld, 1990). Children with more severe visual impairments are more delayed in developing motor skills than children with milder visual impairments (Hatton, Bailey, Burchinal, & Ferrell, 1997). Because children with visual impairments are less likely to explore their environments, they are less aware of objects and the environment around them about which they could communicate. An example of what may happen to young children with visual impairments when adults in the environment do not understand subtle communicative cues or facilitate communication is provided below.

Jay and Alex sat on the floor in their toddler class at the daycare center. Jay looked around the room and saw his favorite toy on the shelf. He crawled over to it, used the shelf to pull himself up, but could not quite reach it. The teacher came over, and Jay looked at her, then at the toy, and then back to the teacher. He stretched his arm out toward the toy. “Would you like the truck?” she asked. Jay smiled and bounced up and down. She handed him the toy truck, and he sat down and begin spinning the wheels and looking at the people seated inside. “Can you make that truck go?” his teacher asked, and modeled how to roll the truck across the floor. Jay waved his arms, reached for the truck, and pushed it a short distance across the floor. “That’s it,” his teacher said. “You can do it.”

While Jay and his teacher were communicating about the truck, Alex continued sitting quietly on the floor rocking gently back and forth. Alex has extremely low vision and rarely raises his head to look around. Although he likes playing with trucks, because he does not know how to search for one, he remains idle and does not initiate play.

Few researchers have examined the development of nonlinguistic/prelinguistic communication in children with visual impairments, but the existing studies show consensus on four general points, as described below.

  • Children with visual impairments engage in nonlinguistic/prelinguistic communication that is interpreted and responded to by their mothers (Als et al., 1980; Baird et al., 1997; Behl, Akers, Boyce, & Taylor, 1996; Chen, 1996; Preisler, 1991; Recchia, 1997; Rogers & Puchalski, 1984; Rowland, 1984; Urwin, 1984).
  • The repertoire of nonlinguistic/prelinguistic communicative behaviors of children with visual impairments is more limited than that of typically sighted children (Baird et al., 1997; Chen, 1996; Preisler, 1991; Recchia, 1997; Urwin, 1984).
  • Mothers of children with visual impairments engage in patterns of communication that differ from those used by mothers of typically sighted children (e.g., increased controlling communications and decreased action-based communication routines) (Als et al., 1980; Baird et al., 1997; Behl et al., 1996; Chen, 1996; Rogers & Puchalski, 1984; Rowland, 1984).
  • Compared to typically developing children, children with visual impairments vocalize less and may be more negative in their vocalizations (Rogers & Puchalski, 1984). These children also display more negative facial expressions, which mothers may interpret as a sign the children do not want to interact.

These studies also provided tentative evidence supporting more specific aspects of nonlinguistic/prelinguistic communication that are affected by visual impairments. While this preliminary evidence is helpful, further replication is needed.

Very young children with visual impairments use many behaviors to communicate nonlinguistically. They smile, coo, and attempt to imitate adult speech at ages similar to children with normal vision (Preisler, 1991). They imitate to elicit communicative responses from their mothers (Urwin, 1984), and they respond to their mothers’ use of routines for communication (Preisler, 1991; Urwin, 1984). Children who are blind, however, do not demonstrate some conventional gestures such as showing, waving, and nodding (Rowland, 1984). Children who are blind develop communication skills in a sequence that is similar to that of children with typical sight but may experience periods of regression (Als et al., 1980). Children who are blind respond to mothers’ communicative initiations with attentive stillness (i.e., becoming motionless in order to listen to what is happening in the environment), which may be misinterpreted as a lack of interest in communicating (Als et al., 1980). Children who are blind do not use deictic gaze (i.e., a child and parent looking at the same object at the same time) or pointing (Preisler, 1991) and do not engage in social referencing (i.e., referring to an adult to decide how to respond to an unknown situation) (Recchia, 1997).

Mothers of children with visual impairments and no additional disabilities demonstrate patterns of interactions and use of routines that are similar to those of mothers of children with typical sight (Behl et al., 1996). They are, however, more likely to be physically involved (Behl et al., 1996) and to engage in controlling behaviors (Behl et al., 1996; Chen, 1996). Mothers of children with visual impairments may modify common interactive routines to encourage their children to participate (Urwin, 1984). The routines are more likely to involve social play or imitation and less likely to be action based than are routines used by mothers of children with typical sight (Chen, 1996).

Well-intentioned attempts to engage a child with a visual impairment in communication often result in controlling and unnatural interactions as in the following example:

Bettina and her mother arrived at their neighbor’s house for the Thursday morning toddler playgroup. Bettina walked in holding her mother’s hand. Her mother placed Bettina’s hand briefly on the entrance hall table and said, “Table. Say ‘table.’”

Bettina babbled, “Ta-ta-ta.”

They passed a large potted rubber tree, and Bettina’s mother brushed Bettina’s arm against it, saying, “Plant.” Bettina pulled her arm away from the plant.

They went to the living room, where the other children sat on the floor. “Look, Bettina,” Bettina’s mother said, holding out a stuffed cow. “It’s a cow. What does a cow say?” Bettina brought the stuffed black-and-white toy close to her face. “What does a cow say?” her mother repeated. “Say ‘moo,’” her mother prompted.

Children with visual impairments and additional disabilities develop fewer communicative behaviors, and their behaviors are often idiosyncratic. Teachers of children with visual impairments (TVIs) and families can, however, learn to read children’s communication.

Interpreting nonintentional communication may be more difficult if children have additional disabilities. Mothers of children with visual impairments and additional disabilities appear to interact differently with their children than do mothers of children who are typically developing (Baird et al., 1997). They may engage in fewer positive and more negative vocalizations with their children. They also identify fewer behaviors as communicative and are more likely to interpret the behavior as a negative communication. At this point, no one knows if these differences are appropriate modifications for the children’s disability or if parents should be encouraged to change their interaction patterns. This uncertainty underscores the importance of intervention to support families as they learn to identify and interpret children’s communicative signals.

Children with visual impairments and additional disabilities are delayed in their development of intentional communication. Often they develop more idiosyncratic methods of communicating, possibly due to physical disabilities or motor delays (Rowland, 1984; Urwin, 1984). Over time, parents generally learn to interpret idiosyncratic communication (e.g., opening mouth when happy because child’s facial muscles do not allow a smile), but other adults may find it difficult to interpret children’s communication (Baird et al., 1997; Preisler, 1991; Rogers & Puchalski, 1984; Rowland, 1984; Urwin, 1984). Even when parents respond to children’s behavior, they do not always recognize the behavior as a form of communication. Some children may have very limited behaviors and require assistance in developing recognizable means of communicating.

Wilma carried her daughter Lillie into the doctor’s office for her usual monthly visit. Because of Lillie’s multiple medical and physical needs, she was seen at least once a month by the pediatrician who monitored her condition. Whenever problems arose, the family would have to borrow a car and drive 2 hours to see specialists in a nearby city. A new nurse ushered Wilma and Lillie into an exam room and prepared to check Lillie’s heart rate. Wilma spoke softly to Lillie, saying, “Here comes the stethoscope. It may be a little cold.” As she spoke, she gently rubbed Lillie’s chest where the nurse would listen to her heart.

Lillie squirmed a little when she felt the cold metal of the stethoscope. After the nurse listened, Wilma rubbed the spot again and said, “All done with that. You were a good girl.” Lillie arched her back and threw her head as far back as she could.

The nurse looked surprised and said, “She didn’t seem to like that.”

“Oh, no,” said Wilma. “That’s what she does when she is happy. She gets excited, and that’s her way of telling me she likes something.”

H. Visual impairments and language development

Children with visual impairments develop language at approximately the same time and at the same rate as typically developing children, but some children with visual impairments demonstrate differences in their use of language. Differences in language development occur as a result of transactional interactions between children and their caregiving environment.

Table 4 and Handout G provide examples of adaptive and nonadaptive transactional interactions that impact communication development. These examples demonstrate how child behaviors and parental responsivity can influence developmental outcomes.

Table 4 Examples of Adaptive and Nonadaptive Transactional Interactions That Impact Communication Development
StepsAdaptive InteractionNonadaptive Interaction

Step 1

Sophia, 18 months old, has optic-nerve hypoplasia with object perception. She is sitting on a blanket with a few favorite toys. While playing, her toys roll out of her field of vision.

Sophia, 18 months old, has optic-nerve hypoplasia with object perception. She is sitting on a blanket with a few favorite toys. While playing, her toys roll out of her field of vision.

Step 2

Sophia briefly searches for the toys but does not find them. She remains seated on the blanket and begins using her hands to press her eyes.

Sophia briefly searches for the toys but does not find them. She remains seated on the blanket and begins using her hands to press her eyes.

Step 3

Sophia’s mom notices she has stopped playing and is pressing her eyes. She walks over and joins Sophia on the floor. Calmly she says to Sophia, “I see you cannot find your toys. Let Mommy help you.” She gently uses hand-under-hand to help Sophia locate her toys.

Sophia’s mom notices she has stopped playing and is pressing her eyes. Discouraged that once again Sophia is eye pressing, she calls out across the room, “Sophia, hands down!” She walks over and pushes the toys back onto the blanket.

Step 4

After this happens several times, Sophia begins to vocalize when her toys move out of reach. Her vocalizations let her mom know that she needs assistance.

After this happens several times, Sophia begins to call out “Hands down” when her toys are out of reach.

To date, there are no studies or published reports that suggest that children with visual impairments experience difficulties in developing phonology (the rules that govern speech sounds), morphology (the rules that determine the internal organization of words), or syntax (the rules that govern the form and structure of sentences). However, differences in the development of semantics (the rules that determine the meaning of words and word combinations) and pragmatics (the rules that governs how a given language is used in different social contexts and environments) have been documented. These differences are discussed below (see also Handout H).

The semantics of children with visual impairments may seem similar to those of typically sighted children, but many of the specific characteristics are different. In a comparison of children with visual impairments and children with typical sight, Ferrell, et al. (1990) found that children with visual impairments said their first word at 10 months compared to typically sighted children who said their first word at 7.9 months. Compared to standard language scales, 10 months is within the typical range for expressing first words. Another study (Ferrell, 1998) reports that children with visual impairments use meaningful 2 word utterances 5 months later than children with typical sight, at 24.9 months rather than at 20.6 months. Children with visual impairments and no additional disabilities have expressive vocabularies that are similar in size to sighted peers’ vocabularies (DeMott, 1972). However, the first 50 words of children with visual impairments have more specific nominals and fewer general nominals than typically sighted children (Bigelow, 1987; McConachie & Moore, 1994). Specific nominals are nouns that refer to one object; general nominals refer to a class of objects. For example, a child could say “dog” and mean all dogs (i.e., a general nominal) or only the child’s dog (i.e., a specific nominal). Furthermore, although sighted children will use rhetorical questions (e.g., “You know what?”), children with visual impairments rarely ask rhetorical questions (Erin, 1986).

Jerry and his family were visiting his grandmother for the weekend. After his grandmother finished kissing and hugging him, he began to explore her living room. He looked at the furniture, the walls, and the windows. His grandmother said, “Jerry, there is a toy on the couch for you.”

Jerry looked confused. “Over on the couch, Jerry,” his mother prompted. “You just walked past it.”

Jerry looked around and then walked over to his mother. She picked him up and carried him to the couch. “Here’s your toy, Jerry,” she said handing him the toy as she sat down on the couch.

“Where couch?” Jerry asked.

“Right here. We’re sitting on it.”

“Uh-uh,” Jerry said. “Not couch.”

Jerry was confused because the couch at home was a hideaway bed with a rough multicolored covering on it. His grandmother’s couch was small and covered with soft white fabric. Jerry could not relate the couch in his living room to the one in his grandmother’s home.

McConachie (1990) found that children with severe visual impairments exhibit discrepant expressive and receptive communication scores. Approximately half of the participants had significantly higher expressive scores than receptive scores, and approximately half of the participants had significantly higher receptive scores than expressive scores. Young children who are blind are also less efficient at verbal classification than are same-age peers, but the difference disappears by age 11 (Dimcovic & Tobin, 1995).

Pragmatics refers to the ways in which language is used to communicate within different contexts and environments. There are many components of the pragmatics of language, including turn taking, posture, initiation, and responsivity. Typically developing children learn the pragmatics of language through social interactions with adults and other children. Children with visual impairments often display differences in their pragmatic language use.

Children with visual impairments develop social smiles (i.e., smiles in response to human faces or human interactions) at the same age as do typically sighted children (Rogers & Puchalski, 1986) and engage in similar numbers of communicative acts with their mothers compared to typically sighted children (Conti-Ramsden & Pérez-Pereira, 1999). The details of these communicative acts differ, however. Children with visual impairments take fewer verbal turns and more nonverbal turns than do their sighted peers. Unlike children with typical sight, children who are blind take shorter speaking turns than their mothers (Kekelis & Prinz, 1996). Parents are more likely to initiate interactions with children who are blind than with children with low vision, indicating that the degree of visual impairment may influence social interactions (Moore & McConachie, 1994). Visual impairments also affect children’s ability to use and read “body language,” due to lack of clear visual information.

Maggie and her father are in the waiting room at the vet’s office for their family cat to get her immunizations. Maggie’s father is showing her all the different items in the vet’s office.

“Look at the big bags of dog food, Maggie,” her father says, pointing to the stacks of dog food. “Dogs eat a lot more food than our cat, don’t they?”

Maggie squints in the direction her father points. He carries her over to a display of leashes and animal tags. “Look at all this stuff. This tag looks like a house. How funny is that?”

Maggie takes the silver tag and tilts her head as she looks at it. She smiles and hands it back to her father. Maggie’s father continues his circuit of the room, stopping at a large picture of a dog and a cat sleeping together. “Look at that,” he says, tapping the picture.

“Kitty,” Maggie says, pointing at the cat.

“Yes, that’s a kitty just like ours.”

Children with visual impairments use questions more frequently than peers, and primarily use questions to request an action from the communicative partner (Erin, 1986). Children with visual impairments also rely more on routines, imitation, and repetition than their sighted peers do (Erin, 1990; Pérez-Pereira & Castro, 1992; 1997).

Children with visual impairments and additional disabilities may be delayed in their development of language due to the additive nature of their disabilities. These children experience all the challenges that are present for children with only visual impairments, plus they must deal with the impact of additional disabilities on language development. Additional disabilities such as cognitive impairments or developmental delays also impact language development (Hatton et al., 1997). The effects of the disabilities “add up,” resulting in greater language delays and impairments. Gosch, Brambring, Gennat, and Rohlmann (1997) found that children who were blind and had extremely low birth weights were more delayed in developing language skills than were children who were blind but whose birth weights were not extremely low.

Several specific delays in language development have been identified in children with visual impairments and additional disabilities. Receptively, children with visual impairments and additional disabilities are significantly delayed in following daily routine directions compared to children without disabilities (25 months compared to 20.5 months) (Ferrell, 1998). Expressively, children with visual impairments and additional delays often do not say their first word until they are 19 months old (Ferrell, et al., 1990). Compared to children with typical development, children with visual impairment and additional disabilities are significantly later to use 2-word utterances (36 months compared to 20.6 months) and first person pronouns (36.1 months compared to 24 months) (Ferrell, et al. 1990; Ferrell, 1998). Pragmatically, children with visual impairments and additional disabilities often do not play interactive games with adults (e.g., pat-a-cake) until they are 18 months old compared to typically sighted children who generally begin to play interactively at 9.7 months (Ferrell, et al., 1990). 

Often children with visual impairments and additional disabilities rely partially or wholly on alternative communication systems (Fazzi & Klein, 2002), including touch cues, alternative communication devices (high tech and low tech), signing, or hand-in-hand signing. Children with visual impairments and additional disabilities also show differences in the pragmatics of communication. They attempt to initiate communication less frequently, and communicative partners spend less time facing the child (Kekelis & Prinz, 1996; Moore & McConachie, 1994). Often, additional disabilities may impair a child’s ability to interpret information about “body language,” facial expressions, and other nonverbal aspects of communication.

In summary visual impairments, alone or in combination with other disabilities, may impact attachment, early communication, and language development. Interventionists and educators who are attuned to the impact of visual impairments on communication and language can collaborate with families to promote optimal communication and language development in these young children.

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