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Eye ConditionEffects On VisionEducational Considerations

Achromotopsia (color deficiency, colorblindness, achromacy, or rod achromacy)

Cone malformation, macular deficiency, and partial or total absence of cones.

  • Limited or no color vision
  • Colors may be seen as shades of gray
  • Loss of detail
  • Decreased acuity
  • Central field scotomas
  • Normal peripheral fields
  • Associated with  nystagmus  and Photophobia
  • Adapted color-dependent activities
  • Alternate methods for matching clothing
  • Support of eccentric viewing
  • High contrast materials
  • May need to use sunglasses, visors, or hats outdoors and indoors as well
  • Reduced or diffused lighting
  • Supplement vision with auditory and tactile information

Albinism

Total or partial absence of pigment, causing abnormal optic nerve development

Lenses and tinted lenses may be prescribed.

  • Decreased acuity
  • Photophobia
  • Increased sensitivity to glare
  • High refractive error
  • Astigmatism
  • Central scotomas
  • Nystagmus
  • Muscle imbalance
  • Eye fatigue with close or detailed work
  • Reduced depth perception
  • Magnification (e.g., hand-held magnifier, electronic magnifier, screen enlargement software, telescope, etc.)
  • Close viewing
  • High contrast materials
  • May need to use sunglasses, visors, or hats outdoors and indoors as well
  • Lighting from behind
  • Reduced glare
  • Line markers and templates - placeholders
  • Frequent breaks

Amblyopia (was Anopsia, called “lazy eye”) See strabismus

Reduced visual functioning in one eye, which causes the person to use one eye instead of both.

With young children, eye exercises, oclusion or patching of one eye or surgery may help.

  • Monocular vision
  • Reduced visual field
  • Reduced depth perception
  • May develop blindness in one eye
  • Reduced visual-motor abilities
  • Eye fatigue with close or detailed work
  • Frequent breaks
  • Seating should favor functional eye.
  • Familiarization with new environments
  • Time to adjust in new situations
  • May need adaptations for activities requiring visual-motor coordination

Aniridia

A rare genetic disorder that causes absence of all or part of the iris, usually affecting both eyes

It also causes the cornea to lose clarity over time by inhibiting the stem cells that “refresh” it with new, clear epithelial cells. Aniridia is often associated with amblyopia, cataracts, the development of closed angle glaucoma, and sometimes, displaced lens, under-developed retina, and nystagmus. Contact lenses with an artificial iris, tinted spectacles, or bioptic glasses may be prescribed. iris and stem cell implant surgeries are now possible.

Hereditary aniridia is associated with Gillespie syndrome. Sporatic Aniridia may cause nephroblastoma (Wilm’s tumor), and it is associated with WAGR syndrome

  • Decreased acuity
  • Photophobia
  • Large pupil that may be misshapen
  • Generally, respond very well to use of low vision devices
  • Corneal involvement: Scattered light, increased glare, blurred vision, and further reduction of  acuity
  • If cataracts develop: further reduction of visual acuity, blurred vision, and decreased color vision
  • Fovial involvement: loss of detailed (fine) vision
  • If glaucoma develops: fluctuating visual functioning, field loss, poor night vision, and decreased sensitivity to contrast

 

  • Vision stimulation for infants to maximally develop the visual cortex
  • May need to use sunglasses, visors, or hats outdoors and indoors as well
  • Allow time for adjustment to lighting changes
  • Provide seating in the front of the classroom with back to windows
  • Reduced glare
  • Provide lighting from behind
  • Reduced or diffused lighting
  • Lamps with rheostats and adjustable arms
  • Magnification (e.g., hand-held magnifier, electronic magnifier, screen enlargement software, telescope, etc.)
  • Use of a black chalkboard and bold chalk
  • If white board is used, bold black markers are recommended over other colors
  • Felt-tipped pens and tinted paper with bold lines
  • Place paper/worksheets on a dark/black background (e.g., blotter, construction or butcher paper, posterboard, etc.)
  • Provide copies of materials presented on the board.
  • Use black backgrounds and white san serif fonts in slide presentations

Anophthalmia

Absence of one or both eyeballs

Causes can be heredity, injury, or secondary to disease. Prosthetic eyes are prescribed to preserve the health of the eyelids and surrounding tissues.

  • Monocular vision:
  • Reduced fields
  • Reduced depth perception
  • Blindness
  • May need visual efficiency training to develop scanning skills
  • Seating and presentation of materials should favor functional eye
  • May need tactile and auditory learning media

Aphakia

Absence of the lens

Although it can be caused by injury, aphakia is usually a result of cataract surgery. Treatments include lens implants, contact lenses, and/or glasses.

  • Inability to accommodate to varying focal distance
  • Inability to accommodate to lighting changes
  • Reduced depth perception
  • May have peripheral field distortions
  • Support wearing of any prescribed lenses
  • High contrast materials
  • Magnification (e.g., hand-held magnifier, electronic magnifier, screen enlargement software, telescope, etc.)
  • Enlarged printed materials
  • Close viewing
  • Adequate lighting (e.g., lights with rheostats and adjustable arms)
  • May need to use sunglasses, visors, or hats outdoors and indoors as well
  • Allow time for adjustment to lighting changes

Astigmatism

Irregularity in the curvature of the cornea and/or lens, which prevents light rays from being properly focused on a single point on the retina

Astigmatism commonly occurs with myopia and hyperopia. It also can be associated with albinism and keratoconus. Corrective lenses may be prescribed.

  • Blurred vision at any distance (uncorrected)
  • Distorted vision
  • Tendency to squint to create a pinhole effect
  • Visual fatigue associated with close work
  • High contrast materials
  • Adequate lighting (e.g., lamps with rheostats and adjustable arms)
  • Frequent breaks from close/detailed work

Buphthalmos (Infantile glaucoma)

Enlarged eyeballs

Caused by congenital glaucoma; hereditary; onset from birth to three years; can cause enlargement and increased depth of the anterior chamber, damage to the optic disc, and/or increased diameter and thinning of the cornea; requires surgery, and blindness occurs if left untreated.

  • Photophobia
  • Reduced central acuity
  • Corneal opacity
  • Excessive tearing
  • Refractive error
  • Eye pain

 

  • May need to use sunglasses, visors, or hats outdoors and indoors as well
  • Reduced or diffused lighting from behind
  • Sunglasses, visors or hats may be worn indoors
  • Allow time for adjustment to lighting changes
  • High contrast materials
  • Magnification (e.g., hand-held magnifier, electronic magnifier, screen enlargement software, telescope, etc.)
  • Enlarged printed materials
  • Close viewing

Cataracts

Opacity or cloudiness of the lens, which restricts passage of light to the retina; usually bilateral

Opacity increases over time until “mature” cataracts can obscure the fundus and the pupil may appear white. Mature cataracts are usually removed surgically, requiring lens implants or contact lenses.

  • Reduced visual acuity
  • Blurred vision
  • Reduced color discrimination
  • Photophobia
  • Associated with nystagmus
  • Visual ability fluctuates according to light
  • If cataracts are centrally located, near vision will be reduced
  • Increased sensitivity to glare

 

  • Support of the wearing of any prescribed lenses
  • Magnification (e.g., hand-held magnifier, electronic magnifier, screen enlargement software, telescope, etc.)
  • Enlarged printed materials
  • Close viewing
  • Support of eccentric viewing
  • May need to use sunglasses, visors, or hats outdoors and indoors as well
  • May need reduced or diffused lighting
  • Lighting from behind
  • May need lamps with rheostats and adjustable arms
  • Reduced glare

Chorioretinitis

Posterior uveitis, or an inflamation of the choroid that spreads to the retina

This can be caused by tuberculosis, histoplasmosis, or toxoplasmosis.

  • Blurred vision
  • Photophobia
  • Distorted images
  • Central scotomas
  • Support of eccentric viewing
  • Magnification (e.g., hand-held magnifier, electronic magnifier, screen enlargement software, telescope, etc.)
  • Enlarged printed materials
  • Close viewing
  • Diffused, less intense light to enlarge the pupil
  • Telescope
  • May need to use tinted lenses, sunglasses, visors, or hats outdoors and indoors as well
  • High contrast line markers or templates for reading, finding math problems, or locating other information

Coats’ Disease  (Exudative Retinitis or retinitis telangiectasia)

A congenital, nonhereditary, and progressive disorder that is characterized by abnormal development of the blood vessels behind the retina

Coats’ occurs mostly in males. Symptoms typically appear in children around six to eight years old but they can appear in infancy. Coats' usually affects only one eye. Severity depends on the size and number of affected blood vessels. Leakage of blood and fluids cause retinal swelling and detachment. Cryotherapy and laser photo-coagulation sometimes are used to stop the progression of blood vessel growth and leakage. 

  • Decreased central acuity
  • Loss of detail
  • Progressive central field loss
  • Reduced night vision
  • Loss of color vision
  • May develop strabysmus
  • May have iritis
  • May have glaucoma
  • May develop cataracts
  • May be blind in one eye
  • Peripheral fields can be affected
  • Avoid contact sports and other high risk activities to prevent retinal detachment
  • Seating and presentation of work should favor more functional eye
  • Visual efficiency training to develop scanning skills

 

Coloboma

Hereditary birth defect that causes a notch or cleft in the pupil, iris, ciliary body, lens, retina, choroid, or optic nerve

A “Keyhole” pupil often occurs. It can be associated with refractive error, cataracts, nystagmus, strabismus, and glaucoma (later in life).

  • Decreased acuity
  • Photophobia
  • Muscle imbalance
  • Restricted fields (if retina is affected)
  • Reduced depth perception

 

  • High contrast materials
  • Magnification (e.g., hand-held magnifier, electronic magnifier, screen enlargement software, telescope, etc.)
  • Average to bright light
  • Reduced glare
  • May need to use sunglasses, visors, or hats outdoors and indoors as well (if iris is affected)
  • High contrast line markers and templates may be helpful for reading, finding math problems, or locating other information

Color deficiency (colorblindness) 

See Achromotopsia

 

 

Cone Monochromacy

See Achromotopsia

 

 

Corneal Ulcers, Corneal Opacities, Corneal Scarring, Keratitis, and Interstitial Keratitis

An open sore or scarring on any part of the cornea

It can be caused by bacteria, viruses (herpes), fungi, vitamin deficiency, injury, a hypersensitive reaction, diabetes, or severe dry eye. Superficial ulcers (called abrasions) usually heal quickly and completely, but deep ulcers cause growth of scar tissue or new blood vessels that impair vision. Corneal ulcers are usually quite painful, and other symptoms may include vision loss, squinting, and tearing (watering). Early diagnosis and treatment are crucial. With extensive scarring, a corneal transplant may be necessary. There are promising results with use of artificial corneas, which seem to be less likely to be rejected.

  • Photophobia
  • Fracturing of light (like looking through broken glass)
  • Increased glare
  • Blurred vision
  • Reduced acuity
  • Blindness

 

  • May need to use sunglasses, visors, or hats outdoors and indoors as well
  • Reduced or diffused lighting
  • Sunglasses, visors or hats may be worn indoors
  • Seating in front of room with back toward windows
  • Reduced glare
  • High contrast materials
  • Diffused lighting from behind
  • Lights with rheostats and adjustable arms are helpful for close work.
  • Magnification (e.g., hand-held magnifier, electronic magnifier, screen enlargement software, telescope, etc.)
  • Enlarged printed materials
  • Frequent breaks from visual tasks
  • Support of eccentric viewing
  • May need auditory materials for longer reading assignments

Cortical Visual Impairment (CVI)

A neurological visual disorder resulting from damage to the optic nerve and/or parts of the brain that process and interpret visual information (i.e., visual cortex)

CVI is characterized by:

  • Specific color preference, especially for red and/or yellow
  • Attraction to movement
  • Visual field preference, especially for peripheral fields
  • Visual latency: delayed visual processing - in directing gaze, identification, recognition, and/or discrimination
  • Difficulties with discrimination and interpretation of complex visual information
  • Poor visual attention
  • Atypical visual responses (e.g., looking at something while appearing not to look)
  • May not look at an object and reach for it simultaneously (look first, then look away while reaching)
  • Better visual performance with familiar objects/settings
  • Unique visual features (i.e., light gazing and non-purposeful gaze)
  • Fluctuation in visual functioning
  • Reduced visual fields
  • Photophobia
  • Fatigue has a negative impact on visual performance
  • Use of movement to increase visual attention
  • Use of preferred color to increase visual attention
  • Present visual information in preferred visual field
  • Present visual information on a solid background (e.g., black or white cloth)
  • Use of bright, high contrast materials
  • Increase line spacing and white space on a page of text and/or images to reduce visual clutter and complexity
  • Use high contrast templates to reduce the amount of information seen at one time
  • Close viewing
  • Vision efficiency training
  • Frequent breaks from visual tasks
  • High illumination from behind
  • Sunglasses, visors or hats may be worn indoors
  • Support use of one sense at a time
  • Reduce visual, auditory, and tactile distractions
  • Extra time to respond
  • Extra time to adjust to new environments
  • Use of consistent language
  • Use of color coding as visual cues for recognition
  • Use of consistent visual cues across settings

Diabetic Retinopathy

Changes in the blood vessels of the retina, causing hemorrhaging in the retina and vitreous

It is caused by juvenile or type 2 diabetes. It may lead to retinal detachment and blindness.

  • Increased sensitivity to glare
  • Lack of accommodation
  • Floating obstructions in the vitreous
  • Fluctuating acuity
  • Diminished color vision
  • Reduced visual fields
  • Double vision
  • Blindness
  • Adequate high quality lighting (e.g., lamps with rheostats and adjustable arms)
  • High contrast materials
  • Magnification (e.g., hand-held magnifier, electronic magnifier, screen enlargement software, telescope, etc.)
  • Large button/key technology may be helpful
  • Training in use of auditory materials may be needed due to loss of vision and tactile sensitivity
  • Training in use of speech recognition input software may be helpful
  • Precautions related to decreased sensitivity in hands and feet (e.g., burns, cuts, falls)

Diplopia

Muscular defect that restricts the ability of the eyes to work together

It causes double vision, as the image from one eye is imposed on the image from the other eye. Left untreated, this condition can develop into amblyopia. Corrective lenses may be prescribed.

  • Visual confusion
  • Double vision
  • Dizziness
  • Suppression of the image from one eye, causing monocular vision
  • Eye fatigue
  • Blurring of print
  • Headache
  • Loss of place in visual tasks
  • High contrast materials
  • Reduced glare
  • Extended time to adjust to new situations
  • Frequent breaks from visual tasks
  • High contrast line markers or templates for reading, finding math problems, or locating other information
  • Familiarization with new environments

Dislocated Lens

The lens is not in its natural position.

It is sometimes associated with coloboma, Marfan’s syndrome, or Marchesani’s syndrome. Also, it may be associated with diplopia or cataracts.

  • Blurred vision
  • Double Vision
  • Visual fatigue during close or detailed visual tasks

 

  • Frequent breaks from visual tasks
  • High contrast materials
  • Adequate lighting (e.g., lamps with rheostats and adjustable arms)
  • Reduced or diffused lighting
  • High contrast line markers or templates for reading, finding math problems, or locating other information

Enucleation

The anterior chamber or the entire eyeball is surgically removed from the orbit (eye socket).

Prosthetic eyes or scleral shells are usually recommended.

  • If one eye is removed, there is no depth perception.
  • Monocular vision
  • Reduced visual field
  • Effects of any eye condition(s) of the remaining eye
  • Blindness
  • Effects visual-motor skills, especially reach and negotiation of steps and drop-offs
  • Training in care of prostheses
  • Vision efficiency training (i.e., scanning)
  • Considerations related to the visual impairment of the remaining eye
  • Considerations related to possible changes in learning media

Esophoria, Esotropia, Exophoria, and Exotropia   See strabismus

 

 

Glaucoma

An eye disease which causes increased pressure in the eye because of blockage in the normal flow of the fluid in the aqueous humor

Causes include changes in the lens or uveal tract, trauma, reaction to a medication, surgical procedures, and heredity. Eye pain and headaches are associated with glaucoma. Prescription eye drops to reduce pressure must be used regularly, and surgery may be necessary. Untreated, glaucoma can lead to degeneration of the optic disk and blindness.

  • Fluctuating visual functioning
  • Field loss
  • Poor night vision
  • Photophobia
  • Difficulty reading
  • Difficulty seeing large objects presented at close range
  • Decreased sensitivity to contrast
  • Eye redness
  • Hazy cornea
  • Wide open pupil
  • Stress and fatigue have a negative affect on visual performance

 

  • Support use of sunglasses, visors, or hats in bright sunlight and bright lighting indoors
  • Allow time for adjustment to lighting changes
  • Reduced glare
  • Adequate lighting (e.g., lamps with rheostats and adjustable arms)
  • High contrast materials
  • May benefit from magnification (e.g., hand-held magnifier, electronic magnifier, screen enlargement software, telescope, etc.)
  • May need visual efficiency training to develop scanning skills
  • Frequent breaks from visual tasks
  • May need instruction in tactile learning and braille
  • Teachers must be alert to signs of pain and increased ocular pressure.

Hemianopia (hemianopsia)

Blindness or impaired vision in one half of the visual field in one or both eyes

If both eyes are affected, vision loss may occur on the same side in both nasal fields, or in both temporal fields. Visual acuity in the unaffected field(s) remains unchanged. Hemianopia can be caused by stroke, other brain trauma, tumors, infection, or surgery.

  • Field loss
  • May be unaware of missing visual information
  • Visual efficiency training to develop scanning skills
  • Use markers at the beginning and/or ending of each line of text to facilitate reading the entire line

Histoplasmosis (Presumed Histoplasmosis Syndrome - POHS)

This is a syndrome affecting the choroid and retina, which is characterized by peripheral atrophic chorioretinal scars, maculopathy, and atrophy or scarring adjacent to the optic disc. Vision loss is secondary to macular and choroidal neovascularization (CNV).

POHS is most likely caused by a fungal infection acquired through exposure to spores in bird droppings and bat guano. Treatments include steroids to treat the initial infection, laser, anti-vascular endothelial growth factors, and photodynamic therapy. Prism lenses may be prescribed.

  • Distorted vision
  • Blind spots
  • Macular damage or central scotomas cause “patchy” fields, central vision loss, and reduced color vision.
  • Peripheral damage causes loss of night vision
  • Lamps with rheostats and adjustable arms
  • High contrast line markers or templates for reading, finding math problems, or locating other information.

Central damage:

  • Eccentric viewing
  • Magnification to enlarge an image beyond the scotoma
  • Enlarged printed materials
  • Close viewing
  • Adapted color-dependent activities
  • Alternate methods for matching clothing
  • Diffused, less intense light to enlarge the pupil so that more area can be viewed
  • CCTV with reversable foreground and background (white on black)

Peripheral damage:

  • High illumnation
  • NOIR lenses or overlay filters may be helpful
  • CCTV for maximum contrast
  •  Night vision devices (e.g., Streamlight flashlights, Third Generation® Night Vision Devices, etc)
  • Visual efficiency training in organized search (grid) patterns
  • May need to be seated farther away from the front to see more of the viewing area (e.g., board, screen, chart, etc)

Hyperopia (Farsightedness)

A refractive error in which the focal point for light rays is behind the retina

It is caused by the eyeball being too short from front to back. Corrective lenses are usually prescribed.

  • Distance acuity is better than near acuity
  • Uncorrected, close visual tasks may cause headache, nausea, dizziness, and eye rubbing

 

  • Support use of prescription lenses for close visual tasks
  • Magnification for near tasks (e.g., hand-held magnifier, electronic magnifier, screen enlargement software)
  • Frequent breaks from close visual tasks
  • Alternate near and distance visual tasks

Hyperphoria, Hypertropia, Hypophoria, Hypotropia    See strabismus

 

 

Hypoplasia  See Optic Atrophy

 

 

Keratitis See Corneal Ulcer

 

 

Keratoconus (KC)

Degenerative disorder in which the cornea thins and takes on a conical shape

Keratoconus is often bilateral but not symmetrical, so vision may be significantly better in one eye than the other. Vision deteriorates at varying rates (sometimes quite rapidly), and plateaus of stable vision can occur. Although it seems to be hereditary, keratoconus is typically diagnosed in adolescence. It is sometimes associated with retinitis pigmentosa, Down’s syndrome, Marfan’s syndrome, and aniridia.  Treatments include prescription lenses and various surgeries: intrastromal corneal ring segments, cross-linking, mini asymmetrical radial keratotomy, and corneal transplants. There are promising results in transplants with use of artificial corneas, which seem to be less likely to be rejected.

  • Slightly blurred vision in early stages, increasing as KC progresses
  • Distortion of entire visual field, which worsens in low light
  • Decreased visual acuity especially distance vision
  • Irregular astigmatism (parts of the field are in focus, and parts are out of focus)
  • Increased sensitivity to glare
  • Decreased night vision
  • Multiple images
  • Flaring of images
  • Streaking
  • Stationary objects/lights may appear to move
  • May develop photophobia
  • Cornea can rupture
  • Can lead to blindness
  • Avoid activities that could cause corneal damage, such as  contact sports and swimming in heavily chlorinated water
  • Reduced glare
  • Diffused lighting
  • Lamps with rheostats and adjustable arms
  • High contrast materials
  • High contrast line markers or templates for reading, finding math problems, or locating other information
  • Magnification (e.g., hand-held magnifier, electronic magnifier, screen enlargement software, telescope, etc.)

Leber’s Congenital Amaurosis (LCA, Leber’s Congenital Amaurosis)

A rare hereditary disorder that leads to degeneration of the macula

LCA becomes evident within the first few months of life. Progressive central field loss can occur, although vision is generally stable. LCA is a subset of retinitis pigmentosa with at least thirteen described types that are distinguished by genetic cause, patterns of vision loss, and associated eye conditions. Nystagmus, keratoconus, photophobia, extreme hyperopia, and sluggish (or absent) pupilary response to light are often present with LCA. Excessive rubbing of eyes (also poking or pressing) is a characteristic behavior. 

 

  • Decreased acuity
  • Reduced night vision
  • Progressive central field loss
  • Loss of color vision
  • Loss of detail
  • Peripheral fields can be affected
  • May need visual efficiency training to develop scanning skills
  • Support of eccentric viewing
  • Magnification (e.g., hand-held magnifier, electronic magnifier, screen enlargement software, telescope, etc.)
  • High contrast materials
  • High contrast line markers or templates for reading, finding math problems, or locating other information
  • Enlarged printed materials
  • Close viewing
  • Adapted color-dependent activities
  • Alternate methods for matching clothing
  • Lamps with rheostats and adjustable arms
  • Support use of sunglasses, visors, or hats in bright sunlight
  • Seat in the front of the room with windows behind back
  • May need frequent breaks from visual tasks
  • May need instruction in use of auditory materials
  • May need instruction in tactile learning and braille

Leber’s Hereditary Optic Neuropathy (LHON, Leber’s Optic Atrophy)

It is a rare hereditary disease caused by a mitochondrial mutation and passed on by the mother. It is characterized by rapidly progressive and severe optic nerve degeneration (atrophy).

It occurs in young men and, rarely, young women. Onset is usually in young adulthood. Most often, there is acute vision loss in one eye and then, a few weeks or months later, in the other eye, but vision loss sometimes occurs in both eyes simultaneously. It can include other types of central nervous system involvement.

  • Reduced central acuity
  • Vision may be blurred
  • Fluctuating visual performance
  • Color vision may be impaired
  • Visual perception may be impaired

 

  • High illumination
  • High contrast
  • Enlarged printed materials
  • Magnification (e.g., hand-held magnifier, electronic magnifier, screen enlargement software, telescope, etc.)
  • Avoid visual clutter:
  • Present visual information in isolation
  • Avoid busy backgrounds
  • Avoid wearing patterned clothing when presenting visual information

Macular Degeneration (Macular Disease, Congenital Macular Disease, and Age-Related Macular Degeneration)

Progressive (degenerating) damage to the central part of the retinal cones

The dry form involves yellow deposits (celluar debris) on the macula and eventually, thinning of cells in the macula, which leads to tissue death. In the wet form, there is abnormal growth of blood vessels in the choroid underneath the macula. These blood vessels leak blood and fluid into the retina, causing distortion, blind spots, loss of central vision, retinal scarring, and risk of retinal detachment. Macular degeneration is the leading cause of blindness in people over sixty, but it also can occur in children below age seven. Factors contributing to the development of the disease include heredity, diabetes, head injury, nutritional deficits, high cholesterol, smoking, and exposure to sunlight without eye protection. There is no cure, but treatment can slow progress of the disease. Treatments include nutritional supplements, laser therapy, and medication. 

  • Reduced central acuity
  • Peripheral vision is not affected
  • Central scotomas
  • Distorted vision
  • Blurred vision
  • Decreased color vision
  • Slow recovery from changes in light
  • Loss of contrast sensitivity
  • Visual fatigue
  • Support of eccentric viewing
  • Support use of sunglasses, hats, or visors in bright sunlight
  • Allow time for adjustment to lighting changes
  • Adequate lighting (e.g., lamps with rheostats and adjustable arms)
  • Diffused lighting may allow the pupil to enlarge so that more area can be viewed
  • Close viewing
  • Magnification (e.g., hand-held magnifier, electronic magnifier with light text on dark background, screen enlargement software, telescope for distance viewing etc.)
  • Reduced glare
  • High contrast materials
  • High contrast line markers or templates for reading, finding math problems, or locating other information
  • Seating in front with back to window
  • Adapted color-dependent activities
  • Alternate methods for matching clothing
  • Frequent breaks from visual tasks
  • Avoid standing in front of a light source when speaking to the student

Microphthalmia (Microphthalmos, nanophthalmia, nanophthalmos)

A hereditary, developmental disorder that causes one or both eyes to be abnormally small

It may occur with other congenital abnormalities such as club foot, additional fingers or toes, webbed digits, polycystic kidneys, and cystic liver. This disorder can be associated with Patau Syndrome, Triploid Syndrome, or Wolf-Hirschhorn Syndrome. It may result in  cataracts, glaucoma, aniridia, and coloboma.

  • Decreased visual acuity
  • Photophobia
  • May have fluctuating visual abilities

 

  • High contrast
  • Reduced glare
  • Average to bright light
  • May need magnification (e.g., hand-held magnifier, electronic magnifier, screen enlargement software, telescope, etc.)
  • Expectations may need to be adjusted due to the frustration related to fluctuating visual abilities
  • Frequent breaks from visual tasks
  • Instruction in strategies for stress reduction and dealing with frustration related to fluctuating visual abilities

Muscle Imbalance See Strabismus and Amblyopia

 

 

Myopia (Simple and Degenerative Myopia, nearsightedness)

A refractive error in which the image of a distant object is formed in front of the retina and cannot be seen distinctly; eyeball is elongated from front to back

Degenerative myopia is progressive, causing increasingly severe nearsightedness, so that visual acuity often cannot be corrected to normal with lenses. It can lead to retinal detachment, choroidal hemorrhages, reduced central vision, opacities in the vitreous, macular swelling, and cataracts. Treatments include corrective lenses and LASIC surgery.

  • Reduced distance acuity
  • Near vision is better than distance vision
  • May squint and frown when trying to see at a distance

 

  • High illumination
  • Reduced glare
  • May need to be seated closer to the front in order to see written information, videos, and demonstrations
  • If myopia is progressive, take precautions to protect the retina

Nystagmus

Involuntary eye movements, which can be horizontal, vertical, circular, or mixed

Causes can be heredity, neurological disorders, toxicity, pharmaceutical drugs, alcohol, inner ear disturbance, or unknown. Nystagmus can be increased by stress, spinning, and rhythmic movements. 

  • Inability to maintain steady fixation
  • Reduced visual acuity
  • Visual fatigue
  • Vertigo (rare)
  • Stripes and other patterns may increase the rate of the nystagmus
  • Shifting gaze or tilting the head may help to find the null point at which the nystagmus slows.
  • Frequent breaks from close visual tasks
  • Vary visual tasks
  • Adequate lighting
  • Good contrast
  • Line markers, rulers, typoscopes, and other templates may be helpful for keeping the place on a page
  • Instruction in stress reduction strategies

Optic Atrophy (Optic Nerve Atrophy)

Hereditary or acquired damage to the optic nerve that limits or stops transmission of visual information from the eye to the brain

It is evidenced by a pale optic disc and reduced pupilary response. Acquired optic atrophy can be caused by disease, pressure on the optic nerve, trauma, glaucoma, or toxicity. Type 1 optic atrophy is progressive.

 

  • Fluctuating visual performance
  • Color vision may be reduced
  • Night vision may be reduced
  • Visual perception may be impaired
  • May have photophobia
  • Visual stimulation in infancy and early childhood.
  • Low vision training in early childhood to help the child interpret visual information
  • Supplement visual information with tactile and auditory information
  • High illumination
  • If photophobia is present:
  • May need to use sunglasses, visors, or hats outdoors and indoors as well
  • Provide adequate lighting through use of lamps with rheostats and adjustable arms)
  • High contrast
  • Enlarged print
  • May need magnification (e.g., hand-held magnifier, electronic magnifier, screen enlargement software, telescope, etc.)
  • Avoid visual clutter:
  • Present visual information in isolation
  • Avoid busy backgrounds
  • Avoid wearing patterned clothing when presenting visual information
  • May need adapted color dependent activities
  • May need alternate methods for matching clothing
  • May need instruction in tactile learning and braille

Optic Nerve Hypoplasia(ONH)

ONH and Septo-Optic Dysplasia (SOD) are related disorders of early brain development. ONH is a congenital, nonprogressive condition in which the optic nerve is under-developed and small.

It may affect one or both eyes, and when both are affected, side-to-side nystagmus is frequently present. During the first few years of life, vision may improve as the brain continues to develop. The incidence of strabismus is increased with ONH. It is one of the three defining characteristics of Septo-Optic Dysplasia, which is also called DeMorsier’s Syndrome. Learning disability, autism, cerebral palsy, and intellectual developmental delays can occur with ONH and SOD. Possible causes include young maternal age, genetic mutation, fetal alcohol syndrome, trauma, and viral infection.

  • May have decreased visual acuity
  • May have better acuity In one eye than in the other
  • May have nystagmus
  • May have strabismus
  • May have variable field restrictions
  • Visual perception may be impaired
  • High illumination
  • High contrast
  • Enlarged printed materials
  • May need magnification (e.g., hand-held magnifier, electronic magnifier, screen enlargement software, telescope, etc.)
  • Avoid visual clutter:
  • Present visual information in isolation
  • Avoid busy backgrounds
  • Avoid wearing patterned clothing when presenting visual information
  • Provide opportunities to confirm or clarify visual information through tactile exploration
  • May benefit from verbal descriptions to help make sense of visual information.
  • May need adapted color dependent activities
  • May need alternate methods for matching clothing
  • May need instruction in tactile learning and braille

Peter’s Anomaly

A congenital, genetic disorder that involves clouding (opacity) and thinning of the cornea

It is caused by abnormal development of the front third of the eye (anterior segment), and central opacities are most common. The iris may or may not be attached to the cornea (Type 1), and cataracts and other lens abnormalities may be present (Type 2). It is very common for amblyopia and glaucoma to develop. This condition can be associated with peters plus syndrome.

  • Blurred vision
  • Decreased central acuity
  • May have scotomas in peripheral fields
  • Photophobia
  • Increased sensitivity to glare
  • Reduced color discrimination
  • Visual ability fluctuates according to lighting
  • May have reduced near vision

 

  • Support of eccentric viewing
  • May need visual efficiency training to develop scanning skills
  • May need to use sunglasses, visors, or hats outdoors and indoors as well
  • Adequate lighting from behind using lamps with rheostats and adjustable arms
  • Reduced glare
  • Seat with back to windows
  • Magnification (e.g., hand-held magnifier, electronic magnifier, screen enlargement software, telescope, etc.)
  • Enlarged printed materials
  • High contrast materials
  • High contrast line markers or templates for reading, finding math problems, or locating other information
  • Close viewing
  • May need adapted color-dependent activities
  • May need alternate methods for matching clothing
  • Frequent breaks from visual tasks

Photophobia

Abnormal sensitivity to light (any type)

It is usually associated with an eye disease or disorder (e.g., iritis, ocular albinism, aphakia, aniridia, dislocated lens, cataracts, glaucoma, etc.). However, many people experience mild photophobia that is unrelated to another eye condition. Other causes include corneal inflammation, some medications, and eye injuries. Severe photophobia can be quite painful, even in relatively dim light. 

  • Squinting
  • Closing the eyes
  • Eye pain
  • Headaches
  • Eye fatigue
  • May need to use sunglasses, visors, or hats outdoors and indoors as well
  • Reduced or diffused lighting
  • Provide lighting from behind
  • Use of shielded lamps with rheostats and adjustable arms)
  • Reduced glare
  • May benefit from use of NOIR sunglasses and/or filters (colored overlays) when reading
  • May need breaks from visual tasks or rest periods in a darkened area

Phthisis bulbi

Abnormally low intraocular pressure, which can cause shrinkage of the eye

It may occur as a complication of eye surgery, or it can be caused by eye diseases, serious and long-term inflammation, or injury. Low pressure damages the macula. The tissues inside the eye deteriorate, become disorganized, and scar tissue is formed. In some cases, the eye can become completely nonfunctional. Sometimes a scleral shell prosthesis is prescribed for proper lid function, eyelash direction, healthy tearing, protection of the cornea, and aesthetics. 

  • Reduced central acuity
  • Reduced color vision
  • Blindness
  • Average or bright light
  • Reduced glare
  • May need high contrast
  • May need magnification (e.g., hand-held magnifier, electronic magnifier, screen enlargement software, telescope, etc.)
  • May benefit from use of high contrast line markers or templates for reading, finding math problems, or locating other information
  • May need some materials presented auditorily
  • May need instruction in tactile learning and braille

Presbyopia

The gradual loss of flexibility of the lens that occurs with age

It results in inability of the eye to focus at near distance. Presbyopia generally begins to noticeably affect visual functioning around age 40, and people often need prescription lenses by age 45. Options for prescription lenses include glasses for near-distance tasks, bifocals, transition lenses, and monovision contact lenses. Vision also can be corrected by reshaping the cornea using lasers (LASIK), radio waves (conductive keratoplasty - CK), or gas bubbles (IntraCor). Other surgical treatments include artificial lens implants, corneal inlays, and corneal overlays.

  • Blurred vision at normal reading distance
  • Headaches from doing close visual tasks
  • Further compromises the vision of aging adults who have existing visual impairments

 

  • Adequate lighting
  • High contrast
  • Frequent breaks from near-distance visual tasks

Ptosis

Drooping (sagging) of the eyelid

It may affect upper and/or lower lids and one or both eyes. Ptosis is usually due to weakness of the muscles that control the eyelids, damage to the nerves that control these muscles, or very loose skin of the upper eyelids.  Commonly associated with the aging process, ptosis also can be congenital and hereditary, or caused by injury or disease. A ptosis crutch may be prescribed to elevate the eyelid. Medications may be prescribed for those who have myasthenias gravis. Children with severe ptosis need eyelid lift surgery early in life to insure normal visual development and to prevent amblyopia.

  • Severe ptosis obscures the upper visual field
  • Long-term reduction of visual field can cause amblyopia

 

  • May need visual efficiency training to develop scanning skills
  • Ensure access to information that is elevated (bulletin boards, black/white boards, video screens, etc.)

Retinal Detachment

An emergency situation in which parts of the retina pull away from the underlying tissue that nourishes it and from the supporting structure of the eye

Detachments can be repaired if treated within 24-72 hours, but detached parts deteriorate rapidly. Any detachment endangers the entire retina. Detachments are caused by retinal tears, fluid under it, or shrinkage of the vitreous. These conditions may be due to injury, inflammatory eye disorders, advanced diabetes, degenerative myopia, and other retinal disorders.  

  • Field loss
  • Blind spots (scotomas)
  • Blurred vision
  • Possible loss of central vision
  • May develop myopia and/or strabismus
  • Avoid contact sports and other high risk physical activity to prevent retinal detachment
  • Magnification (e.g., hand-held magnifier, electronic magnifier, screen enlargement software, telescope, etc.)
  • May need visual efficiency training to develop scanning skills
  • Support of eccentric viewing
  • High illumination
  • Reduced glare
  • High contrast line markers or templates for reading, finding math problems, or locating other information
  • Seating in front with back to window
  • Adapted color-dependent activities
  • Alternate methods for matching clothing
  • Frequent breaks from visual tasks

Retinal Dysplasia

A rare, hereditary disorder resulting in abnormal development or growth of the retina and characterized by retinal folds, overgrowth of cells, and rosettes of retinal tissue

It can be associated with Meckel syndrome. 

  • Field loss
  • Blind spots (scotomas)
  • Blurred vision
  • Possible loss of central vision
  • Reduced visual functioning at night or in dimly lit places
  • Nighttime orientation and mobility evaluation
  • Magnification (e.g., hand-held magnifier, electronic magnifier, screen enlargement software, telescope, etc.)
  • Visual efficiency training to develop scanning skills
  • Support of eccentric viewing
  • Lamps with rheostats and adjustable arms
  • Reduced glare
  • High contrast line markers or templates for reading, finding math problems, or locating other information
  • Adapted color-dependent activities
  • Alternate methods for matching clothing
  • Frequent breaks from visual tasks

Retinitis Pigmentosa (RP)

A group of hereditary disorders causing degeneration of the retina

It is characterized by progressive loss of vision and reduction of visual fields, usually from the periphery inward. However, in some cases, central vision is affected first. RP may be associated with Usher’s syndrome, Leber congenital amaurosis, Laurence-Moon Biedl, and Bassen-Kornzweig syndrome. 

 

  • Loss of peripheral vision
  • Night blindness
  • Tunnel vision
  • Decreased acuity
  • Decreased depth perception
  • Blind spots (scotomas due to retinal scarring
  • Photophobia
  • May develop cataracts
  • May become totally blind
  • May be associated with myopia, vitreous opacities, cataracts, and keratoconus
  • Avoid contact sports and other high risk physical activity to prevent retinal detachment
  • High illumination
  • Reduced glare
  • NOIR lenses or overlay filters may be helpful
  • Video magnifier for maximum contrast
  • Night vision devices (e.g., Streamlight flashlights, Third Generation® Night Vision Devices, etc.)
  • Visual efficiency training in organized search (grid) patterns
  • Orientation and mobility evaluation at night and in dimly lit places
  • For central vision loss: magnification (e.g., hand-held magnifier, electronic magnifier, screen enlargement software, telescope, etc.)
  • For peripheral field loss: increase viewing distance to see more area.

Retinoblastoma

A rare type of cancer in which malignant cells grow in the retina

It usually develops in early childhood. The majority of children who develop this cancer have mutations only in eye cells (non-germinal). They will not pass on the mutation, and usually, retinoblastoma develops only in one eye. When the mutation occurs in all body cells (germinal retinoblastoma), the disease is hereditary. These children are more likely to develop retinoblastoma in both eyes, pineal brain tumors (trilateral retinoblastoma), and other forms of cancer anywhere in the body. Current treatments include surgery, radiation, and chemotherapy. Retinoblastoma can become life threatening if the tumor extends beyond the eye, so enucleation is frequently necessary.

  • Strabismus is one of the first signs of retinoblastoma.
  • Restricted fields due to removal of tumors
  • Blind spots (scotomas) due to removal of small tumors
  • With monocular vision, there is no depth perception and visual field is restricted.
  • Blindness
  • Medications can negatively affect residual vision.

 

  • Avoid contact sports and other high risk physical activity to prevent retinal detachment
  • Orientation and mobility evaluation at night and in dimly lit places recommended
  • May need visual efficiency training to develop scanning skills
  • Support of eccentric viewing
  • May need magnification (e.g., hand-held magnifier, electronic magnifier, screen enlargement software, telescope, etc.)
  • May benefit from access to auditory materials
  • May require instruction in tactile learning and braille

Retinopathy of Prematurity (ROP, retrolental Fibroplasia)

Incomplete development of the blood vessels of the retina

It occurs in premature infants. The vessels also may grow abnormally from the retina into the back of the eye. They may bleed into the eye, scar tissue may develop, and retinal detachment may occur. The major risk factors are degree of prematurity and low birth weight. There are five stages of ROP, ranging from mildly abnormal blood vessel growth in stage one to retinal detachment in stage five. ROP may be associated with other issues caused by incomplete development. Lasers or freezing (photocoagulation and cryotherapy) may be used to stop the abnormal blood vessels from continuing to grow. Also, surgery may be done to re-attach the retina. 

  • Retinal scarring
  • Decreased visual acuity
  • Severe myopia
  • Field loss
  • Partial or complete retinal detachment
  • Blind spots (scotomas)
  • Strabismus
  • Total blindness
  • May develop glaucoma

 

  • Early intervention and sensory stimulation
  • Avoid contact sports and other high risk physical activity to prevent retinal detachment
  • Nighttime orientation and mobility evaluation
  •  May need visual efficiency training to develop scanning skills
  • Visual efficiency training in organized search (grid) patterns
  • Adequate to high illumination (e.g., lamps with rheostats and adjustable arms)
  • Reduced glare
  • High contrast line markers or templates for reading, finding math problems, or locating other information
  • Frequent breaks from visual tasks
  • May benefit from access to auditory materials
  • May need instruction in tactile learning and braille
  • May benefit from magnification (e.g., hand-held magnifier, electronic magnifier, screen enlargement software, telescope, etc.)
  • Reduced glare
  • Night vision devices (e.g., Streamlight flashlights, Third Generation® Night Vision Devices, etc.)
  • Balance need for a larger viewing area with the need for magnification
  • Balance need for close viewing against the need for increased distance and a larger portion of the text/pictures
  • Adapted color-dependent activities
  • Alternate methods for matching clothing
  • Support of eccentric viewing

Retinoschisis

A degenerative disorder in which the retina splits into two separate layers, resulting in progressive loss of vision, beginning in the fields that correspond to the areas where the retina splits

The hereditary form (juvenile X-linked retinoschisis) affects mostly boys and young men. The more common form can affect both men and women, and it usually is acquired in middle age or older (senile retinoschisis). Both forms may be associated with cysts (sack-like blisters) that form a spoke-like pattern in the retina. Retinal detachments can occur, and if detected early, they sometimes can be repaired with surgery. Prismatic glasses may be prescribed to increase field of vision.

  • Strabismus
  • Nystagmus
  • Central field loss
  • Peripheral field loss
  • Reduced visual acuity
  • Reduced color discrimination
  • Blind spots (scotomas)
  • Blindness

 

  • Avoid contact sports and other high risk physical activity to prevent retinal detachment
  • May need visual efficiency training to develop scanning skills
  • May need visual efficiency training in organized search (grid) patterns
  • Adequate lighting (e.g., lamps with rheostats and adjustable arms)
  • Reduced glare
  • High contrast line markers or templates for reading, finding math problems, or locating other information
  • Frequent breaks from visual tasks
  • May benefit from access to auditory materials
  • May need instruction in tactile learning and braille

For central vision loss:

  • Nighttime orientation and mobility evaluation
  • Magnification (e.g., hand-held lighted magnifier, electronic magnifier, screen enlargement software, telescope, etc.)
  • High illumination
  • Night vision devices (e.g., Streamlight flashlights, Third Generation® Night Vision Devices, etc.)
  • Adapted color-dependent activities
  • Alternate methods for matching clothing

For peripheral field loss:

  • Increase viewing distance to see more area
  • Support of eccentric viewing
  • Balance need for a larger viewing area with the need for magnification

Rod Achromacy     See Achromotopsia

 

 

Scotoma (pl. scotomata, scotomas)

A portion of the visual field that is blind or partially blind and surrounded by relatively normal vision, depending on the presence of other eye conditions

Scotomas can occur in any part of the visual field. They can be caused by retinal disorders, tumors, stroke, or traumatic brain injury. 

  • May affect central or peripheral fields
  • Reduced acuity
  • May cause loss of detail
  • May cause photophobia
  • May cause reduced color vision
  • Visual efficiency training to develop scanning skills
  • Support of eccentric viewing
  • Seating and presentation of work should favor more functional eye
  • May need to use sunglasses, visors, or hats outdoors and indoors as well
  • Reduced glare
  • May need lighting from behind using adjustable lamps with rheostats and adjustable arms
  • Magnification (e.g., hand-held magnifier, electronic magnifier, screen enlargement software, telescope, etc.)
  • May benefit from enlarged printed materials
  • May benefit from close viewing
  • High contrast materials
  • High contrast line markers or templates for reading, finding math problems, or locating other information
  • May need adapted color-dependent activities
  • May need alternate methods for matching clothing

Septo-Optic Dysplasia See Optic Nerve Hypoplasia and "Syndromes"

 

 

Strabismus (muscle imbalance

Abnormal alignment of the eyes; an inability to look at the same point in space with both eyes at the same time

It can be caused by a defect in the extra-ocular muscles or in the part of the brain that controls eye movement. It can be hereditary, and it may be associated with brain tumors, cerebral palsy, Down syndrome, extreme farsightedness, cataracts, or having much better vision in one eye than in the other. Strabismus includes:

  • “phorias”– muscle imbalances that are controlled by the brain's efforts toward binocular vision. Not always present, they tend to manifest when the person is tired.
  • “tropias” - observable deviations that the brain cannot resolve. They are always present.
  • Eso – turned inward/nasal (esophoria and esotropia)
  • Exo – turned outward/temporal (exophoria and exotropia)
  • Hyper – turned upward (hyperphoria and hypertropia)
  • Hypo – turned downward (hypophoria and hypotropia)

Treatments can be effective for young children: eye exercises, occlusion of the better eye, medications, and surgery. Prismatic glasses may be prescribed to increase field of vision.

  • Impaired ability to achieve binocular vision
  • Decreased depth perception
  • Affects eye-hand coordination
  • Difficulty fixating
  • May have difficulty scanning, tracking, and tracing
  • Difficulty following fast-moving objects
  • Difficulty making eye contact

 

  • Orientation and mobility evaluation recommended, specifically for negotiation of drop-offs and stairs in unfamiliar places
  • Vision efficiency training in scanning, tracking, and tracing

 

Toxoplasmosis

Congenital or acquired inflammation of the retina and choroid (retinochoroiditis), which can cause retinal scarring

Toxoplasmosis is caused by infection with the toxoplasma parasite found in animal feces and unpasteurized milk. Unborn babies are most vulnerable to the infection, and it can cause damage to the brain, eyes, or other organs. Treatments include anti-inflammatory medications, photocoagulation (laser) therapy, and cryotherapy (freezing).

  • Scotomas
  • Peripheral field loss
  • Central field loss
  • Loss of visual acuity
  • Decreased color vision
  • Photophobia
  • Increased sensitivity to glare
  • Visual efficiency training to develop scanning and eccentric viewing skills
  • Reduced glare
  • May need lighting from behind using adjustable lamps with rheostats and adjustable arms
  • Magnification (e.g., microscopic lenses, electronic magnifier, screen enlargement software, telescope, etc.)
  • May benefit from enlarged printed materials
  • May benefit from close viewing
  • High contrast materials
  • High contrast line markers or templates for reading, finding math problems, or locating other information
  • May need adapted color-dependent activities
  • May need alternate methods for matching clothing

Trachoma

A contagious bacterial infection of the eyes and eyelids, causing scarring and buckling of the eyelids

This causes the eyelashes to turn under, which leads to corneal scarring. Repeated and prolonged infection causes permanent visual impairment and blindness. Trachoma is spread through direct contact with secretions from the eyes, eyelids, or nose of an infected person. It is the leading cause of preventable blindness worldwide.

  • Photophobia
  • Fracturing or scattering of light (as in looking through a broken windshield
  • Increased glare
  • Blurred vision
  • Reduced acuity
  •  
  • Sunglasses, visors or hats outdoors, and indoors as well
  • Reduced or diffused lighting from behind (e.g., lamps with rheostats and adjustable arms)
  • Front row seating with back toward windows
  • Reduced glare
  • High contrast materials
  • Magnification (e.g., hand-held magnifier, electronic magnifier, screen enlargement software, telescope, etc.)
  • Enlarged printed materials
  • Frequent breaks from visual tasks
  • Support of eccentric viewing
  • Auditory materials for long reading assignments
  • May need instruction in tactile learning and braille

Uveitis

Inflammation of the uveal tract (middle layer of the eye), which consists of the iris, choroid, and ciliary body

The most common form affects the iris, and it may be called anterior uveitis or iritis. The cause may be unknown. Known causes include autoimmune disorders, infection, toxoplasmosis, tuberculosis, and histoplasmosis. Complications can cause glaucoma and damage to the retina or cornea, leading to permanent vision loss.

  • Photophobia
  • Blurred vision
  • Floaters
  • Decreased acuity
  • Glaucoma
  • Retinal scarring
  • Corneal damage

 

  • High contrast materials
  • Reduced glare
  • Allow additional time for adjustment to new visual conditions
  • Use of lamps with rheostats and adjustable arms
  • May need visual efficiency training to develop scanning and eccentric viewing skills

Wilm’s Tumor (nephroblastoma)

Rare abnormalities of the eye, especially aniridia, related to a malignancy of the kidneys

Although the cause is sometimes unknown, this form of cancer can be caused by genetic changes, which also can be hereditary. Pinhole contact lenses and sunglasses may be prescribed.

See “Syndromes" for associated conditions.

  • Decreased acuity, further reduced by other conditions
  • Photophobia
  • Large pupil (misshapen)
  • With corneal involvement: Fractured light, increased glare, blurred vision
  • With cataracts: blurred vision, and decreased color vision
  • Fovial involvement: loss of detail vision
  • With glaucoma: fluctuating visual functioning, field loss, poor night vision, and decreased sensitivity to contrast
  • May have nystagmus
  • May have ptosis
  • Vision stimulation for infants to develop the visual cortex
  • Sunglasses, tinted contact lenses, visors or hats in bright light outdoors and indoors
  • Allow time for adjustment to lighting changes
  • Front row seating with back to windows
  • Reduced glare
  • Provide reduced or diffused lighting from behind
  • Lamps with rheostats and adjustable arms
  • Magnification (e.g., hand-held magnifier, electronic magnifier, screen enlargement software, telescope, etc.)
  • Use a blackboard and bold chalk
  • Use of bold, black markers on a white board
  • Felt-tipped pens and tinted paper with bold lines
  • Use of dark/black background
  • Provide copies of materials presented on the board.

January 2015

Staffing Pattern For Itinerant Teacher of Students with Visual Impairments

(Adapted from the Iowa Rules for Special Education)

When caseload sizes for itinerant teachers of students with visual impairments are not specified, it is recommended that the maximum caseload be established at 10 full-time equivalents (FTEs) with appropriate adjustments made through application of the formula specified for the following three factors:

  1. the number of students receiving direct services
  2. the number of students receiving consultation services
  3. average daily amount of time spent traveling.

While professional services and traveling time are qualitatively equivalent, both factors must be considered in applying the formula below.

Use the following formula to calculate caseload size for itinerant teachers:

It is [the State of Iowa's] recommendation that the maximum caseload for itinerant teachers of students with visual impairments be established at 10 full-time equivalents (FTEs) with appropriate adjustments made through the following formula.

Formula:

  1. Count each student receiving direct services as 1 FTE regardless of the amount of contact time.
  2. Count 5 students receiving consultative service as 1 FTE, using a fraction if necessary.
  3. Calculate the total number of hours spent traveling in performance of job duties during a typical week and divide by 5 to get the average daily amount of time.
  4. Count 1 hour of average daily traveling time as 1 FTE using a fraction if necessary.
  5. Add the numbers from (1),(2), and (4), above for the total FTEs.

The total FTEs should not exceed 10 for one full-time itinerant teacher of students with visual impairments.

Other factors influencing caseload size which are built into the formula include activities such as parent conferences, pupil staffings, consultation, assessment, evaluation, observation, records, and correspondence. Also included are the frequency and duration of contacts with students receiving direct services, time for professional development, and materials preparation.-

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

STATE/CONTACT

LAW/RULE

REQUIRED MATERIALS

FORMAT/SPECIAL INSTRUCTIONS, INCLUDING SECTION 508/DAISY DTBook

SUBMISSON DATE

ALABAMA

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

ARKANSAS

Sue McKenzie
Textbook Administrator
501/682-4593

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.

ARIZONA

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

CALIFORNIA

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

CONNECTICUT

Statute Sec 10-295

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

   

DELAWARE

Statute Sec 206-14

Print copy of all materials; electronic file on request

ASCII

Upon request

FLORIDA

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

GEORGIA

Kim Hartsell
Dept. of Special Ed.
404/362-2024

House Bill 228 Signed by Governor - Act 321

Textbook Adoption agreement

All recommended textbooks must be provided in electronic format.

   

HAWAII -

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

IDAHO

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

ILLINOIS

Charles Hayes
Principal Consultant
217/782-0734

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

INDIANA

Linda Dierstein
Textbook Adoption Coord.
317/232-9127

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

IOWA

Statute Sec 301.10

All textbooks requested by department

Best format for electronic Braille translation.

Not specified

KENTUCKY

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.

LOUISIANA

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

MARYLAND

Robb Farrell
MD School for the Blind
410/319-5715

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

MICHIGAN

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

MISSISSIPI

Statute Sec 37-23-199

Literary subjects; nonliterary subjects when technology is available.

ASCII

Accessibility

Within 10 working days of request

MISSOURI

Rosalee Backer
Dept. of Special Ed
816/373-5193

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

MONTANA

(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."

   

NEW MEXICO

David Bowman
505-827-1801

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.

NEW YORK

Laurie Munro
Office of Children& Family Services
518/474-6956

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.

 

NORTH CAROLINA

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

 

OHIO

Paul Mauro
ORCLISH
800/672-5474

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.

OKLAHOMA

Mary Boren
405/521-3456

Statute Sec 70-16-106-D

Literary materials; nonliterary when translation software is available.

ASCII

 

OREGON

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

SOUTH CAROLINA

Jim White
Textbook Program
888-202-3953

Contract

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

Electronic formats suitable for transcription into Braille.

Upon written request

SOUTH DAKOTA

NEW (2004)

14-1-66

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

TENNESSEE

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

TEXAS

Chuck Mayo
Textbook Accessibility Prog.
512/463-9606

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

 

UTAH

Shelley Kelson
801-538-7783

Statute Sec 53A-26-111

Literary materials; nonliterary when technology is available.

ASCII

On request

VIRGINIA

Beverly Thurston
Dir. Textbook Adoptions
804/371-2455

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

WEST VIRGINIA

Statute Sec 8-10J-5

Literary materials; nonliterary when technology is available.

ASCII

Not specified

Statewide Resources

Texas Interagency Task Force on Deafblindness

Other State Deafblind Projects

National Deafblind Resources

International Resources

General Resources

by Maurice Belote, Project Coordinator, California Deaf-Blind Services

Reprinted in the Fall 2002 PS News with permission from reSources published quarterly by California Deaf-Blind Services. 

The incidence of sexual abuse among persons with disabilities is staggeringly high, and yet abuse prevention is rarely addressed in school programs for these individuals. Teaching children who have multiple disabilities including deaf-blindness often requires creativity and the ability to adapt and modify existing materials and programs. When teaching abuse prevention, it may not be adequate to simply follow the same instructional objectives used among children without disabilities—don't talk to strangers, run away and tell a safe person if someone is trying to hurt you, etc. For a child who is deaf-blind, intervention will need to encompass many curricular domains, including the areas of communication, self-help, and social skills. The following strategies may be useful in creating an instructional program to address prevention of abuse and exploitation.

Start young.

Issues of sexuality begin at an early age, and instruction during these early years creates a foundation onto which everything else can be built. Some of the early skill areas that will assist in abuse prevention instructional activities include curiosity about the bodies of other people (children and adults), names and function of body parts, and public restroom behavior. In addition, this is the time to make children feel comfortable about talking to their parents or caregivers about personal issues. This comfort level—established at an early age—will be very helpful as the child passes through adolescence and young adulthood. Despite what we may think, national research consistently suggests that teenagers want to discuss these issues with their parents, and that adult-child communication is effective in decreasing sexual risk behaviors.

Know the people who interact with your child.

Sadly, most abusers aren't strangers, but people who know their victims: friends of the family, neighbors, service providers, etc. If a situation doesn't feel right, trust your instincts and intervene. An Internet resource can be found at http://www.sexoffender.com that provides a database searchable by state and also a guide to Megan's Law (don't accidentally type sexoffenders—plural—or you will go to an adult material website). And while vigilance is important, there is probably no need to be overly suspicious of everyone who interacts with children. The vast majority of friends, neighbors and service providers are caring people who would never put a child's safety and well being at risk.

Make sure skills are generalized.

When teaching abuse prevention skills, use the same methods that help ensure that all skills are generalized—teach the skills in multiple locations and settings, with multiple people, and at various times of the day and night. A significant component of skill acquisition is testing to determine if the skill is truly mastered and generalized. Don't assume that a child will perform in a certain way if she or he has demonstrated the skill in a contrived setting with familiar adults. You may need to set up a situation where the child must demonstrate mastery in an unfamiliar setting with unfamiliar people.

Teach terminology, including slang.

It may be difficult for an individual to relay information about abuse or mistreatment if the person lacks a way to communicate this clearly. Building vocabulary regarding body parts and action words is an important step to providing the individual with a communication system that will last a lifetime. It may also be necessary to specifically address the use of slang. For example, an individual who isn't knowledgeable of widely used slang terms for genitalia and sexual acts is more vulnerable because of their lack of sophistication, even if they know the proper "medical" terms for the same things.

Respect privacy; and insist that others do so too.

It is important that we provide children with significant disabilities the same respect and dignity we give all people. It may be necessary to teach the concept of modesty, and be certain that this instruction respects individual family values and norms. For children who require help with daily living, issues of privacy and modesty may be complicated by situations where adults and even peers are providing assistance with physical care needs that require intimate physical contact. One way to handle this, from an early age, is to ask the person's permission before helping with intimate or invasive tasks. If requesting permission is established early and consistently, the person who is receiving help is much more likely to feel she or he is in control of their body, and in control of where they are touched and by whom they are touched.

Teach appropriate behaviors.

We want to teach our children and students to act in the same way we expect others to when those others interact with our children. For example, we want our children to resist if other people try to touch them in inappropriate places on their bodies. This will be difficult to teach if these same children have been allowed to touch others in those same places. The goal is to establish norms, so that behaviors outside of these norms are clearly viewed as such.

Put it in the IEP.

Don't assume that goals and objectives discussed in the IEP meeting will be implemented if they are not part of the written plan. It isn't necessary to includeeverything in an IEP, but too often there is a reluctance to include items in IEPs that are out of the ordinary domains such as functional academics, gross/fine motor, communication, etc. If a particular skill is very important to you, do not accept an explanation that instruction in this skill doesn't need to be written into the IEP because it will be addressed all the time throughout the child's program. The IEP is the family's assurance that a skill will be addressed, and also provides a forum for discussing mastery towards the goal at subsequent IEP and team meetings. For service providers, IEPs provide concrete plans, and help maintain consistency between programs and staff members during times of transition or instability.

Originally published in See/Hear Newsletter, Winter 2008
Versión Español de este artículo (Spanish Version)

By Courtney Stevens, High School Student with Visual Impairments, Houston, TX

Key words: Family wisdom, blind, self-determination, student led IEP meetings

Abstract: A young lady who is a sophomore in High School shares her experiences in learning to lead her own IEP meeting, and gives other students with visual impairments suggestions on how to be successful with their own.


Leading your own ARDs is not something that will just happen over night for most people. It takes time. You really need to go to your own ARDs and sit in and watch how they work before you can really get an idea on how to lead them.

Leading the ARD is tricky; you never know how the teachers, parents, or really how anyone else will respond to the student taking charge. Sometimes it can be okay with no problems and no one will be upset or feel threatened. I myself have never been in a kind of situation where anyone feels this way. I am a normally very shy person. So for me leading my own ARDs, at first, didnt seem like something I could do.

I started attending my own ARDs young, when I was in 4th grade. At my very first ARD I didnt talk much, just agreed when it was right to do so. As I got older I saw the flaws in this, and had to step up. Once I started in middle school my mother was no longer able to attend my ARDs. The school saw this as an opening and would try to place me into classes that I would not want to be in. So I stepped up and started to fight back against things that didnt seem right for me because honestly in most cases I think the student knows what is best for their own needs. My VI teacher, Ms. Elizabeth Eagan, had a better idea of how to help me along this path than I did. Now I am about to enter my second year of high school and I can lead my ARD from beginning to finish.

When a student decides or shows that they want to start trying to lead their own ARD meetings, I think that some parents and/or teachers see it as the students dont really know whats best for them. Some parents may not want to let go of that control for whatever reasons they may have. Teachers may not see things on the same level as the student and not understand why they are asking for whatever it is they are asking.

Students, here is my advice to you. One, make goals before going into your ARD and have good reasons to back them up. I can not explain to you how important this is! Two, if you want something changed or modified let teachers and/or parents know, because if you keep it to yourself it will never change on its own. Third, if you ask for something to be changed and someone kind of just looks over it without paying attention to what you said bring it up again and explain why you want this and why you think it will help you. If you are still looked over do not be afraid to fight for what you want if you really think it will help you. Just ask the other ARD members why they are looking over what you said or why they do not want to listen to what you suggested. Try to convince them this is a good thing, and if they do not see it your way, talk to othersyour parents, your VI teacher, other teachers, whomever you think could help.

Now parents, if you see that your child is starting to show that they can or would want to lead their own ARDs, do not discourage them! Support them. Help them in any way you can, and if you need help, try talking to you childs VI teacher. They are the VI teacher for a reason. Also if you see that your childs VI teacher is not letting them lead their own ARDs, talk to them about why they are doing that. The same also goes for teachers. If you see your student trying to lead the ARD, do not put them down, but instead try to help them! Students more than likely need all the help they can get in something like an ARD, because they wont really know what is going on or how to say what they want. All I can really say is: students, open up, do not be shysay whats on your mind. Teachers and parents listen to them and help them. If they told you something they want to be done, dont say it for them. Let them bring it up and help them to say it to everyone.

New concern arises from:

  1. Full Independent Evaluation processor or
  2. Expressed concern by staff or
  3. Teacher

Step 1

The school nurse conducts hearing screening. Was the concern about the hearing loss validated by the hearing screening?

If YES or if COULD NOT TEST

Staff requests ARD and collects information:

  1. ARDPreparationListWhenHearingLossisSuspected(AppendixB-2)
  2. TeamconductsInformalAuditorySkillsInventory(AppendixC-2).
  3. TeacherofDeaf&HardofHearingiscontacted(TEAQ&A–AppendixE)

If NO:

Hearing loss is ruled out. No additional information is needed at this time.

Step 2

At ARD to consider new assessment:

  1. Team discusses the need for audiological and communication
  2. Team develops Audiological Testing Plan with support from the TD&HH
  3. Obtain parents’ permission for the additional assessment.
  4. TVI collaborates with the TD&HH to complete the communication assessment making sure to address the impact of the vision loss on the child’s access to their preferred communication form and amends the FVE/LMA as needed. Reference these articles:
  • Issues Regarding the Assessment of Vision Loss in Regards to Sign Language, Fingerspelling, Speechreading and Cued Speech
  • Making Sure the LMA, FVE and Communication Assessments Address Dual Sensory Loss

Step 3

All assessment is completed. ARD committee receives all results.

If YES:

The ARD Committee:

  1. Considers educational need and deafblind eligibility. (Deafblind Checklist). Questions about identifying the student as deafblind should be directed to Regional Deafblind Specialist or to the Texas Deafblind Project.
  2. Amends related services, accommodations, adaptations and modifications as needed (see Documenting Adaptations, Accommodations, Modifications, and Related Services in the IEP for the Student with Deaf-Blindness)
  3. Amends IEP goals and objectives as needed. (Reference the IEP Quality Indicators for Students with Deafblindness)
  4. Paperwork is completed by designated school to add student to Texas Deafblind Child Count and submitted to Regional Deafblind Specialist.

If NO:

Hearing loss is ruled out. If there is still concern, the audiologist will make a referral for medical follow-up and/or consider testing for CAPD.  Otherwise, no additional information is needed at this time, but results must be reported back to ARD committee.

New concern arises from:

  1. Full Independent Evaluation process or
  2. Expressed concern by staff or parents about possible vision loss or
  3. New medical information or
  4. Teacher

Step 1

School nurse conducts vision screening. Was the concern about the vision loss validated? NOTE: If Vision Loss Quick Check indicates possible field loss, current screening may not address this type of loss – Continue to step 3.

If YES or Could Not Test, Staff requests ARD and collects information:

  1. Preparation for ARD When Vision Loss is Suspected (Appendix B-1)
  2. Team conducts Informal Vision Skills Inventory (Appendix C-1).
  3. Teacher of the Visually Impaired (TVI) is contacted (TEA Q & A – Appendix E)

If NO:

Vision loss is ruled out. No additional information is needed at this time.

Step 2

At ARD to consider new assessment:

  1. TVI is invited to ARD
    • Team requests VI eligibility information including but not limited to: eye doctor’s report, FVE and
  2. Team develops Vision Testing Plan before eye doctor’s visit with informal support from the Teacher of the Visually Impaired–Appendix D-1
    • Obtain parents’ permission for additional assessment
  3. Following receipt of eye doctor’s report, TVI and TD&HH collaborate to complete the FVE/LMA and to review the Communication Assessment for needed

(Note: In completing the FVE/LMA and reviewing the Communication Assessment it must be determined if vision loss impacts access to the child’s preferred communication form in any educational environments.) Reference the following articles:

  1. Issues Regarding the Assessment of Vision Loss in Regard to Sign Language, Fingerspelling, Speechreading, and CuedSpeech–AppendixF
  2. Making Sure the LMA, FVE and Communication Assessments Address Dual Sensory Loss – Appendix G

Step 3

All assessment is completed. ARD committee receives all results. Is vision loss confirmed?

If YES:

ARD committee:

  1. Considers educational need and deafblind (Deafblind Checklist Appendix Questions about identifying the student as deafblind should be directed to Regional Deafblind Specialist or to the Texas Deafblind Project
  2. Amends related services, accommodations, adaptations and modifications as needed (see Documenting Adaptations, Accommodations, Modifications, and Related Services in the IEP for the Student with Deaf-Blindness)
  3. Amends IEP goals and as (Reference the IEP Quality Indicators for Students with Deafblindness)
  4. Paperwork completed by designated school to add student to Texas Deafblind Child Count

If NO:

Vision loss is ruled out. If there is still concern, the ophthalmologist will make a referral for medical follow-up. Otherwise, no additional information is needed at this time, but results must be reported back to ARD committee.

(Originally published in the June 1994 edition of VISIONS)

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

By Debra Sewell, Teacher Trainer, TSBVI, VI Outreach


Although children play purely for pleasure and not for any goal-directed purpose, they acquire numerous skills during play; Creating fantasies, pretending, interacting with others, moving their bodies, and exploring their environment provide many opportunities to learn. It is important to keep in mind, however, that many children with visual impairments and/or multiple impairments will need to learn "how" to play with toys and games appropriately, as they don't learn this by watching others.

Many games encourage children to develop basic cognitive concepts, e.g. recognition of letters, numbers, colors, shapes, and textures, while also promoting important social skills, such as taking turns, interacting with peers, and participating in group activities.

The following is a list of a few games and skill areas. These are readily available in toy stores and can be played by most blind children with no special adaptations.

Game

Skill Area

Simon Auditory Memory
Perfection Fine Motor
Cootie Fine Motor
Don't Spill the Beans Fine Motor
Hot Potato Social Interaction

 

Musical/auditory toys are important for a visually impaired child as they offer auditory feedback and stimulation. There are many commercially available musical toys that are designed for a wide range of developmental levels. Chime toys, music boxes and musical instruments are good for developing fine motor skills and wrist rotation, and also learning about cause and effect.

Tool

Skill

Keyboards Finger Strength and Finger Isolation
Wind Instruments Lip Closure and Breath Control
Instruments to tap (e.g. drums, sticks, blocks, etc.) Bimanual Control
Instruments to Shake Cause and Effect Concepts
See 'n Say Bilateral Hand Use
Spinning Tops Arm and Hand Strength
Jack-in-the-Box Wrist Rotation
Busy Poppin' Pals Various Hand Skills

The selection of games is very important. The games should be aimed at the appropriate developmental level of your child, and adaptations should be made so they are suitable for a particular child, if necessary. Most importantly, the games should be playable with nondisabled peers.

In addition to using games that need no modifications, there are numerous adaptations that can be made to games that will allow blind and visually impaired children access to a wider range of recreation/leisure activities.

Some of these adaptations are:

  1. Divide sections of game boards with glue, or various textures.
  2. Add braille labels to sections of game boards.
  3. Use velcro in sections of game boards and on bottoms of playing pieces.
  4. Braille the instructions and the game cards 
  5. Tape record game instructions.
  6. Braille regular playing cards or game cards such as Uno.
  7. Use textures or glue to mark differences in game pieces.
  8. Add brightly colored stickers to game pieces and game sections.
  9. Mark dice with braille labels or glue dots.
  10. Make a Tic-Tac-Toe board with a cake pan and magnet strips.
  11. Divide checkerboard with glue and mark red playing pieces with texture.
  12. Play Tic-Tac-Toe with pegs and pegboard.
  13. Use a large box lid to define playing space.
  14. Keep score with peg boards, paper clips clipped to index cards or tokens dropped into a container.

Most of these ideas are for adapting commercially available games. Adapted games such as Scrabble, Bingo, Tic-Tac-Toe, Checkers and large print and braille playing cards are also available through the following distributors:

American Foundation for the Blind
11 Penn Plaza, Suite 300
New York, NY 10001
(212) 502-7600
(800) 232-5463

American Printing House for the Blind
1839 Frankfort Ave.
Louisville, KY 40206
(502) 895-2405

Childcraft
(800) 388-3224

(Originall published in Spring 2005 SEE/HEAR Newsletter)

By Alaine Hinds, Deafblind Family Leadership Participant and TAPVI Co-Chair, LaPorte

Abstract: Pick up on some wonderful tips for supporting parents while their child is in the hospital.

Keywords: Family, blind, deafblind leadership, hospital tips


No matter how prepared I try to be before any surgery or scheduled hospital stay, I always seem to get caught off guard. There is always the unexpected stay after day surgery or the longer than usual stay in the hospital. During these times, I depend heavily on my family and friends. I find that my friends who also have children with special needs seem to be able to tune into what I most need during these trying times. Most of them have been in similar situations and can relate. Here are some suggestions on making any stay in a hospital a pleasant one for a friend and their family.

For major surgery or hospital stays, always consider what you may want and probably forgot. One of the best presents I ever received was a multi-pocketed bag put together by my Sunday School class before my daughter had hip surgery. We anticipated a 5-hour surgery followed by a 2-day hospital stay. The bag contained several bags of chips for the nervous parents who were afraid to leave to get breakfast for fear that we would miss a call from the operating room. Gum and mints were tucked inside as well as change to be used in a vending machine. Pain reliever, Tums, and chewable Pepto-Bismol helped to calm our nervous stomachs and headache. A magazine and short book of “mommyisms” helped to pass the time and did not require too much concentration. Some samples of perfume and make-up helped me always appear presentable as the days wore on. A nail file was included and turned out to be the most used item. A small toothbrush and toothpaste was included. Pen and paper were handy to jot down what the doctor said and remind us of additional questions we wanted to ask. Cards of encouragement and support from members of the class reminded us that a lot of people were pulling for us and a lot of prayers were coming our way.

Additional things I would include would be a pair of socks. Is it my imagination or is it always that cold in the hospital at night? A long distance calling card comes in handy if your friends have family out of the area that they may want to update. Hospital rules usually do not allow people to use cellular phones inside of the hospital and I find that I am always afraid to step away from the waiting area or my child’s side. Cheap phone cards can now even be found in “dollar” stores.

I have found that it is difficult to eat in a hospital if your child is young and needs someone in the room at all times. I am usually reminded to eat and at that point-anything tastes good. Microwave popcorn is one of my favorites. Microwaves can be found at the nurses’stations, in waiting rooms and sometimes near vending machines. You can also buy some pretty good microwave meals that do not require refrigeration. Drinks become very expensive if you have to rely on the vending machines. A six pack of their favorite soft drink can be put over ice that is available at the nurses’ station. For those who cannot function without coffee, you can purchase single servings of a variety of instant coffees or teas. Hot water can be obtained from the nurses’ station or waiting rooms. Speaking of food, the quick delivery of take out to the hospital is always appreciated. Check with the nurses and they can tell you what is available and what they recommend. I have picked up food and delivered it to my friend’s room or in a pinch, pulled up to the lobby and had them meet me to get their hot food. You can also prepay to some delivery pizza places and let them deliver. If the parents are in the hospital for more than a few days, food not prepared at the hospital is a real treat.

After the hospital stay, most of us will agree that it is great if someone stops by with a meal or brings a few fresh groceries. We are usually so exhausted from our hospital stay and are truly in need of quick and easy food. Even a bucket of chicken means I don’t have to cook that night. Someone who offers to quickly vacuum or dust in my home is never turned down. Video or DVD rentals are also appreciated so the family can relax at home together.

Let’s not forget about any siblings who may be feeling left out and confused. A small present for them helps to ease their tension. Offers to watch the siblings or bring them to visit in the hospital are greatly appreciated by the parents. If they are unable to visit, I sometimes offer to take a digital picture of the child with their parents to e-mail to the siblings to assure them that their brother or sister is doing okay. It helps them to feel included and understand what is happening at the hospital. A disposable camera can also be left at the hospital to capture and document the hospital stay. I wish I had thought to take pictures after various surgeries to put in my daughter’s scrapbook later.

I think most of us always remember to bring something special for the patient. It could be a rattle or teether for a baby, a coloring book or paint with water for a child, or a book or video for a teenager. Many hospitals have VCRs and Playstation or Nintendo available to be used by the patients. For children with no vision or the ones who have had eye surgery, magnetic playsets, play dough, talking storybook or a musical toy would be appreciated.

These are just some thoughts about what you may do to help a friend through their hospital stay. You can never go wrong if you put yourself in their shoes and do what you would want someone to do for you. If their stay turns out to be longer than anticipated, stop by their house and pick up clean clothes or buy them a new T-shirt. Ask them if they need anything. Most of us appreciate the help and support our friends give us. Your thoughtfulness and kindness can make a difficult time more bearable. Your friendship is needed most during these hospital stays.

By Craig Axelrod, former Teacher Trainer, TSBVI, Texas Deafblind Outreach

Abstract: Educators can have more positive, responsive and reciprocal interactions with their students who are deafblind by learning how to modify their own interactive behaviors and adapt the interactive context. High quality interactions contribute to improved educational outcomes for students with deafblindness.

Key Words: programming, blind, deafblind, Jan van Dijk, research-based, interaction, behavior, communication, educator-oriented intervention, instructional strategies, video analysis


"Interaction is defined here as the process by which two individuals mutually influence each other's behavior." (Janssen, Riksen-Walraven & van Dijk, 2003b, p.198).

During a visit to Texas School for the Blind and Visually Impaired (TSBVI), Dr. Jan van Dijk suggested that a team from the school review recent research about interactions with students who are deafblind, then develop a process for sharing the information with other educators and helping them put its principles into practice. This article (which first appeared as a two-part article in the Fall 2004 and Winter 2005 editions of SEE/HEAR) summarizes research-based conclusions about interactions with students who are deafblind, and describes the educator-oriented training process developed at TSBVI that incorporates these findings.

A Summary of Current Research: Interaction Problems and Possibilities

Many in the field of deafblindness intuitively value and try to maintain high quality interactions with students who are deafblind. As research continues to validate the role of interaction in attachment, security, relationships, learning and communication, the need for educators of students with deafblindness to develop their interaction skills becomes more apparent. Appreciating the importance of positive interactions is a step in the process. Improving the quality of one's own interactions with students who are deafblind is a bigger challenge.

Typical development

"It is a universal trait of our species that mothers have the innate skill of mothering. They are able (and it seems that this is similar in all cultures) to provide the newborn child with warmth and security. Mothers feel that the newborn child needs a safe harbor for exploration." (van Dijk, 1999, p.1). "Children who are securely attached to their caregivers have a secure base from which to explore the environment... Children see individuals to whom they are securely attached as available and responsive... Secure attachments are built when caregivers are sensitive and responsive to the infant's communications... Positive interactions occur as the caregiver and the infant respond to each other... The infant sends cues, the caregiver responds, and the infant responds in turn. Each partner learns the rules of turn-taking from the feedback of the dydactic partner." (van Dijk & Nelson, 2001, p. 18). "Given that interaction is the 'vehicle of communication,' it is obvious that harmonious (smooth, balanced and finely attuned) interactions are indispensable to develop high-quality communication." (Janssen, et al., 2003b, p. 198).

"Harmonious interactions and their importance have been characterized in various terms. Attachment theorists emphasize the importance of sensitive responsiveness: A sensitive caregiver is keenly aware of a child's signals, interprets them accurately, and reacts promptly and appropriately so that the child feels understood. During such harmonious interactions, the child learns to trust the caregiver's availability as a source of emotional comfort and support." (Janssen, et al., 2003b, p.198). Dr. van Dijk has referred to this quality of sensitive responsiveness as "IT." This is how he once described IT. "I have been looking all over the place to find a CD-ROM fragment of Suzanne with her mother interacting. Mother wants her to clap her hands, but S. wants her to touch her lips. Mother adjusts her intention to S.'s request. This is IT." (personal communication, October 18, 2002).

"Harmonious caregiver-child interactions have been found to relate to later socioemotional development in various empirical studies... a secure infant-parent attachment relationship - which clearly relates to sensitive parenting - predicts various developmental outcomes for children up to late adolescence... early harmonious interactions influence the development of brain structures and brain functions that mediate the future regulation of emotions, adaptation to changing circumstances, and ability to cope with stress... Particularly, the sharing of high levels of positive affect during interactions appears to have beneficial effects on early brain development." (Janssen, et al., 2003b, pp. 199-200).

The impact of deafblindness

"Children who are deafblind often require considerable time as they establish relationships with others and become comfortable in new environments... The ability of children with severe multiple disabilities to develop secure attachment and turn-taking social interactions may be threatened by multiple factors including: (a) time spent in intensive care units separated from their parents, (b) severe health problems which may have limited physical contact with caregivers, (c) low levels of arousal and an alert state that is not long enough for attachment to occur, (d) extremely elevated levels of arousal that lead to over-stimulation, (e) communicative cues that are atypical and difficult to read, and (f) limited ability to read caregiver cues (e.g., if vision is limited, the young child may not be able to imitate the social cues of his caregiver such as a smile and he may not know when he should take his turn in a social interaction)." (van Dijk & Nelson, 2001, pp. 4, 18-19).

Interactive challenges

"Various studies have indeed shown both deafblind children and their parents to encounter serious difficulties with their interactions. The visual impairments of the children greatly affect quality of the children's interactions with their parents. Eye contact, reading facial expressions, or mutually gazing at the same object are virtually impossible. Lack of responsiveness or over-sensitive reactions such as 'slipping away' in the children may cause feelings of disappointment or frustration in the parents... Auditory stimuli are not well-perceived or processed by deafblind children due to sensory-neural impairment. They may respond very little, not at all, or even negatively to voices and other sounds. Caregivers are therefore dependent on touch and proprioceptive stimulation to keep the interaction going... Rowland (1984) showed the mothers of multiple handicapped visually impaired children to encounter difficulties with the regulation of turn-taking and to inconsistently respond to the vocalizations of the child... Preisler (1996) found deafblind children to elicit contact with their parents by means of body movements, facial expressions, and vocalizations. The children can also take part in joyful interactions, mostly in the form of body games. It is nevertheless difficult to read signals of deafblind children. Their movements and expressions are often very subtle or vague and unfold at a much slower pace when compared to those of sighted and hearing children. Use of idiosyncratic signals and forms of communication by the deafblind can easily lead to misunderstandings." (Janssen, Riksen-Walraven & van Dijk, 2002, pp. 88-89). "The attachment process described by Bowlby (1969), through which the child develops a secure bonding with his primary caregiver allowing him/her to explore and access new opportunities for experience and learning, is endangered in children with multiple disabilities due to the described difficulties in establishing readable signaling systems." (Amaral, 2003, p. 4).

"For educators, the first hampering factor in building harmonious interactions is the lack of natural skills to participate in the deaf-blind world of touch and proximity".

In her study of the communicative interactions between children with multiple disabilities and their teachers, Amaral (2002) concluded that teachers do not spontaneously develop the interaction and communication skills that are necessary for responding to the needs of such children... The educators of deaf-blind children are often not fully aware of the importance of developing harmonious interactions before they focus on understanding the children's message or on further developing communication and language." (Janssen, et al., 2003b, pp. 198, 201). "When the educator of deafblind individuals lacks the insight and skills to understand the world of the deafblind child, one can observe how the individual retreats into himself, avoids touching objects, and attempts to cope with his 'unbalanced organism' by exhibiting stereotypic behaviours." (van Dijk, 1999, p. 2). "Professional educators, such as teachers, classroom-assistants, and the residential staff face the same interaction problems as the parents and sometimes even more serious problems. The educators typically start interacting with the deafblind children at a later age than the parents, which means that many of the children have already developed a number of idiosyncratic and 'difficult' behaviors that can hamper further interaction." (Janssen, et al., 2002, p. 89). "The final factor that is known to hamper harmonious interactions with deaf-blind children holds particularly in institutional settings (schools and residential facilities) and concerns continuous changes. While professional educators regularly rotate from one class, home setting, or group in a residential facility to the next and thus from one deaf-blind child to another, the risk of disharmonious interactions increases with each switch, particularly when the professionals have not been sufficiently introduced in the new work setting and too many staff changes occur at the same time." (Janssen, et al., 2003b, p. 202). "It is obvious that when a child, whose emotional balance is easily disturbed, is provided with many different caregivers, it is hard, if not impossible, for the foundation of security to be laid." (van Dijk, 1999, p. 3). "Given that the principles of individuals' communication and interaction are often not well recorded, the risk of disharmonious interactions following such staff switches increases." (Janssen, et al., 2003b, p. 202).

Adult-dominated interactions

Rick van Dijk and his colleagues noted, "In normal language development, one would expect a parent or a professional teacher to leave the initiative in communication to the child and to respond in a contingent way whenever the parent or teacher felt that it was possible for the child to take the initiative. Only in this manner does the child have the opportunity to explore his or her communicative possibilities... Communication will only lead to language development if the child is enabled to actively take part in communication... we know that parents often have a tendency to control interaction with a deaf child because they cannot fully understand the utterances of the child. Although understandable, this control is in itself detrimental to language development. The more parents try to control the responses of a child, the turn-taking interaction, and especially the topic of conversation, the more slowly language development will proceed. There is solid empirical evidence that use of a less controlling interaction style by parents facilitates not only higher-quality interaction between parents and deaf children but also the process of language development... there is no reason to think that this is not also the case in children who are deafblind." They suggested that "...if one studies interaction and communication, and most certainly if one studies these processes in relation to the facilitation of language development, one will also want to study aspects such as initiation of interaction, contingent and noncontingent reactions of communication partners, and the functions of interactive turns." (Vervloed, van Dijk, R., Knoors & van Dijk, J., 2006, pp. 337, 343).

A study was designed to analyze the interactions between a teacher and his 3-year-old student with congenital deafblindness. The primary research question asked, "...to what extent it would be possible for the teacher to attend to the deafblind child's initiatives and responses and respond appropriately, with contingent interaction patterns thereby resulting... Three target activities that offered many opportunities for close interaction were chosen for the present study... These events were selected because they recurred daily and fit in the schedule of daily routines for this boy. It is widely accepted that such daily routines foster effective interactions and enhance memory processes." Videotaping the observations was considered necessary "...because otherwise it is extremely difficult to notice all the potential communicative signals exhibited by the deafblind child." (Vervloed, et al., 2006, pp. 337, 338).

"Over a period of 4 months, a total of 16 hours of recordings were made during bathing, dressing, and playing... specific events were chosen for video recording in order to capture the most favorable conditions for the elicitation of social interaction and communication.... Three criteria were used to determine if a scene would be included in the study: 1. Both the teacher and the child should be within reach of the camera. 2. The recordings should be of good quality. 3. There should be a period of communicative activity lasting at least several seconds." Of the original recordings, "...less than 2% of the recording time contained prolonged interactions between teacher and child... most of the failures were due to the teacher being too far away from the child to be able to communicate properly or due to the total absence of prolonged communication periods between the two." (Vervloed, et al., 2006, pp. 338, 340). Video fragments that met the criteria were reviewed, and each of the teacher's and student's interactive behaviors were assigned to one of six main observational categories:

  1. The child acts to influence the teacher's behavior
  2. The child reacts to the teacher
  3. The childs actions are not in response to the teachers initiatives, or there is no response
  4. The teacher acts to influence the childs behavior
  5. The teacher reacts to the child
  6. The teachers actions are not in response to the childs initiatives, or there is no response. (Vervloed, et al., 2006, p. 339).

The authors then counted the frequency of these interactive behaviors and analyzed the transitions between them, to learn more about the teacher and childs current interactions, and to predict the nature of their future interactions. If interactive behaviors of the teacher and/or child didn't change, it was likely, with varying degrees of probability, that the characteristics of their interactions would remain the same. They concluded, "The amount of interaction was representative of normal daily interactions between this teacher and deafblind boy... only a limited portion of the time when the teacher and deafblind child were together was devoted to communication and interaction... There existed a true interaction between teacher and child, although each frequently missed the initiatives of the other... Both teacher and child did not respond significantly to each other's responses... the number of teacher initiatives exceeds the number of responses considerably." They also speculated "...that interaction between the partners stopped after one response." From this study, the authors determined that "&it is possible to quantify interaction between teachers and deafblind children and that this can be accomplished in a way that gives insight into the elements of the interaction and communication processes that are important for the development of language." (Vervloed, et al., 2006, pp. 341, 342).

Consequences of disharmonious interactions

"It is likely that the emotional and behavioral problems of deafblind children are at least partially due to the difficulties they experience, from birth on, in their everyday interactions with caregivers. High quality interactions with primary caregivers who sensitively respond to normal children's signals and needs have been found to foster a sense of security and competence in the children and to positively affect both their social and personality development in later years. In contrast, children with insecure attachment relationships reflecting a history of disharmonious interactions with their primary caregivers have been found to be at risk for development of disorders such as problems in self-regulation, depression, and conduct disorders... Given that the interactive signals of deafblind children are often subtle and difficult to interpret, they are frequently missed or misunderstood by caregivers. As a result, children tend to intensify their signals, express frustration via self-abuse or aggressive behaviors or both, and withdraw into stereotypic behaviors or passivity. Such 'inappropriate' behaviors can then elicit inadequate responses from the caregivers, with the risk of both the caregiver and child getting caught in a downward spiral." (Janssen, et al., 2002, pp. 88, 90).

Educator-oriented intervention

Dr. Marleen Janssen and her co-authors designed an educator-oriented intervention program to improve the quality of interactions between deafblind children and their professional educators. To determine the program's effectiveness, their research questions were, "(1) Does the intervention produce an increase of appropriate [educator] responses and a decrease of inappropriate [educator] responses to the interactive behaviors of the children? (2) Does the intervention result in an increase of appropriate interactive behaviors and a decrease of inappropriate interactive behaviors on the part of the children? (3) Is the intervention effective with different educators and in different situations?" (Janssen, et al., 2002, p. 90).

After identifying appropriate and inappropriate child behaviors, and appropriate and inappropriate educator responses, "First, the educators were trained to respond more appropriately to the children's interactive behaviors. Second, the educators were trained to adapt the interactive context to facilitate the occurrence of appropriate interactive child behaviors. Such adaptations were as follows: (1) offering communicative aids [in an] orderly [way], (2) offering choices, (3) removal of distracting stimuli, (4) removal of stimuli not wanted by the child, (5) attuning activities to child's abilities (sensory or motor), and (6) demonstration of appropriate interactive behaviors to the child." (Janssen, et al., 2002, p. 94).

The study concluded that "...it is possible to improve the interactive competence of deafblind children by teaching their educators to respond more appropriately to [the children's] interactive behaviors. In three of the four target children, both an increase in appropriate interactive behaviors and a decrease in inappropriate interactive behaviors were observed. The intervention also proved to be effective for different educators across various situations." (Janssen, et al., 2002, p. 104).

Development of an intervention model

As a continuation of their earlier work, Dr. Janssen and her colleagues developed "a diagnostic intervention model as a guide for designing and conducting interventions to foster harmonious interactions between deaf-blind children and their educators in various settings - The intervention is educator oriented and thus aimed at achieving the goals of intervention for the children who are deaf-blind by changing the behaviors of their educators." (Janssen, et al., 2003b, pp. 197, 208).

In this model, the behaviors of both the child and educator are assigned to one of eight core categories of interactive behavior. "The definitions of the categories are adapted for the purposes of an intervention and are translated into concrete behaviors per individual case." (Janssen, et al., 2003b, p. 207). The eight core categories of behavior "&are as follows:

  1. Initiatives: starting an interaction or raising something new as part of a reaction
  2. Confirmation: clear acknowledgement that an initiative has been noticed and recognized
  3. Answers: positive (approving) or negative (disapproving) reaction to an utterance of the partner
  4. Turns: turn taking, or becoming the actor, and turn giving, or allowing the other to become the actor
  5. Attention: focus on the interaction partner, the content of the interaction, and the people and/or objects within the interaction context
  6. Regulation of intensity of the interaction. For the educator: waiting while the deaf-blind child regulates the intensity of the interaction. For the child: appropriate regulation of intensity by, for example, withdrawing (turning his or her head away) or some other individual signal (such as laying his or her hand on the partner's hand) and apparent processing of information, and inappropriate regulation of intensity by, for example, self-abusive or aggressive behaviors
  7. Affective involvement: mutual sharing of emotions
  8. Independent acting. For the educator: acting with no focus on the child. For the child: executing actions independently (e.g., putting a garment or part of a garment on alone)." (Janssen, et al., 2003b, p. 207).

"On the basis of video analyses, the educators learn to recognize a deaf-blind child's signals, to attune their own interactive behaviors to those of the child, and to adapt the interactive context to promote the occurrence of certain target behaviors... The intervention is evaluated in terms of the intervention aims and the occurrence of particular behaviors before and after intervention." (Janssen, et al., 2003b, p. 208).

A companion study summarizes the successful implementation of the intervention model described above, with six congenitally deafblind children and adolescents, and their teachers, caregivers and parents, in different settings and interactional situations. (Janssen, Riksen-Walraven & van Dijk, 2003a).

Research to Practice: The Interaction Training Process at TSBVI

Based on the research summarized above, and other resources, Kim Conlin, Tish Smith (communication specialists at TSBVI) and I designed a two-day training for TSBVI educational staff. At this time (February, 2008), seven trainings have been facilitated at TSBVI, with four participants in each training. Regional trainings in two other Texas cities have also been held.

When determining who will be invited to participate in interaction training, we consider interested staff who are teaching students with deafblindness and understand the basics of good programming, such as structuring a routine and using a calendar system. They have interactive challenges with their students that we want to address. Staff may also be teaching newer students we want to better understand. The students represent a variety of abilities and needs.

Introduction to the training model

The educator-oriented learning goals of interaction training are to:

  • Understand the role of high quality interactions in early development
  • Understand the challenges to high quality interactions with children who are deafblind
  • Identify student-specific factors that impact interactions
  • Recognize the components of interaction
  • Analyze the interactions between adults and students who are deafblind
  • Identify and implement intervention strategies that improve the quality of those interactions

Several weeks before interaction training, participants are asked to notice and think about the interactions they have with their students, then bring those observations and questions to the first day of training. As the training progresses, and more is understood about the unique characteristics of deafblind children, interactions with deafblind children in general, and with their students in particular, concerns, goals and possible intervention strategies for improving the quality of those interactions become more refined and specific.

On the first morning of training, after introductions and clarification of the learning goals, information is presented about interaction problems and possibilities of students who are deafblind. To help exemplify these ideas, participants view and discuss the videotaped interactions between a student and three adults. The three interactions are clearly very different, and the student's abilities also seem to differ. An Interaction Data form is introduced as a tool to help graphically represent those differences.

Interaction data

The Interaction Data form codes these components of an interaction:

  • Description of Turns: Each interactive turn is briefly described. This enables the people coding to quickly match information seen on the video to its corresponding location on the Interaction Data form.
  • Interactive Turns: Each turn is assigned a letter, A-F, based on the six observational categories identified by Rick van Dijk and his colleagues.
    1. Student Initiates: the student's action is directed at the adult in order to influence the adult's behavior
    2. Student Responds: the student responds to the adult
    3. Student Acts Independently or No Response: the student acts without an intent to influence the adult's behavior, or does not respond to the adult
    4. Adult Initiates: the adult's action is directed at the student in order to influence the student's behavior
    5. Adult Responds: the adult responds to the student
    6. Adult Acts Independently or No Response: the adult acts without an intent to influence the student's behavior, or does not respond to the student
  • Connecting Consecutive Turns: Arrows are drawn between "related" consecutive turns, reflecting the duration of an interaction on a particular topic.
  • Interactive Behaviors: Each turn of the student or adult is then assigned one or more numbers, 1-8, corresponding to behaviors that describe the turn's interactive qualities. These interactive behaviors are adapted from the eight core categories of behavior as defined by Marleen Janssen and her colleagues.
    1. Initiatives: starting an interaction or bringing up something new as part of an answer
    2. Confirmation: clear acknowledgement that a partner's action has been noticed and recognized
    3. Answers: a positive or negative response to the partner
    4. Turn Taking: becoming the actor
    5. Turn Giving: allowing or encouraging the partner to become the actor
    6. Attention: focusing on the partner, the content of the interaction, or the individuals and/or objects within the interactive context
    7. Regulation of Intensity of the Interaction: for the student ' appropriate or inappropriate interaction; for the educator ' waiting while the student regulates intensity, or regulating behaviors that influence the student's intensity (such as proximity to the student [e.g., nearer, further away], pacing [e.g., faster, slower], animation [e.g., facial expression, size of movement], voice [e.g., inflection, volume] and amount or type of touch [e.g., frequency, degree of forcefulness])
    8. Affective Involvement: sharing positive emotions with the partner
    (If during an interactive turn, the student or adult "acts independently or gives "no response," C or F, no interactive behaviors are credited.)

Interaction Data form

Interaction Data form (75k)


Interaction Data

Student's Name:

Date:

Adult's Name:

Topic:

Interactive Turns:

A - Student Initiates; B - Student Responds; C - Student Acts Independently / NR; D - Adult Initiates; E - Adult Responds; F - Adult Acts Independently / NR

Interactive Behaviors:

1 - Initiatives; 2 - Confirmation; 3 - Answers; 4 - Turn Taking; 5 - Turn Giving; 6 - Attention; 7 - Regulating Intensity; 8 - Affective Involvement

Connect "related" consecutive turns with arrows

Interaction Data Form
Description Of Turns

 

 

 

 

 

 

 

Interactive Turns

 

 

 

 

 

 

 

Adult's Interactive Behaviors

 

 

 

 

 

 

 

Student's Interactive Behaviors

 

 

 

 

 

 

 


B is 19 years old and has microcephaly secondary to an encephalocele (a congenital protrusion of the brain through a cranial fissure). He's legally blind with a cortical visual impairment, is suspected of having a hearing loss, and has multiple disabilities that include mental retardation and cerebral palsy.

Coded video fragments from B's three interactions are analyzed, to identify and compare components of the interactions that reflect their different characteristics and result in his varying degrees of interactive competence. This activity also familiarizes participants with the Interaction Data form. Later in the training, they will use the form to code and analyze video fragments of their own interactions.


Interaction Data

Student's Name: B

Date: 5/02

Adult's Name: Teacher

Topic: Physical Therapy - Therapy Ball

Interactive Turns:

A - Student Initiates; B - Student Responds; C - Student Acts Independently / NR; D - Adult Initiates; E - Adult Responds; F- Adult Acts Independently / NR

Interactive Behaviors:

1 - Initiatives; 2 - Confirmation; 3 - Answers; 4 - Turn Taking; 5 - Turn Giving; 6 - Attention; 7 - Regulating Intensity; 8 - Affective Involvement

Connect "related" consecutive turns with arrows

Student B Physical Therapy - Therapy Ball
Description of TurnsTeacher unbuckles seatbelt Teacher takes towel Teacher says "Let's get out of the chair," etc. Teacher stretches B's arm Teacher says "There you go." Teacher stretches B's fingers Teacher picks up B to reposition

Interactive Turns

F

 

F

 

D

 
F
 
D
 
F
 
F

Adult's interactive Behaviors

------

 

-------

 
1
 
------
 

2

 
------
 
------

Student's interactive Behaviors

                         

B and the teacher - stretching on the therapy ball: The teacher talks to B twice in this fragment, but acts independently during the other turns. He prepares to move B, positions him on the therapy ball and stretches parts of his body with no interactive behaviors, no expectation for B to take a turn and no connected turns.


Interaction Data

Student's Name: B

Date: 5/02

Adult's Name: Aide

Topic: Eating

Interactive Turns:

A - Student Initiates; B - Student Responds; C - Student Acts Independently / NR; D - Adult Initiates; E - Adult Responds; F- Adult Acts Independently / NR

Interactive Behaviors:

1 - Initiatives; 2 - Confirmation; 3 - Answers; 4 - Turn Taking; 5 - Turn Giving; 6 - Attention; 7 - Regulating Intensity; 8 - Affective Involvement

Connect "related" consecutive turns with arrows

Student B Eating
Description Of TurnsAide waits, then offers spoon B takes a bite Aide wipes B's mouth B chews and swallows Aide offers spoon B refuses bite Aide puts down spoon and gets milk cup
Interactive Turns
D
image006
B
 
F
 
C
 
D
related to next cell to the right
B
related to next cell to the right
E
Adult's Interactive Behaviors
1, 4, 6, 7
     
------
     
1, 4, 6, 7
     
2, 4, 6
Student's Interactive Behaviors    
3, 4, 6
     
-------
     
3, 4, 6
   

B and the teacher aide - eating lunch: The aide is attentive to B, and waits until he's ready before offering a bite of food. B responds once by accepting the spoon (answering "Yes") and once by rejecting it (answering "No"). When he refuses the food, she confirms his response by putting down the spoon and getting the milk cup. Turns in both of these sequences are connected. She acts independently by wiping his mouth. There is no observed enjoyment (affective involvement) of the interaction.


Interaction Data

Student's Name: B

Date: 5/02

Adult's Name: Visitor

Topic: Conversation

Interactive Turns:

A - Student Initiates; B - Student Responds; C - Student Acts Independently / NR; D - Adult Initiates; E - Adult Responds; F- Adult Acts Independently / NR

Interactive Behaviors:

1 - Initiatives; 2 - Confirmation; 3 - Answers; 4 - Turn Taking; 5 - Turn Giving; 6 - Attention; 7 - Regulating Intensity; 8 - Affective Involvement

Connect "related" consecutive turns with arrows

Student B Conversation
Description Of TurnsB vocalizes Visitor says "What?" B extends finger in lap Visitor says "There goes that finger to the nose." Visitor extends and lifts finger to nose, says "Hey&" B lifts finger to nose Visitor lifts finger to nose and says "Hey&"
Interactive Turns
A
related to next cell to the right
E
related to next cell to the right
B
related to next cell to the right
E
related to next cell to the right
E
related to next cell to the right
B
related to next cell to the right
E
Adult's Interactive Behaviors    
2, 5, 6
     
2, 4, 6, 8
 
1, 2, 4, 6, 8
     
2, 4, 6, 8
Student's Interactive Behaviors
1, 4, 6
     
1, 4, 6
         
4, 6, 8
   

B and a visitor - having a conversation: B initiates the interaction by vocalizing. The visitor responds by asking "What," which confirms B's initiative and gives him a turn. B introduces a new initiative by extending the index finger of a hand in his lap (preparing to touch it to his nose). The visitor takes a turn, and confirms B's initiative, by saying "There goes that finger to the nose." He also shows affective involvement with facial expressions and tone of voice. The visitor then expands on B's initiative by extending his own index finger, positioning it under B's other hand, raising B's hand and saying "Hey" each time he (the visitor) touches it to his own nose. His affective involvement continues. B responds by lifting his finger, touching it to his nose, and smiling. The visitor takes a turn, and confirms B's actions, by laughing, saying "Hey" and touching his own nose again. B and the visitor are attentive and responsive to each other throughout the interaction. All turns are connected.

General Profile

Prior to training, participants develop General Profiles of their students, by compiling information about them that may impact the quality of their interactions. This includes:

  1. Medical/Sensory Information:
    • etiology
    • medication(s)
    • vision (near and distant acuities, fields, and other visual considerations)
    • hearing (functional implications of hearing loss with and without amplification, and recommendations)
    • touch (hand guiding, tactile instruction, mutual tactile attention, tactile signing, etc.)
    • primary and secondary sensory learning channels
  2. A "Communication Assessment [based on the communication model developed at TSBVI for nonsymbolic and early symbolic students with visual and multiple impairments, including deafblindness]:
    • Form: the vehicle for conveying meaning; nonsymbolic to symbolic
    • Social Aspects: these include the social skills and communicative functions which impact the quality of the student's interaction with other people
      • Social Interaction Skills: maintaining joint attention, bonding with primary caregivers, initiating an interaction, turn taking, etc.
      • Functions: requesting, rejecting, commenting, labeling, reporting on past events, etc.
    • Communicative Content: what the student has to talk about
      • Topics: the specific subjects of interaction or conversation which emerge from the student's experiences with varied objects, people and events; swimming, snack, bathing, skating, etc.
      • Meaning Categories: the broad divisions for organizing topical knowledge. They provide a framework for teaching concepts and vocabulary; objects, actions, people, locations, attributes, etc.
      • Context: the situation in which communication occurs; here and now, past or future events, unfamiliar situations, etc." (Hagood, 1997, pp. 6-7).

    The Communication Assessment often includes a description of the student's calendar system, which, among its many benefits, plays "an important role in supporting and expanding students' communication." (Blaha, 2001, p. 10).

  3. Present Levels of Educational Performance, especially in the areas of:
    • Language Arts
    • Social Communicative Interactions
    • Emotional Development
    • Organization - Senses and Motor Skills
    • Basic Concepts
    • Representation/Cognition
    • Other (such as behavior)
  4. Instructional Modifications: Examples include fine task analysis of activities, highly structured routines and learning environment, special materials to structure activities, extended time for processing, increased response time, concrete symbols, tactile symbols and special communication systems.
  5. Appetites/Aversions (Likes/Dislikes): "One sheet is completed for each student. Over a period of time, through observation and listening to stories from others, a list is developed of things the student likes and doesn't like. We all enjoy things that we are good at and that we understand. A student's 'Likes' will be areas of strength and indicate sensory channels that are working. 'Dislikes' will be areas of weakness and indicate sensory channels that may not be working efficiently. The information gathered on this form will suggest underlying themes that can be used for modifications, teaching strategies, topics of communication, and activities. (van Dijk, 1985)." (Blaha, 1996, p. 20).

After the video fragments of B's three interactions are analyzed, participants review their students' General Profiles and summarize them to the group.

Video analysis

Within a few weeks of training, a baseline videotape is made of each participant/student pair engaged in an interaction. (Participants are taped interacting with the same students on the second day of training.) When determining what to videotape, participants are asked to consider these criteria:

  • They are 1:1 with their student
  • Interaction (rather than independence) is a component of the activity
  • The activity is, or has the potential to be, mutually enjoyable and/or satisfying
  • The activity is familiar and occurs at least a few times every week
  • The activity can be repeated during the training

After the General Profile summaries are shared, each baseline video is reviewed in its entirety, to provide an overall sense of the activity, and to identify general participant and student interactive strengths and challenges. A brief fragment from each video highlighting these qualities is selected for coding and analysis. The fragment is coded on the Interaction Data form, then analyzed to identify aspects of the interaction that are successful and those that may be contributing to interactive problems. Based on this analysis, participants discuss ways their interactions might be improved, by changing their own interactive behaviors, and by adapting the interactive context. Changes in student behavior that might indicate improved interactions are also identified. For example:

  • If coding indicates that most interactive turns progress from adult initiations to student responses (D to B), strategies that might encourage more student initiations followed by adult responses (A to E) are identified
  • If few interactive turns are connected by arrows, indicating only brief interactions around topics, increased adult responsiveness to the student's interests could result in more turns on those topics
  • If an adult's interactive behaviors are predominantly initiatives (1) and turn taking (4), attention (6) to a student's actions, confirmation (2) of those actions, turn giving (5), regulating the intensity of the interaction (7), by slowing the pace or pausing, and affective involvement (8) may encourage the student to make more initiatives (1). Additional student interactive behaviors that would reflect a more preferred interaction include attention (6) and affective involvement (8)

On the second day of training, participants are videotaped with their students, as they incorporate new intervention strategies into the same activities that were taped for the baseline. Videos of these interactions are then reviewed, representative fragments are coded and analyzed, and strategies are further refined for future implementation.

At the end of the second day, to conclude interaction training, participants discuss what they've learned. They also describe how they will apply the principles of interaction training, in other situations with the same students and with their other students.

What we learned: 4 case studies

Matt and J

J is 13 years old and deafblind due to prematurity. He is totally blind and has a severe to profound hearing loss, bilaterally (moderate when amplified).

J expresses interest and affection for his primary caregivers by smiling, laughing or hugging. He initiates familiar interaction routines when an adult is nearby. He maintains preferred, turn taking interactions for a long time. In stressful situations, these people can calm him with deep pressure hugs, redirection to a preferred activity, or by reviewing his schedule and giving him more time to process information.

J knows 125 receptive signs, and uses more than 60 expressive signs to request activities, interactions, assistance, and information about the day. These signs are often inexact, but recognized by familiar people. He'll place his hands in the adult's hands, sign "now" to ask about what's happening next, and sign "then" to ask about the day's sequence of activities. He is beginning to comment about past and future events. J recognizes at least 50 tactile symbols that represent activities on his calendar, identify possessions and activity areas, etc. He also uses them to choose between people, food and leisure activities.

J has a daily calendar, with an expansion strip that gives additional information about the "who," "what" and "where" of each activity, and a weekly calendar with a highlighted activity scheduled on each day. It's important to review J's daily schedule with him throughout the day, especially in the morning. J anticipates and completes "next steps" in familiar routines.

J's favorite topics are movement, food, sounds or music, and activities that incorporate these interests. He enjoys knowing what his peers are doing, attends to their actions if they're close and, with support, will pass them materials in structured routines.

J may express frustration about changes in the schedule by refusing conversation, banging his head or crying. He often calms after multiple reviews of the new schedule, along with additional support and reduced demands.

Matt's goal was for J to communicate more spontaneously during his daily calendar discussions. The coded baseline video fragment indicated that Matt had nice interactive behaviors, such as confirmation, turn giving, attention and affective involvement, but he initiated most turn sequences and J primarily responded (D to B). Matt decided to be more responsive to J's initiations (A to E) and initiatives. It was thought that J might initiate more if he was encouraged to get his tactile symbols from the storage bag in the order they interested him, rather than prompted to get them from the slantboard behind his calendar in the order they occurred. After a conversation about each activity, he'd put its symbol on the slantboard. When all of the activities had been discussed, the symbols would be brought from the slantboard and scheduled left to right on J's daily calendar.

These are the strategies Matt introduced in the second taping

  • Encourage J to get his tactile symbols from the storage bag in the order they interest him, rather than prompt him to get them from the slantboard in the order activities occur
  • Respond to J's initiation of touching a tactile symbol (A to E) by touching it with him (confirmation, attention), then identify/label and comment (confirmations, answers) about the activity represented by that symbol before putting it on the slantboard
  • Sign the word "Now" (turn giving) after a response, to emphasize anticipation that J will bring up something new about the activity being discussed (initiative), or get another symbol (initiation)
  • Use a third person standing behind J to help model initiations and initiatives for him

When Matt first implemented these strategies, the new expectations seemed to confuse J a little, but he did initiate more, especially when Matt gave him turns by waiting, signing "Now" or showing him the bag of calendar symbols. J also had more initiatives on topics, and Matt was more responsive to those initiatives. J wasn't always sure what to do with the symbols he selected. The strategy of putting them on the slantboard before they were scheduled on his calendar was confusing, and needed to be further modified. Nevertheless, J continued to initiate and make initiatives on topics that interested him, sometimes with Matt's hands!

After the training, Matt replaced the slantboard with a carpeted tray that is positioned on his lap, between him and Jarvis (adapting the interactive context). He also changed the "Now" sign to an open handed "What?" gesture (turn giving), as encouragement for J to add something new to the current topic (initiative). Using a third person to model initiations and initiatives was awkward, and discontinued.

These new strategies have resulted in even more initiations and initiatives from J. Now he shakes all of his daily symbols onto the tray, and hands Matt symbols in the order they interest him. Matt responds by identifying, labeling and commenting about each activity, and helping J schedule the symbols on his daily calendar. He also gives J turns to make new initiatives on a topic. When all of the symbols have been discussed and scheduled, Matt and J preview the entire calendar sequence.

Laura and L

L is 21 years old and has CHARGE Syndrome. He recently lost all of his vision, and has a profound bilateral hearing loss. L also has a history of perseverative, aggressive, destructive and mildly self-injurious behaviors, which are being treated with medication.

L enjoys interactions, forms bonds with adults and peers, and asks about them when they're not present. He expresses affection toward preferred people and encourages them to communicate with him. Before becoming totally blind, L initiated interactions by sight. He's now learning to get people's attention by tapping their arms or raising his hand, but interactions are usually initiated by others.

L has many topics of conversation, and an expressive vocabulary of approximately 200 signs, which he typically combines in 2-3 word phrases. He initiates conversation, in structured and unstructured situations, to request objects, activities, assistance and people, and to make comments. L also requests information about things that have happened in the past and will (or might) occur in the future.

L participates well in structured routines, has preferences and makes clear choices. L has a daily calendar with the sequence of his daily activities and a monthly calendar for scheduling important events, such as which weekends he's going home or staying on the dorm, when he's going grocery shopping or to a restaurant, etc. Before losing his vision, L used standardized pictures, drawings, photos and some sight words with his calendar, for cooking recipes and other sequences, to label storage areas, etc. Calendar activities are now represented by object symbols and some alternate objects. Tactile symbols are gradually being introduced at the calendar and in a few other situations.

L is able to move about in his classroom without assistance, and has learned to travel many familiar routes independently. He's learning an organizational system for his calendar symbols and other symbols.

Laura's goal was to have a more "connected" interaction with L during his footbath routine, which she knew he enjoyed. In the past, L had often introduced conversational topics unrelated to the activity at hand. After losing his vision, he was constantly asking questions about current and former classmates (what they would be doing in 100 days, whether they were flying home that weekend or riding the bus, etc.). This also occurred during his footbath.

The baseline videotape reflected a chaotic conversation, with Laura and L both initiating on different topics. (Laura communicated about the footbath while L asked about other students.) Only two or three turns were taken on the same topic. One person would initiate, the other would respond then initiate about something else (D to B to A to E to D to B to A to E, etc.).

Laura wanted to increase the number of L's initiations around mutually interesting and less repetitive topics. She also wanted them both to have more turns (initiatives, turn taking, turn giving) around those topics. This would be represented on the coding with more turns connected by arrows, indicating that Laura and L were taking multiple turns on the same topic.

Laura's strategies were to:

  • Make the footbath more mutually interesting (attention, affective involvement) by introducing novelty, such as wearing a toe ring
  • Label the environment to reduce the need for "procedural communication" such as giving directions
  • Share the activity more wholly with L by having her own footbath next to him. This would give her an additional role (besides helping L, answering his questions and following his commands), creating opportunities for them to help each other and comment about their mutual experience
  • Encourage L to have more contact with the objects used in his footbath routine. This would enable him and Laura to increase their interactions around those objects

L smiled and enjoyed himself (affective involvement) during the second videotaped interaction. He and Laura took several turns around the same topic (more arrows!), and she was more responsive (confirmation, attention, affective involvement) to his initiations and initiatives.

Introducing novelty to a topic helps L pay attention to it. Setting up the environment to give tactile procedural information, such as storing materials in consistent places and labeling storage areas (adapting the interactive context), reduces the need to tell him what to do, where to go, etc. He and Laura can then put more emphasis (attention) on mutual enjoyment (affective involvement) of the interaction. Laura will also begin using objects and parts of objects to support L's expanded conversation about other interesting topics (parties, changes in the schedule, etc.), introduce more tactile symbols in the environment, and add tactile symbols of people to his daily calendar.

Hank and S

S was born prematurely and is 9 years old. He has light perception in one eye and a moderate to severe hearing loss. He drinks Pediasure from a bottle and does not eat solid foods.

S will initiate interactions when a partner is near, but most interactions are initiated by others. He recognizes familiar people and initiates interaction games specific to each of them. He encourages (requests) interactions with others by smiling, laughing, signaling, repeating their words, taking and giving turns, saying "Thank you," and giving hugs. He can maintain interactions for up to 10 minutes on topics that incorporate music or movement, and will interact around topics with other sensory aspects (such as inflating and deflating balloons to feel the air, and imitating the sounds they make) for shorter periods of time. Some topics (for example, food and oral stimulation) appear to trigger strong negative reactions that disrupt interaction. He discourages (rejects) these interactions by gently pushing away people or objects. S is drawn to the sensory experience of touching Hank's hair with his palms and face. If those behaviors last longer than 5 seconds, they seem to cause sensory overload, which results in S hitting Hank and biting himself on the arm.

When S does not feel in control, he tries to end an interaction by saying "Finished," or turning away from the activity. He is often less focused and more nervous in new environments or with novel materials. Information is taught within routines, which increases S's sense of security and ability to focus. Novelty is infused into familiar routines to broaden his understanding of concepts and vocabulary. A divided choice board is used to present options within routines.

S understands numerous phrases spoken consistently in his routines and a few signs produced without speech. He can process signs and speech simultaneously. S expressively signals with his body and voice, hand guides adults, gives them objects, and is beginning to request leisure activities with tactile symbols during structured choice times. These symbols are stored in an accessible place so he'll be able to initiate requests. He uses mitigated echolalia (repeating phrases previously heard in appropriate contexts for communicative purpose), and often repeats an adult's spoken words immediately after hearing them.

S's morning or afternoon activities are represented by tactile symbols in a 5-compartment calendar box. Expansion strips are used to pair two tactile symbols in each compartment, introducing the concept that familiar words can be combined in novel ways. Touch prompts remind him to scan left to right. Materials in S's routines are also sequenced in a calendar box, to provide additional structure and give him practice scanning left to right.

Hank was comfortable following S's lead during preferred interactions, such as playing with a balloon. He chose to analyze S's grooming routine because he wanted experience implementing intervention strategies during more outcome-oriented routines. Hank's goals were to feel calm during his interactions with S, be less directing, and follow S's lead more often.

  • Help S stay engaged (attention) without becoming overstimulated (regulation of intensity of the interaction), by slowing the pace, using a quieter voice, focusing on feeling calm, and providing deep pressure to S's arms with lotion
  • Make the routine more conversational, by pausing (turn giving), allowing S to introduce something new (initiatives), observing (attention), and appropriately responding (confirmation, positive answers, turn taking) to those initiatives

During the second interaction, Hank felt calmer, the pace was slower, and the routine was more conversational. He commented and paused more, S had more initiatives, and he was more responsive to those initiatives. Simple, familiar labels spoken in a rhythmic manner ("jaw, jaw, jaw," "chin, chin, chin," "lip, lip, lip") helped S stay organized, focused (attention) and calm (regulation of intensity of the interaction). Hank's sound effects and funny voices also kept S engaged (affective involvement). When Hank modeled toothbrushing, he was able to redirect S from his hair to his face before S became overstimulated (regulation of intensity of the interaction). While deep pressure to S's arms seemed to help calm and organize him, he showed signs of being overwhelmed by the lotion. Hank got a lot of information about how S was feeling by watching his hands (attention). This helped him fine tune his responses.

Hank will keep interactive turns short in situations where S might become overstimulated, and be sensitive to what his hands are "saying" during interactions (attention, regulation of intensity of the interaction). He'll incorporate rhythmic, turn taking vocal games into interactions, to help S stay engaged, focused, organized and calm (attention, regulation of intensity of the interaction, affective involvement). He will continue to give S deep pressure, but no longer use lotion, and ask the OT for additional calming and focusing strategies. Hank will also continue inviting S to introduce initiatives, by commenting then pausing.

Sara and N

N is 9 years old. She had a corpus callosotomy (surgical severing of the corpus callosum, the large fiber bundle that connects the two sides of the brain) at 4 years of age, to control seizure activity that began at 4 months. She has a cortical visual impairment and a suspected mild to moderate hearing loss. Without amplification (which she does not tolerate wearing), "She will at least be able to detect speech at a normal conversational level."

N bonds quickly with her primary caregivers. These relationships are reinforced through resonance-level turn taking interaction routines, in which frequent pauses allow her to signal for continuation of the interaction. N is affectionate with familiar people, seeks them out and allows them to calm her when she becomes upset. Vibration, deep pressure touch and vestibular stimulation help calm N and enable her to attend. N will explore unfamiliar experiences with the people she trusts. Unexpected touching and guiding through movement may overstimulate her.

N receptively understands some object symbols, natural gestures and points. She will move toward, touch, or physically guide people to desired objects, actions and locations. An object symbol placed in a single compartment calendar basket helps N anticipate the "next" activity in her day. She demonstrates recognition of those symbols by performing appropriate actions on the objects or moving toward the correct activity areas. The symbol is placed in a "finished" basket to conclude the activity. N shows a general awareness of the time of day by, for example, going to the breakfast table after arriving at school in the morning, and getting her jacket in the afternoon as she anticipates going home. She recognizes her classroom, calendar area, seat at the table and possessions.

A 3-step sequence box is used in some routines, such as breakfast, to help N anticipate the sequences of steps and to establish clear beginnings and endings. With other routines (for example, hygiene) she chooses the order of steps in the sequence. In general, N is more willing to participate in activities that have become familiar, when high demand activities are followed by those with low demand, and if she is allowed to observe and join in without being forced, then retreat and process the input. She is less distracted in learning environments where visual and auditory clutter is reduced.

Sara's goals were to increase the length, and improve the quality, of her interactions with N during functional routines. She selected a hygiene routine to analyze.

After studying the baseline video, Sara decided to:

  • Put more emphasis on creating and maintaining a positive social atmosphere and less on getting the job done (regulating the intensity of the interaction, affective involvement)
  • Increase the number of turns on N's topics (C to E and A to E)

During the second interaction, Sara was more responsive to N's topics (confirmation, positive answers, turn taking, turn giving, attention, affective involvement), and less focused on completing the routine. When N needed to take a break and process information, Sara let her do this. By allowing these pauses, and providing calming proprioceptive and vestibular input at other times, Sara helped N manage her own biobehavioral state (attention, regulating the intensity of the interaction). The interaction lasted longer, and N stayed in the activity area. There were also more arrows between turns, indicating longer periods of connectedness within the activity, and the turns were often on N's topics (C to E to B to E, etc., or A to E to B to E, etc.). When N signaled a request (initiatives, turn taking), Sara responded (turn taking, positive answers), then gave N another turn (turn giving). During toothbrushing, N let Sara touch the toothbrush (turn giving), which she usually doesn't allow, and was attentive (attention) to Sara's imitation (confirmation, positive answers) of her actions. N and Sara both enjoyed this interaction (affective involvement).

The most effective way to support an interaction on N's topic is to pause (turn giving), observe (attention) her independent or interactive behavior, imitate that action (confirmation, positive answers, turn taking), then pause again (turn giving) so she can take another turn. This verifies to N that her initiative has been acknowledged and approved.

Since the training, N has begun initiating and maintaining interactions from further away (indicating that she seems to be moving into a coactive phase of interaction), and attending for longer periods of time, sometimes for as many as 10 turns. The hygiene routine now goes on for quite a while, and sometimes must end before N is ready, so she can participate in other scheduled activities. When N is allowed to initiate interactions on topics of her choice, even within functional routines, and the adult responds positively to those topics, she more willingly participates on the adult's topics at other times.

Enduring effects

In a recent study, Dr. Marleen Janssen and her colleagues found "...that it is possible to improve the interactive competence of deafblind children by teaching their educators to respond more adequately to the children's signals and to adapt the interactional context." (Janssen, Riksen-Walraven & van Dijk, 2004, p. 88). They also concluded that "...the positive effects of the intervention were retained for two children and diminished but nevertheless remained well above the baseline level for two other children." (Janssen, et al., 2004, p. 89). In addition, these positive effects endured even after staff changes were made following the intervention. This was attributed to training provided by previous staff to new staff, and consisted of "...two components: a) the new staff member observes an educator working with a child and is given information by the educator; b) the new staff member is later coached by the educator while working with a child. While not instructed to do so, the current staff apparently transferred the principles of the intervention to the new staff members via either explicit teaching or having the new staff observe their improved interactions with the deafblind children." (Janssen, et al., 2004, p. 89-90).

At TSBVI, continuity in the implementation of student-specific intervention strategies is maintained with videotapes and written summaries from interaction training, ARD documentation that incorporates information learned during the training (communication assessment recommendations, IEP objectives, instructional modifications, etc.), end-of-the-year videotapes, instructional support staff who provide services to the same students for multiple years (especially communication and behavior specialists), and previous classroom staff, who may be teaching other students on campus but are available to assist new team members. Continuity is also provided by past interaction training participants, who have generalized their understanding and application of interaction principles and intervention strategies.

Participant feedback

"These intensive trainings are extremely useful. Observing and analyzing oneself on video is so important. It always amazes me to see things that I'm not even aware of doing, or not doing. It is also useful to get feedback from a variety of people. Everyone has an opinion about how to make an activity better."

"I was shown how to effectively communicate with my student, as well as how to increase his participation during activities. I liked being able to discuss my student with the other participants, share instructional challenges and frustrations, and brainstorm together. Through our discussions, and the information that was provided, new solutions and strategies were discovered."

"I'll carry away valuable information that will help enhance the quality of my interactions with my students. Being aware of your own interactions, consciously thinking about them, can help improve them."

"I will be more aware of possible initiations by my students, and remember the importance of having both physical and emotional presence during activities. The coding helped me break down interactions, and showed how even a student's most seemingly insignificant gesture may be an attempt at communication."

"I received a lot of helpful information about what a good interaction should look like and feel like; giving and taking turns, etc. I will introduce more novel routines, and label the environment so I can be there to comment, instead of always being the one to provide information. The before and after videos with my student showed me that positive interaction is possible, and that we can both enjoy the activity."

"I will be more aware of my interactions with my students, and mindful about allowing maximum opportunities for student initiation. I really appreciated and valued the opportunity to evaluate my performance, to set goals and to see them being achieved. It helped respark my enthusiasm to try new ideas and see how they benefit my students. It also encouraged me to focus on the positive aspects of my teaching. Sometimes it's easy to see only the negative."

Conclusion

We hope this information has motivated you to take a closer look at your own interactions. Learn more about the unique characteristics that impact your deafblind student's ability to interact. Analyze your interactions. Recognize and celebrate the qualities that are successful, and identify specific ways to improve the interactions, by changing your interactive behaviors and by adapting the interactive context. Remember, you make the difference.

References

Amaral, I. (2003). Analyzing teacher/child interactions: What makes communication successful? Paper presented at the Communication is the Key to Opening Doors Worldwide XIII DbI World Conference. Mississauga, Canada.

Blaha, R. (2001). Calendars for students with multiple impairments including deafblindness. Austin: Texas School for the Blind and Visually Impaired.

Blaha, R. (1996). Thoughts on the Assessment of the Student with the Most Profound Disabilities. SEE/HEAR Newsletter, Fall 1996, Vol. 1, (#4), 13-21.

Hagood, L. (1997). Communication: A guide for teaching students with visual and multiple impairments. Austin: Texas School for the Blind and Visually Impaired.

Janssen, M.J., Riksen-Walraven, J.M., & van Dijk, J.P.M. (2002). Enhancing the quality of interaction between deafblind children and their educators. Journal of Developmental and Physical Disabilities, 14, 87-109.

Janssen, M.J., Riksen-Walraven, J.M., & van Dijk, J.P.M. (2003a). Contact: Effects of an intervention program to foster harmonious interaction between deaf-blind children and their educators. Journal of Visual Impairment & Blindness, 97, 215-228.

Janssen, M.J., Riksen-Walraven, J.M., & van Dijk, J.P.M. (2003b). Toward a diagnostic intervention model for fostering harmonious interactions between deaf-blind children and their educators. Journal of Visual Impairment & Blindness, 97, 197-214.

Janssen, M.J., Riksen-Walraven, J.M., & van Dijk, J.P.M. (2004). Enhancing the interactive competence of deafblind children: Do intervention effects endure? Journal of Developmental and Physical Disabilities, 16, 73-94.

van Dijk, J. (1999). Development through relationships: Entering the social world. Proceedings of the Developing Through Relationships XII DbI World Conference. Estoril, Portugal: Casa Pia de Lisboa.

van Dijk, J., & Nelson, C. (2001). Child-guided strategies for assessing children who are deafblind or have multiple disabilities. Sint-Michielsgestel, the Netherlands: IvD/MTW, AapNootMuis.

Vervloed, M.P.J., van Dijk, R.J.M., Knoors, H, & van Dijk, J.P.M. (2006). Interaction between the teacher and the congenitally deafblind child. American Annals of the Deaf, 151, 336-344.

By Craig Axelrod, Teacher Trainer, TSBVI, Texas Deafblind Outreach

Abstract: Educators can have more positive, responsive and reciprocal interactions with their students who are deafblind by learning how to modify their own interactive behaviors and adapt the interactive context. High quality interactions contribute to improved educational outcomes for students with deafblindness.

Key Words: programming, blind, deafblind, Jan van Dijk, research-based, interaction, behavior, communication, educator-oriented intervention, instructional strategies, video analysis


Interaction is defined here as the process by which two individuals mutually influence each other's behavior." (Janssen, Riksen-Walraven & van Dijk, 2003b, p.198). During a visit to Texas School for the Blind and Visually Impaired (TSBVI), Dr. Jan van Dijk suggested that a team from the school review recent research about interactions with students who are deafblind, then develop a process for sharing the information with other educators and helping them put its principles into practice. Part One of this two-part article summarizes research-based conclusions about interactions with students who are deafblind. Part Two, which appears in the Winter 2005 edition of SEE/HEAR, describes the educator-oriented training process developed at TSBVI that incorporates these findings.

Interaction Problems and Possibilities

Many in the field of deafblindness intuitively value and try to maintain high quality interactions with students who are deafblind. As research continues to validate the role of interaction in attachment, security, relationships, learning and communication, the need for educators of students with deafblindness to develop their interaction skills becomes more apparent. Appreciating the importance of positive interactions is a step in the process. Improving the quality of one's own interactions with students who are deafblind is a bigger challenge.

Typical development

"It is a universal trait of our species that mothers have the innate skill of mothering. They are able (and it seems that this is similar in all cultures) to provide the newborn child with warmth and security. Mothers feel that the newborn child needs a safe harbor for exploration." (van Dijk, 1999, p.1). "Children who are securely attached to their caregivers have a secure base from which to explore the environment…. Children see individuals to whom they are securely attached as available and responsive…. Secure attachments are built when caregivers are sensitive and responsive to the infant's communications…Positive interactions occur as the caregiver and the infant respond to each other…The infant sends cues, the caregiver responds, and the infant responds in turn. Each partner learns the rules of turn-taking from the feedback of the dydactic partner." (van Dijk & Nelson, 2001, p. 18). "Given that interaction is the 'vehicle of communication,' it is obvious that harmonious (smooth, balanced and finely attuned) interactions are indispensable to develop high-quality communication." (Janssen, et al., 2003b, p. 198)."

Harmonious interactions and their importance have been characterized in various terms. Attachment theorists emphasize the importance of sensitive responsiveness: A sensitive caregiver is keenly aware of a child's signals, interprets them accurately, and reacts promptly and appropriately so that the child feels understood. During such harmonious interactions, the child learns to trust the caregiver's availability as a source of emotional comfort and support." (Janssen, et al., 2003b, p.198). Dr. van Dijk has referred to this quality of sensitive responsiveness as "IT." This is how he once described IT. "I have been looking all over the place to find a CD-rom fragment of Suzanne with her mother interacting. Mother wants her to clap her hands, but S. wants her to touch her lips. Mother adjusts her intention to S.'s request. This is IT." (personal communication, October 18, 2002).

"Harmonious caregiver-child interactions have been found to relate to later socioemotional development in various empirical studies…. a secure infant-parent attachment relationship - which clearly relates to sensitive parenting - predicts various developmental outcomes for children up to late adolescence…. early harmonious interactions influence the development of brain structures and brain functions that mediate the future regulation of emotions, adaptation to changing circumstances, and ability to cope with stress…. Particularly, the sharing of high levels of positive affect during interactions appears to have beneficial effects on early brain development." (Janssen, et al., 2003b, pp. 199-200).

The impact of deafblindness

"Children who are deafblind often require considerable time as they establish relationships with others and become comfortable in new environments…. The ability of children with severe multiple disabilities to develop secure attachment and turn-taking social interactions may be threatened by multiple factors including: (a) time spent in intensive care units separated from their parents, (b) severe health problems which may have limited physical contact with caregivers, (c) low levels of arousal and an alert state that is not long enough for attachment to occur, (d) extremely elevated levels of arousal that lead to over-stimulation, (e) communicative cues that are atypical and difficult to read, and (f) limited ability to read caregiver cues (e.g., if vision is limited, the young child may not be able to imitate the social cues of his caregiver such as a smile and he may not know when he should take his turn in a social interaction)." (van Dijk & Nelson, 2001, pp. 4, 18-19).

Interactive challenges

"Various studies have indeed shown both deafblind children and their parents to encounter serious difficulties with their interactions. The visual impairments of the children greatly affect quality of the children's interactions with their parents. Eye contact, reading facial expressions, or mutually gazing at the same object are virtually impossible. Lack of responsiveness or over-sensitive reactions such as 'slipping away' in the children may cause feelings of disappointment or frustration in the parents…. Auditory stimuli are not well-perceived or processed by deafblind children due to sensory-neural impairment. They may respond very little, not at all, or even negatively to voices and other sounds. Caregivers are therefore dependent on touch and proprioceptive stimulation to keep the interaction going…. Rowland (1984) showed the mothers of multiple handicapped visually impaired children to encounter difficulties with the regulation of turn-taking and to inconsistently respond to the vocalizations of the child…."

Preisler (1996) found deafblind children to elicit contact with their parents by means of body movements, facial expressions, and vocalizations. The children can also take part in joyful interactions, mostly in the form of body games. It is nevertheless difficult to read signals of deafblind children. Their movements and expressions are often very subtle or vague and unfold at a much slower pace when compared to those of sighted and hearing children. Use of idiosyncratic signals and forms of communication by the deafblind can easily lead to misunderstandings." (Janssen, Riksen-Walraven & van Dijk, 2002, pp. 88-89). "The attachment process described by Bowlby (1969), through which the child develops a secure bonding with his primary caregiver allowing him/her to explore and access new opportunities for experience and learning, is endangered in children with multiple disabilities due to the described difficulties in establishing readable signaling systems." (Amaral, 2003, p. 4).

"For educators, the first hampering factor in building harmonious interactions is the lack of natural skills to participate in the deaf-blind world of touch and proximity…. In her study of the communicative interactions between children with multiple disabilities and their teachers, Amaral (2002) concluded that teachers do not spontaneously develop the interaction and communication skills that are necessary for responding to the needs of such children…. The educators of deaf-blind children are often not fully aware of the importance of developing harmonious interactions before they focus on understanding the children's message or on further developing communication and language." (Janssen, et al., 2003b, pp. 198, 201). "When the educator of deafblind individuals lacks the insight and skills to understand the world of the deafblind child, one can observe how the individual retreats into himself, avoids touching objects, and attempts to cope with his 'unbalanced organism' by exhibiting stereotypic behaviours."(van Dijk, 1999, p. 2). "Professional educators, such as teachers, classroom-assistants, and the residential staff face the same interaction problems as the parents and sometimes even more serious problems. The educators typically start interacting with the deafblind children at a later age than the parents, which means that many of the children have already developed a number of idiosyncratic and 'difficult' behaviors that can hamper further interaction." (Janssen et al., 2002, p. 89). "The final factor that is known to hamper harmonious interactions with deaf-blind children holds particularly in institutional settings (schools and residential facilities) and concerns continuous changes. While professional educators regularly rotate from one class, home setting, or group in a residential facility to the next and thus from one deaf-blind child to another, the risk of disharmonious interactions increases with each switch, particularly when the professionals have not been sufficiently introduced in the new work setting and too many staff changes occur at the same time." (Janssen, et al., 2003b, p. 202). "It is obvious that when a child, whose emotional balance is easily disturbed, is provided with many different caregivers, it is hard, if not impossible, for the foundation of security to be laid."(van Dijk, 1999, p. 3). "Given that the principles of individuals' communication and interaction are often not well recorded, the risk of disharmonious interactions following such staff switches increases." (Janssen, et al., 2003b, p. 202).

Adult-dominated interactions

Rick van Dijk and his colleagues noted, "In normal language development, one would expect a parent or a professional teacher to leave the initiative in communication to the child and to respond in a contingent way whenever the parent or teacher felt that it was possible for the child to take the initiative. Only in this manner does the child have the opportunity to explore his or her communicative possibilities…Communication will only lead to language development if the child is enabled to actively take part in communication…. we know that parents often have a tendency to control interaction with a deaf child because they cannot fully understand the utterances of the child. Although understandable, this control is in itself detrimental to language development. The more parents try to control the responses of a child, the turn-taking interaction, and especially the topic of conversation, the more slowly language development will proceed. There is solid empirical evidence that use of a less controlling interaction style by parents facilitates not only higher-quality interaction between parents and deaf children but also the process of language development…. there is no reason to think that this is not also the case in children who are deafblind." They suggested that "…if one studies interaction and communication, and most certainly if one studies these processes in relation to the facilitation of language development, one will also want to study aspects such as initiation of interaction, contingent and noncontingent reactions of communication partners, and the functions of interactive turns." (Vervloed, van Dijk, R., Knoors & van Dijk, J., 2006, pp. 337, 343).

A study was designed to analyze the interactions between a teacher and his 3-year-old student with congenital deafblindness. The primary research question asked, "…to what extent it would be possible for the teacher to attend to the deafblind child's initiatives and responses and respond appropriately, with contingent interaction patterns thereby resulting.…Three target activities that offered many opportunities for close interaction were chosen for the present study…. These events were selected because they recurred daily and fit in the schedule of daily routines for this boy. It is widely accepted that such daily routines foster effective interactions and enhance memory processes." Videotaping the observations was considered necessary "…because otherwise it is extremely difficult to notice all the potential communicative signals exhibited by the deafblind child." (Vervloed, et al., 2006, pp. 337, 338).

"Over a period of 4 months, a total of 16 hours of recordings were made during bathing, dressing, and playing.…specific events were chosen for video recording in order to capture the most favorable conditions for the elicitation of social interaction and communication…. Three criteria were used to determine if a scene would be included in the study: 1. Both the teacher and the child should be within reach of the camera.  2. The recordings should be of good quality…3. There should be a period of communicative activity lasting at least several seconds." Of the original recordings, "…less than 2% of the recording time contained prolonged interactions between teacher and child…. most of the failures were due to the teacher being too far away from the child to be able to communicate properly or due to the total absence of prolonged communication periods between the two." (Vervloed, et al., 2006, pp. 338, 340). Video fragments that met the criteria were reviewed, and each of the teacher's and student's interactive behaviors were assigned to one of six main observational categories:

  1. The child acts to influence the teacher's behavior
  2. The child reacts to the teacher
  3. The child’s actions are not in response to the teacher’s initiatives, or there is no response
  4. The teacher acts to influence the child’s behavior
  5. The teacher reacts to the child
  6. The teacher’s actions are not in response to the child’s initiatives, or there is no response. (Vervloed, et al., 2006, p. 339).

The authors then counted the frequency of these interactive behaviors and analyzed the transitions between them, to learn more about the teacher and child’s current interactions, and to predict the nature of their future interactions. If interactive behaviors of the teacher and/or child didn’t change, it was likely, with varying degrees of probability, that the characteristics of their interactions would remain the same. They concluded, "The amount of interaction was representative of normal daily interactions between this teacher and deafblind boy…. only a limited portion of the time when the teacher and deafblind child were together was devoted to communication and interaction…. There existed a true interaction between teacher and child, although each frequently missed the initiatives of the other…. Both teacher and child did not respond significantly to each other's responses…. the number of teacher initiatives exceeds the number of responses considerably." They also speculated "…that interaction between the partners stopped after one response." From this study, the authors determined that "…it is possible to quantify interaction between teachers and deafblind children and that this can be accomplished in a way that gives insight into the elements of the interaction and communication processes that are important for the development of language." (Vervloed, et al., 2006, pp. 341, 342).

Consequences of disharmonious interactions

"It is likely that the emotional and behavioral problems of deafblind children are at least partially due to the difficulties they experience, from birth on, in their everyday interactions with caregivers. High quality interactions with primary caregivers who sensitively respond to normal children's signals and needs have been found to foster a sense of security and competence in the children and to positively affect both their social and personality development in later years. In contrast, children with insecure attachment relationships reflecting a history of disharmonious interactions with their primary caregivers have been found to be at risk for development of disorders such as problems in self-regulation, depression, and conduct disorders…. Given that the interactive signals of deafblind children are often subtle and difficult to interpret, they are frequently missed or misunderstood by caregivers. As a result, children tend to intensify their signals, express frustration via self-abuse or aggressive behaviors or both, and withdraw into stereotypic behaviors or passivity. Such 'inappropriate' behaviors can then elicit inadequate responses from the caregivers, with the risk of both the caregiver and child getting caught in a downward spiral." (Janssen, et al., 2002, pp. 88, 90).

Educator-oriented intervention

Dr. Marleen Janssen and her co-authors designed an educator-oriented intervention program to improve the quality of interactions between deafblind children and their professional educators. To determine the program's effectiveness, their research questions were, "(1) Does the intervention produce an increase of appropriate [educator] responses and a decrease of inappropriate [educator] responses to the interactive behaviors of the children? (2) Does the intervention result in an increase of appropriate interactive behaviors and a decrease of inappropriate interactive behaviors on the part of the children? (3) Is the intervention effective with different educators and in different situations?" (Janssen, et al., 2002, p. 90).

After identifying appropriate and inappropriate child behaviors, and appropriate and inappropriate educator responses, "First, the educators were trained to respond more appropriately to the children's interactive behaviors. Second, the educators were trained to adapt the interactive context to facilitate the occurrence of appropriate interactive child behaviors. Such adaptations were as follows: (1) offering communicative aids [in an] orderly [way], (2) offering choices, (3) removal of distracting stimuli, (4) removal of stimuli not wanted by the child, (5) attuning activities to child's abilities (sensory or motor), and (6) demonstration of appropriate interactive behaviors to the child." (Janssen, et al., 2002, p. 94).

The study concluded that "…it is possible to improve the interactive competence of deafblind children by teaching their educators to respond more appropriately to [the children's] interactive behaviors. In three of the four target children, both an increase in appropriate interactive behaviors and a decrease in inappropriate interactive behaviors were observed. The intervention also proved to be effective for different educators across various situations." (Janssen, et al., 2002, p. 104).

Development of an intervention model

As a continuation of their earlier work, Dr. Janssen and her colleagues developed "…a diagnostic intervention model as a guide for designing and conducting interventions to foster harmonious interactions between deaf-blind children and their educators in various settings…The intervention is educator oriented and thus aimed at achieving the goals of intervention for the children who are deaf-blind by changing the behaviors of their educators." (Janssen, et al., 2003b, pp. 197, 208).

In this model, the behaviors of both the child and educator are assigned to one of eight core categories of interactive behavior. "The definitions of the categories are adapted for the purposes of an intervention and are translated into concrete behaviors per individual case." (Janssen, et al., 2003b, p. 207). The eight core categories of behavior "…are as follows:

  1. Initiatives: starting an interaction or raising something new as part of a reaction
  2. Confirmation: clear acknowledgement that an initiative has been noticed and recognized
  3. Answers: positive (approving) or negative (disapproving) reaction to an utterance of the partner
  4. Turns: turn taking, or becoming the actor, and turn giving, or allowing the other to become the actor
  5. Attention: focus on the interaction partner, the content of the interaction, and the people and/or objects within the interaction context
  6. Regulation of intensity of the interaction. For the educator: waiting while the deaf-blind child regulates the intensity of the interaction. For the child: appropriate regulation of intensity by, for example, withdrawing (turning his or her head away) or some other individual signal (such as laying his or her hand on the partner's hand) and apparent processing of information, and inappropriate regulation of intensity by, for example, self-abusive or aggressive behaviors
  7. Affective involvement: mutual sharing of emotions
  8. Independent acting. For the educator: acting with no focus on the child. For the child: executing actions independently (e.g., putting a garment or part of a garment on alone)." (Janssen, et al., 2003b, p. 207)."

On the basis of video analyses, the educators learn to recognize a deaf-blind child's signals, to attune their own interactive behaviors to those of the child, and to adapt the interactive context to promote the occurrence of certain target behaviors…. The intervention is evaluated in terms of the intervention aims and the occurrence of particular behaviors before and after intervention." (Janssen, et al., 2003b, p. 208).A companion study summarizes the successful implementation of the intervention model described above, with six congenitally deafblind children and adolescents, and their teachers, caregivers and parents, in different settings and interactional situations. (Janssen, Riksen-Walraven & van Dijk, 2003a).

To be Continued

Part One of this article summarizes recent research about the importance of high quality interactions with students who are deafblind, including information about characteristics of deafblindness that can result in interaction problems, and the description of an educator-oriented approach that helps clarify and address those problems. In the Winter 2005 edition of SEE/HEAR, Part Two describes the interaction training process developed at TSBVI that incorporates this information. It includes case studies of four training participants and their students with deafblindness.

References

Amaral, I. (2003). Analyzing teacher/child interactions: What makes communication successful? Paper presented at the Communication is the Key to Opening Doors Worldwide XIII DbI World Conference.Mississauga, Canada.

Janssen, M.J., Riksen-Walraven, J.M., & van Dijk, J.P.M. (2002). Enhancing the quality of interaction between deafblind children and their educators. Journal of Developmental and Physical Disabilities, 14, 87-109.

Janssen, M.J., Riksen-Walraven, J.M., & van Dijk, J.P.M. (2003a). Contact: Effects of an intervention program to foster harmonious interaction between deaf-blind children and their educators. Journal of Visual Impairment & Blindness, 97, 215-228.

Janssen, M.J., Riksen-Walraven, J.M., & van Dijk, J.P.M. (2003b). Toward a diagnostic intervention model for fostering harmonious interactions between deaf-blind children and their educators. Journal of Visual Impairment & Blindness, 97, 197-214.

van Dijk, J. (1999). Development through relationships: Entering the social world. Proceedings of the Developing Through Relationships XII DbI World Conference. Estoril, Portugal: Casa Pia de Lisboa.van Dijk, J., & Nelson, C. (2001). Child-guided strategies for assessing children who are deafblind or have multiple disabilities. Sint-Michielsgestel, the Netherlands: IvD/MTW, AapNootMuis.

Vervloed, M.P.J., van Dijk, R.J.M., Knoors, H, & van Dijk, J.P.M. (2006). Interaction between the teacher and the congenitally deafblind child. American Annals of the Deaf, 151, 336-344.| Fall 2004 Table of Contents 

By Craig Axelrod, Teacher Trainer, TSBVI, Texas Deafblind Outreach

Abstract: Educators can have more positive, responsive and reciprocal interactions with their students who are deafblind by learning how to modify their own interactive behaviors and adapt the interactive context. High quality interactions contribute to improved educational outcomes for students with deafblindness.

Key Words: programming, deafblindness, Jan van Dijk, research-based, interaction, behavior, communication, educator-oriented intervention, instructional strategies, video analysis

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

 

The Interaction Training Process at TSBVI

When determining who will be invited to participate in interaction training, we consider interested staff who are teaching students with deafblindness and understand the basics of good programming, such as structuring a routine and using a calendar system. They have interactive challenges with their students that we want to address. Staff may also be teaching newer students we want to better understand. The students represent a variety of abilities and needs.

 

Introduction to the training model:

The educator-oriented learning goals of interaction training are to:

  • Understand the role of high quality interactions in early development
  • Understand the challenges to high quality interactions with children who are deafblind
  • Identify student-specific factors that impact interactions
  • Recognize the components of interaction
  • Analyze the interactions between adults and students who are deafblind
  • Identify and implement intervention strategies that improve the quality of those interactions

 

Several weeks before interaction training, participants are asked to notice and think about the interactions they have with their students, then bring those observations and questions to the first day of training. As the training progresses, and more is understood about the unique characteristics of deafblind children, interactions with deafblind children in general, and with their students in particular, concerns, goals and possible intervention strategies for improving the quality of those interactions become more refined and specific.

On the first morning of training, after introductions and clarification of the learning goals, information is presented about interaction problems and possibilities of students who are deafblind (as described in Part One). To help exemplify these ideas, participants view and discuss the videotaped interactions between a student and three adults. The three interactions are clearly very different, and the student's abilities also seem to differ. An Interaction Data form is introduced as a tool to help graphically represent those differences.

 

Interaction data

The Interaction Data form codes these components of an interaction:

    • Description of Turns: Each interactive turn is briefly described. This enables the people coding to quickly match information seen on the video to its corresponding location on the Interaction Data form.
    • Interactive Turns: Each turn is assigned a letter, A-F, based on the six observational categories identified by Rick van Dijk and his colleagues.
      1. Student Initiates: the student's action is directed at the adult in order to influence the adult's behavior
      2. Student Responds: the student responds to the adult
      3. Student Acts Independently or No Response: the student acts without an intent to influence the adult's behavior, or does not respond to the adult
      4. Adult Initiates: the adult's action is directed at the student in order to influence the student's behavior
      5. Adult Responds: the adult responds to the student
      6. Adult Acts Independently or No Response: the adult acts without an intent to influence the student's behavior, or does not respond to the student
    • Connecting Consecutive Turns: Arrows are drawn between "related" consecutive turns, reflecting the duration of an interaction on a particular topic.
    • Interactive Behaviors: Each turn of the student or adult is then assigned one or more numbers, 1-8, corresponding to behaviors that describe the turn's interactive qualities. These interactive behaviors are adapted from the eight core categories of behavior as defined by Marleen Janssen and her colleagues.
      1. Initiatives: starting an interaction or bringing up something new as part of an answer
      2. Confirmation: clear acknowledgement that a partner's action has been noticed and recognized
      3. Answers: a positive or negative response to the partner
      4. Turn Taking: becoming the actor
      5. Turn Giving: allowing or encouraging the partner to become the actor
      6. Attention: focusing on the partner, the content of the interaction, or the individuals and/or objects within the interactive context
      7. Regulation of Intensity of the Interaction: for the student – appropriate or inappropriate interaction; for the educator – waiting while the student regulates intensity, or regulating behaviors that influence the student's intensity (such as proximity to the student [e.g., nearer, further away], pacing [e.g., faster, slower], animation [e.g., facial expression, size of movement], voice [e.g., inflection, volume] and amount or type of touch [e.g., frequency, degree of forcefulness])
      8. Affective Involvement: sharing positive emotions with the partner

    (If during an interactive turn, the student or adult "acts independently or gives "no response," C or F, no interactive behaviors are credited.)

     

    Interaction Data Form

 


Interaction1


B is 19 years old and has microcephaly secondary to an encephalocele (a congenital protrusion of the brain through a cranial fissure). He's legally blind with a cortical visual impairment, is suspected of having a hearing loss, and has multiple disabilities that include mental retardation and cerebral palsy.

Coded video fragments from B's three interactions are analyzed, to identify and compare components of the interactions that reflect their different characteristics and result in his varying degrees of interactive competence. This activity also familiarizes participants with the Interaction Data form. Later in the training, they will use the form to code and analyze video fragments of their own interactions.


interaction2


 

B and the teacher - stretching on the therapy ball: The teacher talks to B twice in this fragment, but acts independently during the other turns. He prepares to move B, positions him on the therapy ball and stretches parts of his body with no interactive behaviors, no expectation for B to take a turn and no connected turns.


 interaction3


B and the teacher aide - eating lunch: The aide is attentive to B, and waits until he's ready before offering a bite of food. B responds once by accepting the spoon (answering "Yes") and once by rejecting it (answering "No"). When he refuses the food, she confirms his response by putting down the spoon and getting the milk cup. Turns in both of these sequences are connected. She acts independently by wiping his mouth. There is no observed enjoyment (affective involvement) of the interaction.


 

 

by Kate Moss, Family Training Specialist, TSBVI Outreach

Originally published in 2009 in the See/Hear newsletter.

Usher Syndrome is one disorder that comes to mind readily for professionals in both the field of vision and hearing when they think of syndromes which result in dual sensory impairment or deaf-blindness. However, there are many syndromes that have both vision and hearing impairment as part of the conditions that define the syndrome. It is important to be aware of these conditions, since one of the sensory disabilities is often times more evident than the other. This situation makes it easy to overlook the impact of the combined vision and hearing loss.

Below some of the more common syndromes, which can manifest with both vision and hearing loss, are described. If you are interested in obtaining more detailed information about any of these conditions, you may contact: National Organization for Rare Disorders or search the web for organizations under the specific syndrome name.

Most of the information about these syndromes comes from reports provided by NORD. The exception is the information on Congenital Rubella Syndrome which comes from a booklet, "Congenital Rubella Syndrome: Health Care Challenges" written by Dr. Steven Parker from Boston University School of Medicine in collaboration with Perkins School for the Blind, Helen Keller National Center and St. Luke's-Roosevelt Hospital. This publication is available through Perkins School for the Blind.

Alport Syndrome

Alport Syndrome is a group of hereditary kidney disorders. They are characterized by progressive deterioration of the glomerular basement membranes which are microscopic parts of the kidney. This deterioration may lead to chronic renal (kidney) failure causing excess waste products in the blood (uremia). Eventually severe renal failure may develop. Ureamia and kidney failure may cause heart and bone problems.

Abnormalities of the eye may occur in the juvenile forms of Alport Syndrome. The surface of the eye's lens may be cone-shaped (lenticonus) or spherical (spherophakia). The lens of the eye may be opaque or cloudy (cataracts). White dots may appear on the retina (retinal macular flecks or fundus albipunctatis). Children with Alport syndrome may be nearsighted (myopic).

Type I, Type II and Type VI Alport Syndrome includes kidney disease with nerve deafness and eye abnormalities. The difference between these two types is that Type I is a dominantly inherited juvenile form and Type II is an X-linked dominant juvenile form. Type VI is the autosomal dominant juvenile form.

Cytomegalovirus (CMV)

Cytomegalovirus Infection is a virus infection occurring congenitally, postnatally or at any age. CMV ranges in severity from a silent infection without consequences, to a disease manifested by fever, hepatitis, and (in newborns) severe brain damage, and stillbirth or perinatal death.

Symptoms of CMV are also highly variable as well. The infection may be manifested only by CMV in the urine in an otherwise healthy infant. At the other end of the extreme, hemorrhaging, anemia, or extensive liver or central nervous system damage may occur. Infants born with a severe form of the disease typically have a low birth weight and develop fever, hepatitis with jaundice, and hemorrhages into the skin, mucous membranes, internal organs, and other tissues. Enlargement of the liver and spleen, decrease in number of blood platelets, inflammation of the choroid and retina, abnormal smallness of the head, and calcification around the veins of the cerebral portion of the brain may occur. Motor defects, spastic paralysis on both sides of the body, blindness, deafness or seizures may develop.

Vision loss in these children is related to scaring of the choroid (the dark brown vascular coat of the eye between the sclera and retina). Hearing loss in these children is sensorineural. Even though CMV infection may not be apparent in some infants, it may later cause hearing loss.

CHARGE Association

CHARGE Association is a very rare disorder characterized by a variety of symptoms. At least four of the following six characteristics must be present for the diagnosis of CHARGE Association: 1) Absence of some eye tissue, including the iris (Coloboma); 2) Heart disease; 3) Absence of the opening between the nasal cavity and the back of the throat (Atresia of the choanae); 4) Retarded growth and development and central nervous system abnormalities; 5) underdevelopment of the Genitals; 6) Ear abnormalities and hearing loss. The six letters of each of these conditions make up the name CHARGE.

Down Syndrome

Down syndrome is the most common and readily identifiable genetic condition associated with mental retardation. It is caused by a chromosomal abnormality. One additional chromosome is present in each cell. This extra gene material changes the development of body and brain.

About half of these children have congenital heart disease. There is an increased incidence of respiratory problems. Recent studies have shown that there are more eye and ear problems in individuals with Down Syndrome. Eye problems associated with this syndrome are myopia and "Brushfield" spots (gray or pale yellow spots at the periphery of the iris). These individuals may have either sensorineural, conductive or mixed types of hearing loss.

Marshall Syndrome

Individuals with Marshall Syndrome have a distinct flat sunken midface with a flattened nasal bridge or "saddle nose". Their nostrils turn upward, there is a wide space between the eyes, and the upper portion of the skull is thicker than normal. Calcium deposits may also be found in the skull. Eye defects found in these individuals include nearsightedness, cataracts, and eyeballs that appear to be larger than normal because of the wide space between the eyes. Some people with this syndrome may also have crossed eyes, a condition in which the line of vision is higher in one eye than the other called hypertropia, retinal detachment, or glaucoma. Hearing loss may be slight or severe and is sensorineural.

Rubella Syndrome

If a pregnant woman contracts rubella, the virus can infect her fetus. Such an infection is especially dangerous in the first 4 months of pregnancy, causing damage to the developing organs. Although any part of the body can be affected, the eyes and ears seem to be especially susceptible to damage from a rubella infection.

Babies born with Congenital Rubella Syndrome vary greatly from one another. Some are only mildly affected while others have significant disabilities. Some of the problems associated with CRS include sensorineural hearing loss, visual problems such as cataract, inflammation of the retina (retinopathy), nystagmus, small eyes (microphthalmia), and occasionally optic atrophy, corneal haze, and glaucoma. These individuals may also experience hearing problems, neurological problems, growth problems, and other disabling conditions. In later life some individuals also experience glaucoma and detached retina.

Stickler Syndrome

Stickler syndrome is a genetic disorder inherited as a dominant trait. Initial symptoms of Stickler Syndrome may include a broad, flat, sunken bridge of the nose which makes the face look flattened. A cleft palate and small jaw may also be present. In addition, sensorineural deafness may develop. Eye defects may include a high degree of nearsightedness (myopia), irregularities of the lens (astigmatism), and changes of the optic disk. Cataracts, detachment of the retina and blindness may develop during the first decade of life. A form of glaucoma called glaucoma simplex may also occur.

Bone abnormalities in joints such as the ankles, knees and wrists usually occur. During childhood, individuals may experience stiffness and soreness after strenuous exercise. Swelling, redness and a feeling of heat may occur occasionally, leading to cracking and temporary locking of the joints. Incomplete dislocation of the hips is another frequent occurrence.

Other Syndromes

There are many other syndromes and conditions that are associated to some degree with combined vision and hearing loss. Some of these include:

  • Duane Syndrome
  • KID Syndrome
  • Leber's Syndrome
  • Norrie's Disease
  • Pierre-Robin Syndrome
  • Trisomy 13

Of course, vision and hearing loss may occur in children with any type of syndrome or condition in the same way that vision and hearing loss occur in the non-disabled population. However, in syndromes and conditions known to have related vision and hearing loss, we must be certain to provide ongoing, periodic assessment and monitoring of vision and hearing function.

Why is it important to know about syndromes?

1) Specific characteristics of a syndrome may have implications related to educational programming.

Obviously syndromes which have associated vision and hearing impairment can require a great deal of specific modifications to classroom instruction. Understanding the exact visual and auditory functioning of a child in the classroom and home environment can help us to provide these modifications. For example, with Usher Syndrome Type II the child may require the use of an auditory trainer. The child with Type I Usher will probably need a sign language interpreter, may need to be positioned at a specific distance from another signer, and/or may need instruction in the use of tactual signing.

Other conditions associated with a syndrome may direct the focus of instruction. For example, children with CHARGE Association may not have the physical ability to control urinary function until they are older. Trying to potty train a child with this condition at an age of 2 or 3 will likely prove frustrating to both the child and the caregivers. Knowing this, potty training may not be a priority for instruction in the early years of the child's life. Further, the classroom teacher may need the support of a paraprofessional during regular bathroom times in order to change the child's diapers. Consideration may also need to be given to providing a private space for the child during this activity that would not ordinarily exist in the classroom.

2) Specific characteristics of a syndrome may have implications related to career choices.

Some career's require good vision or hearing such as an airline pilot, an architect, or a truck driver. Many jobs can be modified or special technology can make jobs accessible even to individuals without vision or hearing. Sometimes specific jobs in a field may be accessible to an individual with disabilities while other jobs in that field are not accessible. The more information the student, his family, and career counselors have about a typical pattern of progression associated with a particular syndrome, the better prepared they are to make good decisions about future career choices and current programming.

3) Specific characteristics of a syndrome may have implications for ongoing medical follow-up.

Many syndromes such as Congenital Rubella Syndrome have a delayed onset of symptoms associated with them. For example, an individual with CRS is at higher risk for developing glaucoma and diabetes. They are also at risk for having detached retinas. Knowing this, regular eye examinations and medical examinations may help to detect these problems early on so the individual may receive proper medical treatment.

Sticklers syndrome often has hip dislocations associated with it. Knowing this, there may be a need to restrict some physical activities which may put the individual at risk. Other syndromes such as Cornelia de Lange may have gastrointestinal problems associated with them which may require special diets or medicines to prevent more serious conditions from developing.

Whatever the condition or syndrome is which results in long-term disabilities, the more we know about it the better off we are in helping the child. It is sometimes difficult to get a clear diagnosis of specific syndromes, but genetic testing and counseling can be very helpful. Your pediatrician or hospital may be able to refer you to a genetic counselor. Other resources to find out more about genetic testing are the National Society of Genetic Counselors and Genetic Alliance.

 

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

Abstract: This article is based on a book by Dr. Lilli Nielsen titled The FIELA Curriculum: 730 Learning Environments and lists the developmental behaviors in three-month increments as described in this book.

Key Words: Programming, visually impaired, blind, deafblind, Dr. Lilli Nielsen, Active Learning, developmental behaviors.


Many of the children who are congenitally blind with additional disabilities or deafblind have a great deal of difficulty learning because of their inability to access information in the environment the way a typically developing child does. Though they learn in similar ways, the learning process a typically developing child uses before the age of three may not be naturally accessible to the child with vision and hearing loss or motor impairments.

If you watch children under the age of three you see they are constantly moving in and through their environment, interacting with objects. They examine them by tasting, smelling, touching, listening and looking. Through this interaction they use muscles and develop coordination to sing, talk, eat, reach, grasp, lift, bang, shake, and throw. They learn about properties and concepts such as weight, temperature, textures, size, color, shape, and smell by comparing and contrasting the things they contact. Children at this age literally form the neural pathways that help them to see similarities and differences in objects, people, and experiences. This type of learning is the critical foundation of all future learning. Babies and toddlers are also developing emotionally at this age. Beginning with critical bonding to mom and dad, the baby quite naturally learns to accept and interact with an ever-expanding circle of people.

Many congenitally blind and deafblind children fail to develop these foundational concepts in the same way as a typical child because they cannot interact independently with their environments --- their world may only extend only as far as their hands or feet or mouth can touch. Early bonding may be jeopardized by hospitalization and medical treatments. Getting to people or even knowing that there are others around may not be easy. Many of these children continue to function at a very early stage of cognitive and emotional development even after their bodies have grown and they have become much older.

Dr. Lilli Nielsen talks about the importance of addressing the child's development in cognitive, physical and emotional areas. She offers strategies that work to advance the child's learning. I recently reread her book,The FIELA Curriculum: 730 Learning Environments. In this book Dr. Nielsen describes behaviors for developmental levels from birth to 48 months (4 years) in three-month increments. When we are using an Active Learning approach to instruction, it is important to have a clear picture of each stage of development especially with children who are older than 4 chronologically but developmentally below the age of 4. Becoming a better observer of the child's behaviors helps guide material design, learning environments, and interaction strategies when utilizing Active Learning. Below is a list of various behaviors discussed in Dr. Nielsen's book. I would encourage parents and professionals to get a copy of this book for a more in-depth discussion of these behaviors and the adult's role in facilitating development of skills. Being familiar with these developmental behaviors is invaluable in utilizing an Active Learning approach.

Behaviors 0-3 Months

Movements become more and more intentional. Greater awareness of tactile, visual auditory, gustatory and olfactory experiences reinforced by repetition. It is the activities of the child's own body and with objects in his surroundings that form the basis for perception — needs rich environment that provides feedback.

Behaviors 3-6 Months

Developing finger strength and dexterity through scratching. Plays with his/her own fingers, interlacing and fiddling at midline. Wrist rotation also comes from playing with hands. Pushing objects to discover perceptual effects of auditory, tactile or visual nature. Grasping and letting go of objects and experimenting with various ways to grasp, and becoming able to choose the way that works best for a specific purpose. Grasping and keeping - combines ability to grasp with muscle strength to hold. Banging with clenched fists on surfaces and own head. Visually following objects swinging to and fro within reach. Acquiring control of head movements by lifting head and turning while in prone. Bracing feet against everything within reach of feet - builds muscle strength and haptic-perceptual skills to enable the child to bear the weight of his own body. Mouthing fingers and objects - helps to develop skills for eating, speech. Developing varied ways to signal people in his/her surroundings to express wants, needs, well-being, disappointment, pain. To be active in a prone position in preparation of learning to sit unsupported (support bench work typically).

Behaviors 6-9 Months

Rolling on the floor, struggling to stand on hands and knees, sitting and lying repeatedly in preparation to stand and balance. Moving an object from hand to hand. Banging with one hand on the object held in the other hand. Reaching for and letting go of objects. Picking objects up and repeating a series of actions. Using tongue, lips, and gums for exploring objects that continue to develop mouth motor skills - a prerequisite for putting food into the mouth. Banging on objects and surfaces with open hand - child's awareness of the effect he has enhances cognitive development. Using banging activity with an open or clenched hand to contact the person who is carrying him. Reaching towards another person or in other ways signaling that he wants to be held. Experimenting with using his voice in different ways and wanting to present the acquired skill to an adult without actually wanting to communicate. Achieving spatial relations, first within reach in lying or sitting, later by crawling or shuffling around the surroundings. Crawling after the objects he has thrown out.

Behaviors 9-12 Months

Crawling around on the floor, pulling himself to standing and practicing balance. Walking sideways while holding on to sofa or table. Putting an index finger into all available holes and picking up crumbs - develops pincer grasp. Manipulating objects and sucking or biting everything he gets in his hand. Further development of wrist rotation through manipulating objects. Further development of mouth motor skills through sucking and biting objects. Expanding experiential base through expanded manipulation of objects. Banging on everything with some object in his/her hand (tool usage)Separating toys, pouring from containers, placing objects on specific spots (beginnings of constructive play). Experimenting with vocalization without actually wanting to communicate. Using newly acquired skill of babbling for communication. Achieving further understanding of spatial relations — first with objects in relationship to his body, and later by placing objects on certain spots within reach. Achieving further understanding of spatial relations as he develops the ability and desire to explore larger environments. Starting to play hiding games with objects — developing object permanence. Performing simple functions of daily living (taking off hat, putting food in mouth, etc.) — the child needs to have opportunities to use skills learned in games in daily living activities. Begins to respond to emotional attention and develops strong attachments to a few people from people he sees as meeting his needs. May begin to imitate adults with whom there is a strong emotional attachment and to play in an experimental way so he achieves object concept and commences to develop self-identification. May begin to show separation anxiety (rehearsing affective bonding) when not with a trusted adult.

Behaviors 12-15 Months

Crawling up onto sofas or big soft chairs. Walking. Eating using his/her fingers and a spoon alternatively. Drinking from a cup. Playing banging games with objects (banging on a variety of objects to compare with hands or an object). Banging with travel cane (allow some experimentation so the child learns what works best). Playing with big objects while sitting on the floor — this improves muscle strength, coordination of arm movements, enhances balance, improves concepts of size and weight. Building simple dens — he may build the den and immediately knock it down — develops important spatial relations and constructive play. Playing with quantities — rhythmic kicking, clapping, banging and vocalization patterns, putting multiple objects in one hand for banging games. Putting in and pouring from containers and placing objects next to and in front of oneself — builds understanding of quantities and relations between objects, concepts such as full, empty, too much, etc. Placing objects on top of each other — may start to try to stack, may place small object under larger one and immediately remove --- object permanence (Blind children seem to learn object permanence by placing object in a specific place, doing something else and finding it again.) Exploring, examining, comparing and discovering new ways to do familiar activities. Using one-word sentences for expressing wants and needs as well as achieving the concept of relationship between words and actions. Inviting the adult to play rough and tumble games. Drawing at the level of scribbling a few lines on each piece of paper — preliminary to learning to write and to illustrate the surroundings in two dimensions. Improving eye-hand coordination to fixate on activity child is performing — looking at what he is doing. Child has established attachment to parents and key caregivers so he is not as anxious around strangers — he begins to show interest in other children but without making physical contact.

Behaviors 15-18 Months

Climbing up and down on sofas, climbing over obstacles and underneath furniture, and going up and down a few steps — achieving increasing gross motor control. Separating objects. Imitating adult's activities. Attempting to perform "putting together" activities using objects that do not require much accuracy (e.g., magnets on board). Using skills learned at earlier developmental levels in new ways — related to problem-solving and planning another activity. Listening intently to other children's crying or babbling, and maybe imitating sound, but not for the purpose of initiating play. Inviting parents or trusted caregivers and selectively inviting a stranger to participate in give-and-take games.

Behaviors 16-24 Months

Jumping on both sofa and hard materials, as well as walking up and down stairs. Pushing furniture and big boxes, pulling a cart or garden hose, lifting heavy objects. Moving objects around in the room or from one room to another. Placing objects behind cushions or open doors or big soft chairs. Building simple dens with chairs, rugs, sheets. Participating in domestic work. Planning the next activity by placing objects in different spots around the room — purposefully and determinedly moving from place to place. Undressing. Basic role-playing (feeding/drinking with doll, cooking, etc.) May perform movements that belong to a game. Exploring and experimenting — related to problem-solving. Sharing an experience with other people, as well as protesting about untimely interference or interruption of his/her activity. Moving towards another child — to watch, listen, touch, pull hair, hit, and poke.

Behaviors 24-30 Months

Running, jumping, walking, experimenting with balancing on one leg, walking on curbs, dancing with an adult --- may be surprised and afraid if he falls even though he is not necessarily hurt. Experimenting with numbers of items and with concepts such as full, empty, big, heavy, and color. Experimenting with scissors and crayons. Enjoying making himself dirty in a puddle or by using food or paint. Experimenting using a knife for cutting and spreading. Transferring to various daily living functions the skills achieved while playing such as pouring, washing dishes, dressing, etc. Very inquisitive --- will leave an activity to find out what made a sound or what someone else is doing. Playing with words, using short sentences while talking to self and others. Still shy with some strangers, but expands circle to include more familiar people. Sits and plays next to another child, occasionally imitating, but still very engrossed in own objects and activities. Becomes shy away from familiar surroundings or people. Has difficulty separating from parents or caregivers.

Behaviors 30-36 Months

Understands 50-70% of what he is told. Improving language by using an increasing number of words — knows he can make his/herself understood and will become frustrated if you do not understand. Improving gross motor skills by crawling up slopes, gym equipment, playground equipment, riding tricycles, swinging, jumping, dancing, etc.Improving fine motor skills by putting small objects in small holes, model cars in model garage, making representational drawings (mom, dog, etc.). Can share available toys to some degree. More and more independent in daily living skills activities. Will become very angry with parents or caregivers if they try to help him do things he wants to do own his/her own. Has a need to share his/her experiences with an adult — the child must initiate the sharing.

Behaviors 36-42 Months

Experimenting with high speed while bicycling, swinging, running, kicking. Jumping on one foot. Experimenting with any tool he gets hold of such as hammer, saw, beater, scissors, tube of toothpaste, saltshaker, etc. Role-play using miniature cars, houses, people, animals. Building a new den every day, sometimes rebuilding it many times each day --- bringing toys and other belongings to the den. Still improving ability to talk — asks for names of things. Begins to understand instruction at three years of developmental age. Trusts most people — may follow or walk away with strangers who are nice to him.

Behaviors 42-48 Months

Using all skills learned previously while playing alone or with others. Beginning to understand there is a future — may not want to take down den but rather save it for tomorrow's activity. May furnish den more like his/her home. Plays with dolls, miniatures, cars, animals, etc. - often in a dramatic manner. Participates in group activities and playing with other children or adults. Busy throughout the day. Willing to follow simple instructions to complete task if not too long.

Reference:

Nielsen, Lilli, 1998. The FIELA Curriculum: 730 Learning Environments. SIKON, Copenhagen, Denmark.

Presented at the AER 2002 International Conference
July 17 – 21, 2002
Toronto, Ontario, Canada
By
Duncan McGregor, Ed.D. & Carol Farrenkopf, Ed.D.

Download an RTF version (39k)

Strategies

  • Experiential learning (literacy instruction rooted in experiences)
  • Link new experiences with those already learned
  • Use concrete objects whenever possible
  • Learn by doing
  • Unify experiences
  • Pair real objects with representational forms (pictures, miniatures)
  • Pair real objects with symbolic forms (print, braille)
  • Read aloud to and with the student
  • Pretend reading by the student
  • Pretend writing by the student
  • Use repeated readings to build fluency and confidence
  • Integrate instruction of the mechanics of reading and writing (how to turn the pages, identifying the cover of a book, finding the page number, locating the print/braille text, learning how to put the paper in a braille writer, learning how to hold a marker/crayon/pencil, the act of writing/brailling)

Building the Foundation for Literacy

  • Time: Print/braille instruction every day, 1 – 2 hours per day, direct instruction as well as integrated instruction at other times of the day
  • Consistency: Same teaching schedule (avoid cancellations), same teacher of the visually impaired, same teaching style, same expectations
  • Exposure: Braille/print labels throughout the student’s school environment (label as much as you can), especially in the classroom
  • Accessibility: Braille/print books in the classroom and school library
  • Application: Opportunities to apply braille/print reading and writing skills throughout the day, in various environments (gym, office, washrooms, library)

Two Types of Books You Can Create

  1. Concept Books (e.g., letters, numbers, words, shapes, size, position, colours, classification/categories).
  2. Story Books
    1. Mass-produced books that can be adapted (simple, easy-to-read, large type, clear pictures)
    2. Photocopy of already-made books (e.g., Sunshine Series)
    3. Made-up stories (by you, the student, other children, parents)

 

Creating a Braille/Print Book

Materials:

  • Two sturdy book covers (e.g., heavy construction paper, artists’ board, “real” braille book covers, file folders, cardboard)
  • Binding (usually 1 inch binding is a good size… it’s easier to turn pages with larger binding); binder rings, twist-ties, pipe-cleaners, string, and floral wiring also work well.
  • Braille paper (to make the pages in the book)… usually 4 – 5 pages in the book is a good number to start off with for a young child
  • Crayons/coloured markers/black marker to colour pages
  • Glue stick and/or hot glue gun
  • Tape
  • Concrete, familiar items to put in the book that are related to the topic of the book
  • Scissors
  • Braille writer/slate and stylus
  • Braille labeling sheets or Dymotape
  • Photocopied and enlarged pages of a story (if making this type of book)

Creating a Book FOR a Student

Method:

  • Determine an appropriate topic for the book
  • If creating a letter book, base the book on a letter the student already knows or is learning (start with the first letter of the child’s name)
  • If creating a number book, keep the number of items on a page within the capabilities of the child (by gr. 1, most children know how to count to 30)
  • If creating a shape book, consider making the cover and the pages of the book the shape of the topic (e.g., circular-shaped book about circles)
  • If creating a positional book, carefully consider the placement of items on the page so as not to confuse the student.
  • Indicate the page number in braille and in print on each page of the book
  • Include some sort of object on the cover that indicates what the book is about so the student can identify the book independently
  • Include a print and braille title on the cover of the book
  • Braille the text on the bottom of the page so text can be changed easily (if need be); it also allows more space for items to be put on the page
  • If the book is an enlarged photocopy of a book, colour in only one or two identifying parts of the pictures—too much colour may cause confusion; colour only what is most important (raised lines and textures may also help the student focus attention to the most important parts of the story)
  • Use strong fasteners (e.g., glue, tape, pipe cleaners) to keep the objects from falling out of the book. Placing objects in plastic bags that can be opened/unzipped is also a good idea.
  • Use large binding materials because all of the objects inside the book will make it an extra thick book
  • Initially, read the book together. Allow the student to guess at the content and pretend to read what it says
  • Encourage proper position of the book, fingers over the braille, scanning of the pages, and turning only one page at a time
  • Make reading the book as fun as possible!

Creating a Book WITH a Student

Method:

  • Have all of the book-making materials with you (binding, covers with pre-cut binding holes, braille paper with holes, glue, objects, etc.)
  • Allow the student to direct the creation of the book
  • Bring a bag or box of all the materials you think the student may want to include in his/her book—include a wide variety of items so the student may choose some items over others

OR

  • Place items that can be used in the book in the student’s classroom/work area so that he/she can “discover” them accidentally
  • Allow the student to be creative with his/her stories and the placement of objects in the books
  • If the student is creating a story based on a storybook that has already been made, review the original story first and then use that book as a model for the new one the student is creating
  • With the teacher’s assistance, the student may braille the text at the bottom of the page
  • Think about including another child in the book-making experience
  • Encourage the child to read (or pretend to read) the book aloud—encourage smooth line tracking while the child reads the line of braille)

Some Final Suggestions

  • Include the books in the classroom/school library
  • Encourage the child to share his/her book with classmates
  • Allow the child to take the book home to share with friends/family
  • Start a book club
  • Have lots of fun!

 

 

by Kate Moss, TSBVI Deaf-Blind Outreach Family Training Specialist and Linda Hagood, TSBVI Deaf-Blind Outreach Education Specialist

Children with deaf-blindness have unique educational needs. Although they are deaf the adaptations needed for their learning style will differ from the child who only has deafness. Although they are blind the adaptations needed for their learning style will differ from the child who only has blindness.

In order to understand what this means we can examine a variety of issues that might be addressed for three different children with disabilities in a regular preschool class: one born with a severe hearing loss, one born with visual impairment resulting in acuities of 20/600, and one born with a combined severe hearing loss and visual impairment resulting in acuities of 20/600.

It is important to note these are not actual children and that instruction for any child with a disability must accommodate his/her individual needs. Our intent is to demonstrate some of the basic differences in educational approaches to address each of these disabilities. It is also important to note that the additional disabilities experienced by the majority of children with deaf-blindness further complicates program development.

Imagine each child is in a preschool classroom structured around play centers such as the House Center, Art Center, Block Center, Library Center, and Science Center. There is a morning welcome, a story time, and films which occur in a large group. Small group activities are conducted around a theme or unit such as Families, Animals, etc. The play centers have materials which require some explanation or direction from an adult. For example, the teacher must demonstrate or have examples to help the children make animal puppets from socks. Recess occurs in a large group and the child may choose an area of recreational activity, i.e., swings, slide, tricycles, wagons, or the sandbox. All the children eat together in the cafeteria. Using the example of a unit on farm animals, we can look at the difference in teaching strategies and content modifications that might be made for each of these three children.

Teaching Strategies and Content Modifications

The Child with Hearing Impairment

Most of the same teaching strategies used to instruct children who do not have a disability would be appropriate for the child with a hearing impairment. This child will learn from what he sees and what he does (action). He learns a great deal incidentally by watching others. Instruction in a large group can be very beneficial for this child because he can prepare for his response while waiting for his turn.

Adaptations for teaching communication and auditory training goals include small group or individual instruction. Real experiences should be the basis of units that are taught, however this child would probably be able to relate story books, role play, and discussion to the real experience. The teacher may also rely on print, pictures, gestures, and movements to support or give instruction.

Issues for the child with hearing impairment include difficulty with English language structure which can effect the development of reading and critical thinking skills. Special attention should be given to teaching such structures as "why", past tense verbs, complex sentences, etc. He may also need additional practice in using language to explain and make predictions such as, "Why didn't the brick house fall down?" or "What will happen if you don't take a nap?"

The child with hearing impairment would probably have an experiential base about animals before he began to study the unit on farm animals. He might have a pet at home, has probably seen birds and squirrels in his yard, or has watched animal stories on television. He will understand stories about farm animals if it is signed and he can see the pictures. He might play with plastic farm animals and farm figures in the sandbox. He might color pictures of farm animals in the Art Center and sort zoo and farm animal figures in the Science Center. At recess he could pretend to be a horse that pulls a wagon outside. During auditory training he might try to discriminate between the sound a pig and a cow makes or point to the appropriate picture of each animal in the Old MacDonald song. Speech or speechreading might focus around the names of farm animals. At the end of the week his class may visit a working farm which would build on his week-long study of farm animals.

The Child with Visual Impairment

Some of the same instruction strategies could be used with the child who has a visual impairment. However, his learning will take place primarily through his own actions/experiences and information he receives auditorily. He can learn many things through group instruction with minimal support. Unlike the child with hearing impairment, this child will need more instruction that occurs through real experience. Imaginary play may be difficult for him, reducing the effectiveness of role play as an instructional tool. Language instruction for this child should be paired with ongoing activities. The use of pictures and print would be of limited value.

Using the example of a unit on farm animals, the child with visual impairments would likely have less knowledge of animals to begin with than the child who is deaf. He would not have seen the television programs or watched animals playing in his yard. He might have a pet and perhaps has some knowledge about caring for an animal. This unit may be most meaningful for him if the visit to the farm was scheduled before beginning classroom instruction.

Although he might be able to sort the animals in the Science Center using visual cues of color and shape, he may or may not relate them to the real animals. A more appropriate activity might be telling a classmate or teacher whether the animal lives in the zoo or on the farm after they name the animal or make the animal sound. Then he could put the animal in the proper area. Instead of coloring animal pictures he might use modeling clay to make an animal figure or scraps of fur to make tactile pictures. He could interact with other children in the wagon while working on the concepts of "left", "right", "fast", "slow", "stop" and "go" pretending to drive the horse. These concepts might be taught and practiced individually within orientation and mobility training. New textures can be introduced at the sandtable. Working on listening skills during story time may also be somewhat effective, especially after the child visited the farm. He could be encouraged to explore his environment to search out the sound of a mooing cow.

The Child with Deaf-Blindness

The child with deaf-blindness requires considerable modifications to teaching content and different teaching strategies. He cannot learn from what he sees like the deaf child does. He can not learn from listening like the blind child does. He learns only by what he does. This means that no learning is taking place for him while waiting for others to take their turn. For this reason small group or individual instruction becomes more critical. Large group instruction is only valuable if he can be consistently active (e.g. playground activities).

This child also may have problems experiencing new things. Encountering the world without benefit of vision and hearing requires a great deal of trust. Bonding with the child is critical for the instructor, therefore it is important to evaluate the child's response to an individual when determining who will be the primary provider of instruction. He may be withdrawn or passive, content to stay in one place and let the world come to him. Remember for him he will learn only through doing.

Things often magically appear and disappear before him. Cause and effect are elusive. People do things to him but not necessarily with him. There is little explanation of events before they occur. For this reason it is important to make interactions balanced (my turn, your turn) to encourage him to be responsive. Instruction that is always directive requires no response from him.

Safety is also of critical importance to this child. Not only must the environment be made safe for him, but he must feel safe in order to move around on his own. If he does not, he is likely to stay glued to one spot resisting interaction with his environment and the people in it. Instruction and support from an orientation and mobility specialist is very important. She may need to help staff evaluate the environment for hazards and develop travel routes for the child to use. She may work directly with him to orient him to that environment, and provide training on travel techniques and travel equipment.

The curriculum focus for the child with deaf-blindness will differ from that of the child with only a single sensory impairment. The deaf education focus may be primarily on using language to code existing concepts. The curriculum focus for a child with visual impairment may be more oriented toward building concepts and experiences which can provide a firm cognitive foundation for language. The curriculum focus for a child with deaf-blindness should be on bonding and developing interactions and routines for expanding the frequency and functions of communication. This child will not learn about objects or actions incidentally. He cannot tie together the fragmented input he receives without interpretation and instruction from others. He must be taught to use and accept this instruction.

Developing a communication foundation for learning is a priority. Typically communication is tactile in nature using signals, objects, gestures and later on sign language or tactile symbols or some combination of forms. Language is developed through the use of routines, calendar systems, discussion boxes, etc. Because of the degree of vision impairment and his inexperience with real events in the world, the use of print, pictures, and demonstration will be of little or no value to this child. He may not understand pretend or role-play as an event that relates to some real experience. The child with deaf-blindness may first need to be moved co-actively through an activity to know what is expected of him. After he understands what is expected, this support would be faded to avoid building prompt dependence.

Because concepts develop so slowly for this child, there should be a focus on making learning functional. Great care needs to be given to developing clear goals and objectives for this child. Typically these objectives need to be limited in number since this child will need many opportunities to practice skills before he is able to generalize the concept to other situations.

This child would have a very limited knowledge of animals because he can not observe them or hear them. He has not seen television shows about animals. He may have a pet at home, but might only encounter it if the pet is placed in his lap or brought to him. His experience with that animal would be primarily tactile. He may not be able to distinguish his long-hair cat from his long-hair dog if he only pets the animal. Or he may experience the animal as a thing that licks or smells a certain way.For this reason vocabulary (concepts) which are taught should be more broad in nature. Careful consideration should be given to concepts which can be applied to other units throughout the year and across a variety of settings.

For example, the farm animal unit might focus on action concepts such as feed, pat, rub, pull, walk, open, close, pour. These same concepts should be applied to other units or in different environments. For example, "pull the leaf", "pull the wagon", "pull the drawer", "pull off the lid" and so forth. This child may have a "pull" unit throughout the year that is embedded in the various units the other students will study. If this child has a pet at home, another approach to instruction could focus on things this child can learn to do with his pet. For example, he might learn to feed his pet, walk it, pet it, brush it, etc. Units could be developed around things that can be fed, walked, brushed, etc.

The child with deaf-blindness could meaningfully participate in the play centers but his goals would be different from the other children. For example, while the other children pretend to be animals, the child could "rub" or "pat" them as if he was the farmer they come to for attention. In the Art Center he could "pat" and "pull" modeling clay to help a classmate form an animal shape. At recess he could direct the other children to "pull" him in the wagon or practice pulling them with help from a classmate. The teacher for the hearing impaired or other staff could help him to learn to vocalize to get the other children's attention before he signs "stop" or "go". In the Science Center he could use his vision to find objects in the sandbox. Then he could "open" and "close" the door to the toy barn, "pour" sand on the toy animals, "pull" the shovel out of the sand, etc.

When he visits the farm with the other children he would experience the differing size, textures and smells of the animals, but his goal might be to use his cane or sighted-guide technique in unfamiliar environments. If field trips are regular events, he might also learn a field trip routine. Unless he actually lives on a farm, learning about the animals and what they do will be of little value to him even though it may be a very pleasurable event.

Obviously this child will require a great deal of individual support. Initially this may need to be provided by the teaching staff. However, if good interaction and communication skills are modeled for the other students and an effort is made to draw them into successful play situations together, they may be able to provide instructional support for some activities.

Conclusion

The educational needs of a child with deaf-blindness are unique. Teachers without specific training in the area of deaf-blindness may be unable to appropriately program to meet these needs without specialized training and support. Few school districts have even one teacher with this kind of specialized knowledge. In addressing the child's education from birth - 21 a large number of teachers and support staff as well as community members and human service staff must work with the child. However, if his unique learning style is not addressed, the child with deaf-blindness is at risk for being excluded from the classroom, the family and the community.

This article originally appeared in the January 1995 edition of P. S. NEWS!!! published by the Texas School for the Blind & Visually Impaired Deaf-Blind Project.