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Adapted from:

Cowan, C. & Shepler, R. (2000). Activities and games for teaching children to use monocular telescopes. In F. M. D’Andrea and C. Farrenkopf (Eds.) Looking to Learn: Promoting Literacy for Students with Low Vision (pp. 137-161). New York, AFB Press.

 

Goal: The student will demonstrate skills for magnifier maintenance.

Objective:  The student will:

  1. hold the magnifier properly.
  2. communicate the purpose of the device.
  3. clean the magnifier appropriately.
  4. assume responsibility for the magnifier.
  5. store the magnifier in a convenient location for quick retrieval.
  6. initiate use of the magnifier.

Goal: The student will demonstrate skills for the use of magnifier usage.

Objective:  The student will:

  1. position self for optimal viewing.
  2. stabilize the reading material / object.
  3. stabilize the hand using the magnifier.
  4. adjust the head-to-lens distance.
  5. coordinate the hand, head, and eye movements specific to the type of magnifier.
  6. use the magnifier to read on a flat surface.
  7. read a variety of print formats. 
  8. track at a speed which allows for reading commensurate with reading level.
  9. develop stamina for the duration of an age-or grade-appropriate assignment.
  10. use the magnifier to read textbooks.
  11. use the magnifier to read class handouts
  12. select the appropriate magnifier for the task.
  13. use the magnifier for non-print activities.

This article was originally published in the Spring 2004 edition of See/Hear Newsletter.
Versión Español de este artículo (Spanish Version)

By Melanie Knapp, Parent, Missouri City, TX

Abstract: A mother shares her thoughts about connecting with her son, who is deafblind, while reading an experience book together at the doctor’s office.

Key Words: deafblind, family, personal story, experience books, expanded core curriculum

Editor’s Note: Melanie shared this story during the Transition Weekend we held February 21-22, 2004. I’ve asked her to share it with you, as I think it really brings home how anyone can access a story about an experience they are familiar with and “read” it with someone else. If you would like to learn more about experience books, including how to make your own, you can read the article “Creating and Using Tactile Experience Books for Young Children With Visual Impairments” by Sandra Lewis. You may access the article in the See/Hear archives at www.tsbvi.edu/Outreach/seehear/spring03/books.htm .

Gary and I picked up Christian, our 23-year-old son who is deafblind, from school one day so that we could take him to his doctor’s appointment. His intervener, Ann Bielert, and Christian had been to Whataburger that day, and had made an experience book about their trip. Christian brought his book home with him so we could talk about it. On each page of the book, they had glued an item they picked up on their trip beside a tactile calendar symbol that related to the item. For example, they had taken the plastic lid and straw from his drink and glued it next to his symbol for drink. While we were waiting in the examining room for the doctor, I pulled the book out so we could read it together. Christian and I read each page. He would feel the symbol, and I would sign to him, and then help him sign it. We were having the best time; he was smiling and laughing. We were just about finished reading when the doctor came in and asked what we were doing. Well, this was the perfect opportunity for me to brag...so I did. We read the book again. Christian enjoyed it just as much. Meanwhile, his other doctor came in, and she wanted to know about Christian’s book. We read it again. I was so proud of Christian. He loved it just as much the third time as he did the first. We laughed. Everyone was so impressed and had lots of questions.

This was “one of those moments” that you cherish and remember. It was the most incredible experience for me. We read this book together and I know he understood everything we talked about.

Developed by Texas Deafblind Outreach, TSBVI Outreach Programs                

Updated December 2016

 You may download a prin version of this document in Word or PDF.

An intervener is a paraprofessional who provides direct support to a student with deafblindness for all or part of the instructional day.  The intervener receives training in communication methods and sensory accommodations that are needed for an individual student with deafblindness to access information in various learning environments.  The intervener supports the existing service delivery model, collaborating with the student’s team in implementing the student’s IEP.

Most students with deafblindness need to develop a bond and a trusting relationship with a consistent communication partner in a predictable environment in order to progress to higher-level learning. For many students who are deafblind, this trusted communication partner is the intervener. 

Teaming is essential in the success of this model. Classroom teachers and other professionals on the instructional team provide the supervision, direction, and support that are necessary for interveners to be effective in their role.  An intervener should never carry out his/her duties independently, but instead function as an integral part of the student’s instructional team.    

Primary roles of the intervener

In summary, the primary role of the intervener is to:

  • facilitate the access of environmental information usually gained through vision and hearing, but which is unavailable or incomplete to the individual who is deafblind;
  • facilitate the development and/or use of receptive and expressive communication skills by the individual who is deafblind; and
  • develop and maintain a trusting, interactive relationship that can promote social and emotional well-being.  (Alsop, 2002)

More information on the roles and responsibilities of the intervener, teacher, and administrator using this model of instruction can be found in the booklet Interveners in the Classroom:  Guidelines for Teams Working with Students Who Are Deafblind.  (Alsop, et al, 2007)

Is an intervener needed for your student?

This document is designed to help the IEP team to determine whether an intervener is an appropriate support for an individual student with deafblindness in a school setting.  It is a guideline for discussion about all supports needed to provide the student full access to the educational experience based on: 1) individual student assessment; and 2) consideration of the existing and/or proposed services for the student. 

Step 1: Complete, Update, and Review Assessment

In order to use this form effectively, student assessment in critical areas must have been completed or updated to reflect the impact of deafblindness on instruction.  Critical areas may include, but are not limited to:

  • vision and hearing, including the degree and complexity of sensory losses:
  • orientation and mobility;
  • communication:
  • concept development:
  • self-help and daily living skills:
  • adaptive technology;
  • behavior;
  • and social/emotional needs.

The questions asked in the next steps of this document will clarify issues to focus upon when reviewing or completing assessments, so that appropriate issues related to deafblindness are fully considered and addressed.  The deafblind-specific accommodations needed to appropriately support the student’s full access to instruction will be suggested by these questions, and will be helpful in guiding current and future assessment.

If you would like additional understanding of the issues that lead to meaningful assessments for students with deafblindness, you might also find the following documents helpful:

  • Documenting Instructional Considerations for the Student with Deaf-Blindness by Robbie Blaha, Education Specialist and Kate Moss, Education Specialist, Texas Deafblind Outreach
  • IEP Quality Indicators for Students with Deafblindness developed by Texas Deafblind Outreach
  • 10 Issues to Always Consider When Intervening for Students with Deafblindness by David Wiley, Texas Deafblind Outreach
  • A Process for Identifying Students Who May Be At-Risk for Deafblindness by Robbie Blaha, et al, Texas Deablind Outreach
  • Assessment of Deafblind Access to Manual Language Systems (ADAMLS) by Robbie Blaha & Brad Carlson (2007).  From DB-LINK:  https://nationaldb.org/library/page/88
Have all critical student assessments been completed, updated when needed, and reviewed in light of the issues raised throughout this document and other literature about deafblindness?
  Yes ­– Use assessment information when answering the questions found in this document.
  No – Complete, update, and/or review assessments before making decisions about an intervener.  Use the questions in Steps 2 & 3 steps to help guide assessments.

 

Step 2: Questions about the Student with Deafblindness

The decision by the IEP team to provide intervener services is based on the level of support a student who is deafblind needs in order to gain access and effectively participate in all of his/her instructional environments.  The team should discuss how to address all identified issues. 

A variety of support approaches and strategies may be creatively employed by the team to address the student’s individual needs.  In some cases an intervener trained in deafblind-specific knowledge and skills may be the most appropriate, effective, and/or efficient service delivery model.

The questions in the following table can assist the team in determining how to address the supports related to the student’s deafblindness.

Questions about the Student with Deafblindness

1. Does the student need assistance to effectively detect, gather, and/or prioritize information from communication partners and the surrounding environment?

 
Yes No
   

            If yes, how will this access issue be addressed, and by whom?

 

2. Does the student rely on the sense of touch or near vision to gain information, so that he/she is unable to reliably get information that other students get from a distance?

Yes No
   

            If yes, how will this need be addressed, and by whom?

 

3. In a group instructional setting, is it difficult for the student to gather information or follow a discussion?

Yes No
   

            If yes, how will this need be addressed, and by whom?

 

4. Does the student use equipment or adaptive aids, but not efficiently or effectively enough to keep up with the pace of the instruction being given?

Yes No
   

            If yes, how will this need be addressed?

 

5. Is the student unable to orient him/herself to the environment or move to different learning environments without assistance?

Yes No
   

            If yes, how will this need be addressed?

 

6. Does the student rely on communication methods not generally used or understood by many of his or her communication partners (teachers, staff, or peers)? Consider all the various environments the student accesses throughout the entire school day.

Yes No
   

            If yes, how will this need be addressed?

 

7. Does the student often need individual intervention by a trained or knowledgeable support person in order to communicate effectively receptively and/or expressively?

Yes No
   

            If yes, how will this need be addressed?

 

8. Does the student need a high degree of consistency in strategies and communication systems, so that working with numerous people during the day causes him/her confusion and frustration?

Yes No
   

            If yes, how will this need be addressed?

 

9. Due to sensory isolation, does the student have difficulties in trusting, bonding, or relating and responding to a variety of people?

Yes No
   

            If yes, how will this need be addressed?

 

10. Because of sensory impairments, is the student unfamiliar with certain common information, so that in order to fully understand concepts or common references used in instruction or conversation, the student frequently needs more explanation than that given to other students.

Yes No
   

            If yes, how will this need be addressed?

 

11. Is the student unable to access the same information as classmates who are not deafblind?

Yes No
   

            If yes, how will this need be addressed?

 

 

Step 3: Questions about the Instructional Team

Answering the questions in the next table will help the ARD committee decide if the support described above can be provided in the proposed or current instructional arrangement without additional supports.

Questions about the Instructional Team Yes No

1. Does the student’s need for effective deafblind-specific intervention strategies and communication methods require additional education and training for staff members?

   
  • If numerous staff will need training, would it be more efficient to concentrate training on fewer specialized individuals?
   

2. Does the specialized educational programming recommended through assessment and the IEP create a need for an additional trained support person?  Before answering this question, examples to consider include, but are not limited to:

  • due to other demands in the classroom, does the instructor find it difficult to remain in close enough proximity so the student can maintain visual, auditory, and or tactile access to instruction;
  • due to the needs of other students, does the instructor find it challenging to adjust the pace of instruction so the deafblind student has enough time to get understandable information through either modified communication or tactile/close-vision exploration;
  • do any instructors have difficulty or unfamiliarity with the student’s preferred communication modes (e.g. tactile symbols, sign language, tactile sign);
  • does existing staff find it challenging to schedule time for deafblind-specific material adaptation and equipment maintenance (e.g., communication aids, vision devices, hearing devices, etc.) ;
  • Other (explain). ______________________________________________
 
   
   
   
   
   

3. Is it challenging to limit the number of individuals working with the student so that he/she can form trusting relationships?

   

4. Is it challenging for the team to be consistent due to the large number of individuals working with the student?

   

5. Is it challenging for the team to provide necessary background and fill-in information to help the student fully understand instruction and conversation across all settings?

   

 

Step 4: Determine the Need for an Intervener

Now that you have completed the Steps 1-3, you are ready to use that information to discuss and make a recommendation about the need for an intervener for the student with deafblindness.  Any items answered “yes” in steps 2 and 3 should result in discussion and planning.

Is an Intervener Needed? Yes No
Is a paraprofessional with specific knowledge and skills in deafblindness needed for all or part of the educational day to ensure that the student can access information and effectively participate in all of his/her instructional environments to complete IEP objectives?     

 

Additional Information

If an intervener is recommended, this should be noted in the Supplemental Aids and Services section of the IEP.

IEP Quality Indicators for Students with Deafblindness is another tool designed to help educational teams develop appropriate IEPs for students with deafblindness.  Completing that document can also provide input for the intervener question.

References

Alsop, L., Blaha, R., & Kloos, E.  (2002).  The intervener in early intervention and educational sttings for children and youth with deafblindness (Briefing Paper).  Monmouth, OR:  NTAC, The National Technical Assistance Consortium for Children and Young Adults Who Are Deaf-Blind.

Alsop, L., et al (2012).  A Family’s Guide to Interveners for Children with Combined Vision and Hearing Loss.  Logan, UT:  SKI-HI Institute.

Alsop, L., et al (2007).  Interveners in the classroom:  guidelines for teams working with students who are deafblind.  Logan, UT:  SKI-HI Institute.

Texas Deaflind Outreach. (2009).  IEP Quality Indicators for Students with Deafblindness. Austin, TX:  Texas Deafblind Project at Texas School for the Blind and Visually Impaired.

Texas Deaflind Outreach. (2000).  Interveners for students with deafblindness in Texas.  Austin, TX:  Texas Deafblind Project at Texas School for the Blind and Visually Impaired.

Additional Resources on Interveners

For more information on the topic of the Intervener Team Model, visit:

National Consortium on Deaf-Blindness (NCDB): nationaldb.org/library/list/74

NCDB Intervener Initiative: https://nationaldb.org/groups/page/9/national-intervener-services-initiative

SKI-HI Institute, Utah State University: intervener.org

By Jim Durkel, Statewide Staff Development Coordinator, TSBVI Outreach

Originally published in the Summer 2003 edition of See/Hear newsletter.

There is a term used by professional cooks called "mise en place." Translated from French, it means something like "put in place" or "prepared ahead of time." It is the idea that when cooking, the first step is to measure all the ingredients and line them up in the order in which they will be used. The thinking behind this is that it might not be convenient to be in the middle of a recipe and discover that you need to get and measure some ingredient. By using the idea of "mise en place," you also don't run into the problem of trying to remember if you have already added a certain ingredient to what you are cooking; if the bowl with the measured ingredient is empty, then you added it!

There is a similar idea related to house cleaning. Experts in this area will tell you to fill a bucket or caddy with all the cleaners, paper towels, rags, etc. that you need to complete cleaning tasks. The thought here is that you can take these materials from room to room, instead of having to go from the room you are cleaning back to where the materials are stored, then back to where you were cleaning.

This kind of organization is important for all children, especially those with visual impairments. Thinking about an activity before it happens, thinking about what materials will be needed, reviewing the steps that will be needed to complete the activity, then gathering all the materials ahead of time saves time and effort.

Take the example of "mise en place" while cooking. As a person who is sighted, it often takes me several minutes to locate an ingredient, especially if it is something I don't use very often. (And yes, my kitchen is organized!) Sometimes it just takes time for me to look in the cabinet where I keep the herbs and spices to find the turmeric, which I rarely use. Sometimes the time I take to look for an ingredient is all the time that is needed for what I am cooking to burn or get lumpy or, well, you get the idea. And I really hate it when I have started to cook something and am half way into the recipe when I realize that I don't have any turmeric at all! If I had measured all my ingredients ahead of time, I could have saved myself some problems.

As parents and teachers, we can help children with visual impairments develop organization skills in several ways. One way is that we can model these behaviors. Children who are sighted might be able to see me organizing my space as I get ready to do something. For a child with a visual impairment, I might want to "think out loud" as I get ready for this task.

To continue with the example of cooking, as I get ready to make dinner I might read the recipe out loud and say things like: "OK, first heat the oven to 350 degrees." "Next, I need a 13 by 9 inch pan. Lets see, all those pans are in the cabinet under the toaster oven." "Next I need a bowl and a mixing spoon." "I think I will measure out everything before I start mixing." By saying these things out loud, we provide a model for our children to copy later.

Think about other tasks during the day. Do you make grocery lists before going shopping? Do you write down the names of items that you need as you use them up? Do you look through the refrigerator and cabinets to see what you need before you go shopping? Does your child know about how you get ready to go shopping?

What steps do you follow when you get ready to pay bills? Do you get your checkbook, a calculator, envelopes and stamps ready before opening this month's bills? When you finish paying one bill, do you start a pile of the bills that are ready to go to the mailbox? Does you child know that you do these things regularly as part of paying bills?

As teachers, when we are getting ready to do a lesson with a child, do we model organization? Do we have materials ready ahead of time? Do we have the area arranged? Have we made our organizational strategies obvious to our students? Do they realize that we have made a plan ahead of time?

There are many different ways we can help ourselves be organized. Think about dresser drawers. Some of us may organize by similar clothing items: all the socks go in this drawer, undershirts go in that drawer, etc. Others might organize by association: gym socks are in the same drawer as gym shorts and shirts we wear when exercising. It doesn't matter what your system is if it works for you. What matters is having a system, and then helping a child use the system that works for them. Doing this proactively may help prevent some behavior problems later. It is not fair to yell at a child for taking so long to get dressed if we have not helped her learn how to organize her closet and dresser. (If she has a system and doesn't use it, however, then some consequences might be appropriate!) This also means that as a parent, I should soon stop putting clean clothes away for my child and make that her job. Putting clothes away is part of developing and learning to use organization skills.

Children with visual impairments often have quite a bit of stuff they need to use during the school day. It is up to us as teachers to help create a system in the classroom that helps the student find their materials easily. We then should expect the student to be responsible for using that system.

There are many ways to organize a study space or a desk. Some us might want to arrange things in drawers; others may want everything in its own container on top of the desk. Go to "The Container Store" and see all the different ways you can organize a desk or drawer or closet! Then go back and think about how you can organize a space with materials already in the classroom or with things you can buy at "The Dollar Store"!

Sometimes storage is what is needed. I saw a student that had a small cart on wheels. The cart had several shelves that held a Braille embosser, Braille paper, the child's abacus, and other materials the child needed. This student could then roll the cart with all his materials to wherever he was working.

Sometimes having a clearly defined workspace may be the problem. This is especially true when students work in small groups at tables. How can we let the visually impaired child know where her workspace starts and ends? Does she need a mat to help her have landmarks so she can easily find materials? Maybe she needs a tray to keep her things from rolling into another group member's space.

Does the child need help organizing materials? Ask the child for his ideas and talk with him about his preferences. Some people may want to organize materials in a left-to-right fashion: whatever I need first is to the left side of my workspace, and what I need last is the farthest to the right. Other people may like to organize in a top-to-bottom fashion, starting with the first material at the top of the workspace and the last material at the bottom. Again, what matters most is that we help our children find a system that works for them and then help them make using that system a habit. Teaching the child to put something down in the same spot is not teaching obsessive-compulsive behavior. It is teaching the child a strategy that can save the time and effort it takes to search over and over for materials.

For younger children and children with multiple impairments, organization helps support the development of concepts. Consider the example of making nachos. We can help the child understand the concept of "making nachos" by getting all the materials and ingredients we need ahead of time. "Making nachos" becomes associated with having a plate, chips, grated cheese, and hot peppers. We help the child further understand the concept of "making nachos" by arranging the materials and ingredients in the order in which they will

be used: first the plate, then the chips, then the peppers, and then the cheese. When we reach the end of the ingredients, it is time to put the plate in the microwave.

For older students, we can use these same organizational strategies to help them make associations and develop categories. Asking questions helps students organize their thinking and make a plan. For example, we can ask: "Where are chips stored, in the cupboard or in the refrigerator?" "Where is cheese stored?" "Where do you buy cheese, at Sears or at Krogers?" "In the grocery store, where do you find cheese? Is it in the produce aisle? Is it at the meat counter?"

Organization can support concept development, and that supports better thinking and problem solving. "A place for everything and everything in its place" can become a powerful strategy for teaching and learning.

By Melvin Marx, COMS, Houston ISD, Houston, Texas

This article was originally published in the Summer of 2004 edition of See/Hear newsletter.

Abstract: This article provides a sampling of modifications in O&M techniques for use with deafblind students.

Key words: programming, orientation and mobility, O&M, deafblind, modifications, orientation and mobility techniques

Do you have indelible memories of your collegiate experience? As a graduate of Stephen F. Austin State University in the field of rehabilitation, majoring in orientation and mobility, I frequently think back on many positive memories. I fondly remember the orientation and mobility practicum lessons under blindfold in downtown Lufkin, the chaotic noise of twenty five Perkins Braillers hammering out inharmonious melodic lessons in the Braille 301 class, or waking up at 8:10 for Dr. Weber's 8:00 Rehab classes. Do these memories ring a bell? These may be a few of your favorites as well. For me, each memory holds a special place in the journey of what makes me who I am.

I believe that for all orientation and mobility professionals one memory that makes a lasting impression in the field of O&M is the study of the "Blue Book." The "Blue Book" is officially entitled Orientation and Mobility Techniques: A Guide for the Practitioner. Written by Purvis Ponder and the late Dr. Everett "Butch" Hill, the "Blue Book" is chock-full of precise technological application on every pre-cane and cane technique known to the O&M field. This book is a point of reference for every O&M who has reached out to teach and empower the life of a visually impaired or blind student. If the O&M profession had a bible, the "Blue Book" would be it.

Full of confidence and success in my "Blue Book" knowledge and teaching strategies, I continued along teaching fellow coworkers and students in the utilization of proper O&M techniques. I continued on my daily crusade of furthering my students' independence until one day when I received a phone call from my supervisor. She instructed me to go and evaluate a new student who was entering our program. This particular student was totally blind and profoundly deaf and yet cognitively on target with his age. As I began working with this student, I quickly came to a shocking reality. My method for teaching the "Blue Book" techniques to this student was functionally impossible.

Needless to say I did continue working with this student and eventually had many success stories in relation to developing his understanding of O&M concepts and the purpose for their use. I have also discovered that, as the years have gone by, I have evaluated and picked up more of these students for O&M service. Tragically, however, I have come to find out that this population of students is highly underserved. Probably the largest reason has to do with the lack of preparation and schooling in this specific population. When it comes to teaching students with dual sensory impairments of vision and hearing, we in the O&M field must be willing to step out of the box of standardized teaching. Modification of what we have learned from the "Blue Book" must become our mantra.

The information that follows is a sampling of a few modifications to the O&M "Blue Book" techniques. I hope you find this material helpful as you assist your deafblind students in achieving the highest level of independence that they deserve to reach.

  • In teaching sighted guide the traditional method can be taught having the student holding on to the guide's arm just above their elbow. For younger students the grip will have to be modified to holding the guide's index finger or wrist depending on height and strength needs.
  • For more receptive communication to assist the student's knowledge of what is coming up in his/her environment, move the student's sighted guide position to a hand under hand guidance. This method will allow the guide to wrap his/her thumb on top of the student's hand for more proprioceptive feedback. The examples listed below should be given to the student right before the requested movement takes place:
  • Left turns: hand movement goes twice towards the left.
  • Right turns: hand movement goes twice towards the right.
  • Ramps: Angle hand 45 degrees in a descending or ascending direction depending on how you are traveling on the ramp. Give an upward or downward hand motion, in the 45-degree position, twice to indicate the direction of the ramp.
  • Straight ahead: a forward surge of the hand given in intervals depending on the length of the straight travel.
  • Stop: hand moves from a 0 degree position to a 90 degree position. Pause in the stopped position to relate the requested action to the student.
  • Advanced directionality: This is for students who are emerging in their understanding of sign language. The directions left and right can be signed with an "L" or "R" in the student's hand to communicate which direction they are being requested to take.
  • Up: hand movement goes twice in an upward elevation.
  • Down: hand movement goes twice in a downward elevation.
  • If some students need more proprioceptive feedback to grasp the concepts of up and down, have the hand under hand guidance also establish contact at the guide's waist. This will give additional communication to the student to the length of the step up or drop off.
  • Touch cues have additional communication benefits for students who are utilizing adaptive mobility devices or for those who are engaged in trailing activities. These examples should be given to assist the student in understanding movement they are being requested to initiate.
  • Left turn: Using your index and middle fingers, make a sweeping motion down the student's left upper arm.
  • Right turn: Using your index and middle fingers, make a sweeping motion down the student's right upper arm.
  • Straight: While standing behind the student, make a sweeping motion across the student's shoulder with the side of your hand. Your pinky finger should be the only finger of contact on the student.
  • Stop: Place your hand firmly on the student's upper shoulder.
  • Squaring off: You will need to have good rapport with your student for this modification. The reason for this is because you will be physically maneuvering his/her body into a correct positioning initially. After using the stop touch cue, drag your index and middle fingers down the middle of the student's back to indicate squaring off. Position the student so that their shoulders and feet are touching the wall in the correct squaring off position. Then give the student a positive "good job" touch cue by patting them on the shoulder.

For all of these modifications the key is repetition. Remember, Rome was not built in a day. Your students will need these modifications routinely in order to gain understanding of their purpose and meaning. May these initial modifications assist you in teaching your children to develop to the fullness of their O&M potential.

Editor's Note: Melvin Marx graduated from SFASU in 1991. He has worked both in the rehabilitation and educational fields. He has received specialized training in the area of deaf-blindness from The Helen Keller National Center in Sandspoint, New York. For the past twelve years Melvin has been employed by Houston ISD. His specialty areas of training include the multiply impaired and deafblind populations. You may contact Melvin by email: 


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Great for Young Children

General

Originally published in See/Hear Newsletter, Summer 2007
Versión Español de este artículo (Spanish Version)seis

Chris Montgomery, TSBVI Outreach, Deafblind Education Consultant

Abstract: A former classroom teacher, now Outreach deafblind consultant, shares the observations and educational intervention strategies he compiled when working with one student a few years ago. Natasha had cortical visual impairment, central auditory processing disorder, seizure disorder, and additional sensory integration problems.

Keywords: visually impaired, cortical visual impairment, central auditory processing disorder, deafblind.

Natasha is a seven-year-old girl who has been labeled deafblind. She has a severe bilateral hearing loss, a cortical visual impairment, and a long history of severe seizure disorder that began at four months of age. To restrict and lateralize her seizures, by age three she needed a corpus callosotomy to separate the anterior two-thirds of the corpus callosum. After surgery Natasha made significant improvements in her general health, sleep, growth, development, midline control, and sustained visual gaze. Her seizures continued, and at age six she received a Vagus Nerve Stimulator (VNS). The VNS is a device that sends an electric signal to the Vagus nerve at consistent intervals so regular brain waves can be established, thus minimizing seizure activity.

It has been approximately three years since Natasha's neural surgery. Research suggests that the first three to four years of a child's life is the most critical for the development of neural pathways. Early identification of Natasha's neurological conditions, including CVI provide the best opportunity to take advantage of the brain's plasticity. I feel we are just in time in this regard, and I am noticing improvement in her use of vision weekly.

Observations

In Natasha's case, her CVI had a more profound effect on her vision before her corpus callosotomy. According to her mother her depth perception problems have improved. Her ability to stay on task and recognize people and calendar symbols is also improving. Natasha still exhibits a strong preference for bright primary colors, and usually attends better when her environment is kept visually uncluttered. She does not demonstrate fluctuations in her vision.

Natasha is starting to respond to my voice during familiar activities such as eating breakfast. She will lean her ear toward my mouth to listen to familiar phrases that I say to her. I try to keep these vocalizations as consistent as possible during the routines so they will in effect be paired with the routine we are doing. I am hoping the next step will be her hearing these vocalizations from a further distance, and associating my vocalizations with the particular activity by signal or gesture when we are away from the activity. Natasha is motivated by her near senses including:

  • Vestibular: swinging, being flipped, rocking, swaying, and extreme extension in a inverted position.
  • Oral/Tactile: oral exploration, smelling, tasting, textures (e.g. pegboard, carpet, familiar blanket), water, vibration.
  • Touch/Proprioceptive: deep pressure, physical rough house play, tapping, stomping feet.

Cortical Visual Impairment

Cortical visual impairment (CVI) is a temporary or permanent visual impairment caused by the disturbance of the posterior visual pathways and/or the occipital lobes of the brain. The degree of neurological damage and visual impairment varies with the time of the onset, as well as the location and intensity of the injury. It is a condition in which the visual systems of the brain do not consistently understand or interpret what the eyes see. CVI can have wide-ranging effects. Individuals can have multiple disabilities, and other cognitive disorders, as well as motor impairments that compound their CVI.

The major causes of CVI are asphyxia, developmental brain defects, head injury, hydrocephalus, and infections to the central nervous system, such as meningitis and encephalitis. (Jan & Groenveld, 1993) The damage may be localized to a

specific area of the brain or generalized to different cerebral regions. Additionally the severity of the visual impairment is related to both the gestational age at the time of insult and neonatal seizures. Other causes for cortical visual impairment include toxoplasmosis, cytomegalovirus, and such cerebral degenerative conditions as Tay-Sachs disease, and galactosemia. (Cogan, 1966) Similar injuries to an adult's nervous system may have very different outcomes than those effecting children.

Individuals with CVI may exhibit any of the following characteristics:

  • Their visual acuities may range from light perception to print reading ability.
  • There is almost always a field deficit present.
  • Nystagmus is absent unless there is an additional ocular disorder.
  • The eyes show no apparent abnormality.
  • A high percentage demonstrate light gazing, even though about the same percentage are light sensitive.
  • Visual functioning fluctuates.
  • Color perception is generally intact and many students seem to perceive red or yellow more easily.
  • Difficulties with depth perception are frequently present, particularly with foreground/background perception.
  • Suppressing unnecessary visual information may be difficult. Close viewing may be preferred even though visual acuities are normal.
  • Perception of objects is difficult when they are spaced close together.
  • Avoiding obstacles during travel is easier than using vision for close work. (Smith & Levack, 1997)

While Natasha uses the distance senses of vision and audition, these senses are less reliable. The information gained through them seems to be more difficult for her to process. Natasha sometimes exhibits signs of auditory overload. She may have a difficult time filtering out environmental noises. Sensitivity reactions observed in the past have included withdrawal, covering her ears, vocalizations indicating stress, and shut-down behavior. Extraneous objects in the environment tend to distract her if they are brightly colored or if they have a desirable texture for touching or mouthing. People walking past or about the room also distract Natasha.

Central Auditory Processing Disorder and Auditory Neuropathy

Central auditory processing disorder (CAPD) is a term that refers to some type of problem in the auditory system, which occurs neurologically instead of in the ear itself. A person may have one or more auditory processing problems for a variety of reasons. Differences in auditory nerve (auditory neuropathy) might cause some of these problems, however there is more to the neurology of the auditory system than the auditory nerve.

As the nerve fibers enter the brainstem at the base of the skull they split and cross (similar to the optic nerve at the optic chiasm). Then the fibers go to various parts of the cortex of the brain. Most of the fibers go to the temporal lobe. Differences in neurology, anywhere along the line, might result in the symptoms of CAPD. (Durkel, 2001)

CAPD is similar to CVI in that it results from neurological causes instead of damage to the sensory system itself. Children with cortical visual impairments are at a greater risk of having CAPD, because the damage to their neurological systems which caused the visual impairment may also have caused damage to the auditory system.

CAPD is defined as a disorder with problems in one or more of the following six areas:

  • Sound localization and lateralization (knowing where in space a sound is located).
  • Auditory discrimination (usually with reference to speech, but the ability to tell one sound is different from another).
  • Auditory pattern recognition (musical rhythms are one example of an auditory pattern).
  • Temporal aspects of audition (auditory processing relies on making fine discriminations of timing changes in auditory input, especially in differences in the way the input comes through one ear as opposed to the other).
  • Auditory performance decrements with competing signals (listening in noise).
  • Auditory performance decrements with degraded acoustic signals (listening to sounds that are muffled, missing information or for some reason are unclear, e.g. trying to listen to speech from the other side of a wall. The wall filters or blocks out certain parts of speech, but a typical listener can often understand the conversations.).

Both at home and at school Natasha associates specific locations with specific actions. She travels to various locations in the classroom to perform these actions, leaving and returning to a given activity repeatedly. Natasha seems to process information by interacting with a person or object for several minutes then withdrawing to a calming activity for several minutes. She has recently begun to associate her calming activities with familiar people, and is attaching her calming activities to places or objects in the room with less and less frequency.

Natasha shows significant signs of sensory disorganization. It is not easy for her to attach meaning to what she sees, hears, or how her body feels within a movement or activity. This means it requires a lot of effort on her part to combine her skills. Natasha's sensory processing skills vary throughout the day, and from day to day. There are occasions when it appears she is using her vision to actively explore and search within her environment. There are other situations in which she is less actively attending to her vision, but seems more aware of her own body through movement, sound, or oral/tactile involvement. The appropriate educational strategies and methods are modified according to her responses.

Body position is a strong contributor to functional use of vision. Natasha is able to hold her head steady to scan the environment and make visual contact with adults. However, there are long periods of time in which her head position is constantly changing and the ability for her to combine her vision and midline control is limited. Movements that promote controlled head and neck extension are helpful.

Epilepsy Surgery and Corpus Callosotomy

Most seizures can be controlled with medicine. When medications are unable to eliminate seizures, other therapies are considered, including surgery. When a part of the brain can be identified as the source of seizures, surgical removal of that source will often eliminate the seizures all together. Several different types of surgery can be offered. The temporal lobe is the most common part of the brain involved in seizures and these patients undergo lobectomy. Extratemporal lobectomy, hemispherotomy, and corpus callosotomy are also used in patients with seizure sources in different parts of the brain. In patients who are not candidates for brain surgery, the Vagus nerve stimulator can be used to reduce seizure frequency.

The surgical procedure corpus callosotomy is resection of the anterior two thirds of the corpus callosum. In many cases, limiting the resection provides significant seizure reduction and may avoid some of the cognitive complications that may arise from complete corpus callosotomy. Anterior corpus callosotomy is less likely to lead to significant cognitive difficulties, so-called split-brain phenomenon, than larger resections. More extensive corpus callosum resections can disrupt the cross-hemispheric communication of visual information and may lead to more noticeable neuropsychological problems. All divisions likely cause some deficit and acute, transient problems are common, especially in total resections.

Nevertheless, when anterior corpus callosotomy fails to provide significant seizure reduction, some patients may benefit from a secondary procedure to resect the remaining posterior one third of the corpus callosum.

The goal of these procedures is seizure reduction, not cure. Accordingly, reduction in seizures to a certain percentage is used as a measure of success. Overall outcome has been reported as 8% seizure free, 61% improved, and 31% not improved. In children who undergo corpus callosotomy, quality of life measures improved with seizure reduction, even in the absence of seizure-free status. (Beach, 1998)

A Vagus Nerve Stimulator is used with patients who have medically intractable epilepsy, and are not candidates for resective surgery. The stimulator is placed on the left Vagus nerve, in the neck. A battery is placed under the skin in the chest, like a pacemaker. By using the stimulator, a significant reduction in seizure frequency can be achieved. Although complete seizure freedom is unlikely, the effect of the stimulator seems to improve with continued use. Seizure reduction is greater the longer the device is used.

Learning Implications

In order to address Natasha's unique learning style, the educational team has adopted the following educational strategies.

  • Provide opportunities for a variety of vestibular and tactile stimuli. Allow Natasha to swing for at least 20 minutes prior to a structured activity. This type of vestibular input has great impact on increasing her eye contact and focus on objects and people. Vibration and deep touch are also calming to her nervous system.
  • For sensory motor participation and play, Natasha should direct her own movements as much as possible. Sensory motor play is a chance for Natasha to experience comfort within her own body. The caregiver's role should be to establish trust, offer options, and make themselves available for interaction.
  • Use the near senses (tactile, oral, vestibular, proprioceptive) to gain Natasha's attention and motivate her to attend to visual and auditory information.
  • To promote self-initiation, provide opportunities for Natasha to build a sense of anticipation. The layout and organization of the classroom and calendar systems must be predictable. A quiet uncluttered environment with a limited number of people will help her focus. Combining object symbols, voice, and gesture (e.g. pointing, gestural sign) will help to direct Natasha's attention. Adding rhythmic sounds and singing while Natasha is engaged in an activity helps her to focus her attention as well.

Conclusion

Research indicates that the ear and the eyes neurologically function and develop in much the same way. I feel Natasha still has time to establish neuro-pathways that will facilitate her use of both vision and hearing in meaningful ways. Through the use of consistent activities and communication strategies we are already seeing Natasha make more sense of her world and use her vision and hearing in more functional ways. I feel the future is very bright for Natasha.

Bibliography

Beach, S. (1998). Washington University Neurosurgery (retrieved 2001) (neurosurgery.wustl.edu).

Cogan, D. (1966). "Neurology of the visual system". Springfield, Ill: C.C. Thomas.

Durkel, J. (2001). "Central Auditory Processing Disorder and Auditory Neuropathy." See/Hear, 6 (1).

Jan, J., & Groenveld, M. (1993). Visual behaviors and adaptations associated with cortical and ocular impairment in children. Journal of visual impairment and blindness (JVIB), 87, 101-105.

Jan J., Wong P., Groenwell M., Flodmark O., & Hoyt CS. (1986) Travel vision Collicular visual system? Pediatr. Neurol. 2 (6) 359-62.

Morse, M. (1990). Cortical visual impairment in young children with multiple disabilities. Journal of Visual Impairment & Blindness, 84, 200-203.

Smith and Levack, (1997). Teaching students with visual and multiple impairments. Austin, TX: Texas School for the Blind and Visually Impaired.

Woman driving a car using bioptics.

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

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

  • Distance viewing
  • Bioptic usage
  • Hazard perception

5 Keys to Safe Space Cushion Driving

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

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

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

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

About the Bioptic Driving Exercises

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

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

Exercise 1

Exercise 2

Exercise 3

 

 

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

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

DriversSeat_Miller
Downloads: Transcript (txt) Audio (mp3)

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

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

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

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

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

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

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

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

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

In the Driver's Seat: From the COMS Perspective

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

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

Highway and interstate travel

The first time you complete this exercise use your monocular.  If you have a bioptic, try this exercise a second time to compare the difference.

View from the driver's seat of a multi-lane highway.Your next challenge is highway and interstate travel.  One of the greatest challenges for any driver is long drives on unfamiliar roadways.  Interstate highways involve high speeds (and often heavy traffic) and unpredictable drivers.  County roads and two- or four-lane highways have various speeds, more traffic entering from driveways and roadsides, vehicles that move slowly like tractors or construction vehicles, and other vehicles passing to get ahead of you.  Factors like fatigue and changing light have great impact on any driver.  For your next exercise with your monocular or bioptic, take about an hour’s drive along various county roads, state highways and interstate highways. While you ride along look ahead as far as possible and comment on:

  • The contour of roadways (i.e. hills, curves, dips in the road) 
  • Restricted sight distances, road narrowing, narrow bridge ahead, changes in pavement markings, etc.
  • Traffic signs and lights
  • Speed and driving patterns of cars ahead of and passing you

Considering your observations, answer these questions:

  • What was more fatiguing about this experience from the other driving exercises you have complete prior to this?
  • What aspects of the roadways did you find challenging or think might be a challenge if you were behind the wheel?
  • Did most drivers obey the speed limit and other traffic laws?
  • What unexpected things did you spot along the roadways?
  • What potential “collision traps” did you discover along the way?  How would you handle them if you were actually driving?  For example, choosing to brake suddenly, swerve out of the way, reduce your speed, change lanes, etc.
  • How was your vision impacted by glare, dirt on your windshield, lights, etc.?
  • What did you find that was distracting or potentially distracting while traveling?
  • Did the weather, light or other uncontrollable conditions impact your performance?
  • What skills do you most need to work on related to driving with low vision?

 

Developed by TSBVI Outreach Programs based on materials provided by Chuck Huss, COMS, Driver Rehabilitation Specialist with the West Virginia Bioptic Driving Program

Return to:

Bioptic Driving: Passenger-in-car Skills

Exercise 1

Exercise 2

by Marnee Loftin, Psychologist, TSBVI

All teachers and other professionals in the field of visual impairment recognized that students who are visually impaired can also have learning disabilities. Diagnosing these in a way that is meaningful to the educational process and complies with federal and state law is often difficult. At TSBVI a great deal of effort has been directed toward developing systematic procedures that can be used to document the present of a specific learning disability. At this time, the determination of a specific learning disability in the area of reading is one that has been well developed. Further work is being done in developing specific procedures in the areas of mathematics as well as exploring the concept of dyslexia in students with visual impairment.

The Texas special ed rules state that the presence of learning disabilities may be determined either by statistical comparison of intelligence to scores on tests of individual educational achievement or by informal methods that focus upon observation and classroom data. For a variety of reasons, the second method seems to be the most effective way for determining the presence of learning disabilities. Formal assessment may be used to begin the process of determining a learning disability, but is always supplemented by examples of classroom work and classroom observation.

The formal assessment process will vary depending upon the particular needs that are of concern to the teacher and/or parent. However, in all cases, we begin with a formal measure of intelligence that has been administered and interpreted in a manner consistent with an understanding of the impact of visual impairment. Again this gives us a baseline that allows us a rough "predictor" of anticipated educational achievement. Additional sources of data are discussed below.

READING DISABILITIES 

When assessing the presence of a specific disability in reading, formal assessment data is generally supplemented by a comprehensive speech and language evaluation. Skills assessed usually are those such as verbal sequencing, verbal memory, ability to rapidly retrieve information, and phonological awareness. In addition, history is reviewed to determine age at which letters were first recognized and any difficulties with rhyming that occurred early in life. These are all skills that are frequent deficit areas in students with learning disabilities. They seem to be equally predictive with students who also have visual impairment.

Classroom observations and informal assessments are used to determine functional performance at this time. Aspects such as slow reading rates, numerous false starts and dysfluencies, incorrect use of suffixes, excessive reliance on context clues and good comprehension even in the presence of great difficulties with decoding are all diagnostically significant in analyzing these materials.

Writing samples are often used as further data in establishing the presence of a reading disability. Punctuation and spelling errors do not assume the same importance in diagnosing a reading disability with a student who has a visual impairment. These are often a direct result of a variety of issues associated with visual impairment. Diagnostically, the most important issue may be the sheer simplicity of a writing sample. Given adequate adaptations, clear directions, and appropriate modifications, the final product of a very simple writing sample may be another indicator that all attention is being directed to the encoding process.

As mentioned in the article that appeared in RE:view, care should be taken "not to over identify learning problems by basing any assessment upon poor spelling , punctuation or both; or by doing any such assessment when a student's skills are being affected by a transition to a new medium. Equally, care should be take not to under identify learning problems by refusing to recognize significant problems simply because the student has a visual impairment.

FUTURE AREAS OF INTEREST

Again, efforts are underway to develop a systematic procedure for determining the presence of a learning disability in mathematics. Additionally work is being done in exploring the concept of dyslexia as well as visual processing difficulties. Observation in this environment suggests that both of these issues exist in children with visual impairments and seem to be a separate and severely limiting factor in the learning of new skills. Objectively determining the presence of these conditions as a separate disability is an area of interest for us at TSBVI.