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Many states have enacted laws with specific requirements that publishers of textbooks supply those books to the state in electronic file formats so that they can be reproduced in braille or other accessible media. The following chart identifies the states with such legislation, the statute number or reference, the types of textbooks or other instructional materials that are specified in the law, and the electronic file format required.

Source: Association of American Publishers—Revised 9/1/2005

State Braille Laws







Admin. Rules Sec 290-080-090-.13(25)

All adopted textbooks and supplementary materials, literary and nonliterary.

ASCII or other electronic format compatible with Braille conversion

Not specified


Sue McKenzie
Textbook Administrator

Statute Sec. 6-41-405/Contract

Literary subjects in all adopted texts; nontextual portions of textbooks when technology is available.

Per state contract, ASCII, ICADD-22, SGML, or improved

Per contract, 90 days after request.


Statute Sec. 15-214

Rules in progress that would incorporate NIMAS

Literary subjects; nonliterary when technology is available.

Standard format approved by Dept of Ed compatible with Braille conversion

Not specified


Education Code 60061

All print material offered to any other state. Recommended subjects: Eng/Lang Arts, Visual/Perf Arts, Hist, Soc Sci, For Lang, Math, Sci, Health.

Not specified in Code. Recommended: Braille compatible format, such as ICADD or SGML

Within one month of adoption


Statute Sec 10-295

Establishes fund to provide specialized instructional materials, including Braille and large print



Statute Sec 206-14

Print copy of all materials; electronic file on request


Upon request


Statute Sec 233.0561(5)

Adopted student textbooks for literary subjects; nonliterary when technology is available. Include corrections/changes; if this cannot be accomplished, provide marked tear sheets

Per instructions: ICADD 22 or SGML for DOS; 3.5" double-sided/high density diskette; Labeling: Seq #, ISBN, bk title, file name, pub, typstng co/contract, format option/version, copyright date; Contents: Title page, consultants/reviewers, table of contents, all chptrs, all appndcs, all glossaries, indices. Include special items w/in text file.

Upon request


Kim Hartsell
Dept. of Special Ed.

House Bill 228 Signed by Governor - Act 321

Textbook Adoption agreement

All recommended textbooks must be provided in electronic format.



Statute Sec 302A-442.5

All literary textbooks or other instructional materials sold to the state or any local education agency. Non literary when software is available.

ASCII for literary and for nonliterary (natural sciences, computer science, math, and music) when software is available.

Does not apply to materials written in the Hawaiian language.

Not specified


Statute Sec 33-118

All approved materials for literary subjects; nonliterary when technology is available. (However contract will continue to specify nonliterary.)

Per contract, Word or ASCII

Upon request


Charles Hayes
Principal Consultant

Act 87-1071 Sec 28-21

Literary subjects; nonliterary when technology is available.

ASCII file and print copy of textbook

Within 15 days of request for print copy; 90 days for e-file


Linda Dierstein
Textbook Adoption Coord.

Statute Sec 20-10.1-0-15

Literary subjects; nonliterary when technology is available.

ASCII or other format determined by board.

Within 60 days of request


Statute Sec 301.10

All textbooks requested by department

Best format for electronic Braille translation.

Not specified


Statute Sec 156.476

SB 243 enacted 4/9/02

All adopted textbooks. Beginning with 2004 adoption, a preference given to publishers who provide materials in alternative formats

If publisher submits electronic file in another state that is of a higher level of accessibility than basic ASCII, KY wants equal access to that same file version if that same material is sold in KY. ASCII or any format readily translated into Braille. Provide files to American Printing House for the Blind. Beginning with 2004 adoption: formats comparable to the printed version that are compatible with commonly used Braille translation and speech synthesis software and include corrections and revisions as may be necessary to assure clarity in presentation and use. Navigation within and between files should be reasonably efficient so that the disabled learner is able to fully utilize the material in a manner that yields the same result as the print version affords a nondisabled learner. File format shall be limited to those formats that allow for a comparable version that is readable with text and screen readers such as HTML, XML, or other formats that meet the criteria. For extreme cases where ALT tags are not feasible, a tag may read, This item is too complicated to render with current technology. Legacy materials shall be exempt from the criteria for this preference. ("legacy" means images and graphics requiring release and permission from another source other than the publisher.)

Beginning 2004, files to be provided at the same time as the print book.


Revised Statutes 17:1985

Literary subjects; nonliterary subjects when technology is available

Standard format approved by Board of Ed from which Braille versions can be produced. Per contract, provide files to American Printing House for the Blind

Within 90 days of adoption


Robb Farrell
MD School for the Blind

Statute Sec 8-408(d)

COMAR 13A.05.02.13H

Pupil edition textbooks for literary subjects; nonliterary when technology is available.

A format suitable for conversion into Braille or synthesized speech.

"Technology-based" instructional products should be 508 compliant unless doing so would (a) fundamentally alter the nature of the instructional activity; (b) result in undue finan. and admin. burdens on the agency or (c) not meet all other specs.

Upon request


MCL 380.1704

Literary subjects, nonliterary if the technology is available to convert directly to a Braille compatible format.

A publisher shall not charge a price for the electronic version that exceeds the price it charges for the print or electronic media version

Upon request


Statute Sec 37-23-199

Literary subjects; nonliterary subjects when technology is available.



Within 10 working days of request


Rosalee Backer
Dept. of Special Ed

Statute Sec 170.132

All public elementary, secondary, and post-secondary schools shall preferentially procure IM from vendors who provide electronic files

ASCII: para. Notations, full text, include. All text-related graphics, glossaries, indices and front matter, well organized, logically dev. files, accurately labeled disks to id the title and chap. Or other grouping structures, sequentially numbered disks, if applicable.

ICADD 22 including: full text, all text-related graphics, glossaries, indices and front matter, each chapter, if applicable, formatted as a separate file, accurately labeled disks to id the title and chapters or other grouping structures of SGML: full text, inc. all text related graphics, glossaries, indices and front matter, each chap., if applicable, formatted as separate file, accurately labeled disks to id title and chapters or other grouping structures, sequentially numbered disks, if applicable.

All electronic materials must be offered in the most recent version of Microsoft Windows.

3.5 diskette, ddhd or 5.25 syquest cartridge with 44, 88 or 200 megabyte capacity. Disk/cartridge labeling shall include seq. #, book title, file name, pub. Name and name of typesetting companies

Regs. specifies TE's not required as regs focus on pupils.

Not specified


(NEW 2005)

HB 438

Chapter 490

"In selecting textbooks, the district shall ensure that the materials are made available to each blind and visually impaired child in a timely manner in accordance with the requirements of the Individuals With Disabilities Education Act, 20 U.S.C. 1400, et seq."



David Bowman

SB 301

New law adds workbooks, teacher manuals or editions, blackline masters, transparencies, test packets, software, CD-ROMs, videotapes and cassette tapes. Defines textbook to include a system of instructional materials or a combination of a book and supplementary instructional materials that conveys information to the student or otherwise contribute in addition to textbooks including electronic textbooks.

Mutually agreed-upon electronic format (such as Word, ASCII or LaTex)

Includes private right of action language

Adds publishers to groups the department should consult with before adopting guidelines for implementation and administration of new Braille Access Act.

If adopted, a national file format such as DAISY/NISO XML

Upon request.


Laurie Munro
Office of Children& Family Services

All IM. A preference will be given to vendors who agree to provide materials in alternate formats, except where the IM needed for a course cannot be obtained from any vendor in all alternative formats.

"Alternative format" defined as "any medium or format for the presentation of IM. . . .Including Braille, large print, open and closed captioned, audio, or an electronic file in an approved format as defined in the regulations of the commissioner.

Not specified.



Statute Sec 115C-90

No requirements for publishers.

Contracts allow State Board of Ed to produce Braille, large print, and audio cassette copies for use in state public schools



Paul Mauro

Statute Sec 3329.01

Rules 3301-51-21

Newly adopted materials for which technology exists for translation into Braille

Per Instructions: Windows or MS-DOS; 3.5" ddhd diskette. ASCII, WP or Word; Labeling: Seq #, bk title, file name, pub, typstng co; Contents: Title page, consultants/reviewers, table of contents, chptrs (in indiv. File), appndcs, glossaries, indices; Include special items w/in text file. Include file with description of all codes.

Within 60 days written notice.


Mary Boren

Statute Sec 70-16-106-D

Literary materials; nonliterary when translation software is available.




Rex Crouse
503-378-8004, ext. 261

Statute Sec 343.595

Literary subjects; nonliterary when translation software is available.

Format from which Braille version can be produced.

Upon request from district


Jim White
Textbook Program


Newly submitted literary programs; non-literary when technology available.

Electronic formats suitable for transcription into Braille.

Upon written request


NEW (2004)


Literary or nonliterary, such as natural sciences, computer science, mathematics, or music, an electronic version shall be furnished if the technology is available to convert the textbook directly to a format compatible with Braille translation software.

The publisher shall provide the electronic file to the requesting agency within sixty days of receiving written notice that the file is needed. The cost of the electronic publisher's file may not exceed the cost of a print copy of the same title. Legacy materials are exempt from the requirements of this section. Legacy materials are exempt from the requirements of this section. Legacy means images and graphics requiring release and permission from another source other than the publisher.

Upon written request


Rule 0520-1-2.15

All adopted materials

Electronic files that can be translated to Braille. Provide files to state DE, APH or a national repository.

60 days from request


Chuck Mayo
Textbook Accessibility Prog.

Statute Sec 31.028

Literary materials in English and Spanish language versions requested by State Board of Ed; nonliterary when technology is available. Not ancillary or supplementary.

Per instructions: ASCII, ICADD 22 or SGML for Windows or DOS, or agreed format. 3.5" DDHD diskette, 5.25" Syquest, or other agreed on media. Labeling: Seq #, bk title, file name, pub, typstng co; Contents: Title page, consultants/reviewers, table of contents, chptrs, appndcs, glossaries, indices. Include special items w/in text files



Shelley Kelson

Statute Sec 53A-26-111

Literary materials; nonliterary when technology is available.


On request


Beverly Thurston
Dir. Textbook Adoptions

Code Sec. 22.1-241

State reviewed and contracted basal pupil edition textbooks for literary subjects.

ASCII or other mutually agreed subject.

90 days from written request


Statute Sec 8-10J-5

Literary materials; nonliterary when technology is available.


Not specified

By Millie Smith, Education Specialist, TSBVI VI Outreach
with help from Roger Toy, Occupational Therapist, TSBVI

Versión Español de este artículo (Spanish Version)
Wersja polska (Polish Version)

Johnny is an eight year old child with visual and multiple impairments. He has some light perception and fairly good voluntary movement in his upper extremities although he can't walk. He is about to engage in an activity designed to teach him to brush his teeth. The brush suddenly appears in Johnny's hand. His teacher places her hand over his. The pressure applied to hold the brush is hers. The thought processes to plan the movement of the brush is hers. The spatial memory used to move and place the brush is hers. Finally, her hand and the brush are gone. Toothbrushing is finished. What has Johnny learned? He has learned to be passive and to tolerate having his hands moved for him.

Many teachers and parents of children with visual and multiple impairments are told to provide a level of assistance during activities commonly called "hand over hand." When done correctly with permission, minimal direction and appropriate waiting time, this teaching strategy can be very effective. When done incorrectly with complete other-directed manipulation throughout a task, children lose control of their hands and any potential they might have for learning through the tactual medium. They risk becoming increasingly passive by pulling their hands away and rejecting objects. These students may not actually be tactually defensive, but rather tactually avoidant. Instead of using their hands as tools to interact more and more with the world outside their bodies, they withdraw, turn ever more inward, and spend most of their time engaging in self-stimulatory behaviors. Like Johnny, they have learned to be helpless.

Encouraging Johnny to use his hands confidently and competently to access information about his world and to interact with his world to the fullest extent of his ability requires a two-part intervention. First, create a supportive learning environment and then, facilitate development of functional tactual skills.

Creating a Supportive Learning Environment

Children with visual and multiple impairments tend to have very limited experience with objects. They often form strong attachments to one or two objects and reject everything else. What they choose to do with the objects may be nonfunctional and repetitive. Our job is to widen the experience of these children to include a rich variety of objects and interactions. To do that we must establish a relationship grounded in mutual respect and trust. The key to a trusting and respectful relationship with a child who can't see is to begin by acknowledging that he has a right to control his own hands in exactly the same way that we have a right to control what we look at. We all want to facilitate learning, and the fastest and easiest way to do that is to grab a child's hands. As frustrating as it might be for us at times, development is best facilitated by encouraging rather than demanding (Nielsen).

Why won't Johnny hold his toothbrush?

There are probably many reasons Johnny won't hold his toothbrush assuming he has the motor ability to grasp. When the brush is placed in his hand, he may not know what it is. Most people experience some anxiety about touching something unknown, even when they are in control of the touching. That's why we blindfold people in Halloween fun houses and ask them to feel creepy stuff. Children who cannot see what is around them may be understandably reluctant to touch and hold the unknown (Fraiberg). Or, Johnny may know the object is a toothbrush, but not know what he is supposed to do with it. He may be dropping the toothbrush because he has not memorized the sequence of movements that goes with the rest of the activity (Millar). Another possibility is that Johnny recognizes the brush and anticipates that something he doesn't like is about to happen. He may drop the brush because he hopes that will prevent someone from grabbing his hands and brushing his teeth.

So what do I do to create a more supportive learning environment?

If Johnny won't hold anything and he doesn't like brushing teeth, we can't start with a toothbrush. We have to start with creating a trusting relationship with Johnny. We demonstrate that we can provide an environment that contains things that he likes to touch and hold. We also demonstrate that Johnny can be in control of his own hands. He can control what he wants to touch, what he wants to do with it, and when he wants to stop. It is very important to acknowledge that no teacher or parent will ever do this perfectly. The good news is that children don't seem to require perfection in order to trust us. As long as we are letting them be in control of their hands most of the time, we will probably have the relationship we need.

Here are some suggestions for how to build this relationship:

  1. Offer an object by making a sound with it close to the child or by using the object to touch some part of the body less sensitive than the palm of the hand, usually the arm or leg (Nielsen). Wait for a reach. Repeat the offer if necessary. Do not repeat the offer immediately if the child has a negative response. Offer something else. It is fine to offer something previously rejected at a later time as long as the object is quickly removed if rejected again and as long as the original rejection wasn't extreme.
  2. Engage in parallel play guided by the child. After the child does something with an object, imitate his action. Try to prolong the interaction by taking turns, he with his object, and you doing the same thing with a like object or a shared object (Nielsen).
  3. Model new actions with the object of interest. Offer your hands to the child as you do something with an object. Place your hands under the child's hands, but don't persist in maintaining contact if he removes his hands. This is the "hand-under-hand" method (Miles).
  4. Create safe, consistent, interesting object environments. The child should have total control over these environments. No one should guide his hands or verbally direct his activity when he is in these special environments (Nielsen). Make sure these environments are rich. Some plastic toys are okay if they are favorites, but most children find things like screen door springs and wind chimes much more interesting. Be sure to take the usual choking-hazard precautions.
  5. Always ask permission before taking the child's hand. This can be done non-verbally by placing your hand on top of the child's hand. If the child does not remove his hand, proceed.
  6. Always cue the child so that he knows what you are going to do before you take his hand. For example, give the child a spoon to let him know it is time to eat.
  7. If the child is resisting attempts to engage his hands, leave his hands alone and drop back to reciprocal whole body interactions such as rocking, swinging, bouncing, etc. Remember you are using these interactions to build trust so that the child will value time spent with you. In these interactions, the child will use his body to signal when he wants you to continue or stop (Van Dijk). As he develops trust that you will respond to these signals, he will be more likely to expand his contact with you to eventually include hands.

Yes, but, how do those teeth get brushed?

So, if you know Johnny likes things that vibrate, you offer him a vibrating toothbrush by turning it on close to his head. He might reach over and touch it. If you hold it there so he understands that he is in control of what happens next, he might grasp it. If you turn loose at this point, he might hold it. Then you let him do anything he wants with it. Don't blow the trust by grabbing his hand and making him brush. Johnny needs to memorize movement sequences in activities he really likes before you take on toothbrushing. In the meantime he is learning that he can trust you while he is also finding out a few things about the parts of a toothbrush. Later this will come in handy when you use a brush to cue him that you are going to brush his teeth and he recognizes it. Yes, teeth still have to be brushed, just don't touch Johnny's hands while you are doing it. If he brings his hands up to yours and participates a little with his hand over yours, you will know that you are making progress. Johnny may begin bringing his hand up to push yours away to signal that he wants you to stop. Honor this communication by stopping for a moment. Then begin again. Johnny has learned that he can use his hand to create short breaks. He may try for more, perhaps controlling the amount of pressure you apply or where you place the brush. As Johnny learns that he has more and more control over the activity when his hands are involved, the involvement will gradually increase.

Facilitating the development of functional tactual skills

The cognitive, communicative and social development of children who are tactual learners depends to a large extent on how much information they can access by using their hands and other parts of their bodies to touch and move. A short clarification might be helpful here. The children we commonly refer to as "tactual learners" are really somatosensory learners. The somatosensory system includes the tactile, proprioceptive, and kinesthetic components of perception. The proprioceptive and kinesthetic components relay information to the brain about the position of parts of the body and about what they are doing (Nagaishi). Braille reading is really not a tactual skill; it is a somatosensory skill. The discrimination of the individual characters is primarily tactual, but all the braille fluency skills, finding the next line, etc., are primarily proprioceptive and kinesthetic. For a child without vision, the same perceptual components apply to eating, finding a favorite toy and just about everything else. Historically, one of the highest job priorities for teachers of the visually impaired has been the development of somatosensory skills for children who are potential braille readers. For some reason, there has not been much emphasis in the field of visual impairments on the development of somatosensory skills for students with multiple impairments. In many places the role of the teacher of the visually impaired with this population has been limited to vision stimulation activities (Lewis). Children with visual and multiple impairments are often passively manipulated through tasks without due consideration to building a sound somatosensory base of knowledge about the world.

Why does the teacher of the visually impaired need to be involved; can't the occupational therapist do it?

There is some overlap between the roles of the occupational therapist and the teacher of the visually impaired working with children with visual and multiple impairments. There are also some clear differences. Occupational therapists have a great deal of information about the intactness of the somatosensory system that only they are trained to assess. They are the professionals who guide the team in therapeutic interventions to address problems with the tactual system such as hypersensitivity or hyposensitivity, difficulty with sensory integration and adequacy of sensation thresholds for discrimination. They help address many motor issues related to the potential for the use of the arms and hands to access tactual information. Some of these include trunk stability and range of motion related to the ability to reach, muscle tone and strength, and reflex development. They look at the child's ability to use proprioceptive and kinesthetic information to motor plan tasks (Heydt and Allon). All of this is essential information for the teacher of the visually impaired to have. A close working relationship between occupational therapists and teachers of the visually impaired is extremely helpful.

Occupational therapists do not typically determine what tactual/somatosensory skills a child will need to use to compensate for lack of vision. But these compensatory skills must be learned in order to develop a solid base of cognitive, communicative, social, and functional skills at the highest levels possible. The responsibility for these skills being learned belongs to the person responsible for teaching compensatory skills related to loss of vision - the VI teacher. For instance, some information is accessed by everybody tactually whether they can see or not. When we want information about the temperature of a thing, we touch it. But a tactual learner is accessing a great deal of information about his world with his hands and other parts of his body because he cannot access the same information visually. For instance, the easiest way to find something is to look for it. If a child cannot see, he has to learn the compensatory skill of searching tactually or, more correctly, somatosensorily. As we all know, that skill does not develop automatically. It has to be taught.

If I am going to facilitate development of tactual skills what do I teach?

The literature in the field of visual impairments tends to talk about tactual skills in terms of pre-braille instruction (Smith and Levack). For instance, in their article on tactual development and its implication for the education of children who are blind, Griffin and Gerber (1982) describe a sequence of four stages:

  1. Awareness of the tactual qualities of objects such as textures, temperatures, vibrating surfaces, and different consistencies.
  2. Shape conception and recognition (three dimensional forms).
  3. Understanding of graphic representation (e.g. raised line forms).
  4. Utilization of symbology (braille).

The sequence described by Griffin and Gerber does not address tactual knowledge of the world of people, objects, and actions. Functional tactual skills instruction based on a child's need for knowledge and participation in functional and social activities might include the following (Smith and Levack):

  1. Locating: randomly or intentionally searching for an object.
  2. Exploring: moving the hand over something to get information about the tactual properties.
  3. Manipulating: intentional movement of the object.
  4. Recognizing: associating an object with a memory of the object.
  5. Comparing: discovering similarities, differences, and preferences. Matching and categorizing.
  6. Communicating: using objects to request, refuse, comment, and question.
  7. Organizing: finding objects in their usual place, returning objects to their usual place, sorting or categorizing by placement, gathering materials for a task.

Why are these skills functional?

Many children with visual and multiple impairments access information primarily through their tactual sense. They do this by participating in activities using their hands or some other part of their bodies. The skills they need to actively participate are locating, exploring, recognizing, manipulating, comparing, communicating, and organizing. With these skills a child without vision can participate at some level in games, dressing, chores, and just about everything else.

Why does tactual learning have to be active rather than passive?

Tactual learning as it relates to developing skills that compensate for lack of vision falls into two categories - object knowledge and function knowledge. One requires more activity for learning than the other.

Without vision, knowledge of objects is gathered by sensors in the skin (cutaneous sensors) that give information about temperature, weight, texture, form, size and length (Warren). Cutaneous sensors are located all over the skin surface of the body. The finger tips, lips, tongue and palm of the hand are extremely efficient at gathering this information. Because of that, objects are more easily recognized when explored by the hand or mouth. If hands and mouth are not available for tactual learning about objects, other parts of the body may work, but not as well. Some of the finer elements which help the child discriminate one object from another may be lost. For example, a child might be able to tell that an eating utensil is being placed on his arm, but not be able to tell that the object is a fork and not a spoon. Detection of fine differences seems to be improved by movement of the hand over the object and diminished by movement of the object over the hand or some other skin surface. So, active exploration helps discrimination, but passive exposure may be enough for some recognition. A child without vision who is using his mouth to explore objects because he cannot use his hands should never be prevented from engaging in this behavior as long as he is truly exploring.

Function knowledge is a very different matter. A child may recognize his favorite toy but be completely unaware of the function of the toy. This happens to children without vision all the time and it tends to add to their social isolation. For instance, Johnny's favorite toy is a Lego. He smiles when he finds it with his hands. It is clear that his cutaneous sensors have given him the information he needs about the size, length, weight, texture, temperature, and form of the object so that he can recognize it as his Lego. Johnny happily begins to play with the Lego by tapping it against his teeth. He has no knowledge of the function of the object. He has never seen other people play with Legos. If he understood early on, before his tapping behavior was well established, that a Lego is supposed to be manipulated with other Legos to make new forms, he could play with other children doing this activity and would probably enjoy it more than tapping. Johnny might not be ready to start with the function of snapping Lego blocks together, but he could begin with pulling them apart. He might even need to do that with a combination of hand and teeth for a while before moving on to manipulating it with both hands. He would still be acquiring knowledge about the function of Lego blocks.

Tactual learners get information about function very differently than sighted children. Sighted children learn function primarily by imitating what they see others do with the object. Tactual learners learn function primarily by memorizing sequences of movements (Millar). Memorization occurs when information is gathered through the somatosensory system. In order for information to be gathered there must be a conscious interaction between brain and muscle. This only happens when a child is controlling at least some of his movements. Control allows information about joint movement to be stored so that movements can be repeated almost automatically in the future. If the child is passively manipulated through a task, no memory of the event is stored and function cannot be learned.

How do I get started?

Johnny's team began with a structured observation of his functional tactual skills. Five typical activities were chosen and videotaped. The classroom teacher, VI teacher, paraprofessional, and motor therapists watched the tapes and noted behaviors in each activity corresponding to the functional tactual skills categories mentioned earlier- locating, exploring, manipulating, recognizing, comparing, communicating and organizing. The tapes were sent home and input was provided by the family. Johnny's assessment is shown below.

Assessment of Functional Application of Tactual Skills
Student: Johnny Observer: N. Levack
Applied ContextLocatesExploresManipulatesRecognizesComparesCommunicatesOrganizes
Eat Breakfast. Obtains spoon. Systematically searches for muffins.   Places spoon in bowl. Demonstrates displeasure given wrong object. Performs appropriate action with spoon.   Uses hand to refuse interaction.  
Play with velcro toy. Retrieves ball from usual location. Moves ball over face. Brings ball to mouth. Squeezes ball. Pulls apart ball and velcro pad. Anticipates finding ball when given pad.      
Travel to gym, open door. Finds door handle. Retains door handle placed in hand. Uses fingers to gain information. Pulls door. Moves part of door handle. Performs appropriate action with handle.      
Put lotion on feet.   Plays with toes and fingers. Squeezes foot. Moves part of foot (toes). Performs appropriate action with lotion.      
Put on socks and shoes.   Uses fingers to find opening. Pull sock onto foot. Anticipates event given sock.   Uses hands to request interaction.  

The team learned that Johnny's recognition skills were good. He appeared to be ready to develop more comparison and communication skills but had very few opportunities to use these skills. Johnny's manipulation skills were good with two objects, a sock and his own foot, and very limited with everything else. Location skills were minimal. Johnny made almost no effort to find objects except for his favorite food during mealtime. Some of Johnny's exploration of objects was oral but the team did not consider this to be a problem because it was quick and he used his hands much more.

Based on this assessment, the team's first priority was to increase the number of times within familiar routines that Johnny located objects. For instance, after lotion was squirted into his hand, Johnny loved to rub the lotion on his bare foot. He made no attempt whatsoever to obtain lotion. The team decided to present the lotion bottle with lotion smeared on the outside by holding it close to Johnny's nose. They would wait for Johnny to reach for the bottle. If he didn't, they would touch the bottle to the back of his hand and wait for a grasp. Once Johnny got lotion on his hand by contacting the bottle, he could then rub the lotion on his foot. They would then repeat the procedure several more times. A backward chaining method was to be used to gradually increase the distance between Johnny and the bottle. The location of the lotion on the outside of the bottle was also restricted to the flip-up top area to prepare Johnny for further development on learning to manipulate the lid and squeeze the bottle.

Here are some more examples of interventions planned by the team to encourage development of more functional tactual skills for Johnny.

Functional Application of Tactual Skills Planning Sheet
Student: Johnny Observer: N. Levack
Applied ContextLocatingExploringManipulatingRecognizingComparingCommunicatingOrganizing
Eat Breakfast.   Leave part of paper wrapper on muffin. Break muffin into pieces.   Put undesired food items on plate with muffins. Touches muffin to request muffin.  
Play with velcro toy. . Put variety of different objects on pad.          
Travel to gym, open door. Place hand on door. Allow search for handle..            
Put lotion on feet. Touch bottle to cheek or hand, wait for reach or grasp. Use fingers to find lid. Lift flip top. Squeeze bottle.   Put lotion bottle in container of various bottles when finished Touches lotion bottle to request lotion.  
Put on socks and shoes. Touch sock to cheek or hand, wait for reach or grasp.            


One of the characteristics shared by every member of the human race is that we all want to have as much control over our lives as we possibly can. The amount of satisfaction we derive from living is directly related to how much of what we like we are able to get and how much of what we don't like we are able to avoid on a daily basis. If the company that makes our favorite lotion goes out of business or we get arthritis and can't open the bottle any more, we usually get pretty ticked off and realize that those things were very important to us. Functional tactual skills empower children without much usable vision to have more control over their environments and more ability to participate in relationships with others. Johnny has the potential to develop a preference for a particular type of lotion after comparison, to go to the place in his room where it is kept, to get it when he wants it, and to apply it independently. These are the little things in life that we take for granted until something beyond our control interferes. How could we think that it is not important to teach Johnny the skills that he needs to derive the same pleasures in life simply because he may never develop the ability to read braille or earn a salary?


Fraiberg, S. (1968). Parallel and divergent patterns in blind and sighted infants. Psychoanalytic Study of the Child, 23, 264-300.

Griffin, H.C., & Gerber, P.J. (1982). Tactual development and its implications for the education of blind children. Education of the Visually Handicapped, 13 (4), 116-123.

Heydt, K., & Allon, M. (1992). Motor development: gross and fine motor skills. In C. Cushman, K. Heydt, S. Edwards, M.J. Clark, G. & Allon, M. (Eds.), Perkins Activity Resource Guide (Vol.1, chap. 5). Watertown, MA: Perkins School for the blind.

Lewis, S. (1996). The Editor's Talk: They learn like blind kids. RE:view, 27 (4), 147-148.

Miles, B. (1997). The hands of a person who is deafblind: tools, sense organs, voice. The Individual in a Changing Society: National Conference on Deafblindness Proceedings (volume 2). Watertown, Mass: Hilton/Perkins Program.

Millar, S. (1981). Self-referent and movement cues in coding spatial location by blind and sighted children. Perception, 10, 255-264.

Nagaishi, P. (1993). Motor development. In Chen, D. (Ed.), First Steps: A Handbook for Teaching Young Children Who Are Visually Impaired. Los Angeles: Blind Children's Center.

Nielsen, L. (1990). Are you blind? Copenhagen: SIKON.

Smith, M. & Levack, N. (1996). Teaching Students with Visual and Multiple Impairments: A Resource Guide. Austin, TX: Texas School for the Blind and Visually Impaired.

van Dijk, J. (1988). The deaf-blind child and his outgrowth toward the world of symbols. Papers presented at a national conference on education for deaf-blind children. Tallahassee, FL: Florida State University.

Warren, D.H. (1984). Blindness and Early Childhood Development. New York, NY: American Printing House for the Blind.

From the Winter 98 issue of See/Hear Newsletter, published by TSBVI Outreach and compiled from conversation on the Deaf-Blind List.

by Kate Moss, TSBVI Deafblind Outreach

One of the many issues parents of young adults with Usher Syndrome and other conditions that result in low vision face is whether or not to let their son or daughter get their driver's license. This topic was discussed at great length recently on the Deaf-Blind List. Because I benefited so much from this discussion, I thought it would be worth sharing excerpts with our SEE/HEAR readers. My thanks to all of the Deaf-Blind List members who participated in this discussion and who were willing to share that discussion with those who do not have access to the List. The discussion in its entirety is available through the Deaf-Blind List archives if you would like to read more. You may access those archives at DB-Link at


For many parents of children with low vision, deciding whether or not to let their son or daughter get a driver's license or attempt to drive is a difficult decision. Even though some individuals may have substantial visual field impairments at an early age, they may still be able to pass the Department of Motor Vehicle's (DMV) eye exam since a visual field test which checks peripheral vision is not a part of that exam. Additionally, the driving portion of the test may not take place during the evening hours, so night blindness may also go undetected by the examiners. Students who go through driver education generally do have to undergo part of their driving during twilight conditions, which can create problems for the student with Usher's and some other eye conditions. As you will learn from this discussion, there does not seem to be a "right" answer. For parents of children with Usher Syndrome confronting this issue, I encourage you to:

  • Discuss your child's visual functioning and prognosis with your ophthalmologist or low vision specialist especially as it relates to driving;
  • For the child with Usher Syndrome, discuss "daytime only" driving as an option;
  • Have a frank discussion with your child about his or her vision and the possibility that there may come a time when they can no longer drive; and
  • Contact adults with Usher Syndrome and other parents through support groups or the Usher-List and discuss your concerns with them.

Dorothy Stiefel writes: This is the problem at hand with all young drivers who already know they have compromised vision but "think" they are careful enough. This is denial of another kind. Some really believe their vision is still okay for driving "just in the daytime." Others are hesitant but drive anyway because no one has said they shouldn't be driving. Can we fool ourselves? Usually no, but in the case of peripheral loss, it is so subtle that the would-be but should-not-be drivers do it anyway, mostly because what they are "seeing" that feels like all they should be seeing with. Do you get my drift on this?

Most all of the important mobile activities and contact sports a person engages in, is through the use of the vision's mid-periphery where both cone and rod cells reside. Night vision is governed by the outer perimeter of your field (rod cells), and of course, all detail, acuity and color vision is the responsibility of central vision (cone cells). So, translated here: many episodes of bumping into, knocking down, missing the ball, stepping in holes, etc. are caused by your field of vision having been narrowed past the mid-periphery of sight toward that "tunnel vision" we all talk about. So, if you've been having mishaps out and about on foot, with no explanation for them, what do you think will more than likely happen behind the wheel of a car? Please think carefully on this one.

If a young person has already been diagnosed, becoming a driver may be okay if his field of vision is closely monitored and well within the range of acceptable peripheral sight . . . And, yes, enroll in a driver's education course for people with vision impairment if one is offered in your area. DO NOT drive at night, period; and realize that your driving days are numbered.

The automobile is considered a rite of passage for young males in particular. . . It may be more difficult to deal with quitting what a young male driver has enjoyed for a short time, only to have it taken away from him, than it would be never to have attempted it in the first place.

As Dorothy points out, an important consideration for parents and the student is whether or not they are prepared to lose their driving privileges later on. As you will see, this experience can be quite devastating.

Mary Dignan shared some excerpts from her personal journal of the period when she was coming to terms with life without a driver's license:

February 1989

It hasn't been that bad, a week without driving. In a way, much better than waiting for the inevitable smashup and possible major and even moral injuries. What HAS been bad is the grief and the depression, and the tunnel, which I don't see ending. `You have all kinds of options,' a friend told me. `You just can't see them right now.' He also said that I am not handling things very well"that the issues I have to deal with right now regarding my sight and hearing are so overwhelming that it would be good for me to get some help. He specifically mentioned my anger and the way it is spilling out"exploding"everywhere. Well, I AM angry. I have worked all my life in a world that is not mine, and striven with all I have to communicate with it on ITS terms. Now I look at the television car commercials, and all of a sudden I boil, thinking, damn it, in a world where cars are essential and mobility is success, I now have to figure out how to deal with the world all over again.

I'm tired of this anger, I'm tired of this depression, and I want out. The fact that I don't drive anymore isn't important. The fact that there are options out there is"and it is time for me to claim them. . .

March 1989

So driving, not driving that is, isn't such a big issue. I told my brother last night that I don't miss driving so much as I am missing the ease of mobility. It's not a bad case of restricted mobility, as Andy is an obliging chauffeur. Too much so, in fact to the point that my independence from him is an issue, but it's resolvable.

It's also part of a more basic issue, that of my perception of success and image of myself. I said something about mobility" "mobility is success" "that is a core belief, one that I'm beginning to rattle and shake around, get the dust off, give a reappraisal. There was another one, "cars are essential" I believed it was. That I've already begun to throw out. Personally, driving a car does not necessarily equate with mobility or success. The relationship of mobility to success, on the other hand, is a whole other issue.

From Webster's I note the following significant definitions of being mobile: capable of moving or being moved (movable); changeable in appearance, mood or purpose; adaptable, versatile. Webster's also notes having "opportunity for or undergoing a shift in status within the hierarchical social levels of society." And success is the favorable termination of a venture (i.e. "the attainment of wealth, favor, or eminence"). To succeed is to "turn out well" and to "attain a desired object or end."

The bottom line definition of success, then, can only be a personal definition. Define what it is you want to achieve"to venture"and if you do it well, then you're successful. So, I'm capable of moving and being moved; I'm changeable in appearance, mood and purpose; I'm arguably adaptable and versatile, and as far as I'm concerned I have all kinds of opportunity to "shift my status within the hierarchical social levels of society." But more significant, I have opportunity"options"to shift my status, period, not just in terms of hierarchical social levels. And that's it, right there. Equating mobility with success isn't such a bad thing to do, but it's important to realize that the definition is mine, and it is important to know the definition for what it is. . .

Randy Pope writes: I was diagnosed with Usher II, less than 10 degree (visual fields) total, at the age of 37 back in 1990 of January. Little did I know that diagnosis would change my future forever in a massive way. The doctor told me that I was legally blind and asked me to stop driving. I was stunned and did not know how to respond. Luckily I had a friend with me to drive me home after the eye exam. The shock of the news was overwhelming . . . I could not even talk to anyone, not even my family. You can't even imagine the feelings I was going through. When the initial shock stage had passed, I knew the time had come to carry out the death sentence of my driver's license.

That day ... I left work around 9 a.m. on a sunny day. I only had to walk about a half of a mile to the Department of Motor Vehicles (DMV) . . . it was the longest walk of my life. The DMV building looked like death row. The door seemed like that big heavy steel door in a prison. I opened the door and walked in; funny, for some reason I heard that door close with a loud bang even though I am almost totally deaf. As I approached the desk, the clerk looked like a witch ready to destroy me. . . My whole body was shaken with fears and my mind was whirling like crazy. Tears were running down my face as I gave the clerk my license. She said out loud, but without any passion or feeling, `What was my problem?' I screamed and cursed at her with unprintable language, stating that I was going blind. The other clerk heard me and asked me to come into his office. He listened patiently while I explained my situation with tears and anger. He explained to me that I was making the right decision to protect myself and other drivers on the road ... my freedom was executed on May 1st of 1991.

... My young friends on this list, if you are thinking about getting your driver's license knowing you will lose your vision some day, please don't. The pains and suffering are not worth it. Feelings about losing the license are still there for me. You would be better off not to get it ...

Jeffrey Bohrman agrees: The Great Hippie (Randy Pope) said it loud and clear to the young potential drivers. I was one of the lucky ones who never learned how to drive and I still maintained my independence. It really broke my heart to see many of my friends with Usher's crying when "forced to give up" their licenses ... The pain of becoming blind, losing a job, changing communication modes are bad enough, and I sure didn't need another issue to add.

Still many people feel like Heather Schoenwald feel that the experience of driving was worth going through the loss: I started to drive when I was 15 years old. I enjoyed every minute of it. I worked damn hard to earn my driver's license and after all that work, I was so proud of myself for accomplishing a goal. After I graduated from high school I decided to buy myself a brand new truck. Driving was a big deal to me because it was my freedom . . . I traveled all over and got to see many different things.

When I turned 21 years old I started to have problems seeing in the dark. So I thought . . . all I need is new glasses. . . . The doctor told me that I had Usher's syndrome and he told me to stop driving. I told him that I was going to continue to drive . . . like it or not. I could see just fine during the day, but at night it was hard. . . . I got to drive one more year. I had to stop driving because I became fully blind (as a result of optic neuritis) for three months. I still had my vehicle sitting in the driveway, wondering if I was ever going to drive it again.

One day my parents were not home and I thought it would be cool to just sit in the truck, blast the radio and enjoy it. I was wrong. I got so upset, crying so hard, because in the back of my mind I knew I would never drive again. I started to have nightmares about driving. I was driving; I hit and killed that person. I woke up sweating, heart pounding 100 mph, and I was crying so hard. I told my parents, `Please help me sell the truck, I can't drive anymore.' My parents flipped out and told me that I would get all my vision back and they were not going to sell it. Later my vision (stabilized) and I knew I was finished driving. Finally my parents realized . . . what they had to do. It was very hard for my parents to see something valuable go, something that I worked so hard for.

I am now 24 years old, learning to have a lot of patience with myself and learning to use public transportation. I do miss driving, but I am very happy that I had the experiences of driving. I'll always keep the fun, good memories of having that freedom.

If your child can see, then let them have the experiences of driving . . . if they don't see at night, driving then is not a good idea.

Janet Sand adds: I started driving at age 17 and drove for about 12 years before quitting 20 years ago. I never did drive at night, and the last few years I drove to only three specific, close-by locations . . . I am very glad I did the amount of driving I did. It (1) gave me a feeling of independence and confidence which is still with me; (2) permitted me to develop a sense of direction from a driver's point of view, enabling me to give better directions; and (3) gave me an understanding of automobiles, automobile travel, and the art of driving, all of which are important parts of our culture.

. . . I fortunately never had any kind of accident, and was always aware that my concentration was intense when I drove. I almost never drove other people around because it detracted from my concentration.

My personal feeling is if (a person) is reasonably mature (though 15 or 16 is still pretty young) and has an appreciation for his physical limitations and the responsibility involved; then he should learn to drive and drive regularly if it seems to work out. He will know, of course, that at some point he will most probably have to stop driving because the risks are too great based on his declining vision.

Which brings me to Randy (Pope) and his strong grief over having to stop driving. I really feel that a lot of this comes from his finding out rather late that he had RP (retinitis pigmentosa) and (at the same time learned he) would have to stop driving. The grief over his driving was enmeshed in his grief over the RP as a whole. This is not the case with (your son) and a lot of the others of us who knew from a young age that our vision would decline over the years. I knew that I might some day be blind, but I wasn't then and was capable of driving well (carefully and only in daylight). I expected to have to stop some day . . .

Above all, examining the risk to themselves and to others must be a part of any decision making process:

Tom Peters notes: (One friend in Connecticut) gave up her license just 3 weeks after ... she had a scary, small accident from the late afternoon sun. She tore up her license and sold her car. She said it is not worth carrying the guilt for harming others.

Rich McGann shares this story: (A friend) told me that when he was 16 ... his parents let him drive during the daylight. But he did not know he had Usher's. His parents told him he had to get home at 7 sharp during the spring. When he was at the shopping mall, he met deaf friends and chatted with them. He lost track of time ... it was 10. He tried his best to drive home, and he managed to get home safely ... (Kids) should be given details (about their vision) before they make decisions about taking driver's education.

Randy Pope: Do I want to risk the family's financial situation? No way!!! ... Do you think the insurance will cover the damage resulting from an auto accident? Not necessarily. Worse yet the family whose loved ones get serious injuries or is even killed can sue you way over the limit of the insurance policy if the insurance decides to pay at all.

There are alternatives to being a driver. Here are a few that were mentioned:

Carolyn Alflen notes: If my vision becomes worse, I still need my car because someone will drive (me) ... like an SSP (Support Service Provider) ...

C. C. Davis shares this solution: I have another pair of blind friends, a married couple, who seem to enjoy having their own car. They maintain the car and like to offer it to their friends who drive when they all go out together, or need to run errands. Of course, most of their transportation is public transportation.

Who knows what the future brings? Some of the dreams of those individuals who commented on this topic underline the extreme importance we place on this activity in our society:

Rich McGann suggests: Maybe it would be neat to have electric eyes (on cars) so we can let the computers do the driving and we will feel like we are driving.

Kerry Wadman elaborates: You know those fantastic guiding systems used in missiles ... could also be used in cars ... actually if there were special cars made that would do the guiding for people, then with the exception of software and mechanical failures there would be no accidents even for those who could drive without visual disabilities . . . autopilots do that kind of thing ...

I think Randy Pope sums it up best: Yes, we all should live life to the fullest, like I am doing right now. Most of all losing the driver's license is not the end of the world. I finally learned that. It's tough to live (without a driver's license), but life is not a bed of roses. I am dealing with this pretty well. In fact this experience has taught me quite a bit about life, making me stronger than before. . . By the way, when that dreaded day does come, I will be here along with the others. Giving up your license does not mean you are defeated. You are making a giant leap into the world of courage, strengths, and wisdom where most people will never enter. It will be tough, but you will definitely be stronger than most people.

If you would like more on this topic write to me () or contact some of the other resources below..

National Center on Deafblindness They have a wealth of information on Usher Syndrome and many other topics as well as links to many other helpful websites. For non-Internet users, write or phone DB-LINK at 345 N. Monmouth Ave., Monmouth, OR 97361, (800) 438-9376 (voice) or (800) 854-7013 (TTY).

VisionAware Resources for Independent Living with Low Vision

Driving privileges for low vision patients: a legal, medical, safety issue

This website features information about Dr. Lilli Nielsen's techniques that emphasize simple ways to change the environment so that a child becomes an "active learner". Active Learning Space is developed collaboratively by Penrickton Center for Blind Children, Perkins School for the Blind and Texas School for the Blind & Visually Impaired.

Click here for redirect to Active Learning Space.

Milestone Sequence May Have Areas Of Unique Development.

Visual impairment may effect the specific sequence of gross motor milestone development. This is currently "under investigation" with Project PRISM.

As with all areas of development, the child with vision impairment should be regarded as an individual learner.

"On Schedule" Static Postures, Delayed Movement Postures

The rate of gross motor milestone development may be influenced by a visual impairment.

Milestone Comparison Chart **
 Number Of Months For Each Skill
Head lifted in prone 1 4
Elevates self on elbows in prone 4 8.75
Prone: forearm reaching for an object 3 - 5 9 - 12
Supine: rolls to prone 3 - 5 5 -9
Sits alone steadily 6 - 8 6 - 9
Raises from floor to sitting 8 11
Stands holding furniture 6 - 8 10 -16
Achieves four point crawling 9 - 11 13
Stands alone 11 13
Walks with one hand held 9 -11 16
Walks alone 12 -15 19
** - taken from literature, but should not be regarded as hard and fast data - most of this research has been done on children not receiving early intervention services that specifically target motor development from an NDT perspective.

Influence of low postural tone (hypotonia)

It has been theorized that the reason many babies who are visually impaired have low postural tone because of a lack of experience in the prone position which then denies them the needed proprioceptive stimulation for neuro-motor development. Another theory is that due to the lack of vision, the ability to utilize optical righting (righting head in alignment with visual horizon) is impaired. Without optical righting, . there is reduced motivation to move and turn the head. This dominos into a reduction of practice with head control which influences the muscles control development throughout the neck, shoulder girdle, and spine/trunk.

Reduced motivation to move out in space

  • vision is thought to be the primary incentive for movement
  • sound is not a pure substitute for the lure to move out in space
  • object permanency as it relates to the child who is visually impaired
  • child must have a concept of "the world out there" before s/he will know to move out into space
  • influence of the sequence of sound localization development – beginning at ear level, above ear level, below, and finally in front (use of stereo localization)
  • the process of sound localization is typically tutored by vision - which is not possible with the child who is blind
  • a poor base of support may reduce incentive to fight gravity and move out in space

Quality Of Posture And Movement Factors

Examples of poor quality of posture and movement include:

  • prone: head down (poor extension of the neck)
  • supine: poor flexion against gravity - legs abducted (frog leg appearance)
  • sitting: tipped pelvis (forward or backward), rounded back, elevated shoulders, lack of erect head position
  • standing: knees locked, elevated shoulders, wide base of support.
  • walking: wide base of support, flatfeet, shuffled walk, high guard arm position.

Influence of low postural tone

  • use of postural fixing due to lack of proximal support
  • this is especially evident in milestones involving trunk rotation

Reduced ability to monitor vertical postural adjustment

  • ear infections can contribute to balance problems

Reduced Ability To Learn By Visual Imitation - (depending on level of sight)

Need for deliberate teaching of activities within a purposeful context.

  • teaching should be done with real objects/furniture/situations
  • the child should be allowed to feel the movements of other people

Possible Fear Of Movement

  • Lack of postural stability - may reinforce insecurity of movement
  • Reduced ability to visually monitor the environment
    • sudden noises/movements/touches without warning or possible meaning
  • Overprotection - lack of varied (and praised) experience

Strategies to promote with families:

  • early experience with safe-but-fun rough and tumble floor play
  • exposure to new environments (with success)
  • confidence reinforcement - minimizing bumps and maximizing self challenges.
  • meeting with adults who are visually impaired to learn from their experiences

Compiled by Tanni L. Anthony, U.S.. June 1992

This document is a Resource for the Expanded Core Curriculum. Please visit the RECC.

General Information about Training from TSBVI

There are many, many opportunities for parents and family members to access training to help them in their roles as caregivers.  One quick place to learn about all the training activities occurring throughout the year is the Statewide Calendar of Training Events which includes trainings offered by education services centers, family organizations, and others.  In most cases funding is available through DARS-Division of Blind Services and/or TSBVI Outreach Programs to help parents travel to  events that are out of town (lodging, gas, meals) and any registration costs.  For more information about accessing this support contact Jean Robinson at  or Edgenie Bellah at 

You may also want to check out the events offered by Texas School for the Blind and Visually Impaired.

TSBVI Workshops and Conferences

TSBVI TETN Broadcasts

TSBVI Webinars

TSBVI Outreach Family Leadership Series

TSBVI, DBS and various Education Service Centers work together to help family members become well-informed competent leaders. These events take place in various locations around the state each year.  To learn more about these events and where they will be offered each year, contact Jean Robinson (512-206-9418) or Edgenie Bellah at (512-206-9423).  Parents have the opportunity to attend the following workshops/training sessions:

  • Eye Play – designed for parents with younger children (birth to five years). This training is an overview of the special education system and how to become an effective partner. It is full of basic information, giving parents an opportunity to meet other parents of children with visual impairments; it also encourages families to envision the possibilities for their children. Family members become knowledgeable about active learning techniques and materials that teach concepts leading to communication and literacy for children with vision and/or hearing loss, including those with other disabilities.
  • IDEAL Partners – Quality Education for your Child with Sensory Impairments - This training in an in-depth workshop on the special education process, how to read and understand their child's Individualized Education Program (IEP), discover strategies that leads to positive outcomes for their child's education and to build their confidence in their role as a member of their educational team.
  • Personal Family Leadership Series – This four weekend training is designed not only to help parents and other adult family members (siblings, grandparents, aunts, and uncles) in becoming more knowledgeable and stronger advocates for their children, but also how to step outside their comfort zone to be leaders in the community. The theme of the training is Know Yourself, Know Your Child, and Know Your Community. It provides training in the areas of peer mentoring, raising a child with a visual impairment and deafblindness, quality educational programming and utilizing community resources. The goal is for family members to join with others to improve and shape services not only for their child, but other children across the state.
  • Family Leadership within Different Systems Series – this is the advanced level of the family leadership training. Over the course of three weekends participants meet leaders in the areas of legislative, medical, state agency, community, and educational systems; learn about various leadership opportunities within existing systems; and, broaden their understanding of the issues surrounding visual impairments and blindness beyond their own child. In this training the participants design, develop and complete a personal project that will impact services and support for children with visual impairments.

State Training Events for Families

Deaf-Blind Multihandicapped Association of Texas

Texas Association for Parents of Children with Visual Impairments

Texas Chargers

Texas Parent to Parent Conference


National Training Events for Families

Spanish-speaking Teleconference

A series of nationally sponsored family phone calls, free to families, conducted in Spanish are currently being presented. One is for families with children who have hearing and vision problems and one is specifically for families of children with CHARGE.  Follow either of the links below to get more information.

Llamada de Familia-a-Familia

Llamada de Familia-a-Familia con Niños con el Síndrome de CHARGE

Webinar: Transiciones en la Vida del Estudiante con  Sordo-Ceguera 

Patrocinado por: National Center on Deaf-Blindness (NCDB), National Family Association for Deaf-Blind (NFADB), New York Deaf-Blind Collaborative (NYDBC), California Deaf-Blind Services (CDBS)

Para los bebes, niños y jóvenes adultos que tienen una combinación de pérdida auditiva y visual o sordo-ceguera es instrumental que sus padres comiencen con ciertas rutinas a una edad temprana, para prepararlos a las distintas transiciones que los estudiantes van a tener a lo largo de su carrera académica y eventualmente en su transición a la vida adulta. Estar enterados con anticipación de cómo manejar estos cambios, tanto de lugar, gente o de ambiente entre otras cosas puede ser beneficial para nuestros hijos. Por esa razón NCDB, NFADB, NYDBC y CDBS les ofrece esta sesión en el tema de “Transición” a las familias de habla hispana que tienen un niño que es sordo-ciego. Esta sesión va a ser interactiva y ustedes pueden hacer preguntas que se contestarán al final de la presentación. Si desean recibir una copia de la presentación, favor comunicarse con Clara  o Myrna 

Charge Syndrome Foundation 12th International Conference

The 12th International CHARGE Syndrome Conference is taking place July 30 - August 2, 2015 in Chicago, Illinois. With more than 70+ breakout sessions, poster presentations and demonstrations, the conference offers a broad range of topics for participants of all experience levels. Program information highlights are now available so attendees can begin to think about the sessions that will be of interest to them. 



  • squeezing toys
  • squeezing playdough/clay
  • taking objects out of containers
  • drawing
  • picking up jacks
  • sanding
  • using a cookie cutter
  • using a hole puncher
  • putting pop beads together

With thumb and fingers

  • stringing beads
  • holding paper for cutting
  • using crayons/pencil/paintbrush
  • using glue sticks for art projects
  • pinching playdough/clay
  • using pegboards
  • building towers with blocks
  • picking up jacks
  • painting with paintbrush
  • turning pages of a book
  • picking up small beads/objects with tweezers (may be too visual)
  • paper weaving
  • putting shapes into a shape sorter
  • sorting paper clips, red hots, goldfish crackers
  • buttoning, zipping and snapping - on own body


  • popping bubble wrap
  • picking up small objects
  • tying bows
  • using pushpins
  • sewing cards
  • stringing beads
  • putting pegs in pegboards
  • using geoboards
  • putting clothespins on edges of cans or jars
  • using an eyedropper
  • turning knobs on a wind-up toy
  • putting coins through a small slot


  • giving an object on request
  • stacking activities - cans, blocks, nesting cups
  • sorting activities
  • placing objects in containers
  • the release that is necessary to complete the activities in the "grasp" section

Rotary Motion

(takes place from wrist with stable arm)

  • assembling nuts and bolts
  • using twist ties
  • turning volume knobs on radio & TV
  • manipulating lids on and off of jars/tubes
  • mixing food in bowl
  • turning knobs on water fountains or sinks
  • using wind-up toys, busy boxes, music boxes
  • turning doorknobs
  • scooping sand, gravel, dried beans
  • finger painting
  • finding objects hidden in sand, dried beans
  • unwrapping individually wrapped candy
  • pouring from one container to another

Finger Isolation

  • making fingerprints in playdough/clay
  • pushing buttons on tape recorder
  • pushing buttons on blender and other appliances
  • playing musical instruments
  • turn dial on toy phone
  • pushing push-pins into cork
  • tracing around stencils with fingertip

Bilateral Hand Use

(almost all of these activities involve stabilizing with one hand and manipulating with the other hand, which is hard for VI kids)

  • stringing beads
  • pulling tape off roll
  • tearing paper
  • twisting lids on and off
  • cutting paper
  • using a hole puncher
  • sanding
  • using a ruler to make lines
  • holding container with one hand/placing object in with other
  • stabilizing toy with one hand/using other to play with toy
  • pushing together and pulling apart pop-beads
  • finger painting
  • rolling "snakes" and "balls" with playdough/clay
  • attaching paper clips to paper
  • tracing around an object/stencil
  • holding paper with one hand and stapling with other
  • stabilizing bowl while stirring

Hand And Finger Strength

  • crumpling paper
  • placing clothespins on edges of cans or jars
  • stretching rubber bands
  • manipulating playdough
  • squeezing glue bottles
  • using stapler held in hand
  • using stapler by pushing
  • using rolling pin
  • using a hole puncher
  • hammering
  • pushing together and pulling apart pop-beads
  • pushing together and pulling apart bristle blocks
  • squeezing nerf balls
  • sponge painting

Proper Finger Position

  • each finger has a "job" - lead finger, detective fingers
  • curve fingers over the edge of pencil or ruler

Light Touch

  • work on whole body relaxation - if your body is tense, your fingers will be unable to touch lightly
  • place checkers inside the squares of braille graph paper and have the student move his fingers across them so lightly that he does not move them outside the squares
  • place cotton balls beneath the childs fingers and have him move them across the page
  • learn to "tickle" the dots


  • tracking across lines of yarn, popsicle sticks, etc.
  • tracking across pipe cleaners/straws glued to paper
  • Mangold Developmental Program of Tactile Perception and Braille Letter Recognition (first eight lessons)
    • tracking from left to right across like symbols which follow closely without a space
    • tracking from left to right across unlike symbols which follow closely without a space
    • tracking from left to right across like symbols which have one or two spaces between them
    • tracking from left to right across unlike symbols which have one or two spaces between them
    • tracking from top to bottom over like symbols with follow closely without a space
    • tracking from top to bottom over unlike symbols which follow closely without a space
    • tracking from top to bottom over like symbols which have one blank space between them
    • tracking from top to bottom over unlike symbols which have one blank space between them


Winter 2000 Table of Contents
Versión Español de este artículo (Spanish Version)


By Diane Barnes, Certified Orientation & Mobility Specialist Region 13 Education Service Center, Austin, Texas


As part of the Functional Vision Evaluation / Learning Media Assessment, VI teachers are required to determine if an evaluation by a Certified Orientation and Mobility (O&M) Specialist is needed. Specific skill areas that may impact a child's present and/or future travel skills should be assessed. These skills relate to safe and efficient travel. Instruction in these areas may influence the child's developmental growth, which in turn may impact the level of travel skills he or she may develop. For example, will he develop skills that will allow him to travel only in familiar areas, with extensive orientation, or in very structured settings? Or can he be independent in both familiar and unfamiliar areas?

VI teachers focus on skills which impact the child's functioning in the home and school environment. These skill areas include, but are not limited to: visual efficiency, motor planning, concept development, environmental awareness, object identification and interest, and communication. They employ a variety of strategies to assess these vision skills with infants and young children such as presenting an object or toy at close range, from a specific side, or by moving it. They generally use toys or objects that are brightly colored, have auditory feedback and light sources, or which have been adapted with contrasts. This also helps to encourage optimum participation and interaction by the child during the assessment.

When considering the child's travel skills, the home environment is generally the most controllable environment. Once the child moves into the school environment, the environment can continue to be controlled to some extent. For instance a student might be given additional time to travel from place to place, curbs or steps can be painted brightly, highly contrasting colors used between walls and flooring, and so forth. However, beyond the home and school settings, the child's travel environment is less accommodating and more unpredictable. It is important to address travel skills in both familiar and unfamiliar environments or environments and situations that are less than ideal. On-going exposure to and guidance in handling these types of situations plays a significant role in helping the child acquire the skills needed for travel in both familiar and unfamiliar environments. In addition, instruction may also impact whether she will be able to travel without the use of a cane, needs to use a cane all the time or only in certain situations, knows when the cane is needed, and can interpret and properly respond to cane feedback.


Listed below are some O&M related activities that address these critical skill areas. These are also activities which can assist the VI teacher in determining the need for an O&M referral.

  • Place an item to the right of the child, and have her to reach for it with her left hand; reverse the process. Place item at midline and have child reach for it with alternating hands. This helps develop the ability to cross midline, extend the arm, reach for and contact an object; all of which are critical to success in using a cane.
  • Place pillows on the floor and have child sit and/or stand on them as she reaches for items placed on the couch. This works on coordination and balance necessary for negotiating steps, curbs, wheelchair ramps, or broken sidewalks.
  • Occasionally change the location of an object from where the child expects an item to be located. For example, a favorite toy changes from being stored on the left on the first shelf to being stored on the right or on the next shelf up. A toy basket moves from a spot by the bedroom door to the closet. These types of situations teach such skills as problem solving, route planning, visual searching, tolerance/patience, and soliciting aid. Learning these kinds of skills may allow a child to develop the ability to progress beyond being a "route traveler."
  • Start with completely covering/concealing a familiar item, and have the child to try to identify it as you reveal it little by little. This builds the ability to interpret part, whole, and "clutter." She will need this ability for example, so she can identify a newspaper stand partially obscured by a trash can from a distance. It also helps develop patience and tolerance, problem solving, vision efficiency, and the ability to identify landmarks.
  • Align floor mats, crumbled blankets and towels, and small rugs turned up on one corner in a path on the floor and have the child negotiate these items as she comes to you. This helps to develop a tolerance of terrain changes and works on motor planning and control.
  • Provide instructions to your child with music in the background, the window open, or the washing machine or vacuum cleaner going. This helps teach him not be startled by a trash can knocked over by a dog as he is preparing to cross the street or become distracted by kids opening and closing lockers as he walks down the hall.


If the child demonstrates difficulty at any point with any of these activities, it is probably an indication that the VI teacher needs to make a referral for an O&M assessment. In most instances the VI teacher can ask herself a simple question: Is the child visually impaired and moving (scooting, crawling, pulling up on furniture, walking, reaching)? If the answer to this question is "yes", then the VI teacher should give her O&M Instructor a call to discuss the need for a referral. Determining the O&M needs of children with visual impairments has to be an on-going assessment process. This requires a strong collaborative relationship between the vision teacher and a certified O&M Instructor. Through this collaborative process, the vision teacher should be able to determine when it is necessary for the O&M Instructor to provide direct intervention with the child.

Tanni L. Anthony, Ed.S.
Colorado Department of Education,
201 E. Colfax, Denver, CO, 80203, USA


Over the past several decades, the profession of Orientation and Mobility (O&M) has revised its teaching strategies to focus upon the needs of young children. Within the past five to ten years, a particular emphasis has been placed on the early O&M skills specific to infants, toddlers, and preschoolers who are visually impaired.

With the inclusion of the birth through age five population, the field continues to refine both instructional philosophy and actual teaching techniques. Both have required careful steps; the process of merely "watering down" methodologies which are appropriate for older children has not always proven effective with very young children.

Research on the developmental route of the child with a sight loss has been helpful, but further research is still needed. Areas of specific challenge in each developmental domain have been documented. Based on this information, specific intervention methodologies have been devised, only to be revised with the contributions of new findings. It is fair to note that early intervention for children who are visually impaired is still within it's own toddlerhood of development.

A Proposed "Formula of Purposeful Movement"

Based on current research findings, it may be supposed that three primary areas emerge as important program domains within an early intervention O&M program. A "formula of purposeful movement" is offered for consideration which includes the following three components of program attention: physical readiness, cognitive connection, and motivation invitation.

Physical Readiness

Past research by Selma Fraiberg indicated that visual impairment did not have an effect on the order of gross motor milestone development. This may be changing, however, from the current longitudinal study in progress by Dr. Kay Ferrell and colleagues. Project PRISM (1994) is currently collecting information on the sequence of developmental milestones. Gross motor development maybe an area of noted unique skill acquisition order.

The rate of gross motor milestone development may be influenced by a visual impairment. There is evidence of delayed movement postures. This may be due in part to the possible presence of low postural tone, and the interdependent relationship of movement and the acquisition of true object permanence and/or auditory localization skills.

Physical readiness, however, far exceeds the mere acquisition of typical gross motor milestones of sitting, crawling, walking, and so on. It encompasses both quantity of skillacquisition and quality of movement. It is critical that motor milestones have qualitative excellence.

Quality of movement depicts the "underlying scaffolding" of both the static and dynamic postures of the child. It refers to the level of refinement of a particular gross motor skills. Without vision to confirm the infant's early body movements, the sense of proprioception may not develop to full maturity and low postural tone may be evident.

Brown and Bour (1986)report on one theory that the reason many babies who are visually impaired have low postural tone is because of a lack of experience in the prone position. Limited opportunities in this position ultimately deny the child the needed proprioceptive stimulation for neuro -motor development.

Low postural tone often will compromise the refinement integrity of motor skills involving balance and strength. Balance reactions, hunk rotations, and actual motor milestones may be influenced. For example, a child may be able to sit independently, but the actual sitting posture may be compromised. A rounded back with the legs situated far apart may be the only way the child can achieve independent sitting. Due to low trunk tone, the child may need to establish a wide base of support to maintain an upright sitting posture.

Compensatory patterns such as these may become habitual. If repeatedly used over time, the child is at risk for physiological change in her muscles; some may lengthen and some may shorten to accommodate for the compensatory posture. If left untreated, it is possible that an orthopedic deformity such as scoliosis may develop (Campbell, 1983).

It may be wise to consult with a physical and/or an occupational therapist to ensure that the child's motor skills are developing in a manner that reflects good quality of movement. Attention to positioning and special activities to strengthen the trunk muscles are two ways to address the influences of hypotonia. With consultation from a motor therapist, these activities can be easily incorporated into the child's daily care activities.

Cognitive Connection

Three stages in particular have great influence on the child's acquisition of early travel skills: (a) attainment of object permanence, (b) development of means-end, and (c) the early constructs of spatial relations. As each area is reviewed, it will become evident how one skill area is developmentally intertwined to other skill areas. It is impossible to fully isolate one from the other. For simplicity, however, they will be discussed as separate behaviors.

Object permanence in lay person's terms is simply "out of sight, “out of mind." During the first nine months of life, the infant does not have the memory capacity to search for an item completely removed from view, or in the case of a child with visual impairment, out of touch.

During this time period, however, the sighted infant demonstrates steady progress in the area of memory and search skills. At approximately four to six months of age, she will find an object that is touching her body (Johnson-Martin, Jens, and Attermeier, 1986). These authors further report that the sighted infant will briefly search for a newly dropped object and deliberately uncover a partially hidden object at six months of age.

By nine months, the infant learns that an object continues to exist even if it is covered from view. A favorite interaction game at this age is the classic Peek-a-boo.

Selma Fraiberg (1968) noted that sound is not a substitute for sight; between six and seven months of age, hearing and holding are two separate events for the child who is blind. Her research noted that the beginning of search behavior occurred between seven to nine months of age.

The child who is visually impaired may have a unique timetable as she acquires skills leading to object permanence and more sophisticated memory. Her individual level of functional vision will play an ongoing role in her ability to discern a world outside of immediate touch.

The ability to problem solve with an end result goal mind is called means-end. This indicates that a child is able to understand what means (actions) will result in a certain end (result). Over the course of the first two years, the child learns to construct a simple goal, then use the motor skills within her repertoire to achieve that end result.

The young infant, however, does not initially realize that her body movements knowing produce a certain sensory result. Body movements are not associated with reactions such as the visual movement of a swatted mobile or the chime bells of the kicked chime ball toy. During these early days, the infant is practicing newly acquired volitional movement as motor reflexes are fully integrated. Movement occurs for the sake of movement alone.

With repetition, however, the infant begins to discover that her body movements can make something happen. One of the first indications of intention occurs with deliberate hand watching behavior. With the discovery of her hands as a "working part" of her body, the four month old infant learns to reach for nearby objects.

Tactile cueing may be necessary to help initiate a reach of a desired object. As the child becomes more proficient with her understanding of a world beyond touch (expansion of object permanence), these touch cues will become less necessary.

Other means-end behaviors include early tool use. The child teams to pull a string to obtain the attached toy or use a stick to acquire a toy just out of reach. Clarke (1988) reports that tool use has great implications for a child's ability to successfully use a mobility device or long cane during the toddler and preschool years of development.

As the child expands her understanding of the space beyond her body and has the physical readiness to move out into space, the reach is extended from an isolated arm to a full body movement. This is the hallmark passage of purposeful movement; the child can begin to use self propelled ambulation for an end result. Her worldly travels have begun from a mobility perspective whether in the form of a roll from back to front or a long stretched reach while in a prone position that results in forward movement toward the object of interest.

Spatial relations development involves the concept formation of position, location, direction, and distance from one's own body (Morgan, 1992). Spatial constructs have three primary categories: (a) spatial awareness of one's body, (b) awareness both near and distance space as it relates to one's body, (c) awareness of the space dimensions between objects. All three of these areas have developmental beginnings in infancy.

Each area will be briefly discussed as to the associated developmental skills during the first two years of life.

The infant learns about her body as people touch and move her. Baby massage is an excellent means of proprioceptive input to the infant concerning the spatial dimensions of her body. Touching interaction games such as "I'm going to get you!" and a variety of body positions are also natural teaching methods of body image.

Dressing and undressing activities also play an important role in the internal mapping of the child's body. Dressing and bathing routines will further shape a child's labels of her body parts.

With maturation, the infant will master voluntary movements such as hand watching, midline hand play, and bringing her feet to her mouth. These movements give her even more information about the dimension and parts of her body as they are self regulated. As the infant reaches for her foot, she is participating in the discovery and confirmation of where her feet are located on her body.

Coinciding with spatial mapping of her body, the infant will begin to explore the immediate parameters of the world around her. Toys located on her body and next to her body will be the first ones explored. As she has repeated reinforcement for her random movements out into space, she will begin to actively search for "what is out there." Organized play areas with defined spatial boundaries and content will soon invite her visual and tactile search for people and toys.

Motivation Invitation

The human spirit needs both encouragement and reinforcement to work and to play. For the young child, it is important that the efforts associated with movement be met with inner delight of intrinsic reward.

A child who is engaged in the activity at hand, will be more willing to take a risk such as moving out into new space to continue an activity. In the beginning, it may be as simple as a slight weight shift from one side of the body to the next as a toy is offered in a slightly different location. Later, the child may independently navigate across an open space just to get a hug from her parent.

The goal is to determine what is motivating for the child. Two factors usually create a successful motivator; the child's cognitive development level and sensory preferences. It may be the thrill of reaching toward a colorful music toy for the infant with low vision or the satisfaction of walking across the room to the high chair for an afternoon snack for the toddler who is blind.


It is important for all children to be explorers of their world. The gift of self initiated quality movement in the early years is a priceless and lasting one. Early attention to the child's development from an OEM perspective can offer intervention at a critical time in the child's life.

Meeting the child at her developmental level will greatly assist 0&M practitioners when working with families and other team members. All three of the suggested components can be readily infused into the daily routine of the child. The result will hopefully be a supportive and involved family, a cohesive early intervention OEM program, and a child who moves out confidently and successfully into a world of new leamings.


Brown, C. and Bour, B. (1986) Movement Analysis Curriculum. Florida State Department of Education, Tallahassee, FL.

Campbell, P. H. (1983). Basic considerations in programming for students with movement difficulties. in M. Snell (Ed.) Systematic Instruction of the Moderately and Severely Handicapped (2nd ed.), Charles E. Merrill Publishing, New York, NY. .

Clarke, K. (1988) Barriers or enablers? mobility devices for visually impaired and multihandicapped infants and preschoolers. Education of the Visually Handicapped 2 0 (3), 115 -130.

Fraiberg, S. (1968). Parallel and divergent patterns in blind and sighted infants. Psychoanalytic Study of the Child, 23, pp. 264 - 300.

Johnson-Martin, N., Jens, K., and Attermeier, S. (1986). The Carolina Curriculum for Handicapped Infants and Infants at Risk. Paul Brookes Publishing, Baltimore, MD.

Morgan, B. (Ed.) (1992) Resource Manual for Early Intervention with Infants, Toddlers, and Preschoolers Who Are Visually Impaired and Their Families. SKI'HI Institute, Logan, UT.

Project PRISM (1994), an ongoing longitudinal study by Dr. Kay Ferrell and colleagues, University of Northern Colorado, Greeley, CO.

This document is a Resource for the Expanded Core Curriculum. Please visit the RECC.

Originally publishing in the Summer 2005 edition of See/Hear Newsletter.

By Jim Durkel, CCC-SPL/A, Texas School for the Blind and Visually Impaired Outreach (with help from and thanks to Kate Moss, TSBVI Outreach)

Abstract: This article defines the difference between formal audiological hearing tests and functional, or informal, hearing tests and describes how information from these assessments can be shared to meet the needs of a child.

Key Words: programming, audiological test, functional hearing, auditory functioning, deaf, deafblind

The term functional hearing is being used more and more often these days. What does it mean? What is functional hearing and how is functional hearing determined?

Formal audiological tests stand in contrast to “functional” tests of hearing. This is a bit misleading and unfair to standard tests since they can give a great deal of information about the functioning of the auditory system. A better distinction might be formal versus informal. This informal process is a way of gathering information about how students use their hearing to gather information and how they make meaning out of this information in different environments across the day.

Formal Audiological Tests

There are 2 major categories of formal audiological testing: physiological tests and behavioral tests.

Physiological Tests

Physiological tests include auditory brainstem response testing (ABR or BSER), oto acoustic emission audiometry (OAE), and tympanometry. These tests are functional in the truest sense of the word: they describe the neurological or mechanical functioning of the auditory system. They do not involve active participation of the person being tested. Audiologists can hypothesize about how results on these tests will affect an individual’s use of auditory information but there is not an exact one-to-one correspondence between neurological or mechanical function and what an individual can and can not do with his or her hearing.

Behavioral Tests

Behavioral tests require the participation of the individual being tested. The most common behavioral tests involve pure tones. Pure tones are sounds generated by a machine. These sounds are very controlled for their pitch and loudness. Pure tones do not exist in nature. Even individual musical notes are not pure tones. All natural sounds, especially speech, contain a combination of different frequencies (pitch) of varying intensity (loudness). During pure tone testing, audiologists are trying to find an individual’s threshold at various frequencies. Threshold is the intensity level where a sound can just be detected. There is not an exact one-to-one correspondence between auditory thresholds and what an individual can do with her or his hearing, but pure tone testing is important to use as a starting point for predictions and to use as the basis for hearing aid fitting. Procedures very similar to pure tone testing are also necessary for the fitting of cochlear implants, during the procedure known as mapping.

Pure tones can be delivered to the ear either through the air, by using headphones or speakers, or through bone conduction, which involves a special vibrator being placed on the head. Differences in air conduction and bone conduction thresholds give information to audiologists and doctors about what part of the auditory system might be having difficulty.

There is another type of behavioral testing that many students with deafblindness never have administered. Instead of using pure tones, speech is used. Using speech, an audiologist can determine:

  • a speech detection threshold (how loud speech needs to be for a person to just detect it),
  • a speech reception threshold (how loud a special type of 2-syllable word needs to be before an individual can correctly identify a specific proportion of them), and
  • speech discrimination (what percentage of words at a fixed loudness an individual can correctly identify).

Unfortunately, the measure that is the most like “the real world”, speech discrimination testing (especially when done in the presence of noise), is also the most difficult. This is because the individual who is being tested needs to be able to repeat words, write words, or point to pictures of words. Speech discrimination testing is very important to good hearing aid fitting and in the on-going adjustment of the speech processor component of a cochlear implant. Many children with significant multiple disabilities are not able to participate in speech discrimination testing.

Again, there is not an exact one-to-one correspondence between these formal audiological tests and every day use of hearing. Then why do these tests?

Both physiological and behavioral tests were designed to give specific information about the auditory system. The conditions under which they are given and the type of input used is carefully controlled so that results of one person’s tests can be compared to another person’s tests. And so that performance on a test one day can be compared to performance on the same test on another day. This gives us the opportunity to talk about the integrity of the auditory system with as little regard to other factors, such as cognitive or physical ability, as possible. The advantage of this is that we can identify where in the auditory system a problem might exist. This has very important medical implications and for this reason alone formal audiological testing should never be replaced with informal testing. The two kinds of testing are complementary.

Formal testing allows for the careful evaluation of hearing aids and the adjustment of cochlear implants. Finally, while pure tone testing done in an audiological test booth is a different listening situation than trying to carry on a conversation in a car, pure tone tests can give a ballpark prediction of the success of that conversation. Physiological and behavioral tests give us a very important starting point.

Listening in the Real World

What is it about “real world” listening situations that make predications from formal tests inexact? There are three factors to consider: the source of the sounds, the environment, and the listener.

Sound Sources

Sound is not simple and speech, the sound we often are most interested in, is the most complex. Speech contains a mix of sound energy at different frequencies and this information changes very rapidly. This mix and these changes allow us to hear the difference between the various vowels and consonants. We then have to assign meaning to the speech sounds we hear. This takes cognitive ability. Finally, to create those sounds ourselves takes motor ability and then auditory ability again as we monitor our own speech.

It is important to understand that being able to detect a sound is a different skill than being able to discriminate a sound. I may be able to hear the presence of a sound because it contains energy in a range my auditory system can handle. But if my auditory system can’t give me the whole picture, if I can’t hear all the energy in that sound, I may not be able to hear how it is different from another sound. Talking over the telephone is an example of this. Telephones do not allow the full range of sound energy to go through. Some high frequency information is taken out so that the telephone can work more quickly. This is why the word “fin” can easily be confused with the word “sin”, or “thin”. You can “hear” (detect) the word but have trouble discriminating (understanding exactly what is heard).

A person with enough speech and language experience, often can “fill in” pieces of what was not heard. For example, someone may call to me from another room and all I can hear is, “Do you have the _og?” Now if I know the other person is trying to light a fire in the fireplace, I will fill in the blank and “hear” log. However, if I have just been petting my German Shepherd, I will probably “hear” dog. This effect of experience and context on hearing is just one reason why formal tests don’t predict use 100%. Experience also helps us interpret other sounds we hear. Before cell phones were common, how many of us knew what those sudden noises coming out of nowhere meant? Why would I pay attention to a doorbell if I grew up in a house that only had a doorknocker? I always think Harley Davidson motorcycles sound like they are broken. This is because they normally sound like my car does when its muffler has fallen off. How many of us think rap music is noise but rock and roll is here to stay?

The Environment

The environment in formal audiological testing is very controlled. Typically, there is little competing visual or tactual information and the room is treated to eliminated noise and echo. Now think of a child’s typical listening environment where there are all kinds of competing sights, sounds, smells, and touches. Some children may get so neurologically “distracted” by what they see that they appear “deaf” in typical listening environments but appear to hear just fine in formal testing environments. On the other hand, it is not uncommon for a listener to use other senses to help support and confirm what was heard. For example, people with Usher syndrome often think their hearing is getting worse when really the hearing loss is stable and it is their visual skills that are declining. These individuals have been using visual information to support their hearing for so long they are unaware of doing so.

The Listener

Finally, there is the listener. Part of the “art” of formal behavioral tests is discovering how to motivate a listener to participate in what is a fairly boring, uninteresting task. The formal testing situation may be so unfamiliar to the child being tested that it is scary. Formal testing may be associated with unpleasant experiences in a doctor’s office. The amount of time allotted for the testing may be too short to allow the child to be comfortable or so long that the child’s participation wanes. The time of day of the testing appointment may not be the time that the child is the most alert. Formal testing often treats the child as if he or she were only a pair of ears and ignores the rest of the child.

The Informal Hearing Assessment Process

The goal of informal hearing process is to:

  • develop an idea of how the child uses his or her hearing in various environments across the course of the day; and
  • try to discover what variables support the best use of hearing in order to continuously improve the use of hearing.

During the process, observation will be used to determine what, if any, sounds the child seems to react to and what, if any, meaning the child is getting from auditory information. Observation, of course, is also supported with information from formal hearing tests. Observation also includes setting up situations and seeing how the child responds.

Step 1: General Functioning

The first step of informal hearing assessment is getting an idea of the general functioning of the child.

  • Does the child show any awareness of any sensory information (visual, tactual, etc.)?
  • How does the child show that awareness?
  • What motor behaviors seem to indicate that the child was aware of and responding to sensory information?

Without this information, you can’t tease out hearing from other factors.

Good questions to ask at this point are:

  • What does the child do with sensory information?
  • Has the child learned (or can she learn) to associate movement cues with a pleasurable activity?
  • Does the child show anticipation of an event from seeing or touching an object?

Step 2: Responses to Auditory Information

Now you can ask:

  • Does the child show anticipation or recognition through the use of hearing? That is, does the child anticipate an event when they only hear a sound associated with that event (before they see or touch something associated with the event)?
  • What sounds does the child respond to?

Step 3: Looking for Patterns

At this point, we are looking for patterns of responses. We are trying to find out which sounds under what conditions give the best (easiest to see, most consistent, meaningful to the child) responses.

  1. Is there a difference in performance based on the types of sounds?
    • low pitch vs. high pitch
    • onset vs. cessation
    • simple vs. complex (for example, one instrument vs. orchestra)
    • rhythms
    • loud vs. soft
    • long vs. short (duration)
  2. Are there any clear preferences?
    • people’s voices (male/female, young/old, familiar/unfamiliar)
    • types of music
    • musical instruments
    • objects
  3. Is there a difference in performance in different environments?
    • quiet vs. noisy
    • echo
    • competing (or supporting) information from other senses
  4. Is there a difference in performance depending on where the sound comes from?
    • in front
    • behind
    • right
    • left
    • above
    • below
  5. How long after the input does it take for a typical response to occur?
  6. Do responses vary
    • across different environments? (indoors, outdoors, hallways, carpeted room, tiled rooms, etc.)
    • at different times of day?
    • before or after meal time?
    • before or after receiving medication?
    • with the physical position of the child?

Natural observation (doing nothing but watching the child) might not give you all the information you need at this point. Using information from formal hearing tests, you might want to set up some situations to help you observe patterns. For example, the results of formal hearing tests may indicate that the child should be able to hear loud low frequency sounds, like a drumbeat. You then might want to set up a simple turn taking game involving the beating of a drum to see if the child will listen while you beat a drum then take a turn and beat a drum after you stop. If the child can do this, then you might want to try similar games with other sounds that vary by pitch and loudness to see what sounds the child can use and which he or she can’t. Of course, it may take several repetitions of the game, across several days or weeks, before the child learns their role.

Step 4: What Does It Mean to the Child?

The next step is to ask, “How does the child use auditory information?”

  • At a reflexive, awareness level? Does the child startle to sound but otherwise not pay much attention?
  • At a regulating level? Does sound help the child enter and maintain a quiet and alert biobehavioral state? Are there sounds that send the child into a fussy, agitated state?
  • At a motor level? Does the child turn towards or reach for an object or person making a sound, even if the child can’t see or touch the sound source?
  • At a play level? Does the child enjoy making noise, either with his or her mouth, by activating switches, hitting two objects together, playing musical instruments, etc.
  • At an associative level? Does the child associate a particular sound with a particular event?
  • At a communication level? Does the child recognize any common words, especially his or her name? Does the child try to use any sounds consistently to communicate?

Step 5: Where Do We Go From Here

Gathering this information over time can help guide programming for the child. Information from steps 1-4 should give an emerging picture of what is meaningful to the child. This information should guide our next steps: that is, how do we help the child use a greater and greater variety of auditory information in more and more situations and with better precision and in more and more sophisticated ways. Informal information should be shared with audiologists to help them in the process of deciding how well a hearing aid or cochlear implant is meeting the needs of a particular child and if adjustments need to be made. Information from the informal hearing assessment process can also help guide the formal hearing assessment process by letting the audiologist know typical kinds of responses a particular child might make to various kinds of auditory input.


There is a book, Every Move Counts, by Jane Korsten (Therapy Skill Builders, 1993) that outlines a process that can be useful for gathering information. Every Move Counts deals with all the senses, not just hearing.

Another soon to be released product that helps look at how a child uses sensory information is the “Sensory Learning Kit”, (Millie Smith, primary author) from American Printing House for the Blind. This product should be available sometime in 2006.

Finally, is “A Process for Identifying Students Who May Be At-Risk for Deafblindness”. This is a collection of information and downloadable forms that can be used to support the gathering of information in an informal way.

Teachers for the deaf and hard of hearing typically have training to help look at auditory functioning in this informal way. They may be a valuable resource in this process.