APH SAM - Symbols and Meaning 
Guidebook
 
Millie Smith, M.Ed., TVI
Book 1 of 2
For use in kit 1-08854-00
 
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 (c) 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
 
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
 
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
 
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(r)-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: 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.

 
Chapter 1: Why do we need a program?
 
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 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.
 
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." 
 
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?
 
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
 
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
 
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
 
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?
 
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.
 
  *    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).
 
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
 
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.
 
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).
 
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.
 
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.
 
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
 

Chapter 5: Gathering sensory information
 
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.
 
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)
 
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)
 
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
 
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.
 
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
 
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 
 
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
 
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
 
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.
ReferentSymbol
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 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 tact0ual learners where photos and pictures would be 
used by sighted learners (Chen & Downing, 2006).
 
Photo Caption: Iconic symbol for concrete concept
 
Photo Caption: The string is an arbitrary symbol and "day" is an 
abstract concept.
 
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
 
Level Two - Pictures and part object tactile symbols
 
Level Three - Printed and brailled words
 
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
 
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 ConceptsCategory

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. 
 
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. 
 
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. 
 
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
 
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 timeWhy
  *    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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Appendices
 
Appendix A  

Learning Strategies for Tactile 
Defensiveness
Jennifer Stocker, MHS, OTR/L
 
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?(r) A Leader's Guide to the Alert Program(r) 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).
 
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.
 
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).

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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
 
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.

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.

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 
 
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(r) 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 
    (texture)
    Pressure 
(hardness)
    Static Contact  
    (temperature)
Unsupported Holding 
    (weight)
    Enclosure 
(global shape) 
    (volume)
    Contour Following 
(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
 
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
 
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
 
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
 
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
 
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
 
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.
 
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."
 
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.
 
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?
 
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!"
 
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 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?! 
 
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(r) 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
 
Baskets 
The sides of the SAM baskets can be rolled down to accommodate the 
length of a child's arm.
 
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.
 
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..
 
Sport Bag 
The SAM sport bag can be used to hold game objects during play and to 
store miscellaneous kit items.
 
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.
 
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.
 
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.
 Ben Makes Cookies
 
 
 
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(r) 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(r)
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(r)

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
 

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
 

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
 

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
 

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
 

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.
 

 
Glossary
 
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 (c) 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)

 
Guidebook
 
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
