SAM: SYMBOLS AND MEANING

# APH SAM - Symbols and Meaning Guidebook

Photo of a young girl on a platform swing playing with her teacher. They have a white plastic tub, a spoon, and a blue bowl.

Millie Smith, M.Ed., TVI

Purple square, orange star, yellow triangle, light orange circle, and green diamond

SAM icon of geometric shapes in a basket

Book 1 of 2

For use in kit 1-08854-00

APH logo

American Printing House for the Blind, Inc.
Louisville, KY

In keeping with our philosophy to provide access to information for people who are blind or visually impaired, the American Printing House for the Blind provides an electronic version of this book for large print and braille readers.

Catalog Number 7-08854-00
Copyright © 2012, American Printing House for the Blind
All rights reserved. Printed in the United States of America

This publication is protected by Copyright and permission should be obtained from the publisher prior to any reproduction, storage in a retrieval system, or transmission in any form or by any means electronic, mechanical, photocopying, recording, or otherwise, unless where noted on specific pages. For information regarding permission, write to American Printing House for the Blind, 1839 Frankfort Avenue, Louisville, KY 40206-0085.

# Foreword

The photo shows a toddler in a swing. He wears a hat with a long bill and sunglasses to protect his skin from the sun.

All children depend on the wisdom of the adults in their lives to create and support learning opportunities. For some learners, the need for adult guidance is even greater due to the child's young age and/or the presence of sensory, physical, and/or learning challenges.

Blindness and visual impairment may occur at any time in the child's development. The population of learners with visual impairments is highly heterogeneous. The percentage of learners who are blind and visually impaired with additional disabilities has been reported to be as high as 40-70% (Langley, 2004; Erin, 2007). These numbers tell an important story about the need for well-informed assessment tools and educational practices that address the unique learning needs of this population.

When we, as parents and educators, have proper knowledge and tools, we can be more deliberate when designing experiential-learning environments and activities that are accessible and meaningful to the age and abilities of the child. Both tenets are critical to the child's involvement in learning activities and the ongoing mastery of new concepts and skills. When we pay attention to the sensory avenues available to the child, we know how to customize the learner's instructional materials for optimal access (Koenig & Holbrook, 1993). Accessibility is a critical first step to ensure that the child is able to engage in the learning activity.

We must then take steps to ensure that the learning activity is meaningful to the student. To accomplish this step, we must understand how to identify and expand a child's preferences and present level-of-knowledge. The corresponding vocabulary and related concepts of the activity must have personal relevance to the learner, which enables the child to move forward in his or her conceptual and communication knowledge and skills. We must further understand the child's ability to understand and utilize the symbols involved in the activity.

When we are informed and thoughtful with what we do, our learners reap the reward. Simply put: When we know better, we do better. When we do better, our children do better.

The learners who depend so much upon on the wisdom of the adults in their lives have a good friend in Millie Smith. Thanks to the impressive work of this gifted teacher and commonsense-style author, we now have SAM: Symbols and Meaning.

This invaluable tool advances our understanding of how to create accessible and meaningful learning activities for children with visual and multiple impairments and pre-school children with visual impairments who are just beginning to use symbols.

The SAM: Guidebook fills a gap in our teaching toolbox. The author walks us through an understanding of how children expand their knowledge of the world, what helps to bridge learning when there are accessibility challenges, and strategies for meaningful learning interactions. The information is both practical and insightful.

SAM: Assessment and Games yields four assessment tools that inform our understanding of the child's vocabulary and corresponding life experiences with people, objects, and places. The author guides us through a systematic assessment that informs instructional practice with needed media and target concepts.

When we know better...our children do better. I believe that we will all do better as a result of these materials.

Tanni L. Anthony, Ph.D.
State Consultant on Blindness/Visual Impairment
Exceptional Student Leadership Unit
Colorado Department of Education

# About the Author

Photo of Millie Smith

Mildred (Millie) J. Smith is a private consultant working with students who have visual and multiple impairments. Since her retirement from the Texas School for the Blind and Visually Impaired (TSBVI), Millie conducts workshops, gives private consultations, and is a respected author/consultant to the American Printing House for the Blind (APH).

After teaching high school English for 2 years, Millie returned to school and completed her Master of Education in Visual Impairment and Emotional Disturbance from the University of Texas at Austin. Her graduate internship was working as a specialist in school programs for emotionally disturbed students at Children's Psychiatric Hospital at Austin. Like many vision teachers, Millie started out as an itinerant teacher of students who have visual impairments, working in the Dallas Independent School District. Millie then returned to Austin and began teaching at TSBVI. During her 27 years at TSBVI, she worked as a resource teacher, a classroom teacher, and as an outreach teacher trainer. She has taught classes focusing on visual problems of exceptional children at the University of Texas at Austin and sat on the Advisory Board of the Special Education Department, Program for the Visually Handicapped.

Millie has shared her experience and knowledge with families and teachers by writing numerous articles and through her books, Teaching Students with Visual and Multiple Impairments: A Resource Guide, co-authored with Nancy Levack and published by TSBVI in 1996 and the Sensory Learning Kit published and manufactured by APH in 2005.

Millie has been honored and recognized by her peers as the 2000 co-recipient of the AER Bledsoe Award for Teaching Students with Visual and Multiple Impairments, the 2001 recipient of the AER Division 3 Virginia Sowell Award, and the 2007 recipient of the APH Virgil Zickel Award.

APH is honored that Millie dedicates part of her retirement to help us create much needed intervention products for learners with visual and multiple impairments. Millie is a respected colleague and friend. Thanks Millie.

Tristan Pierce
Multiple Disabilities Project Leader

# Project Contributors

Tanni Anthony, Ph.D., COMS
J.C. Greeley, TVI, O&M
Linda Hagood, MA, CCC-SLP
Zoe Larsen Morgese, MA, CCC-SLP
Amy Parker, Ed.D.
Jennifer Stocker, MHS, OTR/L

American Printing House for the Blind
Project Leader/Research Associate: Tristan Gay Pierce
Research Assistant: Rosanne Hoffmann
Research Assistant: Erica Rucker
Research Assistant: Monica Vaught-Compton
Field Service Representative: Maria Delgado
Technical Research Division Manager: Frank Hayden
Manufacturing Specialists: David McGee and Bryan Rogers

# Message to Readers

Photo of SAM Kit

The following components of the SAM Kit are provided to facilitate implementation of the games included in SAM: Symbols and Meaning.

Baskets, two Digital recorder Plastic story pages, 25 SAM Assessments and Games book SAM Electronic Assessment Forms SAM flash drive SAM Guidebook SAM Videos Sport bag | Story bags, three sizes Story binders, three sizes Story box liners, vinyl Story boxes, six Tray liner, non glare plastic Tray liners, vinyl Trays, two Velcro®-black, strip and coins Velcro-white, strip and coins

Substitute intervention items may be included in your kit due to the occasional unavailability of commercial items. Such items have been selected to serve a similar function.

Your kit was not designed to be used by unattended children. Children should always be supervised by an adult when using items in your kit.

We hope your students/clients benefit greatly from using SAM and that you enjoy using it as much as we enjoyed producing it.

Tristan Pierce, Project Leader
Millie Smith, Author

SAM logo

# SAM: Symbols and Meaning

Snapshot

SAM is
a program that provides strategies for developing a strong sensory foundation for concepts about people, objects, actions, and places so that symbols referring to them are meaningful

SAM is for
students with visual and multiple impairments and pre-school children with visual impairments who are just beginning to use symbols-the late sensorimotor, early preoperational stage of cognitive development.

SAM is used by
teachers of students who have visual impairments to help parents and teachers create daily learning opportunities and provide direct instruction in natural environments.

Purple square, orange star, yellow triangle, green star, light orange circle, and blue diamond

A young girl chooses a black spoon from an array of items on a SAM tray. | A young girl looks closely at the massager on her arm.
A young girl explores a pink, plastic bowl. | A boy rests his up-turned hand in his female teacher's palm. She has a piece of tape on her forefinger.

# Chapter 1: Why do we need a program?

Photo of a baby boy holding a ball with one hand and his foot with the other hand. He mouths the ball and looks at his foot.

Photo Caption: Concepts about people start with knowledge of one's own body.

## Making Sense of the World

In order for any person's world to make sense, a great deal of knowledge about people, objects, actions, and places must be acquired. Three questions are constantly being asked and answered.

- What is it?
- What does it do?
- How does it relate to other things?

"It" may refer to something very simple, such as "ball," or to something more complicated, such as "the United States Congress." The acquisition of information that answers these three questions is often called "concept development." A very simple definition of the word "concept" can be found in Webster's New World Dictionary. It says that a concept is an idea or thought (Neufeldt & Sparks, 1995). The idea or thought is constructed over time and, in the early stages of concept development, the building blocks are direct experiences with people and objects in the environment (Fazzi & Klein, 2002). As these experiences accumulate, learners discover patterns and mentally organize these patterns into "schemas," which form the internalized knowledge of what the world is and how it works (McLinden & McCall, 2002).

SAM Concept Categories

People: The self and others
Concepts about people start with knowledge of one's own body. Self-awareness becomes the core knowledge to which new information is attached. New information includes the characteristics of other people's bodies first and, then, more sophisticated things associated with the body like its emotional content, what it does, where it goes, its name, and how it relates to other bodies.

Objects: Tangible things
Concepts about objects start developing as soon as the blanket touches the newborn's body. Information about the physical characteristics of objects is acquired through the senses. Acquisition of sensory information leads to recognition of the object and associated information about how it is used and how it relates to other objects.

Actions: Body movements of the self and others
Concepts about actions start with random movements of the learner's own body in infancy. The actions become more intentional as certain results are associated with certain movements. Information about the actions of other people's bodies allows the learner to imitate and expand his range of options in choosing how he will interact with his environment.

Places: Where things are, contexts for groups of things
Concepts about places allow the learner to find things. Simple place concepts include things like knowing where to look or to move the hand to find the cup during mealtime. Things have to be in the same place consistently in order for place concepts to develop successfully. Place concepts build mental maps of how things relate to one another spatially. Places are also contexts-environments or surroundings-that provide meaning. A kitchen is the context that helps to provide meaning to objects like pans, spatulas, strainers, etc.

Because of the challenges they face related to acquiring information, learners with visual and multiple impairments and young children with visual impairments may live in worlds that make little sense and are, therefore, confusing and even scary. They may defend themselves by avoiding unfamiliar objects and people (Erin & Spungin, 2004). Reluctance to engage the unfamiliar is a problem because "...delays in active exploration or variations in concrete experiences will affect the rate at which the infant's (child's) intellectual capacity develops" (Recchia, 1997, p. 402).

## Development Variations Due to Visual Impairment

For learners with visual impairments, typical variations in the development of meaning include the following.

### Absent and Incomplete Concepts

Psychologists J.J. Gibson and E.J. Gibson describe infants discovering the world through interactions using their "sensory systems" and their "action systems" (McLinden & McCall, 2002). If a child has a sensory impairment such as vision or hearing loss, "the quality and scope of learning may be limited by reduction in environmental interactions" (Barraga & Erin, 1992, p. 31). Access to people and objects may be limited because search is not motivated by curiosity about things seen and heard. When objects and people are accessed, meaning may not develop because sensory information is insufficient or confusing.

Children who have visual and motor impairments face significant challenges as they try to acquire information about their worlds. In addition to all the variations already discussed related to vision loss, motor impairments bring with them their own variations to the sensing and action systems. The most obvious motor issue affecting the action systems is lack of access. The learner may have fewer interactions with things in her environment not only because she cannot see that something exists beyond her body, but also because, when something is seen, she cannot move her body to it in order to explore it. If the motor impairment is severe, an object only a few inches away from the hand may be inaccessible. Action systems are also impacted by limitations in exploratory behaviors after objects are accessed. Typical children have a range of exploratory behaviors. Before they can grasp, they begin exploring by mouthing objects touching their bodies and by using their fingers to explore textures by scratching at surfaces. Gradually, their hands become more involved in information gathering.

Photo of a baby girl trying to grasp a ball

Photo Caption: The learner's motor impairment makes it more challenging for her to grasp the ball and acquire more information about it.

When they master grasping, they use their hands to bring things to the mouth for oral exploration. Then they develop a hierarchy of exploratory actions as they hold objects. They typically start with banging and progress to shaking, throwing, dropping, banging two things together, taking out, putting in, pulling apart, putting together, stacking, and placing. The child with a severe motor impairment may not be able to use her hands in these ways. Even if she is able to grasp an object, her ability to use her hands to gather tactual information may be compromised further by motor impairment issues related to her sensing system. If the motor impairment is caused by cerebral palsy, "loss of tactile and proprioceptive sensation is common" (Rosen, 1998, p. 238). Alternative tactual exploration strategies are essential for young learners who have visual and motor impairments. See Appendices B and C for more information about this issue.

If cognitive disabilities are added to the mix, experiences may not result in the discovery of patterns and the organization of information into meaningful schemas. Help needs to be provided so that experiences are simplified, repeated, and structured (Erin & Spungin, 2004).

### Objects Experienced Out of Context and Without Intended Function

A child may engage in an interaction with an object or person simply because he enjoys the sensations stimulated by the attributes of the object or person. This characterizes a great deal of the activity that goes on during what Piaget called the early sub-stages of sensorimotor development. A baby at this sub-stage bangs the spoon because he likes the sound it makes. For the baby, the function of "spoon" is noisemaking (Warren, 1994). Later, but still in the sensorimotor stage of development, the child touches his familiar spoon, recognizes it as the object used during the experience of eating cereal, and picks it up with the goal of using it to put cereal into his mouth. In the first instance, the object has a handle and a shallow bowl and is a noisemaker. In the second, it has a handle and a shallow bowl and is a spoon.

The photo shows a boy toddler who holds a wooden spoon and bangs one of three metal bowls turned upside down on a tile floor.

Photo Caption: For this toddler, the function of "spoon" is noisemaking.

It is not sensory characteristics alone that define objects. Equally significant is how those objects are used (Gibson, 1988). Consequently, an object experienced in an arbitrary context, such as a spoon in a bag of objects presented in a play area, cannot contribute to the development of a meaningful concept of spoon. Playing with objects out of context is a wonderful activity at the beginning sub-stages of sensorimotor development. It stimulates sensory curiosity that promotes the development of exploratory behaviors. This is an essential step and the consequences of skipping it or rushing learners through it are passivity, avoidance, and self-stimulation. At the same time, learners need to experience objects in a context that relates characteristics and function, such as mealtime, so that they can develop fundamental knowledge of their worlds.

In these early stages, the child might touch a different, unfamiliar spoon and have no idea what it is. He has not yet had sufficient experience to realize that there is more than one spoon in the world and that there are specific characteristics of some objects that contribute to their use as spoons. A child with visual and multiple impairments, who is ready to learn that there is more than one spoon in the world, can play with a bundle of spoons in his play area; but he also needs to use more than one spoon while eating, explore other people's spoons as they eat, give spoons associated with other people to them for the purpose of eating, and help set the table. Eventually, he can help empty the dishwasher by putting all the spoons in the appropriate compartment of the silverware tray in the kitchen, realizing that all the objects that go in the tray belong to the meaning category of "things used while eating."

An array of photos showing seven different types of spoons, some of which are adaptive spoons.

Basic knowledge requires information about function. Only "doing"-use of the action system-can develop information about function. The concept of "spoonness" cannot be derived in the following ways:

- Exploring the spoon in a context unrelated to its use
- Listening to the sounds the spoon makes while someone else uses it
- Hearing language describing what someone else is doing with the spoon

An experience that allows the child to combine her own sensory and action systems while using the spoon in a meaningful context results in real concept development (Gibson, 1988). All of the bulleted items above may be helpful ways of expanding on basic knowledge once it is established.

### Words Without Meaning

One of the most essential things to understand about using language to help children develop concepts is that there is a significant difference between hearing and saying words and understanding what words mean. Young children start their relationship with words a lot like banging the spoon for the pleasure of hearing the sound it makes. "Babbling stimulates a baby acoustically and kinesthetically, thereby encouraging the infant to continue making sounds. Eventually the child imitates sounds spoken by others and begins to learn to say words" (Dunlea, 1989, p. 1).

For many children, and especially those who have severely limited vision, the ability to say words precedes understanding word meaning (Dunlea, 1989). The ability to develop word meaning depends upon how successfully spoken words are associated with the people, objects, actions, and places to which they refer. The production of speech without these concrete referents may be pleasurable, but it is not truly symbolic.

Referent

"Referent" is the object, person, action, or place being referred to when a symbol, like a word, is used. The word represents its referent.

Concrete Referent

"Concrete referent" means a thing the learner can touch, point to, or do. By this definition, "spoon" and "pull" would be words with concrete referents. "More" and "smooth" are examples of words that do not have concrete referents. "More" is an idea about quantity and can refer to anything and "smooth" is a descriptor of a quality that requires comparative data for meaning (Hagood, 1997).

Hearing words used by others without being able to associate them with their concrete referents is extremely significant socially and emotionally, but it does not contribute to concept formation (Chen, 1999). Language can never be used as a substitute for sensing and acting with young children and learners with multiple impairments.

# Chapter 2: Who will use the program?

The photo shows a girl squinting and smiling at the sun. The sun's light is reflected on her face.

Photo Caption: A girl expands her learning about the day's weather by feeling the sun on her face.

## Cognitive Stage Development

Jean Piaget described cognitive development in three global stages: sensorimotor, preoperational, and operational. There is disagreement among psychologists about the accuracy of some of Piaget's theories about the early sub-stages of the sensorimotor stage and about the helpfulness of looking at global stages, as opposed to looking at the dynamic development of specific domains such as language (Sutherland, 1992). Even so, the Piagetian model remains the prevalent standard for defining cognitive development (McLinden & McCall, 2002).

### Sensorimotor Learners

Typical children spend the first 2 years of their lives in the sensorimotor stage. They use their sensing and action systems to react to and interact with people and objects in their environments (Gibson, 1988). As a result, they develop the cognitive skills of object exploration, object permanence, imitation, causality, means-ends, and basic spatial relationships (Morgan, 1992). The Sensory Learning Kit provides activities for developing these cognitive skills. In the late sensorimotor stage, learners begin to use simple labels for things. These usually consist of one or two words that name the thing being experienced in the here and now. These labels are not fully symbolic at this stage. For instance, the word "nana" may be used to label the white round pieces of fruit in the learner's dish, but would not convey to the learner other images of bananas like the yellow, unpeeled fruit his mother buys at the grocery store. SAM begins at this early labeling stage of symbolic development.

### Preoperational Learners

It is important to understand that cognitive stage development is additive. Sensorimotor learning strategies never go away, but new, more complex strategies are added as development progresses. Children become preoperational learners when they add the strategy of remembering and organizing previous experiences and use symbols that represent components of those experiences. The child can now think about things that are not being presently experienced, and she can use symbols to expedite this thinking.

"The child is no longer tied to the here and now, which is experienced through immediate sensation and action patterns. Now the child can begin to think about the past and contemplate the future" (Fazzi & Klein, 2002, p. 116).

While first words typically appear at the end of the sensorimotor stage, in the preoperational stage, symbol use becomes more extensive and more complex. Symbols, like words and pictures, become the tools of problem solving, pretend play, and social connection (Dunlea, 1989).

## APH Intervention Continuum

### Sensory Learning Kit

The photo shows a young boy sitting in a support chair. He has a Sensory Learning Kit vibrating pad on his lap. On top of the vibrating pad is a stick switch with a piece of orange swimming noodle over the stick. The boy pulls the stick down to operate the vibrating pad.

This program builds sensorimotor level cognitive skills with learners who need carefully-selected materials and carefully-designed activities in order to take in and respond to sensory input. Teachers of students who have visual impairments help parents and teachers provide learning media with sensory characteristics that are highly attractive to the learner. They encourage reactions and interactions with these materials in highly structured activities called routines designed to control pacing, sensory clutter, unfamiliarity, and other variables that produce stress and interfere with learning. Three levels of sensorimotor learning are addressed.

> Quiet Alert: Attention
> Active Alert: Exploration
> Partial Participation: Function

### SAM: Symbols and Meaning

The photo shows a girl sitting on the floor with her female teacher. The girl mimics drinking from a cup.

This program builds late sensorimotor and early preoperational level cognitive skills. It is designed for learners who need help expanding their learning to people and common objects in typical activities taking place in natural environments. A series of games is used to ensure that a strong sensory information base is established for concepts about people, objects, actions, and places. Symbols-objects and words-are paired with concrete referents in each of the above categories so that each symbol is rooted in meaningful experiences. Once meaning is established by pairing symbols and concrete referents, additional games give learners the opportunity to use object and word symbols in communication contexts.

### Tactile Connections: Symbols for Communication

The photo shows a girl sitting in front of a platform communicator. She selects one of three tactile communication cards on the communicator. An adult hand helps to support her sitting position.

This program builds skills for the use of tactile symbols (parts of objects and arbitrary objects organized in categories) in augmentative communication environments where a sighted peer might use pictures. Symbolic skills are expanded from concrete to more abstract and from single-word to multi-word communications.

## Profiles of SAM Users

### Ana

Mrs. Gary, Ana's pre-school teacher, announces to the class that it is circle time. Ana claps her hands and says, "Days of the week," but makes no attempt to move to her carpet square as the other children assemble. The teaching assistant comes over, says, "Let's go," and escorts Ana to her square. Ana sits down facing away from the teacher and is helped to turn in the right direction. The teacher asks, "Who wants to be the special helper?" Hands go up. Ana is quietly singing the "Hello" song to herself as this goes on. When the teacher asks, "Who knows what day it is?" Ana responds by repeating the teacher's words with exactly the same vocal inflection. Later, Mrs. Gary asks the class to count from the first day of the month up to the current day as she points to the numbers on the wall calendar. Ana confidently says the numbers in correct order except she does not stop when she reaches the number for the current day as the other students do. She continues until she gets to 20 in spite of the assistant's directions to her to stop. The teacher points to the weather chart and asks, "What is the weather like today, Ana?" Ana says, "Is it cold, hot, warm, sunny, cloudy, or rainy?" Mrs. Gary says, "Well, which is it, Ana, sunny or cloudy?" Ana says, "Cloudy." When given two choices, Ana has learned that she is expected to say one of the two words offered and she always says the second of the two. Mrs. Gary explains to her that it is sunny today and asks her if she felt the warm sun on her face when she was outside. Mrs. Gary tells the assistant to take Ana to the door so that she can feel the sun on her face. The assistant walks Ana into the sunshine and asks her, "Can you feel the warm sun on your face now?" Ana repeats these words. Back in circle, Mrs. Gary asks Ana, "Is it sunny today?" Ana says, "Is it sunny today? Can you feel the warm sun on your face now?"

### Dari

Mr. Evans, Dari's TVI, has made a picture menu for him using very simple, high contrast, low clutter photos of the lunch options available every day in the cafeteria. To make sure that Dari recognizes the pictured object, Mr. Evans and Dari go to the cafeteria a little early. Mr. Evans shows Dari a picture and asks him where that item can be found. If shown pictures of pizza, hamburgers, nachos, and salad, Dari can go to the area where these items are located. Mr. Evans is working toward a choice making activity with Dari in the classroom before he goes to the cafeteria. The speech language pathologist wants to do a vocabulary expansion activity with Dari using the same technique. She thought it would be a good idea to start with the items Dari had mastered. She borrowed his familiar pictures from Mr. Evans and collected a set of plastic replicas of the corresponding food items. Dari was unable to give her the object corresponding to the pictures she showed him.

### Mariah

Mariah goes to home sciences class with her junior high school peers. She has done a wonderful job of learning to use tactile symbol labels on cabinets to locate materials used for cooking and can get and put away items named by her teacher. Nevertheless, when her teacher asks her what she needs for a certain task, Mariah is unable to answer. For instance, when asked to get the oven mitt, Mariah can go to the cabinet area, read the labels on the drawers until she finds the one with the piece of mitt on it, and get the mitt. But, when asked to show her teacher what she needs before she takes the cookies out of the oven by pointing to the appropriate object in an array of three, Mariah either does not respond or points randomly. Mariah has been told what the mitt is for, but she has not practiced using it to remove items from the oven in the way she has practiced getting it from the drawer.

### Ben

Ben is happy sitting at the group table during arts and crafts time. He rocks back and forth as he listens to the sounds around him and flaps his hands vigorously when he hears something he particularly likes. When the teacher tells him to pick up the scissors, he stops rocking and moves his hands to the table but does not search for or pick up the scissors. The teaching assistant taps the scissors on the table. Ben moves his hand to them and touches them briefly. The assistant puts her hand over Ben's and helps him pick up the scissors. When she removes her hand, Ben taps the scissors on his lips three times and throws them. The assistant retrieves the scissors, uses her hand over Ben's to hold them in his hand and begins to help him cut. Ben starts repeating, "Don't throw, Ben," in a distressed voice. His rocking increases. He tries to pull his hand away and when he is not successful, leans down and bites the assistant. This scenario is played out with the glue bottle, the colored markers, and virtually every other object Ben is required to use throughout the day.

# Chapter 3: How is the program designed?

One photo shows a school bus with the door open and children walking down a sidewalk. Another photo shows a residential home. The last photo shows a young girl smiling.

Photo Caption: Both school and home environments are needed to create a successful SAM program.

## Collaborating with Partners in Homes and Schools

Pre-school children and learners with visual and multiple impairments learn best when their learning opportunities occur regularly and are provided by people (partners) they know and trust (Lueck, Chen, & Kekelis, 1997). The individuals who see these learners every day, parents, interventionists, and classroom teachers, are essential partners. Peers and siblings play an important role, but their role needs to be supported by a trained partner. Teachers of students who have visual impairments (TVIs) are essential to the program. They provide the foundation for good learning opportunities even though they might not see the learner frequently enough to be the primary provider of the activities. The TVI shares information about strengths and needs, helps develop goals, chooses intervention strategies, helps plan activities, monitors progress, helps make revisions, and moves partners on when it's time (Smith & Levack, 1999). This relationship between the person who has specific responsibility for addressing needs related to their professional expertise and the people who have responsibilities and expertise in other areas is called "collaboration." It is a highly effective way to make sure that learners get what they need. The TVI serving a learner in this way is not less involved, but merely involved in a special way. One of the first things that a TVI who uses SAM will need to do is to explain to parents and teachers some of the important foundations of the intervention described in the following sections.

## The Game Approach

The main intervention strategy used in SAM is an activity provided in "game" structure. There are several reasons for choosing this approach.

A young girl holds a kitchen timer, shaped like a blender, close to her face and smiles.

- Games are non-threatening and fun. Learning occurs most effectively when an activity is based on established skills and new skills are added within a comfortable zone of attainment (Vygotsky, 1962). In other words, the game is never too easy and never too hard. Support is given at the appropriate level and then gradually decreased so that the learner becomes more and more proficient while always experiencing success (Bruner, 1983).
- Games have an abiding structure from context to context. Every game has unique materials used while playing and it has rules. When most people think of Scrabble, materials like a board and tiles and rules like "draw seven" come to mind. SAM uses several games. Each has a distinct name so that the learner can make similar associations and therefore predict what is going to happen. This is important because the games will be used in a variety of different environments. Once the learner is familiar with the materials and rules of a SAM game, like the Do It Again game, as it is played during mealtime, he can play the same game during a science activity using a fan and a pinwheel to generate wind power.
- Games maximize active learning. Learning is always a combination of sensing and acting. Games create a consistent expectation for active participation on the part of the learner during his turn. An activity in which the partner does everything while the learner sits and listens is not a game.
- Games are appropriate at any age. From Pat-a-cake to Scrabble, games are a part of life forever. For older learners at the early preoperational level of cognitive development, simple game structures can be maintained while materials are chosen to reflect age appropriate topics.
- Games facilitate sibling and peer cooperative learning. Once the game is familiar to the learner, siblings and peers can be helped to understand their role in maintaining the game so that they can be successful partners.

## Elements of Good Instruction

### Focused

Participation in any activity requires many skills. The sheer volume of challenges facing her may overwhelm an early preoperational learner like Ana, who participates in a complex activity like "circle time." If she receives instruction on every skill included in that activity each time it happens, she is not likely to receive the kind of instruction on any one of those skills that would result in achievement. It may be necessary to break down a complex activity into more discrete sub-parts. Circle time may need to become "Traveling to my carpet square," "Pointing my face at the teacher's voice," "Listening for the helper question and raising my hand," etc. Learning each of these components may require that they be practiced several times in a short period of time. Parents and teachers can focus on one part of an activity, provide instruction on the skill required for that part, and provide higher levels of support during the rest of the activity. When success is achieved on the targeted part of the activity, they can move on to a new skill in another part of the activity.

### Regular

Skills are learned best when they are practiced regularly. Intermittent and random experiences are sufficient, although not ideal, for many older and typical learners; but they are not effective as a strategy for building skills in very young children and learners with multiple impairments. For these learners, repetitions of a response that occurs in an activity that is a part of daily experience over a long period of time results in the best learning. This is why music teachers want their pupils to practice every day. The very best learning happens when these repetitions have a little space between them during which something different happens for a short time (Mulligan, Lacy, & Guess, 1982). These are called distributed trials, and the "your turn/my turn" structure of games makes them ideal for this kind of practice. When experiences are short, random, and infrequent, they may be enjoyable, but they are not likely to be stored in long-term memory in the way that is necessary for meaningful concept development.

### Appropriate

One of the most frequently used terms in the literature addressing the instruction of children with disabilities is "appropriate." The word seems to mean different things to different people, but the most essential meaning is effective instruction related to identified individual needs (IDEA, 2004). Regardless of the setting in which instruction occurs or the type of skill being addressed, individualized programs for learners with disabilities must include highly effective instructional strategies and techniques, even when those strategies and techniques are different from the type of instruction being provided for other learners. Additionally, the targeted skill must be within the learner's zone of proximal development-the gap between what the learner can do without help and what he can do with help to achieve a goal he desires and understands (Jacobs, 2001).

The photo shows a messy pile of children's bakeware.

### Natural

After young children spend a lot of time playing with objects in random ways for sensory pleasure, they begin to be interested in what their primary people are doing with these objects. Now they are interested in the function of objects and how objects relate to each other. For example, a toddler who had enjoyed banging pot lids may become more interested in the fact that the lid can be used to close the opening at the top of the pot. During the first stage, the setting for the banging is not terribly important. Mom might have a basket of lids she puts in the play area. It is the banging that is significant to the learner, not where it is happening. Eventually, Mom needs to get over her aversion to messes in her kitchen and let the learner pull the pots out of the cabinets while she cooks. She might even need to help him pull the pots out. In the second stage, understanding that pots usually contain food items is part of developing the cluster of concepts related to "cooking" within the kitchen environment. As learners begin to use objects to discover their function, place becomes very important. Functions practiced in the place where they typically occur allow other things related to that function to be associated during the experience.

### Consistent

Early preoperational learners thrive in environments that are orderly and predictable, but not boring. An established schedule of daily activities is extremely helpful for young children and learners with multiple impairments. Activities within the daily schedule that occur with the same structure maintained from one day to the next also promote learning efficiency. Including something new or different is important for concept development. New information is used best when it is a small addition to something very familiar.

FRANC

> F... | Focused instruction on one part of the task
> R... | Regular practice in distributed trials each time the activity occurs
> A... | Appropriate goals paired with effective strategies
> N... | Natural contexts that provide meaning and build associations
> C... | Consistent structure for adding new information without stress

## Verbal Instruction: When and How Much to Talk

For early preoperational learners, it is helpful to think of the language provided by others in two categories-chatter and instruction. Both are important, and there are some guidelines for the most beneficial use of each type.

### Chatter

Definition: Chatter is free flowing streams of words containing comments, questions, and commands in no particular order and with changes in topic occurring randomly.

Example: "Let's put your shoes on. Come on over here now. Are you through with your juice yet? We will get you some more juice in a minute. Let's see. Did Mom wash your socks or not? Oh good, we have clean socks, but we won't have clean socks tomorrow unless somebody in this house does some laundry. What did Mom say? Are you going to come here now or is Mom going to have to come over there and get you? Here I come. I'm gonna get you now."

Benefits: The child knows where Mom is. The child knows what kind of mood Mom is in and whether what is coming is likely to be a play opportunity or a demand. The child may have understood a few key words like "shoes" and "socks," thus a guess about what is going to happen may be pretty close. The child hears language patterns that help develop awareness of linguistic components such as syntax and grammar.

### Instruction

Definition: Instruction consists of consciously chosen words that convey a command or a comment, but not both, and are related to one topic. The few words that are used stand out because chatter does not surround them. The chosen telegraphic phrase may be repeated and, if it is repeated, it is said the same way each time. Comment phrases are spoken as behaviors occur.

Example: After Mom has chatted about shoes, which is a great way to let the child get ready, instruction starts.

> "Come here, please." Child turns to Mom.

> "Come here, please." Child goes to Mom.

> "Give the socks to Mom." Child gets socks out of drawer and gives them to Mom. Mom quietly provides help when necessary.

> "Sit down." Child sits.

> Mom puts a sock over toes and says, "Pull the sock." Child finds the top of the sock with one hand. Mom guides the other hand to the sock top without words. The child pulls.

> Mom comments, "Pull sock, good!"

Benefits: The child clearly understands what is wanted. The child is learning verbal word symbols for objects and actions. The child is allowed to feel secure with a small number of symbols with very concrete referents like "sock" and "pull" before new symbols like "top" and "both" with more abstract referents are introduced.

Of course, Mom goes back to chatter as soon as the shoes are on. She talks about how smart and wonderful her child is and how beautiful she looks in her shoes. The most effective way of getting more of a desired behavior is to provide praise. Even when individual words are not understood, the emotional content of the message is.

### Use of Questions

Questions are used more frequently with learners with visual impairments than with other learners (Dunlea, 1989). There are two problems with this. First, questions are more difficult for early language users. They understand simpler forms of language like commands and comments more easily. Second, if they hear a lot of questions, they tend to ask a lot of questions when comments would be more appropriate. So, "Come here." is easier than "Would you come here?" Similarly, a child who hears, "Pull sock, good!" is more likely to say, "I pulled my sock." than "Am I pulling my sock?"

# Chapter 4: A closer look at what we know about concept development

The photo shows a stone-colored, small pyramid sitting in the middle of a large room. A larger white, transparent pyramid is inverted and suspended above the small pyramid.

Photo Caption: Concepts are the blocks used to construct the pyramid, and the pyramid is the schema. Knowledge expands from the bottom up like an inverted pyramid.

## What Are Schemas?

The discussion so far has been mainly about concepts-ideas or thoughts-as the units from which meaningful knowledge of the world is constructed. Schema is a word that means almost the same thing, but cognitive psychologists use it to describe something a little bit bigger. A concept is a unit, or a thought, and a schema is an orderly combination of those units in a definite pattern (Neufeldt & Sparks, 1995). For instance, combining stone blocks in a definite pattern can result in a pyramid if the plan involves arranging those blocks in a cascading fashion. Concepts are the blocks used to construct the pyramid, and the pyramid is the schema. The result of combining thought units into an organized pattern is general knowledge about procedures, sequences of events, and social situations (Matlin, 2008). The biggest potential barriers to success in this construction project are

- delays in active exploration and/or
- variations in concrete experiences (Recchia, 1997).

Sensorimotor level learners need a large quantity of high quality opportunities to actively explore and then use objects with sensory attributes that are very attractive. These interactions encourage curiosity, which, in turn, motivates interactions (Smith, 2005). This is the beginning of the foundation of the building under construction. At the early preoperational level, the foundation is finished by expanding the experienced objects to include common objects that may not be as attractive. Then it is time to start constructing the first floor. In these rooms, knowledge won't be limited to attributes of single objects. These rooms will be constructed to contain knowledge about how people, objects, actions, and places relate to one another in organized patterns. Primary tools used in this construction will be objects and words related to the learner's experiences as they are used to help the learner organize relationship patterns. In this way, single concepts become more complex schemas.

The photo shows a young girl playing with a dollhouse.

Photo Caption: A young girl constructs schemas by organizing information units into patterns of knowledge showing that she understands how people, objects, actions, and places relate to each other.

Schemas

The patterns into which thoughts about related experiences become organized (Dunlea, 1989).

## How Are Schemas Constructed?

Piaget described the construction of schemas as a process of assimilation and accommodation. It works like this. New information is assimilated as the learner participates in events. This new information is processed and, if found interesting and/or important, committed to memory. Entering the memory bank, the new information attaches itself to previously stored information perceived to be related to the new information. These grouped bits of stored information become a schema. Each time a new bit is added, if there is something a little bit different or incongruent about it, the schema adjusts or accommodates and becomes more refined (Matlin, 2008).

The photo shows a young boy kicking his legs in a swing.

Photo Caption: This learner has repeated exposure to similar events on the playground every day.

At the early preoperational stage, the learner develops schemas about the pattern of the relationship of people, objects, actions, and places in events. That knowledge is constructed over time by combining new information with past experiences. Schemas are very handy. They allow learners to take in more information faster and, even more significantly, to moderate their behavior by making predictions about events. Learners notice common features through repeated exposure to similar kinds of activities. Schemas constructed as a result lead to the organized storage in memory of everyday information. Memory capacity limitations may prevent an individual from remembering precise details about his daily life. Schemas, however, allow him to process large amounts of material because he can summarize the similarities from event to event. After some time, any single event is not distinguishable from other, similar events. It has become a composite memory that serves as a quick reference guide (Barclay, 1986).

Schemas develop from a very "autobiographical" point of view to more abstract points of view (Cohen, 1989). The phrase, "It's all about me," describes early preoperational learners perfectly. They understand "lunch" in terms of the direct experiences they have had while eating lunch. It will take years for them to develop a schema about lunch that allows them to understand the topic from non-personal, more abstract points of view like nutrition or culture.

Schema Construction

Integrating new and old information

## How Does Sensory Loss Impact Schema Construction?

For a while, there seems to be no difference between sighted and visually impaired infants as they learn about their bodies. Before they are born, they begin gathering information. They discover that their bodies occupy space through the sensations stimulated by pushing their feet against the walls of their mothers' wombs. Many of them figure out the delights of thumb sucking. They begin listening to things too, but they have no idea that those sensations have any relationship to anything beyond their bodies. For them, it is like tinnitus, but more interesting. Even after infants with typical vision and infants with visual impairments are born, some very early schemas about people and objects touching the body develop very similarly during the first month of life. Both babies are learning a lot about nipples, pacifiers, and fingers as those things relate to sucking objects that touch their mouths. Both babies are becoming exceptionally adept tactual discriminators. Any parent who has put the wrong nipple on a bottle and tried to feed the baby knows this. Babies have nipples they like and ones they don't like.

At the same time, these infants are learning that those vocal noises that seemed to be inside their own heads before birth now seem to be beyond their bodies and somehow associated with the nipple and the stroking and the warmth and the odor that is well on its way to becoming a "mom" or "dad" schema. In these early weeks of schema construction, there is information that is unavailable to the learner with a visual impairment. He may not be able to see the expressions on the faces of his feeding partners, or observe the movement of their bodies resulting in those strokes. Other information may be missing. For example, what is that nipple attached to and where does it go when it is no longer touching his mouth?

Perhaps the most significant way that schema development is impacted by lack of vision is related to the use of objects (Dunlea, 1989). An infant who can watch the movements of people in various events learns the relationships between the people and objects and comes to know how things are used. Long before he has words to describe it, the infant with typical vision knows that spoons are used for scooping because he has watched his mother dip that spoon into his baby food jar and bring it to his mouth with food on it many times. He is very clear about the relationship between Mom, spoon, jar, and his own mouth. In fact, he understands it so well that he may try to take over and feed himself long before Mom would really like that to happen. She may have to block his hands or speed up her delivery to prevent him from making a big mess. On the other hand, an infant with limited vision may have no idea where that little bowl with food in it that touches his lips comes from, or how it relates to Mom's hand or any other object. He may not even realize that it has a handle. Why should it occur to him to do something with his own hands if he has no idea that his mother is doing anything with her hands?

With limited sensory information, schemas about people, object, action, and place relationships in events may not develop or may develop abnormally throughout early childhood (Erin, Fazzi, Gordon, Isenberg & Paysse, 2002). For example, a learner with limited vision who participates in a cookie making activity may be given the opportunity to touch the dough pouch. He might smell and touch the dry mixture as he helps his teacher open the pouch. Another student pours the mixture into a bowl. Another adds an egg, another, the oil. Then everybody gets a turn stirring the mixture. When the bowl comes to the student with the visual impairment, the smell is the same; but "it" is in a different place and feels completely different. He has no idea what occurred to cause that change. His schema for cookie making is something like this.

> You open a pouch of something that feels like sand, but smells like cookies. You stir something that feels like mud, but smells like cookies, and is in a bowl. Then somebody hands you something that feels like a rough, solid disc, but smells like a cookie, and you eat it.

The learner may have no idea how the sand, mud, and disc are related other than by smell. At the preoperational stage of cognitive development, being able to repeat language or point to symbols about adding eggs and oil does not contribute to the construction of a cookie-making schema unless those behaviors have actually been done by the learner as a part of his experience of the event. Symbols like words, pictures, objects, and parts of objects attached to cards are wonderful tools for thinking about and talking about events after they have been fully experienced. Symbols cannot represent people, objects, actions, and places not experienced. The cookie maker in the example above might be able to tell you or show you with a tactile symbol that the next thing after "pouch" is "bowl"; but unless he has poured the dry mixture into the bowl, this would be a rote response without meaning.

The circle chart shows six photos: 1) Hands opening a cookie dough mix, 2) a mixing bowl, 3) a egg, 4) vegetable oil, 5) a stir spoon in a mixing bowl, 6) a cookie. Photos 2, 3, and 4 are screened like a shadow. Photos 1, 5, and 6 are brightly colored.

Photo Caption: The screened photos represent the steps in the group cookie making activity that the student with visual impairment did not experience.

## Intervention Model

Information units organized into patterns of knowledge are called schemas. The construction of schemas cannot be left to chance when a learner is not able to use vision to make sense of random experiences. In order to ensure that learners with visual impairments have the breadth of experiences required for good concept and schema development, a plan is needed. Research indicates that without vision, language and thought in young children tend to be more self-referential. It may be helpful to think of the construction of schemas in the following hierarchy (Bigelow, 1990).

1. Concepts about the learner's own body
2. Concepts about people, objects, and actions touching the learner's body
3. Concepts about people, objects, actions, and places beyond the learner's body
4. Schemas about people-object-action-place relationships in events beyond the learner's body

In this model, the first three levels of construction are concepts-thoughts about things-either touching or beyond the body. There are four concept categories: people, objects, actions, and places. Place is a unique category. It is not included until level three-concepts about things beyond the body-because it requires knowledge of clusters of things. For instance, "kitchen" cannot be understood without awareness of clusters of things found in kitchens such as stoves, refrigerators, cabinets containing pots and pans, etc. Touching one object found in a kitchen may only bring to mind thoughts about that thing (object category); but, if touching that object brings to mind thoughts about a cluster of related objects found in the kitchen, the concept evoked is the place "kitchen." The final level is the organization of these units of concept information from several different categories into a pattern of knowledge about an event. This is a schema.

The photo shows a young girl searching for something on the opened refrigerator door. | The photo shows a young girl placing a cup in the microwave oven.
Photo Caption: A refrigerator and a microwave oven are part of a "kitchen cluster."

In summary, the development of schemas begins with the acquisition of sensory information. For typical learners beyond infancy, vision is the overarching modality because it provides access to distance media, simultaneous events, and whole/part relationships (Dunlea, 1989). Learners with very limited vision must have different strategies for developing schemas. They too start with the acquisition of sensory information, but their strategies are primarily tactual and auditory. A successful intervention model for these learners must take into consideration how this kind of sensory information will impact the development of concepts and schemas.

The inverted pyramid is a good way to think of the information being constructed by early preoperational learners. Knowledge expands from the bottom up and becomes more inclusive and more complex as it ascends.

The Inverted Pyramid

The illustration shows an inverted pyramid. "One Body" is at the bottom tip of the inverted pyramid. "People-object-action-place relationships in event beyond the body" is at the wide top of the inverted pyramid.

# Chapter 5: Gathering sensory information

The photo shows people at a carnival in front of the cotton candy vendor.

Photo caption: Through vision, hearing, and smell, we access information about things beyond the body.

## Concepts and Schemas Start With Sensory Information

Units of understanding-sometimes referred to as concepts-are collected through experiences, stored in memory, and eventually become a schema. This process always starts with the acquisition of sensory information. This is true throughout all levels of cognitive development. A formal operational learner developing a concept about algebraic equations starts with visual information in the form of written graphic symbols. At the late sensorimotor, early preoperational stage of cognitive development, the primary sources of sensory information are people, objects, actions, and places. When those people, objects, actions, and places get symbolic labels, the learner is on his way to being able to think about things he is not currently experiencing. A preoperational level concept has been developed. Next the learner begins to develop schemas by organizing those concepts into patterns of knowledge.

The photo shows two boys in the park. The youngest boy is pointing to something in the distance.

Photo Caption: It is obvious that the boys are using their distance sense of vision to see something far away, but they are enjoying the sounds and smells of the park as well.

## Distance and Near Senses

The sensory information that builds concepts and, eventually, schemas comes to the learner through sensory channels. Distance sensory channels give information about things beyond (not touching) the body and near sensory channels give information about things touching the body. Most people think of distance and near related to vision. For instance, glasses may contain lenses that correct either distance or near vision. This is not the same thing as distance and near senses. In the case of vision, the visual targets used in eye exams to measure both distance and near vision are beyond the body. Vision is the distance sense used to gather information about the symbols on the chart. The other distance senses are smell and hearing. Of course, things touching the body can also be seen, heard, and smelled; but those things don't directly touch the receptors in the body that activate these senses. Touch, however, is always a near sense. Tactual receptors in the skin are not activated unless something touches the skin. Similarly, with taste, receptors in the tongue are not activated until touched (Reeves, 2001). In other words, the learner's shirt does not have to touch his eye in order to see it, but his shirt does have to touch his skin in order to feel it.

Near Senses | Distance Senses
Touch and Taste: Access information about things touching the body. Sensory receptors in the skin and in the tongue are activated when touched by objects. | Vision, Hearing, and Smell: Access information about things beyond the body. Light rays, sound waves, and airborne particles that emanate from objects beyond the body activate sensory receptors in the eyes, ears, and nose.
After primary sensory information about things is established, there is some cross model transfer that goes on. For example, the smell of a cake baking can trigger the visual image of a cake or even of a specific cake-baking event. The sound of a voice can bring up associations with the person to whom it belongs. Certain senses, like smell, are powerful evokers of associated experiential memories (Mesulam, 2000). The association of sensory experiences from several modalities is an important part of concept construction when sources of sensory information are beyond the body.

## Unique Aspects of Tactual Learning

Typically, learning modalities are described in terms of primary sensory channels. Primary channels are usually visual, tactual, or auditory, but for some learners, may include olfactory, gustatory, proprioceptive, or vestibular. Teachers of students who have visual impairments assess learners by observing their responses to media using different sensory channels. Based on these observations, they make a determination about the primary and secondary sensory channels used by the learner and suggest appropriate learning media for those modalities. In the case of early sensorimotor level learners, because all their sensory channels are important, TVIs assess and make suggestions for the most effective use of every viable channel. During the early stage of learning about things touching the body-such as the things typically encountered in contexts like diapering, feeding, and bathing-learners with and without impaired vision develop knowledge of their worlds using the same tactual information base. As soon as sighted infants begin showing an interest in things beyond their bodies, variations appear (Warren, 1994). Without help, learners who rely primarily on tactual information begin to miss out on experiences of things happening beyond their bodies (Dunlea, 1989).

Another very unfortunate variation may develop for the primary tactual learner. After infancy, a need to have control over one's own body becomes increasingly important. Typical children make it quite clear when they want to touch something and when they don't. Except in emergencies and when expediency dictates haste, these preferences are generally respected. A sighted child is not likely to have something placed in his hand or his hand placed on something in order to make him aware that it is there because everyone knows that he can see that it is there. If a person wants to show a sighted child something, he just says, "Look at this," or points to it, or waves it in front of his eyes. The child's hands are not touched.

The experience of children without vision or with very limited vision may be quite different. The dynamic usually begins when partners want the child to "see" something and correctly understand that, for this child, "seeing" means "touching." They put objects in the child's hands or take his hands to objects. Sometimes they hold the hand and move it over a surface or manipulate it in other ways. Even if the learner welcomes this help, making it a habit can encourage passivity. He may not initiate search and exploration on his own (Chen & Downing, 2006). If the learner does not want his hands controlled by someone else, and the partner does it anyway, he may become more and more resistant. He may pull his hands away when they are touched and drop or throw objects placed in his hands (Miles, 2003). If reluctance to touch or to being touched is related to physiological or sensory processing issues, it is called "tactual defensiveness" (McLinden & McCall, 2002). However, if the reluctance is an emotional response to unwelcome invasiveness, it might more accurately be called "tactual avoidance" (Smith, 1998). For information on strategies to facilitate learning in regard to both, see Appendix A.

## Tactual Learning at Its Best

Two informative books about tactual learning by scholars in the field of visual and multiple impairments are currently available. Each offers readers a wealth of valuable information about tactual learning. They are Learning Through Touch: Supporting Children With Visual Impairment and Additional Difficulties by Mike McLinden and Stephen McCall (2002) and Tactile Strategies for Children Who Have Visual Impairments and Multiple Disabilities: Promoting Communication and Learning Skills by Deborah Chen and June Downing (2006). The authors of both books emphasize the importance of thinking about different types of touch.

McLinden and McCall (2002) discuss active and passive touch:

> Active touch refers to touching, usually with the hands which involves independent exploratory and manipulative use of the skin and therefore stimulation of receptor systems in the muscles, tendons and joints. It is commonly used to refer to independent activity on the part of the person who is doing the touching, for example when manipulating and holding an object. Active types of touch imply 'doing' or 'involvement' on the part of the child and are usually distinguished therefore from relatively passive types of touch. (p. 149)

A girl sitting at a table plays with a fluffy paint roller.

Photo caption: The child actively explores the roller.

The authors combine the tactual and proprioceptive sensory channels to describe active touch, sometimes referred to as "haptic perception" (McLinden & McCall, 2002).

> Passive touch refers either to the actions involved in being touched either by an object or by another person (as in the act of massage), or to touching an object but with no independent exploratory and manipulative use of the skin. Passive implies therefore, things being done to, or with, the child rather than the child 'doing' the doing. The distinction between active and passive touch is particularly pertinent to this book given that many children in the population (visual impairment and additional difficulties) are limited in their ability to actively manipulate objects, and are reliant on others to provide information to them through passive modes of touch. When structuring the learning environment it is important to consider how a child can be presented with greater opportunities to be involved in any given activity. (p. 149)

A girl sits at a table and her teacher rolls a fluffy paint roller up and down her arm.

Photo caption: The teacher applies the roller to the passive child.

The authors clearly consider active touch to be the better way to learn and they explain the physiological and neurological basis for this conclusion. The use of hand-over-hand assistance prevents, or at least minimizes the learner's "independent exploratory or manipulative use of the skin" and often results in almost exclusively passive touch. They describe and illustrate an alternate strategy, hand-under-hand assistance. This approach gives learners more control of their hands and therefore encourages active exploration and manipulation. For more information on this issue and for tactual strategies for learners with limited hand use due to motor impairment, see Appendices B and C.

Chen and Downing (2006) also discuss active and passive touch, although they define each a little differently. They include a third type, social touch, at the same level of significance. Their definitions of each are as follows:

> Active or haptic touch is the process by which one interacts with the environment and handles and physically explores an object to obtain identifying information that will assist in discriminating and recognizing it. Active touch involves information from both the skin's tactile sensations as well as the body's kinesthetic sensitivity to movement and spatial position. (pp. 16-17)

> Passive touch occurs when one is touched or one's skin comes into contact with something or someone, and this tactile information is experienced as pressure or temperature that may be unnoticed or may feel soothing, pleasurable, or painful. (p. 17)

> Social touch promotes attachments and emotional relationships and involves both active and passive touch. (p. 16)

In their glossary, Chen and Downing define "tactile" as being synonymous with "tactual" (2006). McLinden and McCall use the two words differently (2006). For them, "tactile" means the physical properties of an object such as temperature, weight, etc., that can be perceived through touch. "Tactual" means the exploration and manipulation of objects performed to acquire information about those properties. Chen and Downing do not define "kinesthetic," but McLinden and McCall say that it usually refers to how we sense the position of our body when moving through space or the movement of individual body parts in relation to one another (2002).

Chen and Downing also discuss hand-under-hand guidance. They suggest that it is less intrusive than hand-over-hand guidance and they give illustrations and guidelines for its use (2006).

## Tactual Information About People, Objects, and Actions Touching the Body

The sense of touch is highly associated, both physiologically and psychologically, with other senses. In First Steps (1993), a book about the early development of children with visual impairments, Patricia Nagaishi refers to the somatosensory system. This is a term used to describe a group of senses-proprioception, kinesthesia, and touch-that are processed in the same area of the cortex. Nagaishi defines each accordingly. Proprioception is the unconscious awareness of joint position; kinesthesia, the conscious awareness of joint position and movement; and tactile, the perception of characteristics of things outside of the body touching it.

How does the learner acquire information about things in his environment by touching? There is a three-step process.

- Receptors take in information about the characteristics of things touched by or touching the skin.
- Nerves transmit that information via electrical impulses.
- The processing centers in the brain interpret and store the information.

The learner understands what he is touching when his brain interprets information sent to it by specialized receptors responding to particular stimuli (Klatzky & Lederman, 2008).

Property | Exploratory Procedure/Hand Motion
--- | ---
Texture | Lateral motion (Scratching or rubbing)
Hardness | Pressure (Kneading, squeezing, and poking)
Temperature | Static contact (Withdrawal of hands after contact)
Weight | Unsupported holding (Waving, banging, transferring from hand-to-hand)
Global Shape | Enclosure (Clutching, grasping, and holding)
Exact Shape | Contour following (Holding with one hand while following edge with fingers of other hand)

The tactual sensory channel gives more detailed information than any other sensory channel at birth (Eliot, 1999). The tactual system continues to mature over the next several years, but mainly in regard to processing speeds. Newborns use the tactual receptors in their mouths to make fine discriminations about pressure, speed, temperature, texture, and shape. Gradually, the hands get involved. By 6 months, infants begin exploring objects with the hands and develop the ability to discriminate differences in textures with their hands (Eliot, 1999). See Appendix A and Appendix C for more detailed information.

Many learners with visual impairments are involved in activities designed to teach tactual discrimination skills. If they developed these skills in infancy, do they need these activities? Learners may be asked to match and sort things like objects, pieces of sandpaper with varying grades of roughness, and textured blocks. In addition, learners may be asked to identify characteristics of objects by giving verbal labels like "wet," "rough," "hard," and "cold." Sometimes partners assume that a learner cannot detect tactual characteristics of objects because they perform poorly on these tasks. Usually, the reason for poor performance has nothing to do with tactual discrimination skills. Cognitive skills are more related to performance in these kinds of tasks. Many learners who are young or multiply impaired cannot match and sort textured blocks because they have not developed the cognitive skill of matching and sorting. Similarly, errors in using verbal labels to identify characteristics like "wet" and "soft" may not have anything to do with tactual discrimination. These errors are more likely related to the learner's ability to do abstract comparative thinking and to understand the language that describes those thoughts. Learners show signs of discomfort when their clothing is wet long before they can use the word "wet" to describe that condition. The discomfort relates to tactual discrimination. The word relates to abstract concept development.

Often, when partners ask learners to match and sort objects and label characteristics of objects using their tactual discrimination skills, they are really teaching cognitive and language skills. That is great. Matching and sorting activities can also be useful in teaching task organization strategies for things like searching, finding designated locations, and aligning materials.

# Chapter 6: Information about people, objects, actions, and places beyond the body

A photo of an airborne motorcycle, a photo of a growling dog, and a photo of a fire engine.

Photo Caption: People experience some degree of stress whenever they hear something that they can't identify.

## Distance Sensory Information

Sensory information is the foundation for the development of concepts about people, objects, actions, and places beyond the body. Typical learners rely upon their distance sensory channels-vision, hearing, and smell-to develop these concepts. Learners with visual impairments use distance sensory information too, but in a very different way. When vision is very limited, information from the distance channels becomes meaningful only after it is paired with near sensory channel information. This means that touch has a unique role in concept development (Huebner, Prickett, Welch, & Joffe, 1995).

## Tactual Bridging

Many of the variations in concept development that become challenging for learners who have visual impairments have to do with acquiring information about things beyond the body (Hughes, Dote-Kwan, & Dolendo, 1998). When a visual impairment is present, touch plays a unique role in gathering distance sensory information. Using touch to obtain information about things beyond the body sounds like an oxymoron. Tactual means touching the body, so how is this modality used as a way of gathering information about things beyond the body? In fact, it can't unless there is a bridge linking near and distance sensory input. For the primary tactual learner, distance sensory information about a thing can be meaningful only if it creates a bridge that connects the current distance experience to the memory of near tactual experiences with the same thing. Impaired visual information may be more confusing than helpful unless it is bridged to tactual experience in memory. Hearing and smell provide no information for anyone about their sources unless bridged to previous experiences pairing those sensations with vision or touch.

## Smell

The sense of smell alerts one to the presence of airborne particles that emanate from objects that are an inch or a few miles away. The olfactory processors in the brain are especially sensitive to smells that convey dangers like fire, noxious gases, and putrid food. Smells also stimulate appetites (Reeves, 2001). Nevertheless, anyone relying primarily on olfactory information for knowledge about his world ultimately would have very shaky concepts. Olfactory characteristics of an object allow learners to identify that object only if the smell is associated with other sensory characteristics of the object experienced previously. For example, the smell of hand lotion does not call to mind the lotion container or the act of lotion being rubbed on the hands unless those experiences are paired with the smell.

## Hearing

Hearing supplies information about sound. It tells the listener if the sound is high pitched or low pitched, loud or soft, sharp or muted, fast or slow, continuous, or intermittent (Reeves, 2001). It supplies no information whatsoever about what is making the sound. In order to know the source of the sound, it must be paired with visual or tactual information (Fazzi & Klein, 2002). A dog's bark is just a sourceless, random, and possibly threatening noise that seems to come from a certain space unless the learner has seen a dog bark, or touched a dog that is barking, sometime previously and can associate that experience with the sound he hears.

One characteristic that makes human beings especially unique among animals is that human babies are born with an amazing appetite for listening to speech sounds and an ability, from birth, to discriminate very fine differences in the qualities of those sounds (Dunlea, 1989). They don't know what the different sounds mean, but they find them fascinating. Very early on, they learn that certain pitches and tempos mean certain things. For instance, when Mom's voice is flat and even paced, she is probably talking on the phone or to Dad and there is no reason to get excited. But, when the pitch of her voice goes up and down musically and the tempo changes from slow to fast and then back to slow again, the baby knows her mom is trying to engage her and good things are about to happen.

When the auditory sensory channel is used as a learning modality for concept development about things beyond the body, environmental sounds are the primary information source for objects and voices are the primary information source for people. Voices yield important information for all sensorimotor and early preoperational learners. The learner uses voice to recognize people, to predict what they are going to do, to find out where they are, and to soothe and entertain himself (Rowland, 1984). Words are part of what voices convey and some of the individual words and phrases uttered by those voices may be useful if they spark an association with a concrete referent.

### Tactual Learners and Overdependence on Auditory Information for Distance Learning

Sometimes, hearing is identified as the primary sensory channel for learners without vision or with very limited vision at the sensorimotor and early preoperational levels of cognitive development. This is especially likely to be true if these learners have multiple impairments including severe motor impairments. Assessments may indicate accurately that hearing is the primary information gathering modality used during observations. Often, these learners do spend a great deal of their time listening. The question is-should they? Is the quality of information obtained almost exclusively through the auditory sensory channel sufficient for good concept and schema development? Attempts to facilitate auditory learning about things beyond the body usually involve the teacher or family member using language to describe and explain. Using this approach, a teacher may assume that the learner with a visual impairment is receiving the same level of instruction as other students when he can label sounds such as the recorded animal sounds in the unit on farm animals. In fact, given this kind of instruction, the learner develops a variation in his concept of something like "chicken" that is quite inferior to that developed by his peers. For him, a chicken is a sharp, intermittent, high-pitched sound. Period. The teacher may hand him a stuffed toy chicken to associate with the sound. In this case, he learns that a chicken is a small, soft, fuzzy, and inanimate object that smells like cloth and somehow goes with that sound. He is probably very confused as he assimilates this information and tries to accommodate it with his knowledge of meat eaten at meals or of characteristics of live birds. This is not good learning. There is only one way for auditory information about things to be useful for concept development. That is to see and/or touch the real thing making the sound. Either vision or touch must be the primary sensory channel until the learner has developed sophisticated linguistic abilities.

This is a photo equation: A photo of a hand playing a digital recorder + a photo of a toy chicken + a photo of chicken nuggets with ketchup + a photo of a child touching a live chicken.

TVIs are sometimes told to encourage teachers and parents to talk to learners about what is happening beyond their bodies as a way of providing information about what the learner may be hearing. This is a highly effective strategy if the learner is a sophisticated user of language and can simultaneously integrate what he hears in the environment and what he is being told. Most late sensorimotor and early preoperational learners are not sophisticated users of language and have some difficulty paying attention to two competing sources of information simultaneously. Therefore, this is not an appropriate strategy for them if the goal is to give them information about what is happening. That is not to say that partners should not talk to learners when they are doing things nearby. This kind of talk may have another important function. It lets the learner know he is not alone and that his partner is connected to him even when not touching him. Partners must decide what they want. If they want to reinforce the social bond, they should talk. If they want the learner to know what is happening, they should give the learner the opportunity to touch what they are touching by either bringing the experience to him or taking him to it.

### Fear and Unknown Sources of Sounds

Environmental sounds can be very scary when they have no known source. A child who experiences the loud sound of a vacuum cleaner and has no idea what is making that noise can get very scared when the noise seems to move around unpredictably and sometimes appears to be coming closer. Fire alarms, car horns, mixers, blenders, hair dryers, hair clippers, lawn mowers, and a host of other things would be perceived as threatening by anyone surprised by those sounds without knowing their source. To understand this, most people only have to remember how they felt the first time they traveled on an airplane and, while seated and just beginning to relax a little after takeoff, heard the landing gear retract. The truth is that people experience some degree of stress whenever they hear something they can't identify, even in much less threatening circumstances-the "things that go bump in the night" phenomenon. A learner with visual impairments has that experience very often and not just at night. For a learner who is young or multiply impaired, the only way to make a sound less threatening is to get information about its source by seeing and/or touching. The white-knuckler on an airplane can relax after the person next to him tells him the sound he heard was just the landing gear retracting because he is a sophisticated language user. An English speaker on an airline with passengers who all speak an unknown language would continue to expect the bottom to fall out of the plane until he figured out by visual observation that no one else was worried. Late sensorimotor and early preoperational learners with visual impairments are not sophisticated language users and many of them can't see the expressions on other people's faces.

The SAM flash drive contains a folder of common sounds perceived to be threatening by many learners. It is included in SAM so that these sounds may be associated with their sources in a carefully controlled, less intense activity.

## Impaired Vision

Vision, when it works well, gives more detailed and complex information about people, objects, and actions at a distance than any other sensory channel (Chen & Downing, 2006). Impaired vision can be a useful tool for gathering information beyond the body and should be used to the maximum extent possible. Especially at the late sensorimotor and early preoperational stages of development, information gathered through an impaired visual channel is more meaningful if it is paired with touch experiences (McLinden & McCall, 2002).

A variety of conditions can compromise the learner's ability to use vision effectively for gathering distance information. For the purposes of this discussion, these conditions are divided into three broad categories-uncorrectable acuity loss, field loss, and cortical visual impairment (CVI). There are many other conditions, such as ocular motility problems or photophobia to name only two, that affect the quality of distance visual information.

Imagine three people seated around a table: one is reading a newspaper, one is writing on a pad of paper, and one is filling saltshakers. A person with acuity loss, standing about 12 feet away from the table, will experience the scene differently than a person with field loss or CVI who is standing at the same distance. No two learners' experiences will be the same.

Different Visual Experiences
Acuity Loss | Sue sees a large object and at various points around that object, the upper parts of three people. She recognizes torsos, arms, hands, and heads. She knows one person has dark hair, but cannot distinguish facial characteristics or expressions. She knows that two of the people are moving their hands, but cannot identify the small objects they are touching.
Field Loss | Jim sees a person seated at a table reading a newspaper. When he moves his head, he sees a person writing on a pad, but can no longer see the person reading the newspaper. He is unaware that there is a third person at the table.
Cortical Visual Impairment | Tom sees a confusing mass of color and movement that is incomprehensible and somewhat threatening. He looks away from the complex-visual target and focuses on a more familiar and simple, near-vision target.

These examples are three of an infinite number of possibilities. Specific knowledge of each individual's visual functioning is necessary in order to know what he might be experiencing. Certified specialists in the field of visual impairments assess the functional visual abilities of learners with visual impairments in order to obtain this knowledge and share it with other team members.

# Chapter 7: Bridging near and distance sensory information

A young girl wears a fire fighter's helmet and feels the outside of it with her hand.

Photo Caption: Pairing a real-life, touching experience with a sound is a good teaching method.

## Challenges for Tactual Learners

A learner who does not get high quality information from her visual channel will rely primarily on touch for gathering the sensory information that will be the foundation of her knowledge of her world. Here is the problem. Smell, hearing, and impaired vision are the only distance senses available to her and none of them provides sufficient information for good concept development. This will be a challenge because she will not be able to access information about people, objects, actions, and places beyond her body in a meaningful way without help.

The primary tactual learner must have a way to bridge the gap between her near learning (touching and tasting) and her distance learning (seeing, hearing, and smelling) so that the information from these separate modalities is combined to provide high quality information about things beyond her body. Two stages of development create the desired result. First, the learner must have experiences that allow her to pair touch with the smell, sound, and sight-to the extent possible-of things as they touch her body (Huebner et al., 1995). Second, she can use the smells, sounds, and sights she has associated with her touch experiences alone for gathering meaningful information about things beyond the body. Making sense of experiences beyond the body can be greatly expedited by the use of symbols (objects and words) to label sources of distance information after basic sensory foundations are in place (Fazzi & Klein, 2002).

## Direct Experience

A girl sits in a wheelchair, with her father in the park. A female teenager with a golden Labrador Retriever is standing next to them. The girl pets the barking dog and her father says "dog." The teenager is holding the leash of the dog.

Photo Caption: The near sense experience of touching the dog is paired with the distance sense sound of the dog barking and the word symbol for dog.

In the first stage, pairing near and distance input, activities must be modified so that the tactual learner is touching and listening when her peers are looking and listening. She will need to touch real things to build concepts about concrete referents before she uses symbols to represent those real things (Chen & Downing, 2006). Tactual learners are often given miniatures and toy replicas to substitute for real things when those things are unavailable. Miniatures and toy replicas are arbitrary symbols for tactual learners. They are like the things they represent visually, like pictures, but the tactual characteristics of the replica are not like the tactual characteristics of the thing for which it stands. In fact, not only do they not feel like their referents, they don't smell, taste, or sound like them either (Chen & Dote-Kwan, 1995). Ana's teacher gave her some plastic replicas of tomato slices, pickle slices, and lettuce leaves when the class was doing a unit on vegetables. The pieces of plastic really looked like tomatoes, pickles, and lettuce. All the sighted learners got the connection immediately. But Ana can't see. What does she learn when she feels a piece of plastic and is told it is lettuce? If she is going to pair sensory information about the feel, smell, sound, and, in this case, taste of these things, she needs real tomatoes, pickles, and lettuce. She will need to have a whole encyclopedia of concept units built from paired near and distance sensory information associated with real things that are the sources of that information. And, she will need to have a label for each of these things.

## Sensory Bridging

The same girl sits at the top of a jungle gym slide, her father is standing beside the slide holding her. Her wheelchair is off to the side. A boy is climbing the steps on the other side. A German Sheppard is in the distance barking. The dog is looking up at his male owner who is holding a ball up. A balloon above the girl's head shows she is picturing the dog she petted, a Labrador Retriever.)

Photo Caption: The distance sense sound of a dog barking calls to mind the experience of touching a dog with a similar sounding bark.

In the second stage, distance sensory information alone is used to bring to mind crucial near information remembered from previous experiences in which near and distance sensory information was paired. Sounds and smells, plus visual images that appear blurry or distorted, are not good primary sources of information about a person, object, action, or place. When these three senses are associated with primary tactual information, they create access to a concept at distance. For instance, a learner who has opened a can of soda before and has heard the sound it made when he pulled the ring tab knows when his peer opens a can of soda because he hears that same sound even though he is not touching the peer or the soda.

Pairing sound and touch information simultaneously during an experience is difficult with some objects. Sometimes the learner is too frightened by a sound to get close enough to touch the object that is its source. An object may be too dangerous to touch while it is making a sound, or it may be in a place that is hard to access. SAM provides a specific game, "Sounds Like," to help build these kinds of bridges.

Smells are a very powerful link to memorized associations (Matlin, 1994). Random smells in the environment tend to grab a learner's attention and can be a problem if information from another sensory channel is more significant for the task at hand. Provision of specific smells for helping the learner think about something can be a very effective way to prepare him for something that is about to happen before he is actually touched. For instance, if Ben smells the glue before his hand is touched, he has a chance to prepare himself for the experience of touching glue.

Severely impaired vision can be an effective distance bridge if vision has been paired with touch in near experiences. One factor that makes visual distance bridging challenging is that visual modifications like clutter reduction and contrast enhancement are often provided in near experiences and may not be provided in distance experiences. A learner dependent upon these kinds of modifications for use of near vision may not be able to use the visual information about an object he learned at near with modifications when he encounters that same object at distance without modifications. Many partners rely upon the use of language to help learners understand what they are seeing at distance. For a more detailed discussion of this strategy, see the section titled "Using Language with Impaired Vision for Distance Bridging" in chapter 8.

## Symbolic Bridging

The same girl sits in her wheelchair with her father sitting on a park bench. A man approaches walking his Beagle. Her father says to her, "dog." A balloon above the girl's head shows her picturing imagining a Labrador Retriever.

Photo Caption: The word "dog." confirms that, even though it sounds very different, the bark still comes from an animal like the one touched previously.

After stage two is established, a symbol can be used to help the learner identify the source of distance sensory information. Learners at the late sensorimotor and early preoperational stage start building their symbolic skills with two foundation level tools-objects and words (Dunlea, 1989). Objects are the static symbol form, somewhat equivalent to written words or pictures. Static forms don't change and they don't go away. Words are the dynamic symbol form. Words are slightly different from speaker to speaker and context to context. They are heard briefly and then they are gone (Blaha, 2001).

Both of these symbol forms, objects and words, allow learners to think about things that are not present in their natural contexts.

At the late sensorimotor and early preoperational stages, learners develop their use of symbols in the object and word categories somewhat simultaneously. Although the two categories support each other and each helps development of the other progress, they are not equal in terms of levels of difficulty. Symbols can be divided into two broad groups related to cognitive difficulty-iconic and arbitrary (Valsiner & Connolly, 2003).

- Iconic symbols have sensory characteristics like their referents. Whole objects used as symbols have a very direct iconic relationship to the concept and schema they represent. They look, feel, sound, taste, or smell like the thing for which they stand. So, an object symbol that is exactly like the object that is used in a natural context is the most iconic and therefore the easiest to understand. This is a good place for all late sensorimotor and early preoperational learners to begin their development of symbolic skills. Pictures and parts of objects glued on cards are still iconic. They share some of the same visual and tactual characteristics of the thing they represent, but not as directly. Therefore, they are more difficult, but not as difficult as arbitrary symbols.
- Arbitrary symbols do not share any sensory characteristics like those of their referents. Arbitrary symbols can be visual, tactual, or auditory.
  - - Arbitrary auditory symbols are frequently used with learners at the late sensorimotor and early preoperational level. Most of these are the words they hear spoken by their partners in messages meant to convey information to them. Words are a grouping of sounds that are associated with something as determined by social history. The sounds in the word, "dog" represented by the letters "d," "o," and "g" represent the thing that barks. In Spanish speaking countries, the sounds represented by the letters "p," "e," "r," "r," and "o" represent the thing that barks. Both are completely arbitrary. If English-speaking ancestors had decided that the sound grouping "soty" represented the thing that barks, that would be the word for the thing that barks used today. Neither "dog" nor "soty" have any sensory characteristics like the thing that barks. They are both equally arbitrary.
  - - Arbitrary visual symbols include graphic designs like a red circle with a line through it to represent "no" or a heart shape to represent "love" and printed words like "Exit," or "Push." Product labels are a special category. They often combine a graphic design and a printed word. This is called a logo. When the logo appears on the object and then in a separate place like a sign, it is more like a picture-more iconic than arbitrary.
  - - Arbitrary tactual symbols include unrelated objects like yarn to represent "hair" or a raised print letter "L" made with glue to represent "lunch" or a piece of pipe cleaner to represent "mobility cane." None of these has any tactual characteristics like the things they represent. Brailled words are also arbitrary tactual symbols.

Sometimes arbitrary and abstract are confused. Abstract means a thing that cannot be touched, pointed to, or done, as opposed to concrete that means a thing that can be touched, pointed to, or done. Arbitrary symbols, like words, can stand for something abstract like "government" or something concrete like "dog." Abstract is about the thing being referred to, the referent, and arbitrary is about the thing that stands for it, the symbol.

Referent | Symbol
--- | ---
Concrete or Abstract | Iconic or Arbitrary
Sign language is arbitrary, but some signs have more of a link to the sensory characteristics of their referents than spoken words do. For instance, there is a tactual link between the sign for drink and its referent because the lips are touched. The link is indirect, but it may be just enough to make use of this symbol easier than the spoken word for some learners. When the referent is abstract, like "more," spoken words and signs tend to be equally arbitrary.

### Object Symbols

Learners develop the ability to use objects as symbols in four steps.

- The tactual learner uses her skin to discriminate the tactual characteristics of real objects in their natural contexts.
  - - Ana is learning with her peers about "community helpers." As her peers read stories and look at pictures of doctors, firefighters, and police officers, Ana is given an object associated with these roles. For instance, when the class listens to the story about firefighters, Ana is given a toy firetruck. She has learned that it is a small, lightweight, smooth, and rectangle-shaped thing with moving parts. She has learned some words that go with it. When she is given the toy, she says, "The firefighter is our friend. He puts out the fire." Ana's TVI knows that Ana is not receiving the kind of instruction she needs in order to develop the concept of "firefighter." First of all, she does not understand the language used in the story. She can repeat it, but she does not understand it. Ana will benefit in other ways from listening to the story with her peers, but it will not provide effective instruction for her on the goal of learning about community helpers. Neither will the toy firetruck. Ana examines it, but to her, it is a meaningless object associated with meaningless words. The TVI decides another object would be a better place to start. In order to determine what that should be, she decides to take Ana to the fire station. While at the fire station, Ana tactually explores many things-big rubber boots, heavy helmets with chin straps, big hoses, and a very big vehicle with a very loud horn. Tactually exploring big things takes some time. Ana liked sitting in the truck cab listening to the radio transmissions, but her TVI wanted her to know what that cab was part of; so, together, they walked completely around the truck with their hands on its body as they moved. Ana used her hands primarily as she explored these objects, but she checked out the helmet and chin strap by making brief contact with them with her lips and tongue as well. She wanted more information about these objects. She was startled by the air horn and needed comforting after she heard it.
- The learner uses that object in its natural context.
  - - Ana went back to the fire station two more times with her TVI in the next 2 weeks. Each time, she explored the same objects. She enjoyed feeling the helmet in the equipment area and on the head of her favorite firefighter. They played a game in which she would help him put it on his head and then he would help her put it on her head. She also played a game with him during which they sat together in the cab and took turns activating the air horn. Ana held her ears, but kind of liked it.

> The photo shows a girl with her fingers in her ears and making a face.

- The learner forms associations with other things related to the object.
  - - The helmet became Ana's anchor object, but she also remembered the other things she experienced in that context, especially the firetruck, the boots, the air horn, and the big hose.
- The learner uses the object, as a symbol, to receive or send a message related to that object or to engage in a conversation about the things related to the object.
  - - Ana's favorite firefighter was only too happy to loan the TVI a helmet that Ana could take to school. Now when she hears the firefighter story, she wears her helmet. And she thinks about all the things she experienced at the fire station that are related to that object. She is beginning to respond to some of the words she hears in the story. When a peer read a sentence about the firefighter putting on his boots, Ana stood up and stomped her feet the way she and her firefighter friend had done when she put on boots at the fire station. One day, when the TVI came into the classroom, Ana found her way to the shelf where her helmet was kept, brought it to the TVI, and said, "Fire station." The TVI easily understood the message sent. "Please take me to the fire station." Another day, Ana heard a siren that was a little different from the siren she had experienced at the fire station and became upset. Her teacher was able to get her helmet, show it to her, and tell her "siren." Ana immediately calmed down and said "Firefighter?"

Sometimes, objects used as symbols are referred to as tangible symbols (Rowland & Schweigert, 2000). The terms "tangible symbols," "tactual symbols," "tactile symbols," and "tactile graphics" are used somewhat interchangeably, but more often, tangible symbol means something different.

- Tangible symbols are things that can be given to somebody or pointed to for communication purposes. Some tangible symbols, like picture cards, require the use of vision. Tangible symbols include objects, similar objects, associated objects, parts of objects glued on cards, photographs, pictures, hieroglyphic pictures (like stick figures to represent people), arbitrary objects glued on cards, and print or braille words (Hagood, 1997). The tangible symbols listed are in order of difficulty from most iconic, like the thing they represent, to more arbitrary, not like the thing they represent and therefore dependent on the learner's ability to remember an arbitrary association. Many late sensorimotor or very early preoperational learners with normal vision and significant cognitive impairments are not successful using pictures in adaptive communication environments like choice boards, speech output devices, and schedules. They may need to use the actual object that is part of an activity in these environments because they require highly iconic symbols with a more direct relationship to the thing they represent.
- Tactual symbols, tactile symbols, and tactile graphics are symbols that do not require the use of vision. Parts of objects, like the tab on a soda can glued on a card and used to represent a soda and arbitrary objects like a paperclip glued on a card to represent "work," are strategies often used in augmentative communication systems for tactual learners where photos and pictures would be used by sighted learners (Chen & Downing, 2006).

The photo shows a tactile communication card for "Brush Teeth."

Photo Caption: Iconic symbol for concrete concept

The photo shows a tactile communication card for "Day."

Photo Caption: The string is an arbitrary symbol and "day" is an abstract concept.

The photo shows a tactile communication card for "Soda."

Whether tangible or tactile, these symbols are used to help the learner think about real things beyond his body. All learners, visual and tactual, need to be proficient users of highly iconic symbols-objects-before moving on to less iconic symbols-parts of objects or pictures of objects.

### Symbol Levels

Level One

Whole objects

The photo shows a girl drinking from a plastic cup.

Level Two

Pictures and part object tactile symbols

This is an illustration/picture of a plastic cup.

Level Three

Printed and brailled words

The photo shows two hands reading braille.

When is a whole object a symbol and when is it a concrete referent? This can be a little confusing. At the whole object symbol level, a can of soda is the symbol for break time and it is the concrete referent object used during break time. The can of soda is a symbol when it is presented at a different time and in a different place than the time and place where it will be used. When the soda is presented in a calendar/schedule or on a choice board, it is the word for break time the same way a picture of the break room or a card spelling out the word would be. The learner understands that in the context of a calendar/schedule, or choice board, he is not drinking soda; he is talking about soda (Blaha, 2001). This may seem like a small step, but for many learners missing this step means that attempts to use more arbitrary symbol levels will be unsuccessful.

When object symbols are new, as soon as she can, the learner needs to associate the object symbol used in a communication context with the referent object in its natural context. After the association is clear, she can use the object as a symbol without the immediate reinforcement of using the object in its natural context. Later still, she can use that symbol as a label for the schema related to it. At this stage, a car key ring used as a symbol doesn't just represent "car ride" as it did originally. Now, it represents associated concept units like car, car seat, seat belt, engine noise, movement, significant fellow travelers, and favorite destinations. When the learner organizes those units into a schema called "going places in the car" and she thinks about that schema when given or getting the car key ring, she is bridging the gap between near and distance.

### Word Symbols

Words used to represent a concept or schema allow the learner to think about things not present in the same way that objects do. For instance, when his teacher says "cup," the learner can search for his cup and get it because he has a concrete referent for that label. When she says "chicken," he can call to mind his experience of the bird in the cage his TVI brought into the classroom and which he helped feed and take care of for a week.

Spoken words are always arbitrary symbols (Dunlea, 1989). These are harder than iconic symbols. The learner must hear the word associated with a person, object, action, or place many times in clear, immediate experiences pairing the word and referent in order to memorize the link between them. SAM games are designed to provide these experiences. The use of language, or words joined together according to syntactical and grammatical rules in speech and writing, is discussed in the next section.

# Chapter 8: Information about people-object-action-place relationships in events beyond the body

The photo shows a family at the kitchen table. They are all smiling as the younger of two sons blows out the candles on his birthday cake.

Photo Caption: Blowing out candles on a birthday cake is an event.

## Complex Concepts and Schemas

An event is a complex concept. The learner's ability to understand what happens in an event, like the blowing out of the candles on a birthday cake at another person's birthday party, depends on being able to put together many different pieces of information about related things. The organization of these pieces into a pattern forms a schema. The basic foundation for understanding is the accumulation of hundreds of pieces of sensory information related to people, objects, actions, and places that are part of the event. Language is another important source of information helpful to the acquisition of information about events. Once the sensory foundation is established, words about those experiences can expand meaning (Chen & Dote-Kwan, 1995).

Information about events is constructed by progressing from simple concepts to more complex concepts and, eventually schemas. So far, discussion has been limited to simple concepts at the first three levels of basic concept development-the learner's own body; people, objects, and actions touching the body; and people, objects, actions, and places beyond the body. For the most part, these have been single-referent concepts and single-category concept clusters.

To help the learner make sense of her world at the fourth level of complexity-people-object-action-place relationships in events beyond the body-the development of multi-category schemas is required. For a primary tactual learner, this level will rely even more heavily upon the use of symbols and distance sensory information for bridging. Words become an essential bridge. But, once again, words are not helpful unless they are grounded in tactual experiences at levels one, two, and three.

## Review and Clarification of Terms Used in SAM

- Symbol: objects and words used to represent their referents
  - - Less iconic and arbitrary symbols are not addressed in SAM. These symbol levels are part of Tactile Connections (APH #1-08837-00).
- Referent: person, object, action, or place referred to by a symbol
  - - These are the concrete referent categories addressed in SAM. Symbols can be used for abstract referents as well. These might include categories like feelings, time, quantity, comparative qualities, etc. Abstract referents and additional categories are addressed in Tactile Connections.
- Event: an occurrence during which many referents from different categories interact in a prescribed way over a distinct period of time
- Single-referent concept: thoughts about one thing
  - - For example, in the people category: mom; object category: toothbrush; action category: chew
- Cluster concept: a small group of things in one category typically experienced in close proximity in both time and space
  - - For example, in the people category: mom, dad, and brother; object category: toothbrush, toothpaste tube, and rinse cup; action category: scoop, chew, and swallow
- Schema: knowledge of the relationship of things from several categories to each other as experienced in events beyond the body over time
  - - For example, a real understanding of the toothbrushing event requires knowledge of the space in which it occurs, what is present in that space (sinks, shelves, drawers), where materials are kept, how materials are used, and what other people do with those materials in that space when not touching the learner. Schemas cannot be constructed from one experience. They require the assimilation of new information in current experiences and the accommodation of existing information based in memories of previous experiences.

## Sensory Bridging, Concepts, and Schemas

Development of meaning in single-referent concepts, cluster concepts, and schemas is based in experiences that provide high quality sensory information. Construction of a concept begins with experiences of things as they touch the learner's body or as the learner uses his body to touch them. As information from distance sensory channels is associated with these touch experiences, the learner begins to understand the world of people, objects, actions, and places beyond his body. Meaning is expanded through the use of symbols-objects used in communication contexts, and words. Symbols expand meaning only if each symbol is grounded in sensory experiences of its concrete referent.

The following descriptions provide an overview of the role of sensory information in the development of concepts and schemas. Two kinds of concepts are included-single-referent concepts and cluster concepts.

### Single-referent Concepts

The simplest way to think about a concept is to think about one thing at a time. This is true whether the thing is the body itself, something touching the body, or something beyond the body-the first three levels of concept development. Thinking about a thing is often triggered by a symbol. For instance, touching an object or hearing a word may be a trigger. Distance sensory information, a sound or smell, associated with the referent may also trigger thoughts about it. If the link between the memory of touching the thing itself and those associated pieces of distance sensory information (sensory bridges) is a strong one, the thoughts about the thing will be rich and meaningful.

Examples of Single-referent Concepts
Category | Touching body | Beyond body bridges
--- | --- | ---
Person: Mother | The learner feels a mass, covered by soft tissue. There are lots of curves. Voice sounds and warm air are associated with the area surrounded by long hair. Appendages produce very nice sensations when applied to the learner's own body. Very strong feelings of comfort, safety, and attachment are associated with being touched by this thing. | The sound of the voice of the person described in "touching body" triggers thoughts of all those experiences. Later, hunger, feelings of loneliness or joy, or smells of certain foods may trigger Mother thoughts.
Object: Toilet | The learner feels a mass with a hard, smooth, curved surface. It is cool and sometimes can be cold. There is a moveable surface attached to a more stable surface, both with a hole in the middle. Sitting over the hole without clothing is required. A loud, roaring noise is associated with this thing periodically. | The sound of a flush or of the toilet seat being lowered triggers thoughts of all related experiences. Later, pressure on the bladder or bowel or certain smells may trigger toilet thoughts.
Action: Push button | After riding the partner's hand while the button on the music player is pushed, the button is found and pushed by the learner. Sound results. | The sound of the click made by the button triggers thoughts of activating the music player.

### Cluster Concepts

While the learner is building these simple single-referent concepts, he is also becoming aware that single-referent concepts tend to be experienced in predictable groups. These can be thought of as cluster concepts. Everything in the cluster has to be experienced as described above in order to have meaning. That is why each thing in the cluster is a single-referent concept. But, it is a single-referent concept clearly associated with other single-referent concepts. This is significant because experiencing one thing in the cluster calls to mind all of the other things associated with it. Cluster concepts are the beginning stage of schema development.

Examples of Cluster Concepts
Category | Touching body | Beyond body bridges
--- | --- | ---
Person: - Mother - Dad - Brother | Sitting with Mother while she reads a story brings to mind similar experiences with other family members. | The sound of a brother's voice overheard on the school playground causes the learner to think of his family.
Object: - Toilet - Toilet paper - Toilet paper holder | After the sitting experience, paper is pulled from a cylinder attached to a wall. Shortly after pulling, a paper-like substance touches the bottom. The learner is not sure how the paper got there. | The sound of the toilet paper roll turning triggers thoughts of experiences with toilet and paper.
Action: - Load CD - Push button | Putting a cassette or CD in the player affects the button-pushing outcome. Push button results in sound only when cassette loading happens first. | The sound of familiar music or of noises made by the player triggers thoughts of loading and activating.

### Schemas

Schemas are more complex than cluster concepts. Like cluster concepts, they require thinking about several things at once, but they also require thinking about how those things relate to each other in current and past events. The word "event" is key to understanding the significance of this kind of concept development. In an event, several things interact dynamically over time. Some single-referent concepts have a simple dynamic aspect such as discovering how an object is used or how a person usually behaves. The dynamic aspect increases dramatically in events. The level of complexity of an event is determined by how many people, objects, and actions are included in the interaction and by how long the event lasts. The toilet and toilet paper cluster described previously involves two single-referent concepts each having a dynamic "use" component-sitting and pulling. The toileting event is much more complex. It includes the space around the toilet and everything it contains, the presence of other people and what they are doing with those things, and the sequence of actions that happens in that space with those things from the beginning to the end of the event. There are many referents, and knowledge of how each interacts with the others is essential to the development of the schema. Most events will contain some symbols referring to things touching the body and some, usually many more, to things beyond the body.

Since events increasingly involve interactions with peers, they are highly social in nature. Understanding and enjoying events is essential to the social development of young children with visual impairments and students with visual and multiple impairments. Learners who are overwhelmed by the sensory input in complex events and who are unable to make sense of it are more likely to self-select less complex and less social activities (Hughes et al., 1998). The learner who sits by herself playing with the buttons on the music player may not be choosing this activity because she loves music or "is stuck on cause and effect," but because it feels much safer.

The following are examples of simple schemas as they might develop at the early preoperational stage.

Examples of Schemas
Event | Touching body | Beyond body bridges
--- | --- | ---
Breakfast | The learner feels the food in his mouth, the utensils held in his hand, the surface of the table or tray as he intentionally moves his hand to find items used during the meal, the chair he is sitting in, and the people and objects in the kitchen he touches as he moves to the eating area. | The smell of food Sounds of people doing things - preparing food - setting the table - unfolding napkins - pouring liquids - passing serving dishes - chewing The sources of these smells and sounds are unknown to the learner unless they have been paired with touch experiences previously.
Toileting | The learner feels his clothing as he pulls his pants down, the toilet seat as he sits on it, the paper as he unrolls it and wipes, and his clothing again as he pulls his pants up. He may also feel doors, the tank and handle, sinks and counters, and other things, depending on his level of participation. | Smells of soaps, cleansers, etc. The sounds of the activities of other people in the space - doors opening - water running - towels being pulled from dispensers - blow dryers, etc. Sources of these smells and sounds are unknown to the learner unless they have been paired with touch experiences previously.
Circle Time | The learner feels the carpet square upon which he is sitting. | Teacher's voice Peer's voices Music Sounds of - pages turning - tapping on charts - Velcro ripping as symbols are moved Movement of peers' bodies Sounds and words used to refer to visual media like number charts, printed words, and pictures are meaningless unless they have been paired with touch experiences previously.

In each of these examples, knowledge of the space in which the event takes place becomes an important part of developing a meaningful schema. Understanding breakfast requires that the learner explore the area in which breakfast takes place, usually a kitchen. Then the learner must have an opportunity to find out what other people are doing in that space. The learner who eats the cereal placed on the table in front of him does not really have a schema about breakfast if he has no idea that Dad is drinking orange juice in the chair next to him, his brother is going to the refrigerator to get yogurt, and Mother is toasting a bagel for herself at the counter next to the stove. Without a chance to tactually explore what is going on, the learner will never figure out that those crackling noises Dad makes aren't related to something he is eating but, rather, the newspaper he is reading. When the learner has had meaningful experiences of going to the refrigerator and getting food items, he will be able to use the sounds his brother makes as he gets his yogurt as a bridge to information beyond his body. He will understand that his brother is interacting with the refrigerator. The learner does not have the luxury of thinking about his breakfast experience in isolation. Sensory information about what his brother, mother, and dad are doing is coming to him simultaneously. In the face of all that, he is still supposed to think about eating his own cereal. He is more likely to be able to do that if he understands what is happening around him.

The photo shows a boy reaching his hand into a compartment on the inside of the refrigerator door.

## Language and Schemas

Language is an extremely helpful way to add meaning to schemas. In the example above, the learner knows, by use of a sound bridge, that his brother got something out of the refrigerator. He does not know what he got. Watching others is one of the major ways sighted individuals empower themselves. Options expand when one has knowledge of the actions of others. A learner who has a visual impairment and who can say, "What get?" and know what the referent tastes like when he hears the answer, "Yogurt," is empowered about his breakfast choices. Similarly, when a child hears his mother making noises at the kitchen counter and recognizes the sound of the toaster, he can get much more useful information if he can have a conversation with his mother about what she is toasting and who will eat the bagel.

The challenge is to make sure that the language used is meaningful. Making good choices about when to use chatter and when to use very telegraphic instructional language is essential to the learner's development. Learners with visual impairments typically put a lot of energy into listening. They may be trying to figure out what is going on beyond their bodies, or they may be entertaining themselves. When sounds, including language, are meaningless, they are more likely to be used for stimulation rather than learning.

Schemas and language develop together under the best conditions. Dunlea (1989) describes an interaction illustrating that point with a child who has typical vision.

> The child learns about the matching of language and world largely through context. A now classic example is Shatz's (1974) analysis of how toddlers successfully respond to such directives as "Can you shut the door?" Basically, the child maps maternal speech onto the objects and actions he sees in the world with the aid of the mother's non-verbal clues. In this instance, the child follows his parent's eye gaze and gesture which are directed toward the door, a strategy which crucially depends on vision. The child's previous observations and explorations equip him with the knowledge that doors can be opened and closed, and the child may pick up the parent's intonation and recognize the utterance as a directive... If the door is open, the child closes it. We do not infer that the toddler understands the grammatical components of his parent's utterance, or the meaning of each word, or how the meanings are combined, but through context, the child comes to solve the puzzle of language. (p. 4)

Solving the mystery of language is more difficult without vision. In the beginning, language development requires the learner to discover the meaning of a word or group of words by guessing. He can only make a good guess if he has good context clues available to him. The preoperational level learner with impaired vision needs to develop his understanding of word meaning first in interactions with things touching his body and, secondly, in interactions using distance sensory bridges. The learner with a visual impairment responding to "Can you shut the door?" may also understand from inflection that his mother wants him to do something. He cannot, however, follow her eye gaze to help him figure out the referent for the word "door." If he has had previous experience with doors, he may associate the sound of a door shutting with the door itself. Therefore, if his mother replaces her visual clue with an auditory one (the sound of the door shutting), the learner can guess that the word "door" in her direction refers to that thing he has touched before that makes that sound. The mother who asks her sighted child to shut the door may really be asking for some help so that she doesn't have to go shut the door herself. The interaction for the mother of the child with the visual impairment is quite different. She is intentionally teaching word meaning. She hasn't saved herself the trouble of going to the door. She is going to have to do that to provide a sound clue for her child in order to give him the opportunity to make a good guess about what the word "door" means in her communication to him.

The photo shows a young boy prepared to open a door with his hand on a door handle. He looks up at the viewer.

Understanding the phrase "Can you shut the door?" is easier when words used in the phrase, like "shut" and "door" are already meaningful symbols. This is accomplished by making sure that the learner has had experiences of hearing the word "shut" as he pushes the door to close it and the word "door" as he touches the panel and handle while entering and exiting rooms. Given this kind of foundation, he will not have to guess as much when he hears more complex word constructions like "Can you shut the door?"

Some young children with visual impairments and students with visual and multiple impairments have difficulty breaking down complex language into individual word units of meaning (Hagood, 1997). The use of language, sometimes very sophisticated language, without understanding of individual word meaning is called "echolalia." Learners who use echolalic speech present some unique challenges for their partners. Appendix E discusses these challenges and provides strategies for addressing them.

While learning labels for people, objects, and actions is the starting point for developing meaning for word symbols for most young children, it is soon followed by an even more empowering kind of understanding. This happens when the child expands his understanding of the meaning of the word from a single concrete referent to something more abstract-the word as a symbol for a whole class of referents. In this way, the word "dog" starts off being a label for the learner's personal pet and expands to be the designator for a certain class of animals containing many different dogs. Dunlea (1989) describes the process this way.

> ...children construct hypotheses about word meanings based on their own unique experiences, their understanding of the world in general, and the way in which their vocabularies are structured at a given point in time. Lexical (dictionary-like) development involves much more than merely establishing a set of one-to-one correspondences between a term and a referent. Children must abstract information associated with early instances of word use and use this information as a basis for generalizing the domain of application to new situations. This process is essential if a term is to move from functioning as a specific "name" to denoting a heterogeneous class of referents. (p. 37)

This expansion is greatly facilitated by the use of pictures for children with vision. Helping the child who is a tactual learner expand his understanding of "dog" will require some different learning experiences. Toy dogs are not helpful. They don't feel like dogs; they only look like dogs. One way to facilitate expansion might be to have a recording of many different dogs barking. (See SAM Sounds on flash drive.) This auditory experience of a significant dog characteristic, a bark, expanded from the familiar bark of the learner's own dog to many different sounds that are also clearly barks, can help the learner understand that there is more than one dog. To the extent possible, some touching of dogs associated with different barks is highly desirable. By combining the touch and sound experiences of dogs, the learner develops a schema about dogs that includes important things like size related to sound.

The photo shows an adult dog and a puppy; both dogs are Shih Tzus.

Photo Caption: These two dogs have different barks (sound) that reflect their sizes (touch).

Partners cannot assume that a learner understands the same thing they understand when a word is used. There are two variations to keep in mind. Dunlea (1989) explains, "Studies of children's early word use indicate that the domain of application for early words may be quite different from adult usage of the same word. Moreover, early meanings for words may vary significantly among individual children" (p. 37).

In other words, a partner may say, "Quack," with the assumption that it will be interpreted by the learner as a symbol for the sound a duck makes. However, the learner's experience with this word has been in a context where her primary association with the word is singing "Old MacDonald's Farm." For her, the referent for the word "quack" is not the animal, but the song. Correspondingly, when her teacher shows her a stuffed toy duck and says, "Quack, quack, quack," the learner starts to sing "Old MacDonald's Farm." She is unaware that the sounds made in that song have anything to do with real or toy animals. Her teacher is equally confused when the learner says, "Quack, quack, quack," when she is requesting "Old MacDonald's Farm" during music circle. The teacher recognizes from inflection that something is being requested, and tries to respond by handing the learner the toy duck. The error is obvious when the learner throws the duck and begins to cry.

### Language and Emotions

The first words learned by typical children are usually labels for objects. Most object words refer to familiar items of food, clothing, animals, vehicles, toys, and people. But, words related to familiar routines, actions, and words involved in social expressions such as greetings also appear very early in language development (Dunlea, 1989). Nelson (1973) showed that there are significant individual variations in the kinds of words acquired by different children. She identified two styles-referential and expressive. Expressive children developed more words related to feelings and needs while referential children developed more words for objects and actions. This research is fairly old, and while it has not been replicated recently, it has not been disputed. It is probably safe to assume that there are many children who are more interested in labels for feelings than for common objects. Even for children who are more interested in object names, learning labels for feelings can be very helpful for a variety of reasons. When a partner can label a feeling being experienced by a learner and the learner understands the same thing the partner does, the learner knows that the partner is aware of something very important to him. Learners usually experience feelings of comfort and safety when they know that their partners understand what they are feeling. See Appendix F for strategies for teaching language about emotions.

### Using Language With Impaired Vision for Distance Bridging

Traditionally, TVIs have encouraged partners to use language to help learners with visual impairments understand what is happening beyond their bodies. Examples given earlier of three learners with different visual conditions trying to understand the activities of people seated around a table reading a newspaper, writing on a pad of paper, and filling saltshakers showed how each might experience significant loss of information. Understanding that acuity loss prevents Sue from identifying specific people or the small objects she sees them moving, Sue's partner might tell her the names of the people at the table and describe what they are doing.

Descriptive language tends to be very complex. Sue might hear something like this.

> "Mr. Miller, Benny, and Pat are sitting at the large table next to the computers. Mr. Miller is reading the sports page of the newspaper. He is frowning because his team lost. Benny is writing a letter to his Grandmother to thank her for making cookies for the open house last Friday. Pat is filling the saltshakers. She is using a scooper and a funnel. There is a pan under the shakers to catch anything she spills."

The description above would probably be very helpful to a learner who understands complex language. Unfortunately, descriptions like these are often provided for learners at the very beginning stages of understanding simple one or two word labels. Late sensorimotor and early preoperational level learners are not helped by these kinds of descriptions. They do not have better information about people, objects, and actions at distance as a result of being exposed to complex verbal descriptions. In fact, they may even get less information because they must divide their attention between sensory information about the event and the words they are hearing.

Words may help the beginning symbol user understand what he is seeing if they are used carefully. First of all, the word will need to be a label that the learner has associated with a person, object, or action in an experience involving touch. Second, that word will need to be used to label a distance visual target very specifically. For instance, the person reading the newspaper might wave at Sue and her partner might label the person and action by saying something like, "Mr. Miller. Wave." At this stage of development, in this context, the fewer words the better. Grammar and syntax are not the highest priority. The learner will have many opportunities at other times to hear complex language spoken with correct grammar and syntax so that these patterns can be encoded. The goal here is to fill in missing sensory information.

# Chapter 9: Troubleshooting Guide

The photo shows a boy and his female teacher facing each other and holding both hands together, as if dancing.

Photo Caption: The information in the Troubleshooting Guide is not comprehensive. Behaviors and causes which lend themselves to this format and which are addressed in published materials easily obtainable by partners are included.

Barrier behavior

- Learner is sleepy or drowsy a great deal of the time
- Learner is fussy and agitated a great deal of the time

Why

- Boredom-lack of interesting learning media, lack of social interactions
- Fear/anxiety-environment is too complex and over stimulating, learning media is aversive, partner is unfamiliar and/or untrusted

Caution! Extended states-sleepy, drowsy, fussy, and agitated-occur related to both biological and behavioral influences. Manipulation of arousal states is complex and requires collaboration among team members with specific areas of expertise. The two examples given above are only examples of what may be involved for a given learner. No assumptions should be made without careful assessment. For instance, fear can cause learners to shut down and appear drowsy; boredom can cause agitation.

Try

- Arousal state modulation techniques
- Environmental characteristic analysis
- Choosing media related to positive sensory responses
- Sensorimotor level routines designed to build trust with partners
- Activity enrichment

Resources

- Sensory Learning Kit (Smith)
- The ABLE Project (Ault)
- Environmental Consideration Checklist (Morse)
- Carolina Record of Individual Behavior (Simeonsson)
- Sensory Profile (Dunn)
- Every Move Counts (Korstan)

Barrier behavior

Learner engages in self-stimulatory behavior a great deal of the time

Why

Sensory input is needed to either calm or stimulate the learner's central nervous system

Try

- Arousal state modulation techniques
- Activity enrichment

Resources

- The ABLE Project
- The Sensory Diet (Wilbarger, Wilbarger)
- Sensory Learning Kit
- SAM: Symbols and Meaning (Smith)

Barrier behavior

Learner responds to others by scratching, biting, spitting, pulling hair, tearing clothes, etc.

Why

- Fear-person unknown, nature of interaction unknown
- Rejection-person and nature of interaction known and undesirable

Try

- Introduce self before touching learner
- Use an object symbol to let the learner know what is going to happen next
- Make sure there are many desirable activities in the day; few undesirable
- Substitute an activity that is more fun when possible; put fun things in challenging activities when they cannot be avoided
- Follow the learner's lead; make sure responses to his efforts to communicate are positive
- Stop when positive behaviors are occurring even if the activity only lasts seconds; add more gradually

Resources

- The INSITE Model (Morgan)
- Calendars (Blaha)
- Sensory Learning Kit
- Better Together (Hagood)
- Starting Points (Chen, Dote-Kwan)
- Essential Elements in Early Intervention (Chen)
- Early Focus (Fazzi, Pogrund)
- Educating Students Who Have Visual Impairments and Other Disabilities (Silberman, Sacks)

Barrier behavior

Learner does not interact with available learning media

Why

- Does not realize media is present
- Doesn't like media
- Doesn't know what to do with media

Try

- Use exploratory environments adapted to enhance accessibility and sensory feedback
- Appetite List
- Model exploration and functional use schemas using hand-under-hand instruction

Resources

- Active Learning Techniques (Nielsen)
- Sensory Learning Kit
- Tactual Strategies (Chen, Downing)
- Learning Through Touch (McCall, McLinden)
- SAM: Symbols and Meaning

Barrier behavior

Learner pulls hand away when touched

Why

- Touch causes discomfort
- Person is unknown
- Reason for touch is unknown
- Person and reason are known and undesired

Try

- Ask OT about tactual defensiveness
- Identify self before touching
- Present object symbol to tell learner what is going to happen
- Always start with something fun
- Use good hand etiquette-offer and invite

Resources

- Sensory Defensiveness (Wilbarger, Wilbarger)
- Talking the Language of the Hands to the Hands (Miles)
- The INSITE Model
- Calendars
- Sensory Learning Kit, Appetite List

Barrier behavior

Learner throws or drops objects placed in his hand

Why

- Startle
- Lack of meaning
- Undesirability of object
- Needs to practice throwing and/or dropping schemas at current level of motor development

Try

- Introduce object by making sound with it before touching learner
- Present object on back of hand; let learner initiate grasp
- Make sure learner knows intended use of object
- Help learner develop new exploratory schemas

Resources

- Talking the Language of the Hands to the Hands
- Tactual Strategies
- Learning Through Touch
- The INSITE Model
- Calendars
- Feelin' Groovy (Smith, Toy)
- SAM: Symbols and Meaning

Barrier behavior

Learner limits self-initiated interactions to one or two favorite objects

Why

- Varied array of objects unavailable
- Available objects uninteresting
- New objects considered threatening; activity with familiar object creates comfort barrier

Try

- Make rich variety of objects available to learner
- Choose objects with sensory characteristics enjoyed by learner; pay special attention to tactual and auditory features
- Invite learner to touch new things by modeling using hand-under-hand interactions; do not use hand-over-hand manipulation to force the learner to touch something
- Add new things to familiar objects
- Put favorite object in basket of similar objects so that learner must encounter new things to find favorite thing

Resources

- INSITE Model
- Tactual Strategies
- Learning Through Touch
- Talking the Language of the Hands to the Hands
- Educational Approaches (Nielsen)
- Child-guided Strategies: The Van Dijk Approach to Assessment (Nelson, van Dijk)
- SAM: Symbols and Meaning

Barrier behavior

Learner has one or two actions, like licking or banging, that he performs with all objects

Why

- Regulation more important than exploration
- Unaware of other actions

Try

- Help learner regulate more efficiently using arousal state modulation techniques
- Model exploration schemas

Resources

- The Sensory Diet (Wilbarger, Wilbarger)
- The ABLE Project
- Sensory Learning Kit
- Tactual Strategies
- Learning Through Touch
- Educational Approaches
- Talking the Language of the Hands to the Hands
- Child-guided Strategies: The Van Dijk Approach to Assessment

Barrier behavior

Learner is unaware of activities of others

Why

- Environmental sounds generated by the activities of others are meaningless and eventually ignored
- Fear-Experiences involving others are unpredictable and complex

Try

- Provide opportunities for the learner to touch the objects he hears other people use as they use them
- Provide activities in which learner shares materials and takes turns with adult partner; add peer; then peer partner without adult; eventually small peer group
- Success in social routines before unstructured play

Resources

- SAM: Symbols and Meaning
- Sensory Learning Kit

Barrier behavior

Learner becomes upset when something unusual happens

Why

- Fear-not knowing what is going to happen next produces anxiety

Try

- Provide a daily schedule; use schedule to inform learner about upcoming changes
- Use bag, box, and binder stories to talk about changes before and after the event

Resources

- Calendars
- SAM: Symbols and Meaning

Barrier behavior

Learner refuses to transition from place to place

Why

- Fear-reason for transition unknown
- New environments feel threatening
- Rejection-what is going to happen next is unpleasant

Try

- Use a transition object symbol
- Make new environments feel safe by exploring them and making sure the learner knows what is going on in them
- Show the learner that something he likes is going to happen when he gets to the new place

Resources

- Calendars
- SAM: Symbols and Meaning
- Sensory Learning Kit

Barrier behavior

Learner does not sustain or complete activities on his own

Why

Activities are done differently each time; completion is arbitrarily determined by another

Try

Provide routines and games with clear beginning and ending steps and a consistent series of intermediate steps

Resources

- Sensory Learning Kit
- SAM: Symbols and Meaning

Barrier behavior

Learner talks to himself using language consisting of repetitions of previously heard phrases and sentences-sometimes whole stories

Why

- Language is used for self-stimulation rather than communication
- Language is interesting, but not necessarily meaningful
- Too much time spent listening rather than doing

Try

- Make sure activities involve doing things with the body and hands
- Limit instructional language during activities to specific word labels for people, objects, and actions that are part of the activity
- Play games designed to associate words with people, objects, and actions
- Write bag, box, and binder stories about real events immediately after participating in the event

Resources

- SAM: Symbols and Meaning
- Communication (Hagood)
- Perkins Resource Guide and Activity Handbook (Cushman, Heydt, Edwards, Clark, Allen)

Barrier behavior

Learner does not follow simple verbal directions

Why

Content of language not meaningful

Try

Make sure learner has solid concepts in place for vocabulary used

Resources

SAM: Symbols and Meaning

Barrier behavior

Learner gives arbitrary incorrect answers to questions

Why

- Vocabulary used in question is not meaningful
- Question words-who, what, why, when-not understood

Try

- Make sure learner has solid concepts in place for vocabulary used
- Use fill-in-the-blank declarative sentence format rather than question format

Resources

- SAM: Symbols and Meaning
- Communication

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The photo shows a boy and his female teacher using a symbol on the SAM tray and a digital recorder.

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# Appendices

The photo shows a woman holding a girl on her hip. Using the hand-under-hand technique, they pat a horse.

## Appendix A
Learning Strategies for Tactile Defensiveness

Jennifer Stocker, MHS, OTR/L

The photo shows a boy withdrawn from the red Christmas garland. He has his head down and his hands in front of his face. Someone supports him under his arms.

Photo Caption: A dislike of certain textures, which causes withdrawal, is clinically documented to have an association with tactile defensiveness.

What is tactile defensiveness?

Definition

Jean Ayres originally discussed the term tactile defensiveness around 1964-1972, in reference to syndrome observations made in the clinic (Royeen & Lane, 1991). It is important for the reader to understand the context in which tactile defensiveness is currently understood. Sensory integration dysfunction occurs when the central nervous system has difficulty processing sensation, especially vestibular, tactile, or proprioceptive, which is manifested as poor praxis, poor modulation, or both. Sensory modulation dysfunction is a type of sensory integration dysfunction involving an under- or over-response to sensory input from the body or environment. Some examples include gravitational insecurity, aversive response to movement, sensory defensiveness, and under-responsiveness. Sensory defensiveness, a type of sensory modulation dysfunction, is a flight or fight reaction to sensation that unaffected individuals would consider non-threatening. Tactile defensiveness, which involves only the sense of touch, is a subset of sensory defensiveness (Bundy, Lane, & Murray, 2002).

The magnitude of sensory defensiveness (of which tactile defensiveness may be a component) varies from mild to severe. In mild cases, learners are able to function in daily living activities but may be viewed as extremely selective or picky. In moderate cases, learners demonstrate problems in two or more areas of daily life as a direct result of sensory defensiveness. Severe cases result in disruption of every aspect of a learner's daily life (Wilbarger & Wilbarger, 1991).

A complete understanding of sensory processing is necessary in order to assist learners who demonstrate symptoms of tactile defensiveness. Sensory processing involves the input of internal and external sensory stimuli to the central nervous system, the interpretation of this input, and the behavioral responses that may follow (Bundy et al., 2002). To understand sensory processing more clearly, read the Special Feature Box highlighted in this appendix. It is also recommended that the reader review the materials and literature in the Sensory Learning Kit, which is available from APH.

Strategies for Learning

Understand

This is a simplified summary of one portion of sensory processing. It is important to understand there are processes occurring at a cellular level much too complex for the scope of this book. The references are a place to start to further understand this complex process.

Recognize

Learn to identify signs and symptoms associated with sensory defensiveness, specifically tactile defensiveness. Some signs and symptoms clinically documented to have an association with sensory and tactile defensiveness include:

- objection to being touched by others
- objection to being in close proximity to others
- objection to grooming or hygiene tasks
- objection to or strong preference for specific textures or types of clothing
- dislike of certain textures/materials
- decreased grasp, avoidance of going barefoot
- decreased awareness of pain, over sensitivity to pain
- dislike or strong preference for specific food
- increased mouthing or chewing of non-food items
- teeth grinding

Refer and Communicate

If tactile defensiveness is suspected, refer the learner for an occupational therapy assessment or evaluation of sensory processing. Find an occupational therapist with additional education and/or specialty certifications in sensory integration areas. There are a number of informal sensory assessments as well as formal evaluations to assess sensory processing. Some examples include interview, Sensory Integration and Praxis Test (Ayres, 1989), Touch Inventory for Elementary School-Aged Children (Royeen & Fortune, 1990), Sensory Profile (Dunn, 1999), and Clinical Observations of Motor and Postural Skills (Wilson, Pollock, Kaplan, Law, & Faris, 2000).

Current Professionally Guided Treatment Strategies

As technology continues to advance, along with evidence-based practice requirements, the strategies used for tactile defensiveness should increase in efficacy. In the meantime, there are a number of strategies that case studies have shown may make improvements in quality of life. Some of these techniques include the Wilbarger Deep Pressure Technique and the sensory diet (Wilbarger & Wilbarger, 1991), direct occupational therapy using a sensory integration frame of reference, How Does Your Engine Run?® A Leader's Guide to the Alert Program® for Self-regulation (Williams & Shellenberger, 1996), and Therapeutic Listening (Frick, 2001).

Practical Ideas for Interactions and Environments

Recognize you are a source of sensory input. Modify voice volume and quality, avoid light/moving/unexpected/unsure touch, and monitor the use of perfumes (Wilbarger & Wilbarger, 1991).

Adapt the environment whenever possible within reason. Create areas where the learner can participate in self-directed activities that require the use of muscles, provide safe spaces with obvious boundaries for the learner to re-organize, and reduce disorganized environmental stimulation (Wilbarger & Wilbarger, 1991).

The photo shows a young girl wearing eyeglasses, a smock, and a head scarf. She plays with a blue Marshmallow Peep. She has Peep candy smeared on her nose, face, and eyeglasses.

Photo Caption: The learner uses her muscles in a self-directed candy activity.

Cautions

When working with a learner who demonstrates sensory modulation dysfunction, it is critical to understand the basis and signs of sensory overload; this is a serious condition. Remember, sensory overload is a sympathetic nervous system response of flight, fright, or fight.

According to the Bantam Medical Dictionary (Urdang, 2000), arousal is "a state of alertness." It states that strong motivation, anxiety, and a stimulating environment encourage the physiological activation of the cerebral cortex, resulting in wakefulness and alertness. It is hypothesized that unduly high or low degrees of arousal lead to neuropsychiatric problems.

The autonomic nervous system controls bodily functions that are not consciously directed; this includes a regular heartbeat, intestinal movements, sweating, salivation, etc. The autonomic nervous system is subdivided into sympathetic and parasympathetic divisions. Sympathetic nerves lead from the middle section of the spinal cord, and parasympathetic nerves lead from the brain and lower spinal cord. The heart, smooth muscles, and most glands receive fibers of both: The interplay of sympathetic and parasympathetic activity governs their working. Sympathetic nerve endings liberate norepinephrine as a neurotransmitter, whereas parasympathetic nerve endings release acetylcholine (Urdang, 2000).

The sympathetic nervous system, activated during sensory overload/shutdown, is a division of the autonomic system that plays a role in the preparation of the individual for emergency situations (Young & Young, 1997). Activation of the sympathetic nervous system includes the narrowing of blood vessels, increased heart rate, elevated blood pressure, increased blood flow to skeletal muscles, and slowing of gastrointestinal activity (Gylys & Wedding, 1995).

The reticular formation is a network of nerve pathways and nuclei throughout the brainstem that connects sensory and motor nerves to and from the spinal cord, the cerebellum, the cerebrum, and the cranial nerves. A single neuron in this network is estimated to have synapses with as many as 25,000 other neurons (Urdang, 2000).

The reticular activating system is the system of nerve pathways in the brain concerned with the level of consciousness-from the states of sleep, drowsiness, and relaxation to full alertness and attention. This system integrates information from all the senses, the cerebrum, and cerebellum. It then determines the overall activity of the brain, the autonomic nervous system, and patterns of behavior during waking and sleeping (Urdang, 2000).

Signs of sensory overload include nausea, dizziness, flushing, pallor, sweating, withdrawal, anxiousness, restlessness, and sleep disturbances (Reed, 1991). Be aware that persons severely overloaded by sensory information may go into shutdown, which may look similar to a low arousal level. If an individual is in sensory shutdown and an intervener increases environmental stimuli, the condition may become elevated.

The photo shows a girl sitting in a wheelchair. She has a cloth tucked under her chin and draped across her chest. Her chin is resting on her chest with her head slightly tilted to one side. She appears to be very drowsy or asleep.

Photo Caption: Sensory overload can cause withdrawal or fussiness.

In their book, Take Five! Staying Alert at Home and School, Mary Sue Williams and Sherry Shellenberger (2001) say the following:

> Children who are sensory defensive cannot be "desensitized" by being forced to participate in activities that their nervous system perceives as dangerous or irritating. These children need our understanding and support. Their engines can quickly go over the edge when their brains try to shut out the sensory bombardment completely; their engines may look like they are in a low level of alertness, when truly their nervous systems are shut down. This is a serious condition of the nervous system.

> Any nervous system will respond to protect the body if the brain's perception is that of danger. To an observer, this may seem extreme, but the brain's first priority is protection of the body. Therefore, a real or perceived threat is handled in the same way. A perceived threat is real to the perceiver, and it needs to be honored as his truth. As parents and teachers, we must honor children's perception of their sensorimotor world and respect their needs. (p. 77)

Special Feature

Somatosensory Process

According to P. A. Young and P. H. Young, in their book Clinical Neuroanatomy (1997), the somatosensory system "pertains to the general somatic senses: somatic pain and temperature, touch, vibration, and limb position and motion sensibility" (p. 321). The somatosensory system transmits and processes information from the sensory receptors on and within the body via receptor cells, spinal cord, brainstem, thalamus, somatosensory areas of the cortex, cerebellum, and reticular formation. The neurons synapse at multiple levels throughout the nervous system (Fredericks, 1996). There are two ascending systems within the somatosensory system, the dorsal column medial lemniscal pathway (DCML) and the anterolateral system (AL). The DCML conveys sensory information such as fine touch, vibration, joint position, tactile discrimination, and object spatial orientation to the brain. The AL carries cutaneous sensations such as pain, temperature, crude touch, and light touch, also to the brain (Young & Young, 1997; Lane, 2002; Fredericks, 1996).

Pain Perception

Pain is a necessary warning of danger that functions to preserve safety and system integrity (Usunoff, Popratiloff, Schmitt, & Wree, 2006). Pain perception is a complex process that involves electrical and chemical activities within the peripheral and central nervous systems (Aydinli, 2005). Many studies suggest the involvement of the thalamus, primary somatosensory cortex, secondary somatosensory cortex, insula, and anterior cingulate cortex, in pain perception. Pain perception is multidimensional and involves sensory discrimination, recognition, learning, memory, autonomic reactions, affect, and cognition (Schnitzler & Ploner, 2000). Chronic pain decreases one's ability to accurately perceive true danger and may become a debilitating disease (Usunoff et al., 2006). The pathophysiology of abnormal pain perception is not fully understood; however, studies suggest differences in regional cerebral blood flow at rest and in response to pain induction in individuals with fibromyalgia when compared to healthy individuals using neuroimaging (Bradley et al., 2000).

Tactile Perception

At the molecular level, touch is the least understood of all of the senses (Welsh, Price, & Xie, 2002). The skin contains a variety of mechanoreceptors able to detect different types of mechanical stimulation. A link between the ability to process and/or interpret tactile and pain sensation and the presence of somatin-like protein 3 was recently found (Wetzel et al., 2007). Mechanoreceptors are divided into categories based on the speed of transmission and sensory modality (Lumpkin & Caterina, 2007). Mechanoreceptors permit skill development such as two-point discrimination, stereognosis (the ability to perceive the form of an object by using the sense of touch), and graphesthesia (the ability to recognize writing on the skin purely by the sensation of touch) (Fredericks, 1996).

References

Aydinli, I. (2005). Physiopathology of pain. Turkish Journal of Physical Medical Rehabilitation, 51, B8-B13.

Ayres, A. J. (1989). Sensory integration and praxis tests. Los Angeles, CA: Western Psychological Services.

Bradley, L. A., McKendree-Smith, N. L., Alberts, K. R., Alarcon, G. S., Mountz, J. M., & Deutsch, G. (2000). Use of neuroimaging to understand abnormal pain sensitivity in fibromyalgia. Current Rheumatology Reports, 2, 141-148.

Bundy, A. C., Lane, S. J., & Murray, E. A. (2002). Sensory integration: Theory and practice (2nd ed.). Philadelphia, PA: F. A. Davis Company.

Dunn, W. (1999). Sensory profile. San Antonio, TX: The Psychological Corporation.

Fredericks, C. M. (1996). Basic sensory mechanisms and the somatosensory system. In C. M. Fredericks & L. K. Saladin, (Eds.), Pathophysiology of the motor systems: Principles and clinical presentations (pp. 78-104). Philadelphia, PA: F. A. Davis.

Frick, S. M. (2001). Listening with the whole body. Madison, WI: Vital Links.

Gylys, B. A., & Wedding, M. E. (1995). Medical terminology: A systems approach (3rd ed.). Philadelphia, PA: F. A. Davis.

Lane, S. J. (2002). Structure and function of the sensory systems. In A. C. Bundy, S. J. Lane, & E. A. Murray, (Eds.), Sensory integration: Theory and practice (2nd ed.). Philadelphia, PA: F. A. Davis.

Lumpkin, E. A., & Caterina, M. J. (2007). Mechanisms of sensory transduction in the skin. Nature, 445, 858-865.

Reed, K. L. (1991). Quick reference to occupational therapy. Gaithersburg, MA: Aspen Publishers.

Royeen, C. B., & Fortune, J. C. (1990). TIE: Touch inventory for school aged children. American Journal of Occupational Therapy, 44, 165-170.

Royeen, C. B., & Lane, S. J. (1991). Tactile processing and sensory defensiveness. In A. G. Fisher, E. A. Murray, & A. C. Bundy, (Eds.), Sensory integration: Theory and practice (1st ed.). Philadelphia, PA: F. A. Davis.

Schnitzler, A., & Ploner, M. (2000). Neurophysiology and functional neuroanatomy of pain perception. Journal of Neurophysiology, 17, 592-603.

Urdang, L. (Ed.). (2000). The Bantam medical dictionary (3rd ed.). New York, NY: Bantam Books.

Usunoff, K. G., Popratiloff, A., Schmitt, O., & Wree, A. (2006). Functional neuroanatomy of pain. Advanced Anatomy Embryology Cell Biology, 184, 1-115.

Welsh, M. J., Price, M. P., & Xie, J. (2002). Biochemical basis of touch perception: Mechanosensory functions of degenerin/epithelial NA+ channels. Journal of Biological Chemistry, 277, 2369-2372.

Wetzel, C., Hu, J., Riethmacher, D., Benckendorff, A., Harder, L., Eilers, A., Lewin, G. R. (2007). A somatin-domain protein essential for touch sensation in the mouse. Nature, 445(7124), 206-209. doi:10.1038/nature05394

Wilbarger, P., & Wilbarger, J. L. (1991). Sensory defensiveness in children aged 2-12. Santa Barbara, CA: Avanti Educational Programs.

Williams, M. S., & Shellenberger, S. (1996). How does your engine run?® A leader's guide to the Alert Program® for self-regulation. Albuquerque, NM: Therapy Works.

Williams, M. S., & Shellenberger, S. (2001). Take five: Staying alert at home and school. Albuquerque, NM: Therapy Works.

Wilson, B., Pollock, N., Kaplan, B. J., Law, M., & Faris, P. (2000). Clinical observations of motor and postural skills. Framingham, MA: Therapro.

Young, P. A., & Young, P. H. (1997). Basic clinical neuroanatomy. Baltimore, MD: Williams & Wilkins.

Jennifer Stocker is an Occupational Therapist at the Kentucky School for the Blind. She is trained in Pediatric Neuro-Developmental Treatment and certified in the Sensory Integration and Praxis Test.

## Appendix B
Impact of Cerebral Palsy and a Visual Impairment on Object Manipulation and Object Use

Jennifer Stocker, MHS, OTR/L

The photo shows a girl with cerebral palsy opening a bottle.

Photo Caption: To open a bottle, intact integration of all body systems is required.

Object Manipulation and Object Use

The ability to conceptualize object features and manipulate objects for function is a complex process involving multiple physiological systems. Efficient object assessment and use requires intact integration of all body systems, especially the musculoskeletal, neuromuscular, sensory, and cognitive systems.

To understand the impact of a single system or subsystem impairment more clearly, one should be familiar with the typical process. Read the Special Feature, titled Systems, highlighted in this appendix for an in depth discussion of the typical process.

Vision

In her book, Developmental Visual Dysfunction: Models for Assessment and Management, Rhonda P. Erhardt (1990) says,

> The function of vision is to establish the foundation of sensory information and experience needed to direct movement. The development of human vision is a long and complex process, involving not only the visual organs but also the brain, nerves, and muscles of the entire body. (p. 3)

Impact of a Visual Impairment and Cerebral Palsy

Suboptimal functioning of any one or a combination of systems and subsystems may lead to decreased task efficiency. Within the diagnosis of cerebral palsy, there are variations of and between each type, which precludes discussion of all possible variations in movement disturbances. Impairments in the neuromuscular system are observed through positive signs such as spasticity, impaired muscle activation, and impaired motor execution. Negative signs of neuromuscular system impairment such as insufficient force generation, impaired anticipatory postural control, hypokinesia, and loss of fractionated or dissociated movements are also possible. Signs of impairment in any or all of the sensory, musculoskeletal, respiratory, cognitive, regulatory, cardiopulmonary, and gastrointestinal systems may be observed (Howle, 2004).

Strategies to Maximize Hand Function in Children With a Visual Impairment and Cerebral Palsy

Understand

Object exploration for the purpose of function involves many body systems and is a complex and highly individualized process.

A female teacher introduces a red and black ball to a baby girl who has cerebral palsy. The girl's hand is fisted. She attends to the ball as it touches her hand.

Photo Caption: With assistance from her teacher, this young learner, who has cerebral palsy, explores the ball.

Refer and Communicate

Refer the learner for an occupational and physical therapy evaluation in order to assess the learner's system integrity and integration of his systems in relation to function.

Direct Occupational and/or Physical Therapy Services

Occupational and physical therapists have an understanding of body systems, their relation to each other and to function. Regimes such as the Neuro-Developmental Treatment Approach require intense didactic and practicum education beyond the college level and have been used with success towards improving quality of life (Adams, Chandler, & Schuhmann, 2000; Arndt, Chandler, Sweeny, Sharkley, & McElroy, 2008; Girolami & Campbell, 1994; Karem, Livanelioglu, & Topcu, 2001).

Environmental Modifications

If the goal is concept development, then the learner should be positioned with proper alignment, referred to a physical therapist, and the object should be placed within the base of support and the child's active range of motion.

The photo shows a girl who has cerebral palsy sitting up straight in her wheelchair. She has a neck support cushion and appears actively alert.

Photo Caption: The girl sits with proper alignment in her chair.

Understand Motor Learning

Motor learning is a process that occurs when a learner is encouraged to develop his own solutions to his problems. Whether due to practice or experience, a relatively permanent change in the capability to achieve a goal is established. Variables that influence motor learning include the amount of practice experienced by the learner, informational feedback (frequency, timing, scheduling), guidance versus discovery learning, part-task and whole-task practice, accuracy versus speed, blocked versus random practice schedule, environmental influences, and pre-practice variables (Nicholson, 1996).

The first photo shows a young boy who has cerebral palsy activating a toy bus by tapping a switch with his cheek. The second photo shows another boy who also has cerebral palsy activating a toy rooster by tapping a switch with his foot.

Photo Caption: The learner on the left practices object manipulation with his face and the learner on the right with his foot.

In order to meet the needs of individual learners, it is recommended that the reader further investigate the motor learning process and design specific strategies tailored to each learner that will influence the nervous, muscular, skeletal, and sensory systems in the best possible manner.

Special Feature

Systems

Musculoskeletal System

The musculoskeletal system consists of bones, joints, ligaments, tendons, cartilage, muscle fibers, and fascia. All these elements normally work in balance. They continually modify their shape, structure, and function in response to load and mechanical demands (Berkow, Fletcher, & Beers, 1992). Kinesiology is the study of movement and the active and passive structures involved. Knowledge of range of motion, alignment, base of support, center of gravity, and movement in all three planes (sagittal, horizontal, and frontal) is necessary to understand the complex process of object conceptualization and object use.

The illustration shows a boy standing with imaginary glass planes dividing his body into horizontal, sagittal, frontal, and median planes.

Base of support refers to the amount of contact area that a resting body covers on a surface. The center of gravity is the balance point in or near a body located where the resultant gravitational force acts (Greene & Roberts, 2005). Maximal ability to reach, grasp, release, and manipulate objects requires that all body parts move in wide ranges off a dynamic base of support in all three planes of motion.

Neuromuscular System

The neuromuscular system includes the nervous and muscular systems. It impacts muscle tone, muscle strength, muscular endurance, muscle activation patterns (fractionation and timing), involuntary movements, associated reactions, coordination, praxis, and speed of movement, balance, and sensation (Fredericks & Saladin, 1996). Motor neurons are nerve cells that conduct action potentials away from the central nervous system and stimulate muscles (via the neuromuscular junction) and glands (Van De Graaff, 1995). The neuromuscular junction is the meeting point of a nerve fiber and the muscle fiber that it supplies. There is a gap between the motor end plate and the membrane of the muscle fiber. A neurotransmitter must diffuse across the gap to trigger a muscle contraction (Urdang, 2000). All parts of this system must work together without interruption in order to manipulate objects, reach, grasp, and release smoothly and efficiently.

Sensory System

The somatosensory system pertains to the general somatic senses: somatic pain and temperature, touch, vibration, limb position, and motion sensibility (Young & Young, 1997). The somatosensory system transmits and processes information from sensory receptors on and within the body to higher neural areas (Fredericks, 1996).

Somatosensory receptors are classified by the type of stimulus detected, location of stimulus, classification of senses, and function of afferent fibers. Contributing author and co-editor of Pathophysiology of the Motor Systems: Principles and Clinical Presentations, Christopher M. Fredericks (1996) lists the types of somatosensory receptors as

- Mechanoreceptors
- Thermoreceptors
- Nociceptors

Mechanoreceptors are activated by distortion due to touch, pressure, vibration, muscle, or tendon stretch (Young & Young, 1997). Not only are they the most numerous receptors, they are regarded as highly specialized in morphology, distribution, and function (Fredericks, 1996).

The photo shows a young girl reaching to touch the massager that her teacher moves on her arm.

Photo Caption: A child responds to the vibration while playing Body Buzz.

Tactile discrimination consists of sensations of touch and pressure with a high degree of localization, phasic sensations such as vibration or movement against the skin, and a sense of the body. Tactile discrimination includes tasks such as two-point discrimination, stereognosis, and graphesthesia (Fredericks, 1996).

In Basic Clinical Neuroanatomy, Paul A. Young and Paul H. Young (1997) define these tactile discrimination tasks:

- Two-point discrimination is the ability to distinguish stimulation by one or two points applied to the skin.
- Stereognosis is the ability to recognize objects by touch alone, using the object's size, shape, texture, weight, etc.
- Graphesthesia is the ability to recognize numbers or letters drawn on the skin. (p. 127)

Both stereognosis and graphesthesia require that the objects, numbers, or letters be known to the learner being tested.

Pacinian corpuscles are sensory receptors for skin touch. They consist of sensory nerve endings surrounded by capsules of membrane in 'onion-skin' layers. They detect vibration extremely well because they are highly sensitive to changes in pressure (Urdang, 2000).

A proprioceptor is a specialized sensory nerve ending located in muscles and tendons that monitors internal changes in the body and transmits information that is used to coordinate muscular activity, including stretch receptors and tendon organs (Urdang, 2000).

A muscle spindle is a receptor, sensitive to stretch, that is embedded between and parallel to the fibers of striated muscles. Coordinated muscular movement is a result of these specialized receptors. Also important to stretching is the Golgi tendon organ. It is a sensory receptor found within a tendon and it responds to the tension or stretching of the tendon by sending impulses to the central nervous system (Urdang, 2000).

A thermoreceptor is a sensory nerve ending that responds to heat or cold. Such receptors are scattered widely in the skin and in the mucous membrane of the mouth and throat (Urdang, 2000).

A nociceptor is a receptor that responds to stimuli responsible for the sensation of pain (Urdang, 2000).

Motor activity requires continuous and detailed sensory feedback. Somatosensory receptors convert a stimulus into an electrical signal, which triggers an action potential in the afferent nerve fiber (Young & Young, 1997). Receptor cells respond most efficiently to a particular form of energy (Fredericks, 1996).

Keep in mind that receptor adaptation may take place. Receptor adaptation is the phenomenon in which a sense organ shows a gradually diminishing response to continuous or repetitive stimulation (Urdang, 2000).

The faster action potentials are conducted, the more quickly the central nervous system receives the information. This is important because some signals (particularly in regards to safety) need to be transmitted to the central nervous system with extreme speed (Fredericks, 1996). Nerve fibers that conduct impulses produced by taction, pressure, vibration, and limb position and motion are larger and conduct faster than nerve fibers that conduct pain and temperature impulses (Young & Young, 1997). Sensory information is coded according to intensity, location, and modality (Fredericks, 1996). There are two ascending systems within the somatosensory system, the dorsal column medial lemniscal pathway (DCML) and the anterolateral system (AL).

DCML | Processes information about fine touch, vibration, joint position, discrimination, and object spatial orientation.
AL | Processes information about pain, temperature, crude touch, and light touch (Young & Young, 1997; Lane, 2002; Fredericks, 1996).

Cognitive System

Cognition is the mental process by which knowledge is acquired (Urdang, 2000). According to the American Occupational Therapy Association (2002), this system involves the functions of consciousness, orientation, energy, attention, memory, perception, categorization, generalization, higher-level cognitive skills (judgment, concept formation, time management, problem solving, etc.), language, calculations, sequencing, and emotion. Cognition is involved in the ability to conceptualize object features as well as the manipulation of objects for functional use.

In summary, the ability to learn about objects is a complex multiple system process. One must consider the large amount of possible variations in functional vision as well as positive and negative manifestations of cerebral palsy. Not to mention that one square inch of skin contains 20,000,000 cells, 78 nerve fibers, 1,300 pain receptors, 19,500 sensation receptors, 160-165 pressure receptors, and 100 sweat glands each containing, 20 blood vessels, 78 heat receptors, 13 cold receptors, and 65 hair follicles (The Wolfe Clinic). All of which may be impacted by cerebral palsy. When helping a child diagnosed with a visual impairment and cerebral palsy to learn about objects for the purpose of a specific function:

- 1) Team members should assess all body systems.
- 2) The team should set realistic, functional, and meaningful goals.
- 3) The team should consider all components required in the task.
- 4) The team should consider which system impairments hinder the function.
- 5) Appropriate team members should address system impairments that may impact function.

References

Adams, M. A., Chandler, L. S., & Schuhmann, K. (2000). Gait changes with cerebral palsy following Neurodevelopmental Treatment Course. Pediatric Physical Therapy, 12, 114-120.

American Occupational Therapy Association. (2002). Occupational therapy practice framework: Domain and process. American Journal of Occupational Therapy, 56, 609-639.

Arndt, S. W., Chandler, L. S., Sweeny, J. K., Sharkley, M. A., & McElroy, J. J. (2008). Effects of a neurodevelopmental treatment-based trunk protocol for infants with posture and movement dysfunction. Pediatric Physical Therapy, 20, 11-22.

Berkow, R., Fletcher, A. J., & Beers, M. H. (Eds.). (1992). The Merck manual (16th ed.). Rahway, NJ: Merck Research Laboratories.

Erhardt, R. P. (1990). Developmental visual dysfunction: Models for assessment and management. Maplewood, MN: Erhardt Developmental Products.

Erhardt, R. P. (1994). Developmental hand dysfunction: Theory, assessment, and treatment. Austin, TX: Pro-Ed.

Fredericks, C. M. (1996). Basic sensory mechanisms and the somatosensory system. In C. M. Fredericks & L. K. Saladin, (Eds.), Pathophysiology of the motor systems: Principles and clinical presentations (pp. 78-104). Philadelphia, PA: F. A. Davis.

Fredericks, C. M., & Saladin, L. K. (1996). Clinical presentations in disorders of motor function. In C. M. Fredericks & L. K. Saladin, (Eds.), Pathophysiology of the motor systems: Principles and clinical presentations (pp. 255-292). Philadelphia, PA: F. A. Davis Company.

Girolami, G. L., & Campbell, S. K. (1994). Efficacy of a Neuro-Developmental Treatment Program to improve motor control in infants born prematurely. Pediatric Physical Therapy, 6, 175-184.

Greene, D. P., & Roberts, S. L. (2005). Kinesiology: Movement in the context of activity (2nd ed.). St. Louis, MO: Elsevier Mosby.

Howle, J. M. (2004). Neuro-developmental treatment approach: Theoretical foundations and principles of clinical practice. Laguna Beach, CA: Neuro-Developmental Treatment Association.

Karem, M., Livanelioglu, A., & Topcu, M. (2001). Effects of Johnstone pressure splints combined with neurodevelopmental therapy on spasticity and cutaneous sensory inputs in spastic cerebral palsy. Developmental Medicine Child Neurology, 43, 307-313.

Lane, S. J. (2002). Structure and function of the sensory systems. In A. C. Bundy, S. J. Lane, & E. A. Murray, (Eds.), Sensory integration: Theory and practice (2nd ed.). Philadelphia, PA: F. A. Davis.

Nicholson, D. E. (1996). Motor learning. In C. M. Fredericks, & L. K. Saladin (Eds.), Pathophysiology of the motor systems: Principles and clinical presentations (pp. 238-254). Philadelphia, PA: F. A. Davis.

The Wolfe Clinic. (2004, September). Skin deep. The Wolfe Clinic News, I, 3. Retrieved August 13, 2008, from http://shopthewolfeclinic.com/store/newsletters/2004/september_01/pdf/Sept_03_2004.pdf

Urdang, L. (Ed.). (2000). The Bantam medical dictionary (3rd ed.). New York, NY: Bantam Books.

Van De Graaff, K. M. (1995). Human anatomy (4th ed.). Dubuque, IA: Wm. C. Brown.

Young, P. A., & Young, P. H. (1997). Basic clinical neuroanatomy. Baltimore, MD: Williams & Wilkins.

Jennifer Stocker is an Occupational Therapist at the Kentucky School for the Blind. She is trained in Pediatric Neuro-Developmental Treatment and certified in the Sensory Integration and Praxis Test.

## Appendix C
Tactual Learning With Limited Hand Use Due to Motor Impairment

Millie Smith, M.Ed, TVI

A young girl who wears glasses and has cerebral palsy sits in an adapted stroller in a playroom full of children.

Photo Caption: This child spends most of her time listening because she cannot use vision or touch to get information about events in her environment.

Most teachers of students who have visual impairments (TVI) have heard the following aphorism. "If the eyes don't work, the hands become the eyes." Neurologists confirm the truth of the statement. They point to images that show regions of the brain normally dedicated to processing visual information given over to tactual processing in individuals without sight. In the case of braille readers, a huge portion of the cortex is dedicated to processing input from the index finger alone (Pascual-Leone & Torres, 1993). But what happens in the brains of individuals without sight who have severe motor impairments? In other words, what does the brain process if both the eyes and the hands don't work?

To answer this question it is helpful to remember what the brain is trying to do with the information it processes. It is trying to help its owner make sense of the world. Young learners discover what is in their worlds and how it works through use of their "sensing" and "action" systems (Gibson, 1988). Making sense of the world without the ability to gather information visually or haptically-through active touching-is a formidable task. Learners who cannot use their hands to explore objects may develop knowledge of their worlds based primarily upon auditory information. Auditory input alone doesn't make much sense.

Imagine two children hearing sounds coming from a music player. Both children are blind. Joe has no motor impairments. Beth has severe cerebral palsy. When Joe becomes curious about the sounds he is hearing, he moves toward them until he discovers a box. He leans down and puts his ear against the speaker. "Yes," he thinks, "this is the thing that makes the sounds I hear." He explores the box with his hands. He finds some buttons on the front of the box. He presses one and the box goes silent. He presses the same button again and the sounds come back. He finds other buttons that change the sounds. He learns that this thing has a name-CD player. When Joe hears someone say "CD player," he thinks of the box with the buttons. When he is exploring his grandmother's house and he comes across a box about the same size with buttons on the front, he recognizes it. "Oh," he thinks, "Grandma has a CD player too."

Beth's experience is very different. She hears the same sounds. She would like to find out from where the sounds come, but she cannot move toward them. Someone puts something (an adaptive plate switch) next to her head. When her head presses against the hard, smooth surface, the sounds stop. When her head presses the surface again, the sounds start. This confuses Beth because the sounds don't seem to be coming from the surface. She is additionally confused when the same surface seems to affect other things in the same way-blowing air, lights, etc. She understands that pressing some, but not all, hard, smooth surfaces make things stop and start. Sometimes she doesn't want to press these surfaces because she isn't sure what will happen. She wonders from where the sounds, air, and lights come. When she hears someone say "CD player," she thinks they must mean the surface or the sounds she hears. She isn't sure.

TVIs know a lot about visual impairments and about how to teach compensatory skills. Touch is the most essential compensatory strategy for children who are blind. How does the TVI facilitate the use of touch to the maximum extent possible in learners who have very limited vision and hand use? The facilitation technique used most frequently is passive touch. Teachers put the learner's hand on an object, or put an object in the learner's hand, and move the learner's hand over the object. Even though the learner's hand is moving, this is still passive touch because the brain activity related to ideation, motor planning, and muscular execution of the movement is occurring in the teacher's brain, not the learner's. If the hands are fisted or otherwise unavailable, teachers often move the object over skin on the arm or back of the hand. Passive touch yields poor quality information.

Problems with passive touch

1. Manipulating the learner's hands is invasive. Some learner's may perceive this as unpleasant or threatening. Avoidant behaviors may result. These may include things like pulling the hands away, biting, pinching, and dropping or throwing objects (Miles, 2003).
2. Passive touch does not stimulate receptors in the learner's muscles and joints. Without the resulting combined tactual and proprioceptive input, information about spatial relationships, dimension, weight, and exact shape is unavailable (McLinden & McCall, 2002).
3. Passive touch gives information about density (hardness), temperature, and texture. The input may be experienced as pleasurable or unpleasant, soothing or exciting, but information received passively, limited to these three properties, would be unlikely to result in recognition of the object providing the input (Chen & Downing, 2006).

Active touch (exploration) is required for object recognition. In active touch, movement is the learner's idea. He plans the movement and executes it to the fullest extent possible. How is this kind of touching, haptic perception, impacted by cerebral palsy? According to Blanche and Nakasuji (2001), the following factors must be considered.

Active touch deficits related to cerebral palsy

1. Sensory and motor deficits are present, including sensory processing and motor planning disorders.
2. Loss of tactual sensation is common and may be due to injury to an area of the central nervous system or impairment of peripheral nerves.
3. Tactual deficits in the hands are more common in children with spasticity than in children with athetosis.
4. The intensity of the tactile deficit is not related to age or cognitive abilities.
5. Tactual processing deficits are common in children with hemiplegia.
6. Tactual and proprioceptive deficits most often include deficits in tactile discrimination, pressure sensitivity, directionality, two-point discrimination, haptic exploration, and grip force.

Imagine Beth at her birthday party. She helps tear the wrapping off of her gift and a lump is placed in her lap. She wants to find out what it is. She can't see it. It doesn't make a sound, have a unique smell, or taste. She can do some haptic exploration of the object, but the quality of the input is impaired. If one of the typical children at Beth's party was blindfolded and put in a heavy arctic parka and thick gloves, he would get about the same quality information that Beth gets. Beth can tell that the object is hard and fairly smooth. She isn't sure how big it is or what shape it is because she can only touch part of it with one hand. She knows that it is a present from her sister and she doesn't want to hurt anyone's feelings, but it really isn't very interesting to her. She has no idea that it is a Barbie® doll. When she is told, "It's a Barbie doll," she recognizes the words and she knows that those are important words to her sister, but she doesn't understand why her sister would be excited about the lump in her lap.

Beth's TVI wants to help Beth use active touch to explore and recognize objects. In order to do that, she will have to consider each of the following questions.

> How do I make a variety of objects available for exploration?
> How do I facilitate exploration?

How do I make a variety of objects available for exploration?

Learners with visual impairments and limited hand use need help accessing objects. Partners are responsible for determining three things: content, format, and context.

- Content is the objects to be presented. Content areas might include the following in addition to other items not listed.
  - - toys
  - - things used while eating
  - - things used while dressing
  - - things used while bathing
  - - things used at bedtime
  - - things used when going in the car or on the bus
  - - things used during calendar circle
  - - things found in the refrigerator
  - - things used when playing music
  - - things I hear Dad using in the yard

> Too often access is limited to only the first content area in this list.

- Format is the way the objects are presented. Objects may be presented one at a time or in arrays.
  - - Presentation of one object is appropriate when learners have demonstrated that they want to engage in protracted exploration over a significant period of time. Leaving a learner with a single object for long periods of time after active exploration has ended, encourages tactual passivity and self-stimulation.
  - - Arrays are helpful when learners are on their own. When the learner loses interest in one object, other objects are available. Arrays can vary in complexity. The array may contain 2 or 3 objects or, as in the case of Dr. Lilli Nielsen's Little Room, around 25. Additionally, objects in an array can be presented singly or in bundles. Bundles of similar objects encourage comparison. Learners should never be left alone with arrays of objects. Observation is required. The learner should not be left in an activity area with an array if exploration is not occurring. When the learner is finished exploring, allowing time for short rest breaks, the array or the learner should be removed.
- Context is the setting in which the object is presented. Contexts are either artificial (not natural) or functional (natural).
  - - Artificial contexts provide no clues about the meaning of the object. All objects presented in artificial contexts are essentially toys-things to be explored for the pleasure of exploration. In the early stages of sensorimotor development, this kind of object exploration is essential. It should be encouraged at the appropriate stage. Arbitrary contexts include trays attached to wheelchairs; active learning environments like Little Rooms, position boards, and dens; floor mats, etc.
  - - Functional contexts provide meaning clues. A hairbrush, presented for exploration while brushing hair during morning grooming in the bathroom, is more likely to develop a concept about hairbrush and how it is typically used.
  - - Artificial and functional contexts support each other. Artificial alone is limited, but artificial used to expand upon exploration of objects also used in functional contexts greatly enhances haptic perception. Objects presented in both contexts maximize potential for good concept development.

How do I facilitate exploration?

Typical children use very predictable strategies for exploring objects. Gibson (1988) and Bushnell and Boudreau (1993) describe three phases.

- Phase 1: Birth to about 4 months
  - Visual attention to objects is minimal
  - Some visual attention to motion is evident
  - Haptic exploration is by means of mouthing
  - Attention is demonstrated to sounds accompanying events
- Phase 2: Beginning around 4 or 5 months
  - Visual attention to objects
  - Motor development makes reaching and grasping possible
  - The eyes work together to provide stereoscopic depth perception
  - The two hands work together to transfer objects from hand to hand
  - One hand is used for manipulation
- Phase 3: Beginning around 8 or 9 months
  - The two hands work together for bi-manual manipulation
  - Finger movements are less repetitive, more intentional
  - Visual and motor abilities allow attention to the larger environment
  - Different features of things and places are explored to see what they offer
  - A variety of actions on objects are tried in order to probe possibilities

These behaviors are extremely important. Ruff, McCarton, Kurtzberg, and Vaughan (1984) found a relationship between manipulative exploration at 9 months and later cognitive functioning; and they suggest a causative relationship between lower levels of manipulation and the emergence of cognitive deficits.

From 5 months on, exploration of objects is haptic and visual. Ruff, Saltarelli, Capozzoli, and Dubiner (1992) found that infants explored novel objects by mouthing followed by looking. Exploratory mouthing decreased with age as visual examining increased. The implication for children with low vision and severe motor impairments is that they must have access to objects in such a way that they can mouth and look at the same time. Exploratory environments designed with accommodations for motor and visual impairments are rare. The active learning environments developed by Dr. Lilli Nielsen provide wonderful haptic accessibility to the mouth and hands (Dunnet, 1997). But, children who have cortical visual impairment, in particular, may experience difficulty with the "mouthing followed by looking" procedure described by Ruff et al. in exploratory environments containing high levels of visual and cross-modal complexity (Roman Lantzy, 2007). Often, TVIs design learning environments to maximize visual regard of shiny, brightly-colored objects. But, teachers need to remember that visual regard alone is not sufficient for object recognition. Even in infants with typical vision, explicit exploration does not start with looking. It starts with touching followed by looking. At about 4 months, infants use vision to detect targets. This curiosity about "something out there" stimulated by vision is vitally important, but it does not answer the question, "What is it?"

When vision is not available to be used with touch for exploration, object recognition depends on haptic perception alone. In 1987, Lederman and Klatzky described the specific hand movements related to the detection of certain properties of objects. They called these hand movements "exploratory procedures" or "EPs." Bushnell and Boudreau (1993) related Lederman and Klatzky's EPs to the development of manual motor abilities in the three exploratory phases referred to earlier. The material in parentheses after the EP is Bushnell and Boudreau's elaboration. The information about phases refers to manual exploration only. Infants develop knowledge of properties orally at earlier ages (Ruff et al., 1992).

Property | Exploratory Procedure & Hand Motion
--- | ---
Texture | Lateral motion (Phase 2: Scratching or rubbing)
Hardness | Pressure (Phases 1 and 2: Kneading, squeezing, and poking)
Temperature | Static contact (Phases 1 and 2: Withdrawal of hands after contact)
Weight | Unsupported holding (Phase 2: Waving, banging, transferring from hand-to-hand)
Global Shape | Enclosure (Phases 1 and 2: Clutching, grasping, holding)
Exact Shape | Contour following (Phase 3: Holding with one hand while following edge with fingers of other hand)

Lateral Motion The photo shows a young hand with the palm open, rubbing side-to-side on a fur-like textured blanket. (texture) | Pressure The photo shows a young hand pressing down with two fingers on a rubber ball, causing an indentation. (hardness) | Static Contact The photo shows a young hand, palm opened, on a blue cold pack. (temperature)
Unsupported Holding The photo shows a young hand holding a small rubber ball with the arm extended. (weight) | Enclosure The photo shows two young hands with fingers wrapped around a soft drink pack. (global shape) (volume) | Contour Following The photo shows a small foam ball in one hand while the forefinger of the other hand travels the curvature of the ball. (global shape) (exact shape)

McLinden (2004) in a study of nine children with visual and multiple impairments found that while the learners performed some exploratory procedures like those described by Klatzky and Lederman, they displayed additional behaviors. For instance, one learner rubbed an object across his lips and another tapped beads placed in her clinched hand against her teeth. McLinden points out that these may have been exploratory procedures related to gathering information about texture, density, and temperature. Bushnell and Boudreau (1993) postulate that certain properties of objects, like weight and exact shape, cannot be detected until the motor skills related to the exploratory procedures develop. Learners of any age with severe motor impairments that prevent them from developing the motor abilities to grasp, lift, transfer, and manipulate also miss out on the corresponding detection of properties of objects. This is a very significant fact given Klatzky and Lederman's later findings (2008) in their work on haptic perception in individuals with low vision. They found that object recognition is dependent upon the ability to detect several properties of objects in exploration carried out over time using a variety of EPs related to the unique features of the object. Learners with severe motor impairments are simply getting less haptic information and, if they are dependent on haptic perception alone because they have a visual impairment, are going to face extreme challenges in developing the concepts that are essential to early cognitive development.

The TVI can facilitate exploration by designing instructional activities with three variables in mind: time, space, and mode.

Time

Under the best of circumstances, the amount of information the hand can gather simultaneously is limited to the part of the object it is touching at the time. Gathering information about the whole object "involves taking a number of tactile samples over time" (Davidson, Abbott, & Gershenfeld, 1974, p. 539). When children, like Beth, have deficits in tactile discrimination, sensory processing, and the motor ability to execute exploratory procedures, even more time is required. One of the major reasons children with visual and motor impairments fail to obtain information about objects in their worlds is that they are simply not given enough time. If Beth is rushed through activities so that she can stay on schedule or keep up with her peers, she cannot possibly have the opportunity to engage in quality exploratory procedures that would lead to recognition of the objects that are part of her activities. Beth needs to participate in activities with her peers, but she also needs exploration time.

> Strategy: Make exploration activities a regular part of the learner's day. Design these activities so that the content, format, context, and pace supports learning according to assessed needs. As often as possible, choose object content that will help with the recognition of objects used in activities shared with peers.

Space: Positioning and modifying

In order to explore, young learners must be positioned so that they can touch and see simultaneously to the maximum extent possible.

Reclined wheelchair

A girl who wears eyeglasses and has cerebral palsy sits in her reclined wheelchair. She tilts her head forward to see the toy on the wheelchair tray.

Many learners spend most of their time at school in this position and it is a position that makes visual regard of objects being touched by the hands extremely difficult. The eyes are aimed at the tops of walls and sometimes ceilings. Looking down at an object placed on a tray at waist level requires good head control. Learners are typically put in this position because they do not have good head control. Using the hand to explore an object on a tray is often very difficult in this position. The arms must be moved toward midline and sometimes down or up as well.

Supine

A boy who has cerebral palsy reclines on his back on a blue mat. His head is lightly supported with a small pillow. This helps him to see the toy positioned at face level on a foam block. His legs are positioned open with a support brace.

Visual regard of objects may be impossible if ceiling lights are directly above the learner's head. Covering or turning off ceiling lights is counterproductive because dim lighting reduces visual efficiency in almost all visual impairments. Objects touched by the hands can be seen only if the hands can be lifted to the facial area or if the head can be turned to the side.

Side lyer

The photo shows a boy who has cerebral palsy positioned on his side on a blue side lyer. The boy lies on his side on the soft, mat base and the 90 degree angle of the back section supports his back. A wide soft strap wraps around his waist, holding him in the side position against the vertical back. A large pillow is between his knees and a foam block and towel help support his head. He holds a green rubber ball between his arms.

This may be one of the best positions for touching and seeing. Objects can be placed close to mouth, hands, and eyes. Stabilization of the downside shoulder and arm may make reaching with the arm on the topside easier for some learners. Visual regard can be enhanced easily with contrasting backgrounds and direct lighting.

Prone on wedge

The photo shows a teen who has cerebral palsy lies on his stomach on a foam wedge. He holds his head up to regard a table top fan, which he operates with a switch.

This is another wonderful position for touching and seeing for learners who can hold their heads up. Visual modifications like those mentioned above are easy to provide. Both hands are available for manipulation.

Prone stander

The photo shows a girl who has cerebral palsy standing at a slight obtuse angle with the support of the wooden prone stander. Her legs, waist, and chest are supported with wide, soft straps. The prone stander has a reclined tray. An interactive toy is on the tray.

This may be a good position for visual regard of hands since the head is usually angled slightly forward and downward. Arms can be supported on a tray with bolsters so that they are closer to midline. One caution is that some children find this position unpleasant. If the learner is stressed by the position, it is not a good context for exploration.

Teachers have a tendency to think that facilitating exploration in spatial arrangements like the ones above always involves bringing objects to the learner. Remember that if objects are brought to the learner and presented in artificial contexts, no clues about meaning are provided. Although it is difficult, positioning devices can move to functional contexts. A wedge can be placed on the floor in the kitchen in front of open cabinets so that pots and pans can be explored. A prone stander can be rolled up to a refrigerator so that contents can be explored. A side lyer can be placed in front of a shelf where a music player can be explored.

Mode: Hands, feet, mouth

The lips and tip of the tongue, the palms of the hands, and the soles of the feet are packed with tactual receptors. These parts of the body are extremely efficient modes for gathering tactual information and, when they are moved intentionally for exploration, for gathering haptic information. Facilitation of exploration with the hands is discussed above. Facilitation of exploration with the mouth and feet is rarely addressed in spite of the fact that these modes might be superior for many children. After infancy, exploring with the feet and mouth is usually discouraged. Teachers try not to do things that call attention to the differences of their students who have impairments, but there is a limit to the amount of learning that can be sacrificed for the sake of perceived normalcy. If a learner of any age cannot use hands for haptic exploration, an alternative mode-mouth or feet-must be facilitated.

Feet

Some learners have better ability to move their legs and feet and may have equal or better tactual discrimination ability in the bottoms of their feet. Children who have developed avoidant behaviors with their hands are sometimes willing to explore things with their feet. If a learner is non-ambulatory, a swing hung so that the learner's feet touch the floor lightly when he is seated in the swing provides an excellent spatial arrangement for haptic exploration with the feet. The learner can turn himself in the swing to find objects placed on the floor around him. All of the exploratory procedures described by Lederman and Klatzky can be executed with the feet as easily as with the hands except for two. "Unsupported holding" and "enclosure" cannot be done with one foot in the same way they can be done with one hand. Both procedures can be done by using the two feet together, but a higher level of motor ability is required.

Mouth

When the extremities-hands and feet-do not work well for exploration due to central nervous system or peripheral nerve damage, learners need to use their mouths to get information about the properties of objects regardless of their chronological age or cognitive abilities. Make objects available-one at a time or in arrays-in spatial arrangements that facilitate oral exploration.

> One object at a time presentation

> Some learners can hold an object placed in their hand and move it to their mouths where they perform exploratory procedures (McLinden, 2004). Objects should be introduced to the hand non-invasively. Teachers should tell the learner that they are going to show them something, tap the back of the hand with their own hand, and then introduce the object to the back of the hand. If the learner moves his hand toward the object or opens his fingers slightly, the teacher can place the object in the hand. Teachers need to be able to tell the difference between oral exploration and oral self-stimulation. All of the exploratory procedures described by Lederman and Klatzky (1987) can be performed orally. None of them require that the object being explored be moved to the back of the mouth, sucked, or chewed. If sucking, chewing, or rubbing with the back of the tongue occurs, it is unlikely that the learner is exploring. Recover exploration through the introduction of novelty (Ruff, et al., 1992).

> If the learner cannot use his hand to bring an object to his mouth, teachers can make the object available to the mouth. Objects should never be placed directly on the lips. Presentation works best when a familiar, trusted teacher tells the learner that she is going to show her something, touches the learner's cheek near the corner of her mouth with her own hand, and then introduces the object in the same spot. Haptic exploration occurs when the learner turns slightly toward the object and moves her lips, and perhaps tongue, over the object while the teacher holds it and moves it slowly so that different parts of the object can be touched. In this spatial arrangement, all EPs are available.

> Arrays

> Make objects presented in arrays available to learners by placing the arrays around the head instead of next to the hands.

Cautions

Objects made available for oral exploration must be sanitized and be larger than the standard size recommended to avoid choking hazards. Schools usually have established procedures for safely sanitizing materials that will come into contact with the mouth. Teachers should check with school nurses and special education administrators if they are not familiar with the approved procedure or individual allergies.

Oral exploration can create social barriers when peers do not understand why it is necessary. Teachers must explain the need for this behavior in the same way that they might explain why a learner has a cane or a wheelchair. Simulations may help peers understand. Teachers can have typical peers play a game in which they are blindfolded and wear heavy gloves. In these games, each child is given a bag containing a variety of sanitized objects. Use things that don't smell or make sounds like white board erasers, spoons, round-nosed scissors, etc. Ask the children to explore each object and tell their partner what it is. Remind them they can use their mouths if they don't come up with that strategy on their own.

References

Blanche, E. I., & Nakasuji, B. (2001). Sensory integration and the child with cerebral palsy. In S. Smith Roley, E. Blanche, & R. Schaaf (Eds.), Understanding the nature of sensory integration with diverse populations. (pp. 345-364). Tucson, AZ: Therapy Skill Builders.

Bushnell, E. W., & Boudreau, J. P. (1993). Motor development and the mind: The potential role of motor abilities as a determinant of aspect of perceptual development. Child Development, 64, 1005-1021.

Chen, D., & Downing, J. (2006). Tactile strategies for children who have visual impairments and multiple disabilities: Promoting communication and learning skills. New York, NY: American Foundation for the Blind Press.

Davidson, P. W., Abbott, S., & Gershenfeld, J. (1974). Influence of exploration time on haptic and visual matching of complex shape. Perception and Psychophysics, 15, 539-543.

Dunnet, J. (1997). Nielsen's Little Room: Its use with a young blind and physically disabled girl. Journal of Visual Impairments and Blindness, 91, 145-50.

Gibson, E. J. (1988). Exploratory behavior in the development of perceiving, acting, and the acquiring of knowledge. Annual Review of Psychology, 39, 1-41.

Klatzky, R., & Lederman, S. (2008). Object recognition by touch. In J. J. Rieser, D. H. Ashmead, F. F. Ebner, & A. L. Corn (Eds.), Blindness and brain plasticity in navigation and object perception (pp. 185-208). New York: Lawrence Erlbraum Association.

Lederman, S. J., & Klatzky, R. L. (1987). Hand movement: A window into haptic object recognition. Cognitive Psychology, 19, 342-368.

McLinden, M. (2004). Haptic exploratory strategies and children who are blind and have additional disabilities. Journal of Visual Impairments and Blindness, 98, 99-115.

McLinden, M., & McCall, S. (2002). Learning through touch: Supporting children with visual impairments and additional difficulties. London: David Fulton Publishers.

Miles, B. (2003). Talking the language of the hands to the hands. D-B Link, The National Information Clearinghouse on Children who are Deaf-Blind.

Pascual-Leone, A., & Torres, F. (1993). Plasticity of the sensorimotor cortex representation of the reading finger in braille readers. Brain, 116(1), 39-52.

Roman Lantzy, C. (2007). Cortical visual impairment: An approach to assessment and intervention. New York: American Foundation for the Blind.

Ruff, H. A., McCarton, C., Kurtzberg, D., & Vaughn, H. G., Jr. (1984). Preterm infants' manipulative exploration of objects. Child Development, (55)(4), 1166-1173.

Ruff, H. A., Saltarelli, L. M., Capozzoli, M., & Dubliner, K. (1992). The differentiation of activity in infants' exploration of objects. Development Psychology, 28, 851-861.

Millie Smith is a private consultant who works with students who have visual and multiple impairments. She retired from the Texas School for the Blind and Visually Impaired. She is the author of the Sensory Learning Kit.

## Appendix D
Supports for Learners With Visual and Motor Impairments: Facilitating Participation in Play and Games

Tristan Pierce, MIA

The photo shows a boy in a reclined wheelchair. He has a CD player on the wheelchair tray and a head switch attached to the chair. Two birthday balloons are tied to the chair.

Photo Caption: Simple modifications, such as a head switch and switch adapted CD player, allow this learner, who has visual and motor impairments, to participate in games.

All children learn through play. Psychologists and educators deem play pivotal to the lives of children; however, prior to the 1980's, little research existed on the play of young children with disabilities (Buchanan & Giovacco-Johnson, 2009). Young children learn through their hands and manipulative play is beneficial to the development of hand skill. When working with children who have special needs, parents, teachers, and caregivers need to use materials that are developmentally appropriate and provide needed supports so the learner's body is adequately supported; this allows not only for the learner's hands to be free to play, but it allows for her concentration to focus on hand movements as opposed to trying to sit up or hold her head up. Consider environmental modifications to make the activity/goal more successful for the learner. Reward the learner with encouragement and praise. Success encourages the learner to repeat and strive for better performance. All infants, toddlers, and older children who have disabilities, whether visually impaired or not, develop arm and hand skill by playing with construction toys and tactile media (e.g., sand, beans, playdough). Adults often view play negatively because they define it as simply having fun, but play is more than a creative urge; it also functions as a foundation for learning (Elkind, 2008). Today, educators feel the pressure and need for standardization and accountability, but it is important to remember the value of play as both an assessment and an instructional tool to support a child's development and learning (Pizzo & Bruce, 2010).

Toni Linder with Susan Dwinal and Anita C. Bundy (2008) provide a very detailed outline of keys to intervention by developmental age in their chapter titled, Facilitating Sensorimotor Development: Strategies for Improving Arm and Hand Use, in Transdisciplinary Play-Based Intervention (TPBI2). Within that outline, it says that by the end of 36 months a typical child shows a stronger hand preference; by the end of 48 months the child uses a tripod grasp on crayons and can stabilize paper when coloring; by the end of 60 months the child can reposition a crayon in one hand following grasp, and when drawing, movement comes from the fingers rather than arm and hand; and finally, by the end of 72 months the child can "walk" the fingers down the crayon to get it in position for coloring. For a child with a visual impairment and cerebral palsy, these incremental steps may take longer to achieve.

> Yoshi is 5 years old, has glaucoma and cerebral palsy. Her mother and father created a series of Yoshi Stories. When it is story time, Yoshi's parents, grandparents, and siblings pay close attention to Yoshi's posture and physical supports. They know Yoshi cannot comfortably use her hands without proper support for her head and torso. Each Yoshi Story has a set of manipulatives to follow along with the story. When reading "Yoshi is an Artist," her paper and crayons are positioned so Yoshi does not have to lean to reach them. She wears her pencil/crayon holder (orthosis) when coloring. Her reader provides verbal support when Yoshi draws, "Yoshi, you draw good circles!" When new items are introduced within a story, Yoshi is allowed ample time to explore each item using hands, feet, nose, or mouth. Yoshi's favorite story is "Yoshi Goes Swimming." She gets to sit in her little pool in the back yard, splash in the water, and explore all the toys in the pool. It makes her mother laugh, Yoshi's favorite sound.

Yoshi's entire family provides physical support, verbal support, environmental modification, and allows extra time for Yoshi to explore and process new information.

Teachers and parents introduce to typical children activities that use scissors in supervised situations between 48-60 months (Linder, Dwinal, & Bundy). Keep in mind that learning to use scissors is not a deal-breaker for a young learner who has severe motor impairments to be successful. Other play-based, success-oriented activities are valid substitutes for cutting with scissors (Haynes, 2009).

> Robbie has optic nerve hypoplasia and cerebral palsy. When very young, Robbie used a plate switch with LED lights to operate toys. In kindergarten he used his platform communicator for making choices and matching activities. Now in grade school his teacher thought he should be able to use the same hand manipulation technique to cut paper for his art assignment. She thought this would be a good reach-grasp-release routine to strengthen arm and hand use. Using a digital recorder, she recorded the snipping sound of the table-top mounted push scissors. She applied reflective tape to the handle of the scissors. With her supervision, she let Robbie explore the scissors using the backs of his hands and his knuckles. With her assistance, Robbie placed a piece of paper in the scissors. She said, "Cut paper, yes." Using the hand-under-hand technique, she assisted Robbie in pushing the top of the scissors down. Robbie heard the snip sound. After several times, the teacher helped Robbie place the paper in the scissors and repeated, "Cut paper, yes." Robbie pushed the scissors down by himself. The digital recording of the "snip sound" became Robbie's sound bridge for cutting paper. Robbie's teacher spoke with his mother who continued the activity with Robbie over the weekend to make holiday decorations.

Using a hand movement that was familiar to Robbie, his teacher added audio to the routine (sensory sound bridge) and provided an environmental modification (adapted scissors and reflective tape). She used consciously chosen words that conveyed a command.

When a child demonstrates a stronger arm and hand preference, Linder, Dwinal, & Bundy (2008) suggest play that encourages the child to roll and toss balls. By 48 months, the child should be able to throw a small ball at least 3 feet and play catch with a large ball. These early skills need to be practiced and incorporated into more advanced games as the child grows. Standard 1 of the National Physical Education Standards states that the student demonstrates competency in motor skills and movement patterns needed to perform a variety of physical activities. State standards provide more precise direction. For children using wheelchairs, hand mobility is extremely important when playing sports; it can even determine how a ball is kicked.

> Carmen's physical education teacher was not happy that Carmen couldn't participate in her 4th grade class's unit on kickball. Her state's Performance Standards state, "that by the end of grade 4 students will demonstrate progress toward the mature form of all locomotor (movement) patterns and selected manipulative and nonlocomotor skills such as throwing, catching, and kicking" (Wisconsin Department of Education, 1997). She consulted Carmen's TVI who collaborated with the district's adapted physical education specialist. Carmen's PE teacher explained the principles of power wheelchair kickball to the occupational and physical therapists. After referring with Carmen's doctor, it was decided that she could play. Carmen's wheelchair tray would remain on during game time, and she would be secured in her wheelchair to ensure she maintained a proper upright sitting position, and that she would wear a helmet. To begin, the physical therapist temporarily removed the tray from Carmen's power wheelchair and placed an electronic sound ball in her lap. Carmen was able to feel the roundness of the ball on her thighs and stomach. Her PE teacher helped her explore the shape further with her arms and the backs of her hands. They experimented with letting the ball roll off Carmen's lap so she became accustomed to hearing the ball bounce. The next day they bounced the ball from a short distance until Carmen showed recognition of the sound and requested the ball. Later, from the same distance, her PE teacher bounced the ball, stopped, turned the ball's sound on low volume, and resumed bouncing the ball. Once Carmen understood the sound was a sensory bridge for the ball and practiced locating it, she was ready to learn how to catch, throw, and kick. Peers in her class took turns practicing the skills with her; she soon was ready to play kickball. A box was fitted to the footrest of her wheelchair with which she kicked the ball. When it was Carmen's turn, she activated the forward motion of her wheelchair with her hand in a manner that when the box made contact with the ball, it rolled forward. The classmate who caught the ball bounced it 20 times to allow Carmen time to run to first base (Lieberman & Cowart, 2011). Everyone counted along and Carmen knew she would make it before they reached 20.

Carmen's PE teacher consulted with specialists prior to implementation. Through task analysis (step-by-step process), the PE teacher and classmates taught her to recognize the ball and to catch, throw, and kick it. The environmental modification allowed Carmen to sit in a proper upright position. An equipment modification was employed by the use of a sound emitting ball. The rule modification of counting to 20 allowed Carmen extra time to maneuver her wheelchair. The fun of the game and Carmen's continued improvement allowed her to experience success while playing with her peers.

When speech is not available to a child, and cerebral palsy prevents reach-grasp-release as a manipulative option, switches and alternative communication devices are tools that can allow the child access to language and literacy.

> Ira is nonverbal, has no light perception, and uses a wheelchair. He was invited to a classmate's birthday party. One of the games played was Where's the Birthday Bird. All the children wore blindfolds and were given a balloon. The string on Ira's balloon was tied to his wheelchair. To start the game, the Birthday Boy removed his blindfold and moved to a location of his choice in the yard and began to sing the "Happy Birthday" song. All the children began to try to locate the song bird. The child who reached the singing Birthday Bird first won the bird's balloon and he or she became the song bird for the next round. The object of the game was to gain as many balloons as possible; the winner having the most balloons. When it was Ira's turn to be the singing Birthday Bird, an adult helped him move his wheelchair to a distant location and he turned on his switch-adapted cassette player and played the "Happy Birthday" song. Although Ira did not win the game, he did win two balloons to take home.

With just a couple of modifications (tying the balloon to the wheelchair and using a prerecorded song), Ira was able to participate and enjoy the party game with his friends.

Linder with Bundy (2008) address the skills of eating and dressing in Facilitating Sensorimotor Development: Strategies for Improving Sensorimotor Contributions to Daily Life and Self-Care. Their keys to intervention by developmental age state that the typical child, by 60 months, needs little assistance with sweaters and socks when getting dressed. When eating, continue to introduce new foods and include the child in all aspects of the meal. Adults teach children what to eat and wear. They teach them how to eat and dress appropriately for the situation. Linder and Bundy stress that adults should make eating and dressing fun, encourage participation and independence, and reward the child's accomplishments. Games can be a great conduit for learning. Always design games for children with visual and motor impairments in a way that the game tangibles are presented in an easy-to-access manner.

> Tina and Fay are twins who have mild cerebral palsy and low vision. They wear school uniforms but get a choice of gray, green, or white socks and button down sweaters. Each article of clothing has either a large black "T" or "F" on the label. A few weeks before starting the 1st grade, their mother began playing a game with them using elements of Go Fish and Yours and Mine, calling it Tina's and Fay's. They played every day the week before school started. To begin Tina and Fay each had their own basket each containing six items: green sweater, white sweater, gray sweater, green socks, white socks, and gray socks. The girls took turns going first. When Tina selected her gray sweater, Fay would select her gray socks. When it was Fay's turn, she selected her white sweater and Tina selected her white socks. After matching all the items together, their mother would place a green sweater on the tray alongside a pair of green socks and white socks. The girls would take turns selecting the associated (sweater to socks) and matching (green to green) items. When the first day of school arrived, their mother laid the clothing selections on the tray on top of the dresser. The girls successfully chose their matching socks and sweaters. Their mother told them how proud she was of them and their father exclaimed how beautiful they were in their uniforms. Eventually their mother moved the items to the top dresser drawer, laid out in the same manner, and the girls continued to wear their coordinated clothing throughout the school year.

Tina's and Fay's mother made learning fun by creating a game. She made the items easily accessible by using baskets and trays. Both parents praised the girls for their accomplishments.

> Peterson has severe myopia with achromatopsia, low muscle tone, and very limited voluntary movement ability due to cerebral palsy. He can follow the movements of hands. Every day at lunch the students are given a choice of three fruits. Coordinating with the cafeteria staff, Peterson's teacher, Miss Gena, began playing Do It Again with him. Peterson's basket contained an assortment of whole fruits often served in the cafeteria. Miss Gena took the banana out of the basket, held it close to Peterson's face, and said, "banana." As Peterson touched the banana with his cheek, Miss Gena said, "Do It Again?" With a popping sound, she began peeling the banana and said, "Peel banana." Miss Gena held the banana within a few inches of Peterson's face; she let him smell it and helped him hand-under-hand to feel the first section of the banana peel fold down. Miss Gena repeated the procedure until all the sections of the peeling were removed. Each day a new fruit was explored. Every morning Miss Gena goes to the cafeteria and gets one of each of the three fruits being offered that day. She lays the fruits on the tray, holds it up to Peterson's face, and says, "Peterson's banana" or "Peterson's grapes." Peterson directs his gaze at the fruit and leans his cheek to touch the correct fruit. Peterson is still working on this, getting it correct about 60% of the time. Miss Gena hopes by the end of the year that Peterson can select from the three fruits while in the cafeteria going through the food line. The cafeteria staff agreed to have a tray ready for Peterson with the three choices laid out. Miss Gena taught Do It Again to Peterson's mother so she can continue the game at home.

Peterson's teacher also utilized a game to teach him about a variety of fruits and the independence of choice making. To help Peterson identify the banana, she incorporated the use of smell, hearing, and touch. The game became a pre-lunch routine that Peterson played every day. Recruiting the assistance of the cafeteria staff was vital to Peterson experiencing a successful outcome.

> Beth is a 5-year-old girl. She is busy learning about her world with the help of her family members, her kindergarten teacher, her teacher of students who have visual impairments, her speech language pathologist, and her occupational and physical therapists. Beth's visual abilities are limited to light perception only. Her motor and haptic perceptual abilities are limited by cerebral palsy. Beth has good head control but requires support for sitting. She can move her right hand at the wrist about 3 inches and can extend the index finger of her right hand with facilitation. Both hands are fisted and splints are worn to help prevent contracture. She has deficits in tactual discrimination, sensory processing, and haptic perception due to central nervous system impairments and peripheral nerve damage. Beth's sister, Jenny, gave her a Barbie doll for her 5th birthday. Jenny was disappointed when Beth seemed to ignore the object. Pam, Beth's mother, wanted to find a way to increase Beth's interest in her toys. She discussed this with Beth's educational team. They decided to give Beth a chance to explore her new Barbie doll with carefully provided support. They placed Beth in her side lyer, left side down. They stabilized the right shoulder and forearm with folded towels so that the right hand lay comfortably about 6 inches from Beth's face. They removed the splint from the right hand and provided some deep pressure and joint compressions to relax the hand. This was followed by one of Beth's favorite tactual games, Body Buzz. When Body Buzz finished, they placed the Barbie doll next to the hand so that it touched the side of the hand. After observing for about 3 minutes and seeing no hand movement, they picked up the doll and placed its shoulder next to the corner of Beth's mouth. Beth immediately turned her head to the doll and brushed her lips over the doll's arm, neck, and head. She drew back when she encountered the hair on the doll's head, but continued to explore the arm. When she got to the end of the arm and discovered the hand, she used the tip of her tongue to probe the crevices between the doll's fingers. Beth's TVI said, "Fingers," as she did this. The TVI then touched Beth's fingers and said, "Fingers," again. Beth laughed. They put the doll back on the mat touching Beth's hand. Beth moved her head to the doll and continued exploring it with her lips and the tip of her tongue using her hand to stabilize it as she did this. Beth enjoyed exploring other toys in this same arrangement. As she developed knowledge about the objects available to her, she developed favorite toys. These were always objects with smooth, hard surfaces, indentations, and-best of all-moving parts. Her favorite toys were not typical toys. The most exciting things to play with for her were her mother's colander and spaghetti spoon, her dad's key chain, Jenny's Guess Who and Count Four game boards, and cassette tapes (the holes and little wheels). The speech language pathologist was thrilled when Beth was able to move her mouth to the named object when two objects were placed on the mat in front of her face. In this way, Beth was able to demonstrate that she knew the names of each of her favorite toys.

> Once Beth had several favorite objects, the team decided it was time to expand her knowledge about those objects. They played the game Yours and Mine with Beth using a hanging array. A swing arm clamped to the back of the side lyer supported a bar in front of Beth's face. Three objects were tied with elastic to the bar so that they hung at mouth level. The two outer objects were accessible with no more than a 4-inch move of the head up or down. Beth's game partner, Jenny, showed her a colander similar to her familiar toy. As Beth explored it with her lips and the tip of her tongue, Jenny said, "Jenny's colander." Jenny then moved the objects in the array so that they made a sound and said, "Beth's colander." Beth smiled and moved her head to her colander and touched it with her lips. Later Jenny enjoyed playing variations on What Do and Go Fish with Beth using the hanging array.

In these games, Beth learned that the cassette goes with the cassette player and she was able to show that she understood what object was associated with the sound of music playing by touching the cassette in her array when Jenny played music and asked her "What do?"

Summary

A variety of intervention strategies and modifications were described in the stories. All the learners have visual impairment and cerebral palsy, but each child is different and play interventions and games must be tailored to the individual needs of each learner. There is one constant and consistent strategy in all of them-team participation. Yoshi's entire family knew the appropriate way to have story time using the story tangibles. Robbie's teacher recruited his mother to tag-team on weekends to keep the knowledge and skills Robbie learned during the week sharp over the weekend. Carmen had a magnificent team; her TVI, the PE teacher, the Adapted PE Specialist, the occupational and physical therapists, her doctor, and all of her classmates. Ira benefited from adults who planned games at the party that allowed Ira to participate. The game Tina and Fay played not only had their parents as team members, but they had each other. They each played a dual role, learner and teacher. Peterson's teacher recruited the cafeteria staff for school days and his mother for weekends. There was a reversal of roles in Beth's situation; her parents recruited Beth's educational team to participate and all were open to the strategy of Beth using her most accessible way of gathering information, her mouth.

The photo shows a boy in his wheelchair surrounded by his entire team, including parents, Physical Therapist, Occupation Therapist, Speech Language Pathologist, etc. They are all smiling and waving to the viewer.

Photo Caption: Team Ira

Research shows that the development of play and communication skills are linked for young learners who are deaf-blind or have visual impairments with additional disabilities. Classroom teachers and parents can use play techniques and strategies to reinforce the development of communication (Pizzo & Bruce, 2010).

For further understanding on arm and hand use, plus other aspects of sensorimotor development, review the reference list and SAM Appendices B, C, and G. To enhance the learning experience while playing SAM games, read Linder's TBPA2. This guide is thorough, well written, and very enjoyable to read. It includes a chapter titled, Strategies for Working with Children with Visual Impairments.

References

Buchanan, M., & Giovacco-Johnson, T. (2009). A second look at the play of young children with disabilities. American Journal of Play, 1(2), 41-59.

Elkind, D. (2008). The power of play: Learning what comes naturally. American Journal of Play, 1(1), 1-6.

Haynes, D. (2009, June 16). Teaching receptive and expressive communication skills to persons with severe and/or multiple disabilities across the age span, Kentucky Deaf-Blind Project Summer Institute EDS 558-022, Louisville, KY.

Lieberman, L., & Cowart, J. (2011). Games for people with sensory impairments. Louisville, KY: American Printing House for the Blind.

Linder, T. (with Bundy, A.). (2008). Facilitating sensorimotor development: Strategies for improving sensorimotor contributions to daily life and self-care. In Transdisciplinary play-based intervention (2nd ed.) (pp. 141-161). Baltimore: Paul H. Brookes.

Linder, T. (with Dwinal, S., & Bundy, A,) (2008). Facilitating sensorimotor development: Strategies for improving arm and hand use. In Transdisciplinary play-based intervention (2nd ed.) (pp. 69-91). Baltimore: Paul H. Brookes.

Pizzo, L., & Bruce, S. M. (2010). Language and play in students with multiple disabilities and visual impairments or deaf-blindness. Journal of Visual Impairment and Blindness, 104, 287-297.

Wisconsin Department of Education. (1997). Wisconsin's model academic standards for physical education. Retrieved from http://www.dpi.state.wi.us/standards/pdf/phyed.pdf

Tristan Pierce is a project leader in the Research Department at the American Printing House for the Blind in Louisville, KY. Seasonally she is a swim coach for students who have visual impairments and blindness. She also works part time with adults who have intellectual disabilities.

## Appendix E
Functions of Echolalia for Very Young Children With Vision Impairment and Blindness

Zoe Larsen Morgese, MA, CCC-SLP
JC Greeley, TVI, O&M

> Vic sits happily on the couch and presses his fingers into his forearm. He says,
> "Squishy finger.....ring!
> Squishy finger.....ring!"

> Mama comments to herself,
> "Squishy finger RING...where on earth did that come from?"

> Vic repeats,
> "Squishy finger...ring!
> Squishy finger...ring!"

> Mama locates Vic's daily note from his teacher and reads it. "Ah-ha Vic! You have been working on the brailler! Now I understand."

A young girl wearing glasses looks directly at the viewer and smiles. The left lens of her glasses is covered with a brightly colored fabric patch.

Photo Caption: The echolalia of a child with vision loss reflects many of the same characteristics of the echolalia of a sighted child.

The above example shows one of the landmark traits of young children with low vision or blindness: persistent and sometimes excruciating (for the listeners) echolalia. The term "echolalia" refers to the verbal repetition of previously heard words, phrases, and sentences. In the above scenario, Vic is home with his mother after a day at preschool. During preschool, Vic had scribbled on the brailler and enjoyed pressing the keys until the bell rang at the end of a line. Now at home with his mother, through his favorite learning sense, hearing, Vic is reliving the pleasant time and practicing what he learned. According to language expert Porges (1998), the ears are used to remember things. The ears-what a child hears and understands-are essential to determining the meaning behind a child's echolalia. And there is more to offer as well-read on.

The echolalia of a child with vision loss reflects many of the same characteristics of the echolalia of a sighted child. However, echolalia by the child with vision loss, especially one with no vision, may be more extensive, used for longer periods of time, and used for more functions than the sighted child. Echolalic responses are almost always communicative, reflective of a child's understanding, and serve a meaningful purpose. The echolalia noted in young children with visual impairment is an effective and positive step in the sequence of communication development.

A father holds his son up in the air. The two look at each other.

Photo Caption: Echolalia speech can be a positive step in the emergence of functional communication skills.

Echolalia is typically heard in the emerging language of young children, peaking at approximately the age of 30 months or about 12 months after the emergence of "true" language (Riddlej, 2007). Echolalic speech is delineated in several ways. It might be immediate, repeated as soon as it is heard, or delayed, heard earlier in time, as much as hours, weeks, or months previously. It might be exact (word for word) or mitigated, changed slightly. It is essential to remember that an echolalic response can contain more than one element. Here is an example:

> Dad: What is this?

> Leslie: Want a spoon?

Leslie's response is communicative in that it demonstrates her ability to label an object on request. It is also a delayed echolalic response in that it mimics a question often asked at home, "Want a _____?"

Pronoun errors are among the most prominent and long-lasting features of echolalia in young children with visual impairment. Such errors include the following:

- Direct pronouns - The child repeats exactly what he hears.
  Parent: Do you want more milk?
  Child: Do you want more milk?
- Third person echolalia - The child refers to himself in the third person.
  Parent: Do you want more milk?
  Child: Does he want more milk?
- Correct pronoun while emerging from echolalia - The child echoes part of a phrase but shows an emerging ability to use the appropriate pronoun.
  Parent: Do you want more milk?
  Child: Do I want more milk?

A young girl who holds a white cane and a black toy dog talks to a young boy with albinism. She points to him. Another boy watches.

Photo Caption: Gestures help clarify pronoun use.

Echolalia typically diminishes gradually. While resolved during everyday routines, it may emerge again when a child is stressed or anxious (Semantic Pragmatic Disorder Support Group, 2007). For example, if a child repeatedly says, "Don't cry, Baby!" when upset, she may be repeating her grandparents' phrase as well as practicing new self-calming skills.

Echolalia is not a new topic in the field of visual impairment and blindness. Thomas D. Cutsforth wrote about echolalia in The Blind in School and Society in 1951. Selma Fraiberg cited it extensively in the longitudinal study described in her 1977 book, Insights from the Blind. As recently as 2007, Michael Brambring reported findings similar to Fraiberg's and earlier research: Echolalia is an important aspect of language development for a child with vision impairment. That it stands largely unchanged in today's time, despite early intervention and child-raising practices, is a testament to its usefulness.

A young child's cognition and language are closely linked. Cognition, leading to language maturity, is dependent on the child's sensory-motor organization and ability to interpret objects through touch and hearing. Visual exploration normally begins at about the age of one month for sighted children. The ability to reach and feel for a sound comes much later, at about the age of 10 months. Locomotion tends to be less motivating until the child's sensory systems have matured and become integrated sufficiently to recognize an object that is felt in the hands and is heard. Until object permanence comes into play, the child is connected only to what he feels and touches with his body. Echolalic speech can be very effective at this time in helping the child to orient, to invite people to interact with him, and to simply enjoy the feeling and practicing of making sounds (Peters, 1994).

Children who have visual impairments often retain echolalia as a part of their expressive language longer than children who have sight. For example, several studies, including those by Fraiberg (1977) and Andersen, Dunlea, and Kekelis (1984) have suggested that the pronouns "I" and "you" were used correctly by sighted children by the beginning of age 3 but were not acquired until age 4 by children who were blind.

Echolalia may serve even more purposes for a child with vision loss or, more particularly, with no vision. For example, it can serve as an orientation function ("Get the bell?") as well as a means to obtain/retain attention ("Where you go?"). It exists from the earliest period of vocalizations when a baby experiences the vibration of movement and sound and delightedly repeats, "b-b-b-b" while bouncing on her Mother's knee. The child continues to perceive tone and intonation through babbling; she understands adult commands and repeats single, critical words such as "ba-ba" for bottle; she uses phrases in relationship to self ("Get cookie"); and to a higher level, she narrates her own activities ("Get a cup, get milk, pour it, careful!"). To avoid an unwanted task altogether, a child may repeat seemingly non-related words: "Farm song, farm song, farm song," when requested to sing a goodbye song at the end of the day simply because she does not want the day to end.

Inner speech might be viewed as the goal toward which the child with echolalia is striving. Self-guidance, or talking oneself through an action, is the central function of inner speech. Self-talk or private speech accounts for 20-60% of a young child's remarks. The child responds to instructions from a parent or older sibling in daily routines first, and then internalizes the instructions in an abbreviated form that he can talk through to himself. The "Stop!" command from a parent can be obeyed by a child around the second year of life, but at that developmental stage he cannot yet follow his own echolalic commands. Though the child says, "No! No touch-hot!" he cannot help but reach for the candle flame. "No," in particular, requires practice, adult modeling, and intervention for the child with little or no vision due in part to its many connotations (stop, get away, don't, no more available, etc.). Because children often spontaneously respond "No" without understanding its meaning, and because the use of yes often emerges later than no, adults quickly learn to offer choices rather than yes/no questions. Around age 4, the child has learned to regulate his behavior within familiar routines by saying out loud the important words and phrases he has heard an adult say ("Ssshh, baby's sleeping, tiptoe"). Usually between 5 and 7 years of age, a child develops the capacity to regulate behavior through talking silently with intention (may still move lips and mutter). These steps are healthy and lead to essential behaviors to be used throughout life, including the important ability to delay gratification ("Wait for Mommy, wait...wait") and to resist temptation ("First I eat sandwich, then I eat candy."). As adults, we pull in inner speech to talk ourselves through unfamiliar or demanding activities. It is a tool that helps us overcome obstacles and continue to acquire new skills; echolalia, at its best, serves as a foundation for learning this crucial element of communication. Indeed, there are many adults who wish, at some time or another, they had practiced echoing, "No! No! No!" a bit longer. The point is to use the intention of the child's echolalia to build communicative and cognitive understanding.

> Extinguishing echolalia without replacing it with more functional and understandable tools will only extinguish the child's attempt to communicate.

While echolalia can usually be described as part of normal language development, it is important to note that less typical echolalia may be present in, for example, children who are described as having autism spectrum disorder. Indeed, many researchers and educators have described echolalic speech as a hallmark of autism spectrum disorder. While such echolalia may seem less functional and to last much longer than typical echolalia, it may still serve an important communicative purpose. For example, the echoing may be more rapid or louder when the child is ill or more prominent when the child is anxious or impatient.

The following are strategies that may encourage a child's emergence from echolalic into more functional and spontaneous language patterns as cognition develops. It is essential to remember that emergence from echolalia is a gradual process, often with a two-steps-forward, one-step-back pattern of development.

Suggested strategies to facilitate progression through echolalic speech

- Use of rhythm/inflection: Utilize rhythm, inflection, exaggerated emphasis, and variations in volume and pitch to assist in meaning. For example, pat the top of the kitchen table at lunchtime with each word/syllable as you say, "NO more beans." Verbal emphasis and a stronger/louder pat to the table should accompany the emphasized word "NO."
- Use of the child's name: Some authors discourage the use of a child's name in, for example, greetings, indicating that this often results in an echolalic use of the name (Semantic Pragmatic Disorder Support Group, 2007). For example, if an adult says, "Good morning, Daniel," the child might repeat the phrase identically. However, in working with a child with vision loss, it is an accepted strategy to use his/her name to identify whose attention is needed. In cases of echolalic speech, use the child's name to obtain attention first, and then follow with the communicative statement. For example, "Celia!" (pause until Celia's attention is gained), "Good morning!"
- Touch cue: A touch cue can be used to address the child, especially in a noisy environment. This kind of cue may also help the child know her attention is needed without use of her first name.
- Hand-under-hand: Hand-under-hand is a strategy that offers a child security and more control. In this approach, an adult slides his/her hand under the child's hand to guide it without holding or grabbing it. The child is allowed to withdraw the contact at any time. Hand-under-hand can be utilized in a variety of situations. For example, the approach can be used to assist the child to `point' to or pat himself or others as a guide to indicate appropriate pronouns. (When she pats her own chest, I is emphasized; when she is guided to touch or point to another person, you receives the emphasis.)
- Reverse chaining/fill-in-the-blank: It is often effective to systematically allow the child the opportunity to complete the final word of a response and then gradually increase the number of words he provides. For example, the adult models, "We have whistles and horns. I want horns," allowing the child to fill in the last word. As the child's skills emerge, the situation can be arranged so that he provides the last two words ("I want horns") or all three words ("I want horns").
- Social/emotional modeling: In instances where the echolalic response provides a social/emotional function, try providing a more appropriate verbal model. For example, if a child repeats her grandpa's words, "Don't cry, Baby!" when she is upset, an adult can comfort the child and pat her shoulder while modeling an appropriate phrase such as "I'm sad," "I'm crying," or "I want Grandpa."
- Exclamations and curses: Family members and other adults should be aware that highly emotional words and phrases such as exclamations and curses are among the words most readily echoed. Words such as these may come back to haunt the adult user!
- Minimize questions: Try to use comments rather than questions. This serves to provide a model, to narrate appropriate vocabulary, and to minimize the opportunity to echo questions, often a hallmark of echolalia. For example, rather than asking "Do you want a cup?" make the comment, "Here is your cup."
- Avoid certain questions: Try to avoid the use of the question "Can you say _____?" This question invites an echoed response. Instead, try a clear direction with statements such as, "Tell Billy-Time to clean up."
- Praise the message through action: Rather than using indirect comments such as "good words" or "good job," adults can reward children's communication efforts by continuing an interaction. For example, "Vic, you walked to the kitchen all by yourself," said in proud tones.
- Model phrases that are within the child's ability: Try to model phrases that are within the child's spontaneous length of utterance or one to two words longer. For example, if the child's typical sentence is two to three words in length, model phrases no more than five words in length that help the child define what he really wants.
- Avoid repetitious phrases: It is easy for a child to pick up on an adult's favorite phrases. Vary your statements. For example, rather than saying, "All done" every time a task is completed, try, "That's done," "I'm finished," and "That's all."
- Avoid excess talking: Allow some wait time so that the child has ample opportunity to process and respond. An initial wait time of 8 to 10 seconds is often helpful before repeating or adding additional speech.
- Natural conversation and consequences: If a child asks a question including a reversed pronoun, ("Do you want a firetruck?") when she is asking for one for herself, try responding to the original question. For example, "No, I don't want a firetruck, but do you want one?" Then provide a touch assist and model, "I want a firetruck!"

A young boy wearing glasses and holding a cane talks to Santa Claus and Mrs. Claus.

Suggestions specific for the reduction of pronoun echolalia

- Touch cue: Provide a light touch to the child's shoulder or chest while modeling, "My turn" or "I want it" with emphasis on the pronoun.
- Hand-under-hand: Utilize a hand-under-hand approach to help the child 'point' as she indicates to whom she is talking. For example, when playing SAM games, guide the child to point toward a peer and model, "Your turn" and then guide her to point to herself or pat her own chest using the hand-under-hand approach and model, "My turn."

Examples of Scenarios

The following scenarios all refer to a young child with vision impairment named Vic. Please note that emergence from the use of echolalia is not linear or sequential. Strategies must be selected on a case-by-case basis. Single or simultaneous strategies might be appropriate in any given situation.

Scenario: Pronoun Missteps

Vic asks for more by saying, "He needs fish!" or by asking, "You want fish?"

- Child's logic
  - Vic has not yet achieved the language sophistication to relate/change an abstract pronoun to himself.
  - Vic has frequently heard his Dad tell his Mom, "Honey, I think he needs more _____."
- Next step: Move toward the use of the personal pronouns "I" and "me."
- Strategies
  - Touch cue
  - Hand-under-hand cue

Scenario: Learning to calm myself

Vic drops his ceramic cup and hears it break. He rapidly repeats, "Don't cry, Honey" with an upset tone as Mom cleans up the pieces.

- Child's logic: Vic has heard these comforting words previously.
- Next step: Vic uses words to tell his Mom, "Broke a cup, need help"; or Vic uses words to tell others about the situation and says, "It's ok, I got it" as he helps.
- Strategies
  - Model appropriate comments for other situations: "I hear a baby crying; it's ok," says Mom as she pats Vic's shoulder.
  - Use hand-under-hand to help Vic pat his Mom. Model an appropriate response.
  - Model an especially calm tone in situations where Vic might be upset.
  - Touch cue
  - Model appropriate comments for Vic: "I broke it," or "I need help, please."

Scenario: Dressing myself with Dad

Vic repeats, "Give me your arm" as he is getting dressed in the morning.

- Child's logic: Vic has heard Dad say this phrase when he is attempting to learn how to push his arm through a sleeve. When successful, Vic has been rewarded with a tickle and a kiss.
- Next step: Vic engages in back-and-forth communication with Dad during daily routines.
- Strategies
  - The timing of the words should match the experience. For example, wait to ask, "Sweatshirt or t-shirt?" until the choices are available to touch.
  - The model should match the length of Vic's typical utterances or be one to two words longer. For example, if Vic spontaneously says, "Where a shirt?" an appropriate model might be, "Shirt on the bed" rather than, "Reach over there and get that shirt that's on the star pillow."
  - Try to give directions that will be appropriate from Vic's point of view. For example, instead of saying, "Give me your arm," while dressing, try simply narrating the routine: "One arm! Another arm! Head! Shirt's on!"

Scenario: Saying goodbye to our readers

- Mama: We're all done here, say goodbye to our readers.
- Vic: Goodbye nice readers, goodbye!

References

Andersen, E. S., Dunlea, A., & Kekelis, L. S. (1984). Blind children's language: Resolving some differences. Journal of Child Language, 11, 645-664.

Brambring, M. (2007). Divergent development of verbal skills in children who are blind or sighted. Journal of Vision Impairment & Blindness, 101,12.

Cutsforth, T. D. (1951). The blind in school and society. New York: American Foundation for the Blind.

Fraiberg, S. (1977). Insights from the blind: Comparative studies of blind and sighted infants. New York: New American Library.

Peters, A. M. (1994). The interdependence of social, cognitive, and linguistic development: Evidence from a visually impaired child. In H. Tager-Flusberg (Ed.), Constraints on language acquisition: Studies of atypical children (pp. 195-220). Hillsdale, NJ: Lawrence Erlbaum.

Porges, S. (1998). The Listening Project, Brain-Body Center, Department of Psychiatry, University of Illinois at Chicago, Chicago, IL. Retrieved June 10, 2008, from http://www.psych.uic.edu/news/porges.htm

Riddlej. (2007, October 16). Life with little children [Online forum]. Retrieved April 7, 2008, from WordPress Web site: http://littlechildren.wordpress.com

Semantic Pragmatic Disorder Support Group. (2007). Echolalia. Retrieved April 7, 2008, from http://www.spdsupport.org.uk/echolalia.html

Suggested Reading

Andersen, E. S., Dunlea, A., & Kekelis, L. S. (1993). The impact of input: Language acquisition in the visually impaired. First Language, 13, 23-49.

Berk, L. E. (1994, November). Why children talk to themselves. Scientific American, 78-83.

Brandsborg, K. (2002). Blindness and autism: What is the relationship between blindness and autism-like difficulties in children? Paper presented at the 11th International Council for Education of People with Visual Impairment World Conference. Retrieved April 7, 2008, from http://www.icevi.org/publications/ICEVI-WC2002/papers/03-topic/03-brandsborg.htm

Field, E. I. (2005). Suggestions for caregivers of children with echolalia. Chapel, Hill, NC: Early Intervention Training Center for Infants and Toddlers with Visual Impairments, FPG Child Development Institute, UNC-CH.

Fraiberg, S., & Adelson, E. (1973). Self-representation in language and play: Observations of blind children. Psychoanalytic Quarterly, 42, 539-562.

Hatton, D. D., Bailey, D. B., Burchinal, M. R., & Ferrell, K. A. (1997). Development growth curves of preschool children with vision impairments. Child Development, 68, 788-806.

Landau, B., & Gleitman, L. R. (1985). Language and experience: Evidence from the blind child. Cambridge, MA: Harvard University Press.

Peters, A. M. (1994). The interdependence of social, cognitive, and linguistic development: Evidence from a visually impaired child. In H. Tager-Flusberg (Ed.), Constraints on language acquisition: Studies of atypical children (pp. 195-220). Hillsdale, NJ: Lawrence Erlbaum.

Urwin, C. (1983). Dialogue and cognitive functioning in the early language development of three blind children. In A. E. Mills (Ed.), Language acquisition in the blind child: Normal and deficient (pp. 142-161). London: Croom Helm.

Zoe Larsen Morgese is a Speech Language Pathologist and JC Greeley is a Teacher of Students who have Visual Impairments and Certified Orientation & Mobility Specialist. Both work at Anchor Center for Blind Children, an organization serving children birth to 5 years with visual impairment and their families. Anchor Center for Blind Children is based in Denver, Colorado.

## Appendix F
Emotional Glue-Making Meaning Stick

Linda Hagood, MA, CCC-SLP

The illustration is a large red heart with rays of many colors extending from the heart to the edge or the painting.

The best and most beautiful things in the world cannot be seen or even touched. They must be felt with the HEART.
Helen Keller

Teaching is both an art and a science. The ideas and strategies in this book focus on the technology, or the "science" of teaching as described by the developmental psychologist and researcher Piaget, who gives many cognitive and rational reasons for the need to connect meaning with experience. Helen Keller's quote, however, reminds us that intuition and feeling, as well as thinking and concrete experience, are essential components of education.

Recent research in the area of social cognition shows that what every grandmother knows may be true: Emotional connection is an important foundation for learning. Children who have high "emotional IQs" are more likely to grow into adults who have the cognitive flexibility and perspective-taking skills that are important for academic and vocational success (Gibbs, 1995; Goleman, 1995; Hobson, 2002). Without important visual cues, the child who has blindness or visual impairment is at a disadvantage in the area of social and emotional development (Sandler & Hobson, 2002). The child who has blindness or visual impairment may not receive information such as facial expressions, the use of body positioning in communication, or the give and take nature of nonverbal turn-taking routines. She may miss incidental learning about relationships that sighted children obtain through their eyes-

- the way a smile looks,
- how a mom kisses dad versus how mom kisses a baby, and
- what a game of hide and seek looks like and how can you tell who is "it."

Even the more accessible auditory and tactile modes of input can be confusing if they are not paired with visual information. Blind children are often uncertain and feel awkward about how to interpret and use tone of voice, volume, and touch to convey feeling.

Children learn these social-emotional skills best, as well as many other important symbolic and cognitive skills, when they are emotionally engaged with their partners. Most of us learn our ABCs, our "times tables," and how to read our first words within engaging social contexts (e.g., singing a song together, reciting for a supportive partner, or looking at a book as our parent reads to us). Through the "emotional glue" generated by interactions with our partners, these skills "stick" in our minds. The emotional glue is so strong that the information is permanently embedded. Compare this to information we learn in isolation (e.g., dates of important Civil War battles, procedures for solving quadratic equations, or the capital letter abbreviations of all of the states). Most of us would have a difficult time recalling these facts, which we learned while studying alone or saying them back to ourselves.

How can I tell if we're connecting?

This seems easy enough, until you interact with students who have hard-to-read faces and bodies, and insufficient language to give you clues. A good starting place for reading the child's responses to you is the conventional one-"Find the Smile." When getting to know a child, or beginning a relationship, the initial goal might be to "find the smile," rather than achieve compliance or performance of specific behaviors. This can be tricky. The smile is not always a reliable cue to the child's mood or feelings about the interactions. Many kids, especially those with "quirky" nervous systems, smile or even laugh when they are anxious or upset. Some children smile unintentionally, while others never smile, even when they are quite content and engaged with another person. So it is important to be a careful observer of your student, and to observe how he communicates his feelings about being with you or the activities you have brought to him.

For some students, body orientation is a good cue. The student who turns toward you rather than away from you may be saying, "Okay, I like to play with you better than being alone." The student who reaches toward you or the object that you offer may be conveying a message of acceptance.

Participation is another important way that students can tell you they understand the activity and are willing and interested in connecting with you. Don't expect immediate participation. For many students, new activities signal challenge and trigger avoidance. A student who has built a trusting relationship with his teacher or parent may be more willing to watch a new activity passively at first than to flee the area; however, true active participation may occur only after repeated passive exposure to a new game or activity. When using hand-under-hand support to introduce the child to the activity or materials, does the child willingly follow your hand; or do you have to "reconnect" with her frequently to maintain the physical support?

Some students have highly idiosyncratic signals for connection and avoidance-one student communicated pleasure and enjoyment by wiggling her feet. This was not apparent to the teacher until the student's sister commented on it.

Last, but not least, remember that YOU are 50% of the connection! Pay attention to your own "emotional barometer" and notice how you are feeling during your time together. Do you laugh and smile during the activity? Do you wish the activity was longer, or do you keep looking at your watch and wondering when you can stop? Do you feel it was worthwhile to have spent the time playing with the student? Sometimes, do you feel amazed that you are actually paid to do this job because it is so much fun?!

The photo shows a boy helping to hold a massager up to his teacher's nose. The teacher squishes his face in response.

Photo Caption: This teacher is 50% of the connection during a game of Body Buzz.

Deafblind educator and researcher Jan van Dijk calls this ability to read and engage with students "It." He feels that some parents and teachers quite naturally "have It," while others need to practice in order to "get It" (personal communication, October, 2007). Spend some time learning about your student and how to read her heart and the "It" you share.

Okay-now I understand "It"-how can I use "It"?

Now that you know how to recognize and measure the connections you have with students, you probably want to find ways to use this information.

1. Teach social-emotional skills as a separate subject area. Spend time every day doing some activities in which the primary goal is to teach relationship-building skills.
   - Use a standard framework for selecting goals and objectives in the area of social and emotional skills. It is important to have a developmental hierarchy of skills and a philosophical framework to profile a student's social strengths and needs, rather than using a deficit model to select specific skills to teach. With a curriculum-based model, progress can be planned and monitored more rationally. One framework that may be helpful for students with skills below the 7-year-level developmentally is presented in the book Better Together: Building Relationships with People who Have Visual Impairment and Autism Spectrum Disorders (or Atypical Social Development) (Hagood, 2008). This curriculum uses four domains for evaluating and selecting social-emotional skills development:
     - Social Interaction
     - Communication
     - Social Cognition
     - Emotional Development
     Another good framework for students at the early linguistic level is the SCERTS Curriculum for children with autism (Prizant, Wetherby, Rubin, & Laurent, 2006).
   - Reframe and rename activities. The author has done an outstanding job of reframing the focus of many activities in this book. By calling them "games" instead of "tasks" and reframing the interactions, both the teacher and the student approach the activity in a more social and interactive way. An activity labeled as a "task" or "work" suggests a focus on independence. The adult directs, evaluates, and prompts the student; the primary goal is completion of a task. On the other hand, when an activity is labeled a "game" or "play," it suggests that it will be fun, and that it will be cooperative with more equity. The primary goals involve connection and joint attention. Relationship Development Intervention (Gutstein, 2007), shows excellent examples of parents reframing everyday activities such as "going to get the mail," or "sweeping the floor" to reflect focus on building relationships. In the parents' minds (and those of their children), the activity is "special time with Mom" rather than daily chores.
   - Build connection rituals into your day. These are brief interactions in which the primary message is unconditional acceptance. Becky Bailey's book, I Love You Rituals (2000), describes many examples of these types of connection activities. The rituals can be as simple as "pat-a-cake" or as complex as writing a story together. However, they must be activities that both you and the student enjoy doing together and that make you look forward to being together. When building these rituals, it may be important at first to incorporate the child's obsessive interests or repetitive play or language. A child who repeatedly flaps her hands in front of her face might be a good candidate for a manicure ritual that occurs every day after lunch. A student who removes his shoes might enjoy a "This little piggy game" or a game with finding a surprise in the sock, or a foot rub before putting his shoes back on. A child who likes to make up silly words may enjoy a "guess the definition" game in which you take turns making up words and using them in sentences. Whatever connection rituals you decide to make, give them a name and schedule them into your daily routine. The more detached and isolated the child is, the more connection rituals he will need to keep him engaged and build a relationship.
   - Teach social skills classes or schedule time for social games. In these activities, higher functioning students may practice specific social skills using role-play, or may provide support or suggestions for peers facing emotional challenges. Students with limited language skills may perform more active or concrete social activities to help them appreciate and understand the importance of being together and sharing joint attention, such as

     > Freeze Dance - One student plays the keyboard; and the others dance until the keyboard player stops the music, and then they all must freeze. Additional movements can be added, including falling down to a glissando or jumping up and down to rapid staccato notes.

     > Passing energy - Clasp hands in a circle, and ask one person to make a simple sound (e.g., "mmmm") and squeeze the hand of the person on his right to "pass the energy." Then, that person makes the sound and squeezes the hand of the next person in the line.

     > Show and Tell - A student brings an item to show and describe. Others in the group ask questions or comment about the object.

2. Use social-emotional connections as a foundation for learning in other areas. Often, the primary goal of a lesson is in another area, such as mobility, fine motor skills, or self-care. Social-emotional skills can be used to "make meaning stick" when the primary goal of instruction is in another area. Students will learn new skills best when they are emotionally engaged with an adult or peer partner. If you have recently taught a student to engage with you playing a "pick a hand-my voice has a surprise for you!" game (Hagood, 2008), you might try to teach matching or object association skills using this game as a foundation. The dialogue could go like this:

   > Teacher: "Joey, my voice has a surprise for you." The teacher holds up two fists, close to her face.

   > Joey smiles, remembering the game, and reaches for the teacher's left hand.

   > Teacher opens her hand and makes a loud "whoop whoop" sound.

   > Joey laughs.

   > Teacher: "Now, Joey, my HANDS have a surprise for you. Can you find something in my hand that goes with this?" (She shows Joey soap.) "My hands have a surprise for you-pick a hand." (The teacher puts a button in one hand, and a washcloth in other hand.)

   > Joey picks teacher's left hand (button).

   > Teacher: "No, not a button, try again. Soap and _____?"

   > Joey picks other hand (washcloth).

   > Teacher opens hand with washcloth and says, "Whoop whoop-you found the washcloth-goes with the soap." (This activity could also be used to teach tactile symbols and their association with specific objects.

   For a teacher trying to teach concepts of high/low, fast/slow, and left/right, the finger play "Two Little Blackbirds" can be used as a foundation for learning directional concepts. The teacher helps the child learn the following finger play sitting either behind, beside, or in front of child.

   > "Two little blackbirds sitting on a hill, one named Jack and one named Jill." (Help child put fists out, with thumbs up.)

   > "Fly away Jack, fly away Jill." (Help child fly hands behind back.)

   > "Come back Jack, come back Jill." (Help child return hands to front. Teacher laughs and gives the "birds" a little kiss.)

   After the child has learned this finger play and begins to anticipate or imitate the movements, the teacher can change it to a context for learning directional and movement concepts, naming the birds "fast and slow," "high and low," and "left and right."
   Tickle games can be expanded to include instruction in naming body parts, sequencing, and pronoun use. ("I tickle your ____" and "You tickle my ____.")
   - Highlight the affective information that naturally occurs in the game or routine. Feelings that incidentally or purposefully occur in natural contexts deserve your teaching time and energy. Remember that the student who has visual and multiple impairments may not learn social skills incidentally (e.g., reading partner responses). Use consistent affective vocal tone to model specific feelings. Avoid sarcasm or flat tone. Allow the child to check your face or body tactually during designated times so that she will have a chance to see what a smile "looks like" and how your body is oriented when you are ready to interact.
   - Plan to imbed affective instruction, which has been taught directly during "social skills lessons," in other activities during the week. For example, if the lesson for the week is on "using body position to stay connected," look for opportunities to teach, reinforce, and assess this skill throughout the week.
     - - During music, give the student praise for orienting toward the teacher during instruction.
     - - In the cafeteria, help the student go from table to table to try to determine which students are connected and which are eating alone, based on their body position.
     - - Remind the student before an activity begins that one of his goals is to stay connected with his body. Practice this before going into the art room and tell the art teacher that he is working on this.
3. Teach the language of feelings and relationships. It is important to help the student learn to read and express feelings using conventional, easy-to-interpret forms that others will be able to interpret without having a "translator." Remember how long it took you to learn to read your student's heart? Others may not be so patient or committed in the future. Often, it is suggested that the language of emotions is "too abstract" or "too high level" for the child who is just beginning to learn language. However, research shows that feeling and connection words are often included in the language of the preschool child (Ridgeway, Waters, & Kuczaj, 1985), and that those children who have the most feeling words in their vocabulary are least likely to demonstrate aggressive behaviors in kindergarten (Denham, 1986). The following strategies may be helpful:
   - Affective vocabulary can best be taught using "hands on" active-learning approaches that are described in this book for other concepts. Pair the words for important feelings and relationship concepts with real-life activities as they occur.
   - Model language rather than asking questions about the child's possible feelings. For example, say, "I bet you felt excited about going to the birthday party!" instead of, "How did you feel about going to the party?"
   - Talk about how YOU feel in specific situations and give the reason for your feelings in simple language to help the child connect causes with feelings. For example, say, "I felt frustrated because I couldn't find my keys." and "I felt proud when you sang on the stage." Although there are 2,000 words to describe feelings in the English language, most adults rely primarily on three pairs of polar opposites to describe their own feelings-happy/sad, hot/cold, good/awful (Baliss, 2006).
   - Rather than just using individual words, teach language that describes relationships and cooperation (e.g., together, group, partners, connected/disconnected, friends, game, and team).
   - Use pretend play and sensorimotor play activities to demonstrate emotional intensity, and to practice calming techniques in non-stressful periods. The "emotion meter" shown on page 172, is a helpful tool to help students identify their own emotional level. It can be taught using a pretend play activity in which the child goes on a rowboat ride with the teacher, encountering exciting and sometimes scary animals, and an out-of-control thunderstorm along the way; each rate a slightly higher number on the emotion meter scale. Once the child has learned the scale in this pretend play scenario, it can be applied to other activities as well, including loudness of a piano keyboard, relaxation during yoga, and more strenuous physical activity (walking = 10, slow jogging = 30, and wild running = 100).
   - Use tactile symbols to represent feelings. Vocabulary used for feelings should be distinguished from other symbols by mounting the symbols on a specific-shaped background that represents feelings. The feeling words can be used to help students describe their feelings when they are engaged in an activity. Then, the student can read a "sentence" or "experience story" in which the feeling symbol is paired with specific activity and/or person symbols (e.g., "Jake scared dentist on Tuesday," "Joey excited hamburger lunch"). Another tactile symbol activity might involve organizing a storage book of symbols based on the student's feelings about specific people or activities (all of the people that make the student feel "happy" on one page, and all of the people or activities that make a student feel "frustrated" on another page).
4. Use strategies to remind yourself, your student, parents, and other staff members of your commitment to understand, develop, and foster a relationship with the student.
   Be supportive. Make your presence signal reward not demand. You want students to be happy when they hear you coming, rather than dreading the interaction or engaging in avoidance behaviors. True, some kids have had bad experiences with teachers in the past that they will bring to their interactions with you; but overall, your goal is for them to be happy to see you each morning. If you continue to see avoidance behaviors, rethink the way you are interacting with your students.
   Use the "Yes-and" approach to interactions and ideas, which is often utilized by improvisational comedy groups (McGehee, 2007). This approach involves accepting whatever idea the child offers, even if the child did not intentionally offer the idea but simply performed a distinctive behavior. For example, when planning a shopping list, the student may belch and laugh; and you may say, "You are so smart Jimmy, we need to remind everyone to belch in the van before we go into the store!"
   Work towards building a balanced relationship (things you like, things I like, things we both like). Realize that relationships, like people, grow developmentally. At first, you may put in much more emotional energy than you get back from your students. Look for the small things that the student does that make you feel good about being with her, and try to reinforce those and shape them into prosocial behaviors or language. As you become familiar with a student, you should expect him to participate in activities that YOU enjoy, instead of only doing the things that he likes to do. As the student's teacher, you are teaching him more than just how to read, talk, or feed and dress himself. You are also helping him learn how to have relationships with friends, family, and caregivers who will be essential in future job, home, and social situations.

Emotion Meter
Number | Emotion | Feels like a
100 | Out of Control | thunderstorm
90 80 | Mad | shark
70 60 | Upset or Getting Silly | dragon
50 40 | Worried or Excited | alligator
30 20 | Relaxed or Happy | fish
10 | Sleepy |

References

Bailey, B. A. (2000). I love you rituals. New York: HarperCollins.

Baliss, M. (2006). Emotional intelligence and clear communication. Retrieved March 6, 2008, from: http://parenting.families.com/blog/emotional-intelligence-and-clear-communication1

Denham, S. A. (1986). Social cognition, prosocial behavior and emotion in preschoolers: Contextual validation. Child Development, 57, 194-201.

Gibbs, N. (1995). The EQ factor: New brain research suggests that emotions, not IQ, may be the true measure of human intelligence. Glencoe Understanding Psychology, Unit 5, Article 1. Retrieved February 13, 2008, from Time Web site: http://www.time.com/time/classroom/psych/unit5_article1.html

Goleman, D. (1995). Emotional intelligence: Why it can matter more than IQ. New York: Bantam Books.

Gutstein, S. (2007, February). Relationship development intervention. Workshop presentation. Austin, TX: Texas School for the Blind and Visually Impaired.

Hagood, L. (2008). Better together: Building relationships with people who have visual impairment and autism spectrum disorders (or atypical social development). Austin, TX: Texas School for the Blind and Visually Impaired.

Hobson, P. (2002). The cradle of thought: Exploring the origins of thinking. London: MacMillan.

McGehee, L. (2007). Les McGehee plays well with others. Austin, TX: Dalton Publishing.

Prizant, B. M., Wetherby, A., Rubin, E., & Laurent, A. C. (2006). The SCERTS® model. Baltimore: Paul Brookes Publishing Company.

Ridgeway, D., Waters, E., & Kuczaj, S. A. (1985). Acquisition of emotion-descriptive language: Receptive and productive vocabulary norms for ages 18 months to 6 years. Developmental Psychology, 21, 901-908.

Sandler, A. M., & Hobson, R. P. (2002). On engaging with people in early childhood: The case of congenital blindness. Clinical Child Psychology & Psychiatry, 6, 205-222.

Linda Hagood is a Speech-Language Pathologist who previously worked at the Texas School for the Blind and Visually Impaired. She is currently employed at the Central Kitsap School District in Silverdale, Washington.

## Appendix G
Using SAM Items

Tristan Pierce, MIA

SAM: Symbols and Meaning

Photo of SAM Kit

Baskets
The sides of the SAM baskets can be rolled down to accommodate the length of a child's arm.

The photo shows a mother and her daughter playing a SAM game using the two SAM baskets. The baskets contain many non kit items, including large plastic yard pinwheels shaped like flowers.

Photo Caption: Mother and daughter play a version of Yours and Mine.

Digital Recorder
The SAM digital recorder is provided so that the partner can record needed sounds for a particular activity. It is recommended that you attach an adhesive label to the back side of the digital recorder or attach a label card with the recording number and sound name of each recording for quick access.

The photo shows a digital recorder that has an adhesive label on the back listing the sounds that are recorded. Attached to the digital recorder is a note card that lists the recorded sounds as well.

SAM Flash Drive
The SAM flash drive contains two folders.

- The SAM Accessible Formats folder provides the consumer with HTML, BRF, DTB, and text files.
- The SAM Sounds folder is a library of common household and environmental sounds that may be frightening to a learner.
  For any sound that is not provided, record the sound with the digital recorder included in the kit. Follow the instructions in the guidebook on teaching a learner about sounds..

The photo shows the SAM Flash Drive.

Sport Bag
The SAM sport bag can be used to hold game objects during play and to store miscellaneous kit items.

The photo shows the SAM sport bag being used as the "deck" along with two SAM baskets being used as players "hands."

Photo Caption: The sport bag and baskets are set up to play an adapted version of the SAM game Go Fish.

Story Bags
Story bags come in three sizes. Only use the story bags for stories to prevent confusion as to the meaning of the bags. Objects are attached to the Velcro strip to indicate the story's title.

The photo shows all three sizes of the SAM story bags. The large bag has a spoon attached to it, the medium bag has a foam puzzle attached to it, and the small bag has a tactile communication card for "cold" attached to it.

Photo Caption: The larger bags use whole objects symbols. The small bag uses a tangible card.

Story Boxes
SAM Story boxes should be used for stories only. Do not use them for daily schedules or calendar boxes; this may cause confusion for the learner. It should be clear to a learner when he is using his calendar and when he is reading a story. Vinyl liners are provided for color contrast.

The photo shows four SAM story boxes, two each sitting side-by-side in SAM trays. The first box contains a girl's flip-flop. The second box contains a tube of sun block lotion. The bottom of the third box is covered with sand and holds a conch seashell. The fourth box contains a cloth napkin.

Photo Caption: Ana's Day at the Beach
Ana put on her flip-flops to go to the beach. Her mother put sunscreen on her. Ana played in the sand and collected seashells. They had a picnic.

Story Books
The SAM Kit includes three different-sized binders to create story books. Plastic pages are included. The pages can be washed with soap and water. Text can be added to the stories by hand writing with a marker or with the use of a computer. Color pages can be attached for color contrast. If an object is too large for the book, an object cue can be used to indicate the whole object is next to the book and can be accessed, or the teacher/parent can slide the object in place on the page.

The photo shows a SAM binder with the title, Ben Makes Cookies. A metal spatula is attached to the cover.

The photo shows the book opened to a page that reads, "Add one egg." There is an orange card on the page. Attached to the card are the halves of a broken egg shell.

The photo shows the book opened to a page that reads, "Ben stirs cookie dough." The background color is green, the type black, and the plastic spoon is white.

The photo shows the book opened to a page that reads, "Put cookie dough on cookie sheet." An orange foam arrow is on the page. The arrow points to a full aluminum cookie sheet sitting on the table next to the book.

Photos Caption: The first three photos show a partial cookie sheet. The last photo shows an object cue that indicates the whole object is next to the story book.

Trays
SAM trays come with a variety of vinyl liners to provide color contrast. The liners can be cleaned. The kit also includes a non-glare, clear plastic liner to which Velcro® can be attached so objects can be lined up to create a sentence.
The sentence, "Mariah walks with Coach Lamont." uses the white liner for contrast and the plastic liner with white Velcro to attach the object symbols.

Hair Barrette | Talking Pedometer |  | Lanyard
object | object |  | object
symbol for | symbol for |  | symbol for
Mariah | walks | with | Coach Lamont.

Velcro®

The SAM Kit includes a variety of self-adhesive hook and loop. The Velcro can be used on the story books, story boxes, etc.

SAM Videos®

To watch the videos of the SAM games, go to http://tech.aph.org/samvid

Read the SAM Guidebook and the SAM Assessments and Games book before watching the videos. Students benefit from the SAM program best when the assessments are conducted and the student is matched to the appropriate game level.

## Appendix H
The Game Planning Worksheet: Getting Started and Moving Forward

Millie Smith, M.Ed., TVI

The graphic shows a grid: four squares down and six squares across. Square 1:1 has the word "People." Row 1 has a photo of a girl playing Hot Potato and a photo of a girl with an adult female playing Show Me Who. Square 2:1 has the word "Objects." Row 2 has a photo of a male teenager and female adult playing Yours and Mine, and a photo of a young child and parent touching a live chicken. Square 3:1 has the word "Actions." Row 3 has a photo of a girl drinking out of a cup while playing "Do It Again" and a photo of a boy and his female teacher playing "Do It Again" with a bowl and spoon. Square 4:1 has the word "Places." Row 4 has two photos of the same boy and his female teacher playing "Clue." In the first photo he reads a sentence strip and in the second photo his teacher demonstrates smelling what is in a bag.

Photo Caption: Select games appropriate for the learner's current level of performance.

Ana needs SAM because she loves listening to speech and making speech sounds, but doesn't know what the words she hears and says mean. She is echolalic. Ana doesn't understand her world. In fact, she finds it rather threatening. Given a choice between listening and doing, she would much rather listen. Ana's pre-kindergarten teacher, teacher of students who have visual impairments (TVI), and speech language pathologist (SLP) chose to start SAM with the Environmental Gap Inventory. Ana's parents, TVI, and orientation and mobility instructor completed that assessment in late August and began instruction on highlighted sub-environments and related people and objects. They were the logical people to do this since 13 of the 14 environments inventoried are at home or in the community. Realizing that they could not begin instruction on all identified sub-environments simultaneously, they chose to use the SARA: Common Words assessment form to prioritize people and objects for immediate instruction. In mid-September, Ana's team met to review her progress. They were pleased to see a large number of new checkmarks in her highlighted sub-environments and agreed that instruction in these areas would continue throughout the school year. In addition, they decided to use the SARA: Common Words activity based assessment to identify instructional needs in the school environment. After completing assessments for several activities including circle time, toileting, lunch, and physical education, they used the SARA: Common Words assessment to document development of near experiences and sensory bridges in natural environments. In mid-October, the team became aware of an additional need. During reading class, Ana enjoyed participating in phonics lessons by saying words and initial consonant sounds with her peers. Ana's SLP was concerned that these words had no meaning for Ana and that repetition of words without meaning was reinforcing her echolalia. The SLP and TVI decided to assess the meaning content of Ana's phonics words using SARA: Academic Vocabulary. The SLP coordinated instruction on identified words with the pre-kindergarten teacher, TVI, orientation and mobility instructor, and parents.

By November, Ana demonstrated that she had developed good near experiences (concrete referents) and sensory bridges in four activities. The team felt it was time to take the next step-using SAM games to build word bridges in artificial communication contexts. They used the Game Planning Worksheet to assign games for each activity by meaning category (see following page). Since some SAM games require more sophisticated skills than others, they were careful to choose games appropriate for Ana's current level of performance. They decided to concentrate on games at the "People, objects, actions touching the body" level with one exception. Ana was stressed by the complexity of sensory input during physical education. The team decided to use Sounds Like to help her understand some of the sounds caused by the actions of others heard during that time.

More activities were added to the Game Planning Worksheet as additional activities were assessed and instruction progressed throughout the year. By February, Ana was ready to do games at the "People, objects, actions, places beyond the body" level with her most familiar activities. In March, the team decided to assess skills related to the general education curriculum so that instruction in those areas could be given more emphasis. They used the Curriculum-based Gap Inventory to prioritize skills and identify instructional strategies. The team expects that this assessment will be a more significant tool during Ana's kindergarten year.

Game Planning Worksheet

Learner: Ana

Game level: People, objects, actions touching the body

Start Date: 11/16/09

The graphic shows a sample Game Planning Worksheet. It is 5 squares down and 5 squares across. Square 1:1 holds the SAM icon of a basket containing geometric shapes and the letters S, A, and M. The word "Activities" is across the top of the grid and the words "Concept Categories" is along the side of the grid. The grid reads as follows: Activity-Lunch, People Games-Show Me Who, Object Games-Slap, Actions Games-Do It Again, and Places Games-Scavenger Hunt. Activity-Toileting, Object Games-Slap, Actions Games-Do It Again, and Places Games-Scavenger Hunt. Activity-Circle Time, People Games-Hot Potato, Object Games-Slap and Yours and Mine, Actions Games-Do It Again, and Places Games-Scavenger Hunt. Activity-Physical Education, People Games-Show Me Who, Actions Games-Simon Says and Sounds Like, and Places Games-Scavenger Hunt.

Dari needs SAM because he guesses at the meaning of most words and because he is unable to use level two symbols-pictures and part object tactile symbols. Dari is very active. He self-initiates interactions with things in his environment and can do things he enjoys independently. His performance is much lower in tasks that involve verbal instruction. Dari's speech language pathologist and TVI talked about this problem with Dari's teacher. They decided to use SAM to develop word meaning related to concrete referents and to use level one symbols-whole objects-in a variety of communication contexts. They started by using SARA: Common Words to assess Dari's understanding of the meaning of words used in some of his activities. They found that Dari could show that he was aware of the referents for only 15% of the words used during band, art, physical education, vocational education, home science, and language arts. The assessment showed that Dari used sensory bridges-sounds, smells, and impaired vision-very efficiently to understand events beyond the body, but he was unable to use symbolic bridges. Dari's team used SARA: Common Words to make sure that he had quality near experiences for each important word in his activities. Dari had touched the things used in his activities many times, but he had not necessarily heard the word label for those things while he was touching them. After 3 months of instruction, Dari was able to touch or do the things referred to by 78% of his key words during activities. Next, the team wanted to see if Dari could use those words meaningfully in communication contexts (SAM games). Dari worked with the games at the "People, objects, actions, and places beyond the body" level for 3 months. In March, he began to use Build a Book games to write stories about some of his favorite activities in language arts class and Clue to learn place words.

Game Planning Worksheet

Learner: Dari

Game level: People, objects, actions, and places beyond the body

Start Date: 11/25/09

The graphic shows a sample Game Planning Worksheet. It is 5 squares down and 7 squares across. Square 1:1 holds the SAM icon of a basket containing geometric shapes and the letters S, A, and M. The word "Activities" is across the top of the grid and the words "Concept Categories" is along the side of the grid. The activities listed are Band, Art, Physical Education, Domestic Science, Vocational Education, and Language Arts. All the games for People, Objects, Actions, and Places are the same except for Language Arts: People Games-Mystery Voice, Object Games-Scavenger Hunt, Actions Games-Sounds Like, and Places Games-Clue. Language Arts list Build a Book game for all concept categories.

Mariah needs SAM because she responds to words and part object tactile symbols used as labels for things, but she does not have good concepts related to the use of the objects represented. Mariah has no vision and she simply has not seen what people do with objects in natural environments. Mariah's speech language pathologist and TVI decided to start her program by assessing her understanding of word meaning in familiar activities using SARA: Common Words. They began with a cooking activity during home sciences class. Mariah was able to touch objects named during the activity, but she could not identify objects using sensory bridges consisting of sounds made as objects when used in natural environments. Mariah's teacher began building good sound bridges for the objects used during cooking activities. She did this by making sure that Mariah used each item. As sighted peers watched the teacher demonstrate the use of an object, Mariah was paired with a sighted peer who helped her perform the action with the object. After a month of this kind of instruction, Mariah could use sound bridges to identify 88% of the words used in her cooking activities. In early October, the speech language pathologist and TVI decided to use SAM games to teach additional concepts at the "People, objects, and actions beyond the body" level. When Mariah played several games related to her cooking activities successfully, the team assessed and began instruction on additional activities.

Game Planning Worksheet

Learner: Mariah

Game level: POA B+B

Start Date: 10/09

The graphic shows a sample Game Planning Worksheet. It is 5 squares down and 7 squares across. Square 1:1 holds the SAM icon of a basket containing geometric shapes and the letters S, A, and M. The word "Activities" is across the top of the grid and the words "Concept Categories" is along the side of the grid. Cooking is the only activity listed: People Games-Mystery Voice, Objects Games-Scavenger Hunt, Actions Games-What Do and Sounds Like, and Places Games-Scavenger Hunt.

Ben needs SAM because his concepts and vocabulary are not expanding in the school environment. Ben has good concepts, sensory bridges, and word labels for common objects that have been part of his world in his home environment. At home he explores on his own, uses familiar objects appropriately, and participates in familiar activities like mealtime, bathing, dressing, and playing. Ben behaves very differently at school. He is overwhelmed by the complexity of the sensory information in his school environments. He cannot use his limited vision, listen, and touch all at the same time. He is very stressed when he is expected to use his hands to participate in a noisy activity. He can stop looking and touching, but he cannot stop hearing. When someone starts manipulating his hands, it is just too much. The teacher of the visually impaired decided to use SAM games to help Ben become familiar with a variety of objects. During the games, she reduced sensory clutter-mainly noise-so that Ben felt less stressed. She also slowed the pace of the games so that she could teach Ben how to participate using hand-under-hand instruction. Her goal was to get him to touch and explore new objects and actions. She knew SAM games were supposed to be used after learners developed good near experiences and sensory bridges in natural environments, but she also knew that Ben was only coping, not learning, in his regular first grade classroom activities. She used SAM games at the "People, objects, and actions that touch the body" level to help Ben touch and recognize objects and actions in his most challenging activities. Then she supported him as he used sensory and symbolic bridges related to these now familiar objects and actions to understand what was happening around him in his natural activities. Ben did not need games for people and places. He used sensory and symbolic bridges very efficiently in these two meaning categories.

Game Planning Worksheet

Learner: Ben

Game level: POA touching body

Start Date: 9/09

The graphic shows a sample Game Planning Worksheet. It is 5 squares down and 6 squares across. Square 1:1 holds the SAM icon of a basket containing geometric shapes and the letters S, A, and M. The word "Activities" is across the top of the grid and the words "Concept Categories" is along the side of the grid. Objects and Actions are the only two concept categories listed: Activity-Arts and Crafts, Objects Game-Go Fish, Actions Game-Do It Again. Activity-Lunch, Object Game-Slap, Actions Game-So It Again. Activity-Circle Time, Objects Game-Yours and Mine, Actions Game-Do It Again. Activity-Physical Education, Objects Game-Slap, Actions Game-Simon Says. Activity-Music, Objects Game-Yours and Mine, Actions Game-Do It Again.

Game Planning Worksheet

Learner: _______________________________________

Game level: _______________________________________

Start Date: _______________________________________

1. In the top row, enter the names of activities with well-established symbol/referent relationships as indicated by SARA:CW assessments.

2. In the squares below, enter the names of games in each Concept Category to be used to allow the learner to practice using those symbols in communication contexts.

The graphic shows a blank Game Planning Worksheet. It is 5 squares down and 5 squares across. Square 1:1 holds the SAM icon of a basket containing geometric shapes and the letters S, A, and M. The word "Activities" is across the top of the grid and the words "Concept Categories" is along the side of the grid. Square 1:2 says People Games, Square 1:3 says Objects Games, Square 1:4 says Actions Games, Square 1:5 says Places Games. A write-on line is in all row 1 boxes. One writes a chosen activity in each box.

# Glossary

The photo shows a boy and his female teacher sorting knives, fork, and spoons in a flatware tray.

American Sign Language Manual (hand) language with its own syntax and grammar used primarily by people who are deaf

Action system Movements used in exploratory procedures performed to gain information about the properties of objects

Active participation Physically taking a role in a group activity, routine, or exertion

Active touch Independent exploratory manipulation carried out with the hands, feet, or mouth: reached out and touched the soft cloth

Acuity loss (uncorrectable acuity problems) The decreased ability of an eye to distinguish object details and shapes

Athetosis A constant succession of slow, writhing, involuntary movements of flexion, extension, pronation, and supination of fingers and hands, and sometimes of toes and feet

Causality The nature of the relations of cause and effect

Chatter Spontaneous, random language used for social rather than instructional purposes

Cluster concept A small group of things in one category typically experienced in close proximity in both time and space

Clutter reduction Removing some (but not all) items from a field of vision

Cognitive development Field of study in neuroscience and psychology focusing on a child's development in terms of information processing, conceptual resources, perceptual skill, language learning, and other aspects of brain development and cognitive psychology

Concept development The acquisition of information that answers questions about what something is, what it does, and how it relates to other things

Concept formation Strategy which requires a learner to compare and contrast groups or categories that contain concept-relevant features with groups or categories that do not contain concept-relevant features

Concrete referent A thing that can be touched, pointed to, or done

Contrast enhancement Using color and complexity reduction to make an object stand out from its background: background red and object yellow

Cortical visual impairment Functional defect Impaired vision due to bilateral dysfunction of the optic radiations and/or visual cortex

Distance senses Vision, smell, and hearing

Distributed trials Repetitious responses that have a little space between them during which something different happens for a short time (your turn/my turn)

Dynamic symbol form Words; one of two foundation level tools used to build symbolic skills

Dyspraxia A neurological disorder of motor coordination usually apparent in childhood that manifests as difficulty in planning unfamiliar motor tasks

Echolalia The immediate or delayed repetition of words spoken by another person without comprehension of word meanings

Empty words Words without meaning due to lack of experience with concrete referents

Event An occurrence during which many referents from different categories interact in a prescribed way over a distinct period of time

Experiential memories Remembering an event/activity in which one participated

Field loss (visual) Lack of space or range within which objects are visible to the immobile eyes at a given time

Fingerspell Different positions of fingers used to represent letters of the alphabet

FM system A communication system for improving speech comprehension in difficult listening situations; a radio microphone is worn by the speaker that transmits wireless signals via frequency modulation (using very high frequency) to a receiver that is worn by the listener

Hand-over-hand The placement of a partner's hand over a learner's hand to help the learner understand the movement of a fine motor activity

Hand-under-hand The placement of a partner's hand under a learner's hand to explore an object together or guide a learner through a fine motor activity or task

Haptic perception The process of recognizing objects through touch. It involves a combination of somatosensory perception of patterns on the skin surface (e.g., edges, curvature, and texture) and proprioception of hand position and conformation

Hearing impairment deafness Full or partial decrease in the ability to detect or understand sounds

Imitation Advanced behavior whereby an individual observes and replicates another's

Kinesthesia The conscious awareness of bodily position, weight, or movement of the muscles, tendons, and joints

Learning modality The sensory channels used for processing and storing information: primarily visual, tactual, and auditory, but also, olfactory, gustatory, proprioceptive, and vestibular

Motor impairment A loss or limitation of function in muscle control or movement or a limitation in mobility

Near senses Touch and taste

Object exploration Use of sensory channels to gather information for detection of properties, identification, and discovery of potentials

Object permanence The knowledge or recall of an object even though it is not there at a given moment

Passive touch The action of being touched either by an object or by another person; to touch an object but with no independent exploratory and manipulative use of the skin

Piagetian model Model of cognitive development, first described by Jean Piaget in three global stages: sensorimotor, preoperational, and operational

Praxis The ability to plan new movements. It is a practical and applied knowledge to one's actions

Preoperational stage The developmental stage identified by using symbols, like words and pictures, as tools of problem solving, pretend play, and social connection

Proprioception The unconscious awareness of joint position

Referent Object, person, action, or place being referred to when a symbol is used; the symbol represents its referent; person, object, action, or place referred to by a symbol

Schema Knowledge of the relationship of things from several categories to each other as experienced in events beyond the body over time

Self-awareness An awareness of one's own personality or individuality

Sensorimotor stage Stage of learning defined by Jean Piaget during which typical children, 0-2 years of age, learn about their worlds through exploratory play by sensing and acting on objects

Sensory attributes Properties of objects that induce one to see, feel, hear, taste, smell, and move

Sensory channels (distance/near) Distance channel receptors are activated by attributes of things without being touched; near channel receptors are only activated when touched

Sensory defensiveness To have an aversion to things that induce one or more senses; a flight or fight reaction to sensation that unaffected individuals would consider non-threatening

Sensory impairment To have a lack of or a diminished capacity to use one or more sense

Sensory information Knowledge of the world acquired through sensory experiences

Sensory overload Activates the sympathetic nervous system used to prepare individuals for emergency situations; may cause nausea, dizziness, flushing, pallor, sweating, withdrawal, anxiousness, restlessness, and sleep disturbances

Sensory shutdown Neurological reaction to sensory overload resulting in unresponsiveness

Single-referent concept Thoughts about one thing

Social touch A combination of active and passive touch that promotes attachments and emotional relationships

Somatosensory system Pertains to the general somatic senses: somatic pain and temperature, touch, vibration, limb position, and motion sensibility

Spasticity Stiff, jerky movements caused by tight muscle groups that limit movement

Spatial relationships Knowledge of the relationship of the positions of parts of the body to each other, the body to objects and people, and objects and people to each other

Symbol Something that stands for or suggests something else by reason of relationship, association, convention, or accidental resemblance; objects and words used to represent their referents

Tactile symbols (tactual or tangible symbols/tactile graphics) Arbitrary or iconic objects or graphic forms used for communication and literacy

Tactual discrimination The ability to detect features and properties of objects through touch for the purpose of identification and comparison

Tactual/Tactile defensiveness A subset of sensory defensiveness that only involves touch

Visual impairment Any uncorrectable degree of vision loss, ocular or neurological, that limits a person's ability to perform visual tasks

Word bridge A spoken word used to trigger thoughts about sensory experiences with things stored in memory

Zone of proximal development The gap between what the learner can do without help and what he can do to achieve a goal he desires and understands

# Acknowledgements

Field Testers

The American Printing House for the Blind extends a special thank you to the following professionals who contributed their time and expertise to the evaluation of SAM: Symbols and Meaning. These individuals stayed focused on this project for a full academic year; many incorporated SAM into their learner's Individual Education Program (IEP).

Anonymous, Teacher and Speech Language Pathologist, Huntsville, TX
Leslie Daniels, Special Education Teacher, Fruitland, ID
Patti Eswein, Students who have Visual Impairments, Braselton, GA
Yvette Hoisington, Students who have Visual Impairments, Alvin, TX
Ramona Lee, Special Education Director, Fruitland, Idaho
Melinda Loyd, Students who have Visual Impairments, Sherman, TX
Barbara McElyea, Students who have Visual Impairments, Johnson City, TN
Anita Medley, Students who have Visual Impairments, COMS, Olive Branch, MO
Joyce Olson, Students who have Visual Impairments, Genoa, NE
Suzan Patillo, Itinerant Visually Impaired Program Chairperson, Grayson, GA
David Presley, Students who have Visual Impairments, Clarksville, TN
Gina White, Special Education Teacher, Caldwell, ID

Photography

Anchor Center for Blind Children, 107, 154, 155, 158
APH Archives, 68, 109, 111, 129
Michael Bicknell, 82, 87, 181
Janie Blome, 3
Robin Bush, 47, 48
Drew Carlsen, 22
Mark Cookman, 45
Meredith Cooley, 138
Michael Drewell, 33
Rita Gale Lane, 29
John Linahan, 43
Colleen MacDonald, 112, 121
Jim Manka-Taylor, 59
Barbara McElyea, 9, 123
Kathy Morrison, 35
James Moses, [BIG], 137, 138, 143, 150
Kathy Neufeld, 55, 181
Mike Peters © 2009, www.mikepeters.com, 66
Tristan Pierce, front cover, 9, 17, 22-23, 25, 40, 55, 67-68, 71, 101, 121, 135, 165, 175-179, 181, 191, 201
Erica Rucker, 39, 55,
Lesley S., 119
Danie Shaughnessy, 16
Larry Smith [BIG], 9, 27, 181
Ann Travis, 1, 12, 15, 36, 83, 120
U.S. Census Bureau, 25
Monica Vaught-Compton, 19, 84
Camille Workman, 153

Illustrations

[BIG], 68
Breanna Burton, 163
Yoshi Miyake, 61-63, 122, 172

Videography

Michael Bicknel, TSBVI - Bag Story (Abraham), Clue, Do It Again (Matthew), Do It Again (Cassie), Finger Tag (Leo), Finger Tag (Matthew), Mystery Voice, Show Me Who, Simon Says, Slap, Sounds Like , Yours and Mine (Abraham)
Scott Blome, APH - Go Fish (Patti)
Donnie Bott, [BIG] - Bag Story (Butter's Bath Time), Box Story, Scavenger Hunt
Kendra Doty, TSBVI - Clue
Stephanie Lancaster, APH - Go Fish (Patti), Binder Story
Marcela Meza - Whoopee Clothes
Sherry Pollen - Body Buzz
Larry Smith , [BIG] - Hot Potato, What Do, Yours and Mine (Jerrita)

SAM icon of geometric shapes in a basket

Guidebook

APH logo

1839 Frankfort Avenue
Louisville, KY 40206
800-223-1839
www.aph.org
info@aph.org

Catalog No. 7-08854-00 Use in Kit No. 1-08854-00