Publications Archive

Information Exchange: The First Five Years

Summary: Education of visually impaired children with severe learning difficulties

• Assessing visual response
• Ideas for occupying and involving mentally handicapped children who have little or no sight
• Classroom management
• Light stimulation of the visual cortex in SLD special needs children (with healthy eyes)
• Vibration and the multi-handicapped child
• The mannerisms of blind children
• Approaches to curriculum (I)
• Approaches to curriculum (II)
• ‘Deaf-blind’ children
• Blind children – with reference to those who are also profoundly handicapped in other ways – some thoughts
• Some of our needs (mine, and my teacher’s)
• Curriculum [A letter from Lilli Nielsen]

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By and for those concerned with children and young people who have severe learning difficulties and little or no sight

Supported by RNIB

'Information Exchange', created by teachers of visually and multi-handicapped children, was first published as a newsletter in 1980. The newsletter was designed to meet an area of very special needs, and it quickly grew in size and in circulation to become a termly magazine written by and for all who are concerned with the education and upbringing of multi-handicapped children with little or no sight.

This publication comprises a collection of major articles that appeared in ‘Information Exchange’ in the five years to 1985. The idea originated from the large number of requests we received at RNIB, for reprints of these articles. Each article carries a date: we believe this is important as ideas develop and situations can change quickly in education.

Thanks go to all the authors who gave permission for their articles to be reprinted here, and to Tracy Winstone, Liz Poole and Jane Pickerden who have assisted with the typing and production of the final manuscript. Special thanks are due to Sally Silverman who has inspired and led the editorial team of IE for more than a decade. So much of what appears here is due to Sally's energy and enthusiasm in generating ideas and provoking thought amongst those educating and caring for multi-handicapped visually impaired children.

At RNIB we were pleased to provide administrative, secretarial and some editorial support to the IE team during the early years, and to assist the magazine as it grew and developed. Now, the magazine has its own, independent editorial board again and we wish them well for the future.

Louise Clunies-Ross
RNIB Education & Leisure Division
January 1991

Assessing visual response

By David Bethell, then Peripatetic Teacher of the Visually Handicapped, Walsall and currently Statements Officer, Walsall

When an adviser for visual handicap first goes into a school, the first question is often:

'What can this child see?'

You may well be responsible for a child who doesn't seem to you to have normal visual responses - he doesn't pay attention to things that would seem to be visually attractive, or he doesn't reach out well, or he stares at light but little else, or he won't hold eye contact, or follow movement with his eyes, or he waves his fingers continually close to his eyes, etc. He's generally thought to have very bad sight, but you don't know how bad, and you're not sure what special programmes he needs or how, if at all, you should adapt your methods for him. What do you do?

1. Collect all information about him that's already available:

a) Find out what the ophthalmologist, paediatrician, or other medical specialists have said about his sight. It may be inconclusive or even inaccurate, but it is the opinion of a skilled person and can be invaluable. If you don't understand the terminology of a diagnosis, get it explained to you in practical terms. If you can get hold of an orthoptist to see the child, her opinion may be the most useful of all the medical ones.

b) Also check out physiotherapists' reports, possible effects on vision of the drugs he may be on, opinions of previous teachers, parents' views about his sight, and so on. Then, if you're still in doubt, proceed as follows.

2. What you can do yourself:

There's no real substitute for a full, formal assessment of visual ability by qualified medical people. Unfortunately, this is only sometimes or even rarely available. If you can't get it, try the procedure suggested below; but remember, you are only trying to observe a child's visual behaviour and use of sight as a help to your teaching. You are NOT able to make any sort of quasi-medical diagnosis, or to label the child as 'blind' etc.

And - we think this is most important - do remember that these children are often at their best in a calm, warm, secure, comfortable, familiar and affectionate situation, one which is intrinsically supportive and motivating. This isn't always easy to reconcile with the fairly precise, controlled work one may have to do with them - eg. working with isolated stimuli in a distraction-free environment - but to put these children into unfamiliar, unnatural, 'guinea pig' situations is probably unkind, possibly unethical, and almost certainly self-defeating, because the child cannot show his true ability in such circumstances.

a) Lookinq at a child's eyes and .qaze:

In SLD children, visual impairment is often caused by brain damage rather than by ocular defects, but check eyes and gaze anyway.

Look at the child from the front, try to hold eye contact (a penlight held between your eyes may help). Normal eyes are more-or-less equally proportioned and clear, and their gaze is straight and steady. They move smoothly and in unison across, up, down, diagonally and around. They fix without flutter. They converge on an object brought very close (bring a small bright object slowly to within a few inches of the child's eyes, then slowly withdraw it). They blink if a rapid movement is made close to them ('menace' reflex - flick your fingers a few inches away from the child's eyes) and the pupils constrict or dilate according to the intensity of the light (observe pupils when you bring a child from shade into sunlight).

Eyes which appear clouded, weeping, inflamed, disproportionate, squinting and which do not fix steadily, or have random, jerky or unsynchronised movements, or which lack pupillary or menace reflexes, may not give full visual acuity (fineness of sight) or full field (area or arc of sight). For instance, unsteady or 'dancing' eyes often mean a loss of acuity, and a strong squint or other sign of dependence on one eye alone may well mean a loss of visual field and of some of the ability to perceive three-dimensional 'depth' and to judge distance. Complete lack of pupillary and menace reflex might suggest a serious sight loss. However, DON'T jump to conclusions; even children with obvious ocular abnormalities may have good sight, so try again to get qualified medical opinion.

b) Observinq and recordinq a child's visual responses:

Before a child can make good use of his sight, even at the most basic level, he must be ableto:

• give visual attention;
• fix (i.e. look steadily at a particular object or part of one);
• track (follow a moving object with eyes and/or head, across, vertically, diagonally, around);
• change focus (converge, or accommodate - alter the focal length of the eye by changing the curvature of the natural lens inside it);
• shift fixation (by so-called 'saccadic' movements, i.e. rapid jumps from one fixation point to another - different from tracking movements).

Normal infants develop these abilities automatically, but visually handicapped SLD children or others with a visual handicap may not have them in full, or at all. Of course, they're bound up with other areas of development - the perceptual ability to distinguish figure from ground, the concept of object permanence helping to motivate visual searching, motor development in eye/hand co-ordination and so on.

You can tell a great deal about a child's visual behaviour by watching him carefully in an ordinary classroom situation, but if you want to make your findings a little more precise, try this method of observing and recording visual responses: (but again a warning: you can only observe how a child is using his vision and to what sort of visual stimulus he responds best; you cannot, from this, make absolute statements about his field, acuity, etc.)

Make an A4 size stencil of the rough visual field diagram shown below:

• 

In the corners leave space with headings for child's name, teacher, date; details of the visual target or' stimulus used (colour, shape, size, movement etc.); the range; the level of background contrast and lighting; and general comments on the child's response. Then remembering our earlier caveat about sympathetic situations, find a quiet corner with a table and two chairs where you have some control over the lighting - an anglepoise on the table, perhaps, but watch the hot shade - and get a helper to sit at the table with the child in her lap, or sit the child at table if he prefers it.

Beforehand, get together a few objects of different shapes, sizes and colours, some bright, some less so, or perhaps a torch with different colours (Pifco Tricolour available at Boots is good). Face the child, with a copy of the diagram handy, and present objects to him according to the scheme below:

• Try to get visual attention with a fairly big, bright object, well contrasted against background, held still (or revolving on itself) close to the child, centrally and a little to each side, first at eye level, then lower. - Where the child gives visual attention, mark a large 'O' on your diagram or record ‘nil response’. Record details under other headings.
• Similarly for fixation: try a smaller object, vary the range (close examination range of a few inches, normal working position, arm's length, across the room, are more functional than so many centimetres or metres). Hold it still, and if the child looks steadily at it, record a fix with an 'X' in the corresponding part of the diagram (you might like to use a new one for every trial you make).
• Similarly for tracking; move an object horizontally, slowly, and not far off centre at first; alter lighting, contrast, object size and range, motion to be tacked etc., and record an arrow to approximately the direction and length of the arc followed. Walk across the room and use yourself as the object if you like. Gradually increase difficulty of task.
• Similarly for other visual skills; for saccadic movement you might need a small screen in the middle of the table from behind which objects can appear/disappear, and you could record with a dotted line between the Xs. Reaching out can be recorded with an arrow with a circle round its tip, and other symbols can be used as needed.

If you do this sort of thing for a few minutes a day for some weeks, you will build up a record of the sort of visual stimulus - if any - to which a child will respond. If you analyse the diagrams you have collected, you will be able to say with some certainty what visual skills a child uses, and what conditions encourage him to look - preferred colour, size, shape of object, lighting and contrast conditions, range, orientation, etc. This can be a great help to you in planning how and what to teach him.

There's nothing hard and fast about the sort of procedure suggested; you may like to modify it or devise an alternative. Of course, frequent short sessions with one or two items and skills are better than long spells. Finally, remember it's an observation, not a test.

Old favourite: if you want to find out how acute a child's close vision is (and close vision and distance vision are often at different levels), go to Tesco or a similar store and get the small size and large size cake decorations called ‘hundreds and thousands’, a pack of Smarties, and another of the giant size Smarties, if you can find them. Use these on the table top in front of the clhild, and if you vary the level of contrast afforded by the background, you have a graded range of stimuli. They're better than the graded plastic balls used in e.g. the Stycar Test (available from NFER Nelson, perhaps better left to the orthoptists and SMOs who often use it) because they can be eaten with impunity! Of course, only for those who reach. And another: black on yellow often gets a visual response, and spirals and symbolic faces of the Mr. Men are often attractive.

To sum up, even if you can't get any formal medical assessment of a child's sight, you can watch the way he uses it and, by careful recording over a period of time, can establish a kind of visual baseline for him. Then you have some data on which to base decisions about teaching methods and programme content, and if any sort of visual training is to be undertaken, you have a point from which to start.

So, observe, record and don't give up - even the smallest bit of vision can be used and can become central to a child's development.

Reference

NFER: National Foundation for Educational Research, The Mere, Upton Park, Slough SL1 2DQ

Issue 2, March 1981

Ideas for occupying and involving mentally handicapped children who have little or no sight

A Collection of Ideas and Information for Parents, House Parents, Nursing Staff and Teachers)

By Linda Hargreaves, then Teacher of the Visually Handicapped, North Yorkshire and currently Teacher for the Visually Impaired in North Tyneside.

Your house or flat can make the best possible classroom for your child - the kitchen, bathroom, bedroom and garden contain lots of possibilities for learning!

You have probably found that your child will need to be told what you are about to do around the house and then he or she will benefit from being as closely involved in that activity as possible.

For example, tell him 'I'm going to turn the hoover on now, you listen and tell me (or raise a hand) when I've stopped'.

Warnings that sudden noises are about to happen (spinner or the washing machine, hammering) may help to prevent startled responses.

Sound Sequence Stories: once your child has become used to everyday sounds around the house then great fun can be had by building up a 'sounds sequence story'. What are the first sounds we hear in the morning? Alarm clock, running water, kettle, school bus beeping its horn etc. These home sounds could be put on a cassette recorder and a little bedtime "sound story of Richard's day" could be made. Maybe brothers or sisters would like to do this for you!

There are lots of everyday household activities which visually handicapped children of all ages and degrees of handicap could help you with:

In the summer a physically handicapped blind child sits on the grass and helps gather together the cuttings after Dad has mown the lawn.

After shopping let your child sit with you as you unpack the basket. The shape and weight of an onion is so different from a tin of beans!

When you are washing up, then perhaps he could have his own bowl too, with one or two unbreakable items in it. If this would cause too much splashing then a wet cloth and a tupperware container or yoghurt pot to wipe would help him feel involved. Songs often seem to help: try singing 'This is the way to wipe the dishes on a Tuesday morning' (tune of 'Here we go round the Mulberry Bush').

When you are busy in the kitchen maybe your child could handle and sort some blunt items from the cutlery box. These are often shiny, make a nice noise and if he has the opportunity to handle them, then later he will be able to help you to lay the table. These early experiences could make all the difference to your child's social skills when he is an adult.

If you are baking, let him have some off-cuts of pastry to squeeze, poke, roll or pat. Some children will enjoy being helped to use a simple cutter and will be proud if they can bake their own jam tarts. For younger and more handicapped children, the feel and texture of the pastry or play pastry will be the main enjoyment and an 'end result' isn't needed.

There are lots of recipes for play pastry. Here is just one from Roma Lear's book "Play Helps":

Play Pastry:

2 cups plain flour

1 cup salt

2 tsps cooking oil

enough water to bind

food colouring to add interest

This mixture will stay fresh in the fridge for about a week (in a plastic bag). Flour, by itself, is cool and soft to play with; it does make quite a mess.

There are so many things you do in the kitchen which are of educational value to your child. Let him feel how cold a packet of fish fingers is when it comes out of the freezer and then, how warm a cake is soon after it has come out of the oven, It is by bringing these sorts of experiences directly to your child that he will discover the variety of smells, temperatures, textures and sounds within his surroundings, and can then start to put them into some kind of order.

When you have to leave your child to occupy him or herself:

Ideas can be difficult to find, the television may not be appropriate for many and too much radio or constant music from the cassette or record player is not helpful in encouraging children to become selective in what they pay attention to. (The ability to develop selective listening skills is so important for a visually handicapped child, e.g. to know where he is in a building, or later to cross a road).

Music Boxes: it is certain that many of your children have enjoyed these (even if the tunes do get on our nerves at times!). They can be very helpful for some children, especially if they have a plastic bangle attached to the end of a drawstring so that the child has a better chance of operating it himself. Some of the wind-up ones are a little difficult. Hestair Kiddicraft make the 'Melody Man'. When you pull the cord it activates the tune and the eyes move from side to side. They also produce 'Tuneful Tim' which is similar to 'Melody Man'.

A certain tune could be used to indicate to the child that a particular routine is about to happen: e.g. bedtime. Or a small (e.g. Fisher Price radio box) music box could be started and put on the child's own chair to help him begin to locate where his own place is around the table. This idea has been used very successfully in a classroom situation to help a blind child find his place within a group of children for our morning 'conversation time'.

Many of the newer music boxes have moving parts which turn as the tune plays and these can be very useful for encouraging the use of any residual vision which the child may have. Sometimes the small plastic shapes could be removed and shiny foil from pie tins or red cellophane biscuit inserts could be attached instead as these would be more likely to attract attention.

If your child sleeps in a cot then there are lots of interesting items which could be attached to the sides to provide interest and stimulation if he wakes up very early or has a nap during the day. These could include herb pillows with different smells, either homemade or bought from some Health Food shops or Department stores. Feely Cushions (see page 111 Roma Lear's book 'Play Helps'), can be lots of fun, an old cushion could be transformed into a Humpty Dumpty shape and then different textures sewn on to him. If you sew on a couple of rings then these could have different objects attached to them every week, e.g. bells, rattles, tinsel. Many younger physically handicapped children feel quite safe propped up in the corner of a cot to play for short periods and the sides mean that toys can't roll far away.

Have you seen these?: (N.B. Some of the toys mentioned below may not now be available but the principles hold good).

Tweety Bird .... a toy suggested to us by a teacher in Walsall. It is a brightly coloured bird which will bounce on a wire making intermittent tweety sounds. It performs for a long time and will help to motivate reaching and looking.

Giggling Ghoul .... this is a brightly coloured hanging toy which makes a laughing sound when the child reaches and swipes at it. Available from Woolworths.

Father Christmas Brooch .... also from Woolworths. When a string is pulled, his face will light up.

Thinking of Christmas .... if you have time, keep an eye open for useful light stimulation toys, coloured torches etc., which are around at this time of the year and then disappear. Xmas lights; there are some available now which rotate and even play a tune! These could be used now and then kept as a light stimulation toy for your child during the long summer holidays!

Keep out some of the shatterproof Christmas balls as well, as many visually handicapped children will love to handle them and hold them up to the light.

Glow Stars .... from the Discoveries Catalogue available from Discoveries, Harrington Dock, Liverpool, L70 1AX, Tel. 051-708-8883. These stars are very small but very effective, they are made from a safe non-toxic material. They are automatically recharged from ordinary light and will fluoresce in the dark for about 45 minutes.

A couple of parents we know of have put these stars on their child's bedroom walls and ceiling and have found that their children enjoy seeing the Glow Stars slowly fade after their lights have been turned out.

Glow Giggly Ghosts are also around in some toy shops and may be better for some children, as they are larger.

Other Homemade Ideas:

Activity Centres: There are lots of plastic Activity Centres on the market now and these are very useful as the moving parts won't fall off and get lost. However, the most interesting ones for children are often homemade. It is often the case that commercially produced activity centres have too many activities and a child will just play with a few in a selective way. (Maybe an older brother, sister or cousin could ask to make one as a project in school woodwork class, or grandparents could be asked).

Glue or screw a series of objects (probably not more than four to six) to a solid board which can then be clamped to a table or cot, or held in place with BluTac or Dycem non-slip matting. The objects could include:

a) a matchbox with a sweet inside to be pulled and pushed open

b) a zip pocket with a toy or sweet inside

c) a light switch

d) a door bell could be wired to a ring

e) there could be a series of four doors all with different ways which the child has to open them, a lock and a key, a latch, a bolt or button catch, a different texture or small object could be behind each door.

For more details of this kind of Activity Centre and for other ideas write off to the National Toy Libraries Association, 68 Churchway, London NW1 1LT. Ask for "Do-it- Yourself" and for a publications list, as they will all be relevant and helpful.

Wrap up a favourite toy (especially a sound-making one) in layers of paper, shake the parcel so that the child knows that there is a reward inside and is motivated to tear the paper off, he can then have fun playing with the torn up newspaper.

Provide the child with a rummage box:

Make a shute out of cardboard (inside kitchen foil, or clear tubing as sold for wine-making, or piece of plastic drainpiping), tie a string around the middle and hang up within the child's reach. The child can then post toys, cars, balls, in one end and listen for them falling out at the other end. Line the tube up so that the objects fall into the box or a metal bin which will give added sound and the objects can easily be collected for posting again.

Cat doors also make interesting posting boxes (!) and may be worth putting in even if you don't have a cat.

A simple wooden stand could be made and be put close to the child. Ideas will have to be thought of to prevent it falling over: an old fashioned clothes horse could be attached by large hooks to a sturdy cupboard or to a wall. A variety of interesting toys and objects could be hung on elastic and changed often. Bells, rattles, crumpled paper, Christmas streamers, strange bags of polystyrene pieces, milk bottle tops threaded through cotton. Many children will benefit from moving their bare legs and feet through these objects as well as their hands. Save the Christmas sweet wrappings! These can be mounted in slide frames or left on their own to hang by the window or from the wooden frame.

Blocks of polystyrene are very good to collect (electrical shops selling TVs often have plenty to spare), cover with a variety of materials both visually attractive and interesting to feel. It is very lightweight and easy for the child, with little strength in his hands, to push around and explore.

Feely Aprons:

If your child is unable to reach out and use his or her hands very much, then you might consider this idea. You may already have a basic play apron or large bib which could be adapted. The idea is to make the apron stimulating and interesting for the child when he makes the smallest movement with his fingers. Sew on about four to six small curtain rings, then with ribbon or elastic attach small bells, beads, lavender bags, pot-pourri sachets or fancy buttons. If these are tied to the curtain rings they can be interchanged for variety and also removed when you want to wash the apron. Pieces of fur, velvet, sequins and little pockets with velcro fastenings could also be added.

Stairs and Steps:

These can cause anxiety to parents and teachers alike, but they can provide hours of fun and exploration to the child, not to mention good exercise and a sense of achievement when they are mastered!

Many of our more modern Special Schools are designed on one level and have no steps at all and, so it is in the home that experiences with steps and stairs can take place most readily.

Children often approach stairs on all fours and will want to feel for the top step with their feet. Bare feet may be safer than shoes, certainly safer than socks, giving the child a better chance to locate his position through touch.

A box or basket of clothes or shoes can keep many children occupied, happy, and will provide a meaningful resource for learning. Dad's shoes are larger and heavier than sister's, new shoes smell so nice. Which are his own?

When you want your slippers from the bedroom then maybe your child could see if he could find them and bring them to you, this is a very real part of 'Mobility Training' and an activity of value to your child.

You may well have found that at birthday or Christmas times your child is more interested in exploring the colourful wrappings and containers than he is in the plastic toy or furry animal inside. This will often be the case, and you are certainly not alone in finding this. These materials are often more rewarding and meaningful to the child with poor sight.

Parents and older brothers and sisters will often make the very best swings and climbing frames, cutlery boxes, the best sorting trays and bread bins, the best early discovery toys.

An Evening Out:

It could be a great experience for some visually handicapped children to be taken out after dark. Bonfire night is a good opportunity, isn't it? Many parents may be planning to take their children out to town centres on evening this Christmas to see the lights. Is it possible to make this experience available to our children who are in hospitals, too?

Reference

'Play Helps: toys and activities for handicapped children' by Roma Lear, London, Heinemann Health Books, 1977.

Issue 4, December 1981

Classroom management

by Steven White, then Peripatetic Teacher working in Huddersfield with multiply handicapped visually handicapped children. Steven White is currently Deputy Headteacher of a S.L.D. School in Halifax.

A. Some Considerations

Children learn to see, and this learning not only depends on the actual process of increasing the use of this sensory mode (vision) but also is greatly influenced by the experiences and learning opportunities to which the child is exposed.

Learning to see is a two-way process, and the extent to which the child's vision develops to its maximum potential has much to do with the amount of environmental visual stimulation the child receives.

Visual training is important for all severely and profoundly handicapped children who make limited use of all sensory information. If there is any vision, then it is worth developing. Planning for the child must include ample opportunities to experience and learn to interpret visual stimuli. It is important to remember that his use of vision will largely be dependent on two factors - how much actual sight he has and the extent to which it is developed. Over the last few years, there have been important findings concerned with use and development of vision in the 'blind' child. One of the most important is that 'blind' children with residual vision who have had no training in 'learning to see' can, with proper instruction, learn to see better. How much the child will finally learn may depend to a large extent on motivation, which is our problem.

B. The Classroom

Lighting:

The best lighting set-up is when the light source is behind you - it can be behind either or both shoulders - and is directed onto the table. In this way, what the child is looking at will be lit, but he will not have light glaring into his eyes, as he would if the light source were in front of him.

Small high-intensity lamps can prove useful for close work as long as the light is directed onto the table where the child is sitting.

When a table or reading lamp is being used, remember that if the ceiling lights are off there will be a sharp contrast. Experiment using lamps at different heights and angles to see if this will increase the child's visual awareness.

White ceilings will improve the level of illumination, as will pastel-coloured walls.

To avoid glare from floor and furniture surfaces, they should be matt finished.

Be aware of the contrast and lighting in your room. Light on dark/dark on light - experiment for individual children.

The use of dark room, or areas within the classroom can be useful for visual training areas and stimulating for all children in the class.

Curtains and blinds can achieve an overall effect in increasing and decreasing light source.

Small rooms with ultra-violet lights are now being used in a number of S.L.D. schools. Ultra-violet light causes certain materials to become fluorescent, thus intensifying the visual stimulus they give. This effect can be used directly in vision training and in a variety of programmes which require visual attention, discrimination and hand/eye co-ordination.

By using a small room, or even a blacked out Wendy House within the classroom, a stimulating effect can be achieved.

A number of conditions and safeguards have to be met before using ultra-violet lights which involves both medical and technical expertise and considerations. (The fluorescent light itself should be long-wave as short-wave burns!).

The use of ultra-violet at Briarwood Special School, Bristol:

A wall about six feet by nine feet is covered with black material (matt black paint) and ultra violet light is directed at it. There is a pulley system so that cut-outs painted with fluorescent paint can be moved backwards and forwards across the screen. Other stationary cut-outs can be pinned to it. The Briarwood system was electrically operated and the children were able to control it themselves, but it could certainly be done mechanically.

C. Classroom

Equipment Around the Room:

Try blindfolding yourself and your assistant and walking initially around your room and then throughout the school. Some appreciation of the problems facing our children may be realised.

Avoid reflective and shining surfaces when working on purely visual work. To limit reflection or shine use matt finishes.

If the child has useful vision in only one eye, then work that side with the child -make sure visually presented tasks are initiated from this direction.

Have a familiar corner, covered with textures (perhaps corrugated paper which could be painted with fluorescent paint) or shiny surfaces so that the child becomes familiar with one place. If you need a shiny background surface for visual attraction use the gold or copper foil paper.

With "blind children" make sure presented toys and equipment are made stable on the work surface (especially if the child is unattended), soap stickers or sellotape 'sticky fixers' are very useful for this. They can be used to put equipment, toys, etc onto the wall or on vertical surfaces so that the child is working on a different plane. (This encourages the children to sit more upright instead of bending over the working tasks).

Textures on sitting chairs and wheelchairs again make 'places' in the classroom more familiar.

Guidelines around the room and in the corridors can aid mobility. A furry line along the corridor can encourage children to feel the wall and aid mobility. Textures under the feet can be used.

For the non-ambulant profoundly handicapped children a prone board with attached table can give the child a new position to work and move from. Visual responses also vary when these children are moved from various positions - prone, upright, sitting etc.

Various 'areas' within the classroom can serve different purposes and can be used by all children, not just the visually handicapped child. A certain area can be stimulating by using foils - gold or copper. Articles can be hung from the ceiling, or you can buy pegged hangers and attach various objects which dangle. Objects can be attached by string, elastic or by using the magnetic attachments (as used on cupboard doors) with metal objects like spoons.

Wall coverings can be magnetic boards or attached with drawing pins, sellotape, 'blutac' teazle graphs, or use a cork-tiled poster area.

Woolley Wood SLD School, Sheffield, have devised their own tactile language scheme which involves various wooden shapes representing words. The children can build-up sentences both by 'reading' and 'writing' with these shapes. Many of the children in the school have progressed to Grade One Braille. For further details write to:- The Headteacher, Woolley Wood S.L.D. School, Sheffield, South Yorks.

For more able children, with some vision, the Partially Sighted Society produces sheets of paper with bold and well-spaced lines for writing aids. Partially sighted children need large, clear pictures, good spacing between lines, words, letters and good quality paper without glare or gloss. Such equipment as easels, copystands, blackboards and typewriters may be considered.

Tape recorders and cassette players are useful for language and 'listening' work. Putting various tactile clues onto the buttons, the child can then operate the machine himself, i.e. rough and smooth buttons, switch and cassette player on or off.

Q.E.D. (Quest Educational Designs) Ltd., 3 High Street, Gosport, Hants, tel. 0705- 581179 produce electronic aids, including easy-to-work touch-pads which can be fitted to ordinary cassette players, so that a simple touch will start and stop them.

D. Space and Place

Children with a mental handicap who have the multiple handicap of visual impairment need their own 'special' place in the classroom and their own 'special' space.

There is the place where they sit to complete skills and tasks. There is the space where they escape to a hide-away place, as children need a den and 'escape' there. These dens can be made up of anything but must give the idea of a space which is close, but not enclosed. This space can be used for play activity.

Soft play areas with foam wedges and cylinder cushions are ideal:- a carpet with texture squares stuck or sewn onto the top of the carpet, provide an interesting base. If you use wooden structures, tactile surfaces can again be used. One of the barrels used in the playground activities could be used and the physically handicapped child can be put in it with a number of attractive toys. Instead of the barrel, a box/cardboard hole can be made or even a reinforced cardboard box -try the local electricity shop for fridge boxes.

E. Activity

There are some good mobility ideas in a leaflet produced by Linden Lodge School for the Blind, London, which is available from the RNIB.

Activities for two children to one teacher can be carried out by rearranging seats away from the tables, e.g. Music and Movement.

Set the children at right angles to you - maybe to the front and one to the side. The child facing - put his feet on yours. The child to the right and also, maybe, to the left - put their legs close enough to touch yours. Singing rhythm and movement can be 'transmitted' - three ply.

Songs, rhythm, can be good teaching aids, include songs on a variety of themes - days of the week, weather, naming parts on the children's bodies, facial features, hands, fingers, feet, etc. A wide variety of ideas for songs and poetry are in two excellent books:-

'This Little Puffin' (Nursery Songs and Rhymes) - compiled by Elizabeth Matterson (Puffin" 1969)

AND

'The Young Puffin Book of Verse' - compiled by Barbara Ireson (Puffin: 1970).

F. Basic Educational Curriculum

Barraga (1976) in her book 'Visual Handicap and Learning - a Developmental Approach' (Wadsworth Publishing Co. Belmont, California) identifies a basic educational curriculum in general terms which seems relevant for our children:-

1) Human Interactions and Relationships

Pleasurable personal contacts, acceptance and trust of teachers, peers and others, recognition of self and others as human beings.

2) Sensory Awareness and Stimulation

Exposure to sounds, odours, tastes, textures and visual stimuli, discrimination and recognition of differences and likeness.

3) Physical Movement and Activity

Body awareness and control (co-active movement with teacher): object manipulation and manual dexterity: exploratory movement in environment.

4) Self-Care and Daily Livinq Skills

Self-care skills of eating, dressing, etc, handling utensils and materials, social play and interaction with others.

5) Lanquaqe Development and Communication

Expression of needs and response to language; word-object or word-action association; psycho-drama, story telling and role-playing (records, tapes etc) following basic commands and instructions, meaningful language expression.

6) Work Attitudes and Language Development

Assigned work duties, personal and group responsibility; use of bus and public transport.

7) Physical Education and Recreation

Physical exercise, adapted games, swimming, arts and crafts, leisure skills.

Obviously these are very very general but I think it is worthwhile considering what we are actually teaching our children and what are target behaviours, overall objectives and aims. Socialisation and living skills would be important areas on which to concentrate, as the more social skills the child has, then the more self-independence he gains. The teaching of social skills lends itself very well to a task analysis approach, whereby the skill you ultimately want the child to learn is broken down into smaller gradual stages. The skill can then be taught, whether by starting with the first stages and building up to the ultimate stage (taking off his socks) or by backward chaining whereby the last step or stage is taught first, (i.e. putting a jumper on) - you would start with the child having his arms and nearly all his head through the jumper so that he only needs to pull it fractionally before achieving the first stage. The next stage would be his head a little further out of the neck of the sweater and so on until you work back to the child putting his arms then his head through the sleeves and neck of the jumper - this approach has the advantage of the child being able to appreciate the overall aim (putting the jumper on) and can be easily rewarded and prompted through the whole process.

G. Task

Try working out the various stages involved in taking your socks off or washing your hands, e.g. here is one on washing your hands:-

1. Locate the basin

2. Find the plug and put it in the sink

3. Find the hot tap and turn on

4. Find the cold tap and turn on

5. When there is sufficient water in the basin, turn taps off (most difficult stage)

6. Wet hands

7. Locate soap

8. Rub soap between palms of hands

9. Put soap down

10. Rub palms and fingers

11. Rub back of left hand with right hand

12. Rub back of right hand with left hand

13. Rinse hands in water thoroughly

14. Pull plug out

Remember your N.T.A., Nursery Nurse or helper are V.I.P.s - any considerations of room management must incorporate them. If you have one visually handicapped child in your classroom, then perhaps your assistant will spend more of her time with this child than with the rest of the class. Difficulties do occur in trying to fully 'occupy' the child when he/she is not in a one-to-one situation and at times 'occupying' proves impossible. Materials have to be adapted so that the child can participate in group work along with his sighted peers. Simple conditions such as: sitting the visually handicapped child next to you so 'contact' with the child is never lost; always using appropriate language even if there is no apparent response. Observe the responses to see if the child is using a different mode of communication.

Kinesthetic Sensory Development

The purpose of materials chosen for this area is to encourage movement. Some of our children are ambulant, while others are almost totally dependent on teachers to aid any type of movement. Increased movement facilitates tactile exploration, and the development of tactile exploration increases the likelihood that children will attempt to move in an effort to reach attractive objects and toys.

Items Responsive to Pressure and Weiqht:

Waterbeds and lilos, foam rubber pieces, pillows, mats, tyre inner tubes, trampoline.

Items Propelled by the Child:

Balls, pull toys, beanbags.

Items moved by mechanical assistance or limited person assistance:

Punching bag, wind-up toys, ball on end of rope, rocking horse, furniture.

Items that move children through space (with initial push by adult or by power supplied by child):

Swings, hammock, inclined boards, slides, tricyle/bicycle, pedal cars.

Other suqqestions

Footprints taped to the floor can be fun to walk on and often create interest. Texture footprints can be used with children in bare feet to explore their immediate environment. In the same way, lines of texture coverings can be stuck along the lengths of corridors, sides of classroom walls, to encourage mobility. A string of Christmas lights or disco 'tube lighting' along a dark strip of wall will always catch a child's eye. Place colourful strips of tape, fluorescent and shiny materials at eye level around the classroom.

Arrange an obstacle course on the floor to walk around or through. The objects used can be large or small; motivate the child so he will want to go through the course. A flashlight to 'lead' him or an RNIB bleepball, or a reward at the end may help.

Label things around the room. Cover the door handles with fur or velvet for recognition. Put different textures on to the child's chair so that he becomes familiar with his 'own' chair. You may find it more helpful using a three-dimensional object like a tube or brush to indicate the chair. Once this is established, move the chair into different positions so that the child with little vision has to explore the classroom environment.

If the child has some useful residual vision, try wearing very bright clothes when you are encouraging mobility, i.e. yellow rain mackintosh; bright knitted gloves. Most boutiques now sell fluorescent pink/yellow/red socks which may help the child with a ‘putting on' or 'taking off' of socks programme.

Sometimes industrial and commercial goods have far better educational value than toys in catalogues or in toyshops. Shiny baking tins, colanders, etc are very useful for object containers, which are important prerequisites for further learning of the relationship between different types of objects - screwing, taking out, pulling apart, etc.

Reference

Partially Sighted Society, Queen's Road, Doncaster DN1 2NX

Issue 5, March 1982

Light stimulation of the visual cortex in SLD special needs children (with healthy eyes)

by Mark Mabon, then teacher of the visually impaired in Manchester. Mark is now working in New Zealand.

This is based upon work undertaken in Manchester during 1978-82. The work concerns the use of different types of light to stimulate the visual pathways existing between eye and brain, in profoundly handicapped, developmentally young, children who are diagnosed as being blind. The work originally was, and indeed still is, practical in its orientation.

A brief outline of the thinking behind the light stimulation programme is appropriate here. The solution to the problem was thought to be a body spatial awareness programme.

A body spatial awareness programme could not be constructed for Special Needs children with a developmental age of less than six months. So there was still a gap to be filled for the Special Needs child whose development lay between 0-six months. This gap was to be filled eventually with a programme based upon the use of light.

Light was selected because it was decided that as there is usually little or no expressive/receptive language, often a hearing loss as well as the visual defect, plus a multitude of other handicaps, all adding to the child's isolation, it was possibly the only means of communication available to use. This rationale initially sounds confused - if a child is diagnosed as being cortically blind, then what is the point of using light to promote contact? There are several answers:

1. Usually there is some residual vision in 80% of all cases of blindness - even registered.

2. Being subnormal, the children, in most though not all cases, are diagnosed subjectively, not objectively. For example, very few brain scans are done on SLD children. The assumption is that if the child has SLD and healthy eyes, yet does not function visually, then the brain damage extends to the visual cortex and hence the child is cortically blind.

3. Even if the visual cortex is damaged, there is evidence that a more primitive sub-system might be capable of responding to certain forms of stimuli, especially moving lines of light.

4. Some compensatory mechanism might come into play if stimulated - this is an area where more and more evidence supports the view that the brain is far more adaptive than thought of to date.

The next question begging an answer then is 'Why, if there is, in some form or other, some capacity for sight, it is not used?' The contention behind the answer to the question is one for which there is very little, if any, proof. The author admits only to intuitively based speculation. This speculation runs contrary to all established thinking on the link known to exist between movement and the development of vision. Basically, the contention is that the profoundly multi-handicapped child born with healthy eyes originally (though not in every case) has the potential for the development of sight. However, having no concept of centre line and no spatial awareness, yet having a large degree of movement imposed upon it (the child) from without (over which the child has no effective control), vision is shut down to reduce sensory input - thereby decreasing the disorientation caused by having no fixed points of reference.

As the child grows and the experience of movement and of being handled increases and becomes more familiar, the child could possibly tolerate visual input, but is unable, having elected at a very early developmental stage to be non-seeing, to use whatever potential for vision was originally present. This is where light stimulation or, to be more precise, the use of different forms of light as a means of stimulating the visual cortex, comes into play.

Initially, all the equipment used was primitive. This equipment is still used in the early stages, both of assessment and stimulation. For example, a piece of hardboard 2 ft x 2 ft with 0.5 inch holes with 2 inches between centres, can be made with ease. The holes are covered with coloured paper in rows of primary colours; green, red, blue, yellow ...... Holding the board one way and using, say, a torch as a source of light, produces a line of all the same colours. The boards can be used to monitor either horizontal or vertical tracking responses. Once the board has been turned from the position where all the colours line up, i.e. through 90 degrees, the lines running horizontally will be a mixture of the primary colours originally selected.

Boards

• 

These boards, as is all the equipment used, are usually presented to a child in a dark environment. There is usually sufficient 'leakage' of light to permit the child's eye movements to be noted and recorded. The teacher or assistant, who knows a child well, will also be able to note changes in behaviour. These changes are usually associated with shifts in attention, and can be used as some indication of whether the child is responding in any way to the presented stimulus.

Other simple forms of stimulation involve the use of what are called 'target fans'. These are about the size of an adult face, oval in shape, made of luminous card with a spiral drawn freehand on the surface, the entire thing mounted on a stick to act as a handle.

Fans and slides

Luminous Card: "Target Fan"

The purpose of the spiral is to confuse the eye - a baby, for the first few weeks of life, cannot focus (accommodate). The vision is fixed somewhere around lm in distance. A baby knows when an object comes near because it goes out of focus. Conversely, when the object is withdrawn it goes back into focus. By moving the Fan slowly, so as not to cause movement of air around the child's face (and thus promote a response) either towards or away from the child's possible field of vision - present from all directions, i.e. up/down, across, towards/away, and note any pupil responses. (These fans work better under ultra violet light as surface contrast is increased. (Please refer to the note about Health and Safety regarding ultra violet light usage at the end of this article).

Other simple methods of light stimulation involve the use of a slide projector. The slides described here can be made with great ease and produce some interesting results. At present 15 slides are employed to produce light stimulation. They are presented, initially at a distance of 1 m and if no response is noted after several presentations, the distance is decreased in stages, to nose tip. The slides, projected on a wall-screen in front of the child (but also to both left and right of centre) are made up of bits of plastic 'gel' (the kind of material placed in front of stage spotlights to give them colour). The first slides are of strong primary colours, red, blue, green, yellow ..... Then the colours with shapes cut out of them - holes, lines - anything (use a sharp knife or a lighted cigarette to produce the lines and holes). Then irregular shapes on a red background. Next regular shapes on a green background and finally, and by far the most successful slide usually, a primitive face on a blue background.

• 

N.B. All of these slides are shown both in and out of focus.

Other useful slides to use are those that project lines of white light, ranging in number from one to a complete slide of lines (known as fine and coarse gratings and available from some suppliers of scientific equipment). If used, these slides are presented both in and out of focus to simulate movement, and the single and two, three, four lines slides are most effective when rotated through 360 degrees (remember that it is the movement of an object that attracts the seeing mechanisms of the brain first - not the object itself).

A further use of a spiral is to make one on a moving L.P. size disc and place it on a moving turntable. The responses to these forms of visual stimulation can be recorded (see attached record sheet - Light Stimulation Record). On the record sheet there is a section for colour glow objects (U.V.).

Ultra-Violet Lighting

This section applies to those who have access to a Iong wave ultra-violet light source. Basically, all the U.V. light does is to increase the possibility of a response to certain forms of presented stimuli by enhancing contrast. A portable desk top U.V. lamp in a wooden case is suitable if there is no existing light fitting in a suitable room, when a U.V. tube can be located (they will fit into any ordinary fluorescent light fitting, all you have to note is the length of the existing tube). These portable units are usually 20" long X 12" high and 12" deep. See below:-

• 

The interior of the 'box' is painted matt white (matt black was subsequently found to be even better) and their main advantage is that they allow close contact with very bright objects in everyday classroom lighting conditions. They can be used to promote visually directed reaching in those children capable of reaching and eye location in those not so capable - also tracking exercises can be undertaken using these U.V. boxes. (Today, some large stores sell battery-powered UV tubes.)

Finally, outside of a specially constructed light booth (see attached sheet for details of 'light booth') any source of moving coloured light is of value. There are some very inexpensive disco lamps producing excellent visual stimulation and usually found in local 'cheap jack' stores. On a more advanced level, boxes containing moving rows of coloured lights are very useful in producing and holding visual attention. These 'Twinkle Boxes', in some cases, can even be operated by the children themselves, using specially made switches linked to control boxes, thus a child has the opportunity to operate upon a part of the environment!!

Projector Image

The projector produces various images depending on the user's selection. The image used by the author consists of rotating lines of primary colours fixed around a black centre.

• 

Rotating lines of primary colours (Author’s selection)

This image is ideal for stimulating a visual cortex and 'we' have Special Needs children who, using the same kind of switches mentioned above (these include touch, sound, suck, wave, pressure and tilt operated devices) will switch the image, making it rotate. In some 'cases, a Special Needs child will even make two switching operations, one to switch the image on, the second to make it move.

Since this article was written, new and very exciting equipment has become available. See Rompa catalogue available from ROMPA, P.O. Box 5, Wheat Bridge Road, Chesterfield, Derbyshire S40 2AE Tel. 0246-2117777.

Issue 7, December 1982

Appendix 2: Light Stimulation Record

Name:

Equipment (see instructions)	Date	Exposure Times	Response	Other Factors
1.Targets (U.V.)
2. Slide Projector
3. Disco Projector
4. Colour glow objects (U.V.)
5.Record Deck

Keynote: Under Item 1-5 on original form, 10 responses are recorded.

Appendix 3: Note on light booth

(Formulated by Mrs. Johnson, ex-head of Special Needs, Mellands. Now head of a Special School, Manchester)

The light-stimulation booth has at least four basic applications. It offers an environment in which a variety of stimuli can be carefully controlled and recorded, so that research into practice can be well designed. It provides an excellent facility for the development of visual assessment techniques. It allows controlled visual stimulation programmes to be designed and carried out for both children with immature, undeveloped vision, and for those with more specific visual handicaps. Finally, it gives opportunities for severely handicapped children to learn to manipulate their environment in order to produce specific rewards in the form of sensory stimulation.

It is at least likely that severely retarded infants will suffer deprivations in environmental stimulation for several reasons. Many of them will be comparatively inactive babies, 'good' babies, and will not perhaps demand parental attention as a normal baby would. They will also fail to reward parental attention by smiling or cooing, and it is likely that gradually such parental attention will tend to become less and less. Since these children remain much longer at the stage of infancy, they will in fact continue to need environmental enrichment much longer than normal babies, as they will be unable to effect changes in their environment for themselves.

If one takes up a basically hierarchical view of development, then the failure of a child to develop one sensory modality will affect co-ordinations between that modality and others, and the results of this retardation will inevitably compound the primary retardation. A substantial body of research supports the view that environmental encounters of many kinds markedly enhance the speed of development in the infant's sensory-motor systems (Altman & Das 1964, Volker & Greenough 1972, Levines and Lewis 1963 and - again - White & Held). Other workers in this field have shown that very specific forms of visual stimulation produce optimal results at certain developmental stages, or under certain conditions. For instance, the beginnings of human perception are specially sensitive to moving stimuli, and - most markedly - to stimuli in the outer peripheral edge of the visual field. Also, at the onset of visual development, the infant does better with monocular than binocular vision (Epstein 1964), and babies under six months of age show no sign of discriminating colour. The light booth enables a visually enriched environment to be specifically applied, tuned to developmental age and also to individual difference. (See Fantz 1962 for work with patterned surfaces).

In the light booth, we can study with some degree of accuracy which forms of visual stimulation prompt responses, and which indeed will act as rewards for subsequently learned skills.

NOTE: The booth measures 8' X 6' X 7'6"

Appendix 5: Hand/eye co-ordination check list

It was considered that a separate quick reference scale of visual ability was advantageous with regard to gaining some knowledge of a child's use of vision as an indicator of cognitive ability in developmental terms.

Age in Months	Auditory Responsiveness	Date
0.1	Responds to sound of bell
2.2	Searches with eyes for sound
2.6	Glances from one object to another
6.0	Looks for fallen spoon

Age in Months	Visual Responsiveness	Date
0.1	Momentary regard of red ring
0.2	Regards person momentarily
0.4	Prolonged regard of red ring
0.5	Horizontal eye co-ordination: red ring
0.7	Horizontal eye co-ordination: light
0.7	Eyes follow moving person
0.8	Vertical eye co-ordination: light
1.0	Vertical eye co-ordination: red ring
1.0	Following moving light with eye
1.2	Circular eye co-ordination: light
1.2	Circular eye co-ordination: red ring
1.3	Free inspection of surroundings
1.6	Turns eyes to red ring
1.6	Turns eyes to red light
1.9	Blinks at shadow of hand
2.0	Turns eye to moving finger or light
2.3	Eyes follow pencil
2.4	Follows pencil torch 90 degrees R/L slow tracking 11" from face
2.5	Regards cube
3.0	Follows or watches a dangling toy
3.0	Looks from one object to another
3.1	Follows ball visually across table
3.2	Head follows dangling toy
3.2	Head follows vanishing spoon
5.8	Attends to scribbling
10.0	Looks at pictures in books
11.0	Looks at people in books
18.0	Can scribble in circles and straight lines
23.0	Recognition of small details in pictures
24.0	Can copy a line - sometimes
24.0	Can copy horizontal and vertical strokes in scribble
24.0	Draw a circle
24.0	Can recognise pictures in favourite book (and photographs of favourite people)
27.0	Can copy a circle

Age in Months	Visually Directed Reaching	Date
3.1	Reaches for dangling toy
3.8	Inspects own hands
3.8	Closes on dangling ring: Right hand (R) Left (L) None (N)
4.1	Reaches for cube
4.4	Eye hand co-ordination, reaching
4.6	Picks up cube - check hand preference (R) (L) (N)
5.0	Persistently reaches - Eye/Hand co-ordination in reaching for small objects
5.2	Lifts inverted cup
5.4	Reaches for second cube
5.7	Picks up cube directly
6.0	Reaches and picks up objects immediately

Age in Months	Visually Manual Behaviour	Date
1.7	Reacts to paper on face
3.8	Inspects own hands
4.5	Watches own hands
4.6	(Grasps mobile, picks up one inch size toy/object)
4.9	Recovers rattle in crib
5.0	(Eye/hand co-ordination in reaching for small objects)
5.2	Lifts inverted cup
5.4	Sustained inspection of ring
5.4	Exploitive string play
5.5	Transfer objects hand to hand
5.7	Pulls string: secures ring
5.8	Lifts cup with handle
6.0	Sustained inspection of objects
6.0	Looks for object that has rolled out of reach
6.0	Reaches and grasps objects
6.3	Reaches out and picks up objects immediately
6.5	Manipulates Bell: interest in details
6.9	Look for objects which have rolled out of reach
7.0	Turns to look when object falls on floor
7.1	Pulls string adaptively: secures ring
9.0	Uncovers a toy seen hidden by a cloth
10.0	Waves "bye-bye" (imitation)
11.0	Finds objects seen hidden in box
11.0	Points with index finger
12.0	Points to near object when wanted
14.0	Removes an object from a bottle
18.0	Points to outdoors (distant objects)
18.0	Builds tower of 3 (after demonstration)
23.0	Throws ball into basket
24.0	Builds tower of 6 (after demonstration)
24.0	Imitates actions

* See programme planner for blind and partially sighted children of lower ability including severely learning disabled children (SLD), available from: Shawgrove School, Cavendish Road, West Didsbury, Manchester M20 8JR. Cost £2.00, Cheques/postal orders to Shawgrove School Fund.

Safety Note

The main theme article refers to the use of ultra violet light. Its use is a very interesting idea, but please be aware that it is potentially dangerous. There is a report available from HMSO about its use in the work situation; this was compiled in America and adopted by the U.K. There are three types of U.V. lighting, and exposure to any can be dangerous. Discussions regarding the need for safety standards and requirements related to its use in education have taken place and this is now receiving the attention of the Health and Safety Executive, 25 Chapel Street, London, NW1 5DT.

There is a need to establish a precise code of safety standards. Once these are laid down, ideas can and surely will be developed, using this light with fluorescent material with the children. Obviously, we do not suggest that you use it before these safety standards are written down for us to follow. Both the Health & Safety Executive and the Department of Education and Science are aware of its value as a teaching aid.

Preliminary Thoughts

Try to find out what assessment of vision has been carried out with each child. Useful questions to ask yourself:-

a) Does the child react to sunlight with his/her eyes and how? For instance, some children's eye lids will flutter when the sun's light falls on their faces.

b) Does the child's vision react to daylight?

c) Does the child's vision react to electric light?

d) Does the child's vision react to a lit gold disc?

e) Does the child focus on small shiny objects?

f) Does the child focus on other objects?

g) Does the child follow many objects?

h) Does the child react to colours?

i) Does the child use hand-eye co-ordination and how?

j) What vision stimulation/training has been carried out?

k) Have any visual aids been prescribed for the child (e.g. glasses)? If so, how are they used?

l) How does the child use vision to search for objects? What objects, how and where?

Issue 7, December 1982

Vibration and the multi-handicapped child

Many parents and teachers are aware that their children with a severe sensory loss can often be fascinated by vibration in all its forms. We often comment on how a child will love to sit with his or her cheek close to the washing machine or will spend periods of time making throat noises or repeating mouth-blowing games against his fingers.

In the two articles that follow, Elizabeth Carrington, Tim Williams and David Byrne show us how we can make use of this enjoyment and motivation in our daily teaching.

A. Vibration for the multiply handicapped child

By Elizabeth Carrington, then Senior Physiotherapist, York.

Why vibration?

Vibration provides a source of interest and fascination for many multiply handicapped children, some of whom may be entirely dependent on the sense of touch where vision and hearing is either damaged or unable to function due to a delay in sensory development.

Several workers have put forward the idea that there is a developmental sequence of responding to sensory stimuli. Initially, the dominant senses are those of smell, taste and touch, i.e. the near senses. Maturation takes the child to the next stage where the distance senses become dominant, first vision and then hearing. Children with delayed or retarded development may stick at the stage of near sense dominance for some time before they mature sufficiently to be able to make use of their potential for seeing or hearing. If they are tested at this time they may be unable to respond and will appear blind or deaf. Clearly there are children who are truly impaired but it is only through the work of teachers and therapists, who are involved with parents in devising programmes of stimulation for young and handicapped children, that an assessment based on observed function can be made.

Application of sensory stimulation should be child specific and related to the child's preference rather than the parent's or teacher's choice. If a child enjoys using his near senses, vibration can be used to enlarge that level of sensory experience with the advantage that it can be structured to help the child to learn in a way that taste and smell games cannot.

Will my child like vibration?

Perhaps your child already likes sources of vibration at home, e.g. the spin dryer, the vacuum cleaner. At school, the back of the piano provides inquisitive hands with wonderful rhythmic vibration. Other sources which your child may already enjoy include clockwork toys, your voice felt through your chest or throat, a trampoline which is stamped on or banged whilst the child is lying on it and a large beach ball treated in the same way

Preference for these types of games will give you a clue but the best way is to try a hand-held vibrator. Turn it on at a low level and move it slowly over the child's body whilst he is either relaxing on the floor or sitting comfortably. If you do not get any adverse reaction you can turn up the intensity of vibration until you reach maximum. Some children need very strong sensory inputs applying before they are able to attend. The Niagara equipment (see-below) will give you a stronger burst of vibration than will a battery-operated model. For many children vibration is extremely pleasurable, but ongoing interest is more likely to be maintained in those children who are unable to see or hear.

What will I see?

1. Stilling and attending

2. An expression of awareness

3. An increase in gross limb movement, e.g. arm waving and kicking, in a severely physically handicapped immobile child

4. Smiling and perhaps laughing

5. Reduction of anxiety and crying

6. Vocalising

7. Alteration in behaviour, e.g. cessation of mannerisms such as eye poking, finger flicking, etc.

Points to watch

1. Avoid vibrating over bony points if a child is thin and is not wearing much

2. Don't vibrate over fragile skin

3. If you cause a startle reaction, turn the intensity of vibration down to a low level

4. Try not to vibrate directly over a spastic muscle with a local application, e.g. hand unit at a high intensity. You may increase the spasticity and make movement more difficult. Where children have physical handicaps in addition to sensory impairment, they will probably be in contact with a physiotherapist who would advise.

5. If your child has very unsteady balance and is ataxic, or has involuntary movements as in athetoid cerebral palsy, vibration may well be disliked as it tends to enhance motor inco-ordination in these conditions. It is best to let the child show you his own feelings about vibration rather than pre-judging the issue.

What else will vibration do?

The effects of vibration are many and are of interest to parents, teachers, therapists and psychologists:-

1. Sensory effects

2. Motor effects

3. Behavioural effects

Sensory

a) Felt by the skin and received by the brain as a pleasurable sensation

b) Reduction of pain, swelling and the stiffness connected with swelling

c) Improvement in circulation in the skin

d) Sensation of vibration increases the child's body awareness and can be helpful in drawing attention to a previously 'neglected' limb

Motor

a) Gentle vibration has a relaxing effect and will reduce the tension in spastic muscles, when the vibrator is placed on them. Vibrate for 10-20 minutes. Effect can last up to four hours

b) Very strong vibration has a stimulatory effect and will cause the vibrated muscles to contract. This may be very useful if your child cannot make the muscle work by himself. When you stop vibrating the muscle, it will relax.

c) If your child has difficulty in coughing and keeping the chest clear of secretions and is perhaps awkward to tip up and clap in the usual way, a vibrator pad under the chest can be helpful in clearing the secretions.

Behavioural

a) Creation of pleasure

b) Catching attention

c) Increased motivation to attend or to move.

d) Vibration has been shown to be a most powerful reinforcer. It acts as a reward for completing a task and may accelerate the learning process. It may be more pleasurable than the child's self-stimulatory mannerisms (which perhaps need reducing so the child can explore a wider world) and can be used to change behaviour. Your child's teacher and/or psychologist will devise learning programmes to do this where it is appropriate.

e) It represents a method of communication with children who cannot speak or hear and who may also have limited mobility.

f) Progression up the sensory hierarchy. Children who develop responses to vibro-tactile stimulation can sometime transfer these abilities to their visual or auditory channel.

g) Training of self-help skills, balance and mobility in deaf blind children.

h) Relaxation of spasticity, in the profoundly physically handicapped, prior to personal care procedures. Comfort is increased.

i) Smiling and movement in an otherwise immobile child will be enjoyed by the carers as well. Vibration can help you to get into closer contact with your child.

NB: Beware of the child who has a tantrum so that he can calm down on the vibrator. Don't leave a child on a vibrator pad for long periods of time or it will no longer be a rewarding experience.

Practical examples of use of vibration

1. General body stimulation with a hand unit to make your child smile, laugh or listen to the altered sound of his own voice if you vibrate over the throat. He may want to put his hands round the vibrator and lead your hands. Use this initiative to play a reciprocal game where you vibrate over your throat whilst singing and then the child reaches for the vibrator and pulls it towards himself for his turn.

2. Having established interest in vibration, your child may be motivated to reach out, find and follow the moving vibrator. You may be able to persuade him to attempt a new movement. The teacher or psychologist will help you to structure the vibratory reward so the child has to work progressively harder to obtain this. Vibration can be altered in intensity, duration and quality. It can be continuous or pulsed.

3. Some vibratory equipment is designed to encourage a particular motor skill, e.g. balancing. For the blind child with delayed motor development, vibration is useful in helping to develop a feeling of mid-line and equilibrium. A balance platform is available which vibrates when the child is evenly balanced on both feet in standing. Correct sitting and kneeling can be trained in the same way. Vibrating walkways, which consist of a series of carpet-covered pressure switches, are used to reward forward stepping and give the child a lot of feedback about the position of the feet.

4. Potties, which vibrate when the child performs, are useful aids to toilet training for deaf-blind children.

5. Selection of the preferred type of vibration, i.e. strong, weak, intermittent, continuous, can help hand skills and perceptual development. Pressure switches which activate a selection of small vibrators mounted on a board, under a table or in a mat on the floor, provide interesting choices.

6. Children who find it difficult to play may be more interested in toys which contain small battery-operated vibrators.

7. The metal strip on the vibrator pad (* see equipment) is useful. Try encouraging a child who can grasp, to place the rattle onto the metal strip and listen to the sound it makes. For those who are unable to shake a rattle spontaneously, the vibrator will do the work.

8. Basic movements in your child's repertoire can sometimes be used as a demand signal for 'more vibration'. For example, putting two hands together may be possible but not used purposefully. Try putting the child into an undemanding posture such as lying on his back, or sitting comfortably with good support. Help him to put his hands together and give a short burst of vibration (count about six) from a pad underneath him, as a reward. Eventually you may find that the child begins to initiate putting his hands together himself in order to obtain more vibration. You have a demand signal - 'more please'. Sometimes movements that represent actual signs from a communication system such as Makaton will be physically too difficult, but alternatives can be found for some children.

These examples represent just some of the ideas which are being developed to help children with profound handicaps.

What sort of equipment is available?

Niagara Therapy UK Ltd., Colomendy Industrial Estate, Rhyl Road, Denbigh, Clywd. 0745-813666

Large pad

Hand Unit

Battery-operated disc

Polymodulated pad (intermittent vibration)

Mr C Black, Vibro-Medico, 20 Church Road, Hadleigh, Essex SS7 2DQ. 0702-557966

Niagara equipment marketed for schools and hospitals - as previously

Plus

Reward Balance trainer

Vibrating steps and slide

Walkway and crawlway

Reward trainer - platform with potty

B. The uses of mechanical vibration on the teaching of children with multiple handicaps

By Tim Williams, then Senior Clinical Psychologist and currently Divisional Psychologist (Children's Section) W. Berkshire Health Authority, and David Byrne, then Teacher in Charge, Mary Sheridan Unit, Borocourt Hospital, Wyfold, Reading.

In this contribution we will attempt two types of description of the uses of vibration. Firstly, we thought that there was a need for a readily digestible review of the published papers on the topic of the use of mechanical vibration. Secondly we thought that it might be helpful if more people knew about the uses to which we have put mechanical vibration at the Mary Sheridan Unit at Borocourt Hospital and also the ways in which we have used vibration in the assessment of profoundly handicapped children. Before considering the published literature on the uses of vibration, I would just like to set out the use of what may seem to be a rather unpromising technique into some kind of context.

Mechanical vibration is just one type of sensory stimulation that can be used to change the behaviour and hopefully the rate of learning of children. It is also possible to use sound, lights or even odours to help the children learn. It is relatively rare to use one of these sensations in the absence of another. This js particularly true of vibration, since the movement of the vibrator inevitably also generates some sounds. However, these are relatively low frequency sounds and as such do not correspond to the sounds made when playing music. Vibration should therefore be thought of as just one in a whole range of techniques that can be used to help children learn.

Surprisingly, there is also a theoretical basis for suspecting that vibration could be used to help children learn. Schachtel (1959) proposed that very young infants were most aware of events that happened very close to them and that they used the relatively primitive senses of smell and touch. Only later do children learn to rely on the distance receptors (eyes and ears) to learn what is happening outside themselves. In brief then, he believes that children begin by learning through changes of feel and smell, and only later do they develop an awareness of the senses of sight and hearing. If this theory is true, then the most handicapped children will tend to respond to touch and smell rather than sight and sound. Since these latter are the methods by which most human beings communicate and hence teach, it is possible that methods using touch and smell might be more effective.

Finally, there are also commonsense reasons for thinking that vibration could be used to help children to learn. This is particularly true of children with multiple handicaps such as the deaf/blind or the visually and mentally handicapped. For these children there are fewer ways in which information can be gained about the environment. In addition, it is often the case that those children with nervous system damage show abnormal reactions to sensory stimuli and the use of vibration may represent the only way to inform the child of changes, and hence teach him about new activities.

Review of published work on the uses of vibration

In this section, we intend to try and bias our comments towards a strictly practical slant, so that it should be possible for teachers and others to find out what is involved in choosing to use vibration for children in their care. We will therefore start by discussing the types of vibration that have been used, and how to assess whether a child is likely to benefit from its use. We will then go on to consider the uses to which vibration has been put.

Assessing what sort of stimulation a child responds to best should be one of the first tasks in working with the child. Many blind multiply handicapped children will be frightened and ill at ease if it is their first time in a new setting and they will often need reassurance. If the mother or father, or someone familiar with the child is there, it is worth observing carefully how they manage to soothe the child. Do they hold the child at all? Do they stroke him? Do they talk to the child or do they perhaps rock the child gently? Often, of course, the parents will have a number of different ways of looking after the child, but it is worth seeing if the components can be separated out. For instance, does the child respond to the first touch from the mother, or does she have to pick him up? If the child does seem to be responding to touch, then it is probably appropriate for the teacher to consider the use of vibration in the teaching programme.

Five studies have been reported in which methods of assessing the usefulness of vibration are described. Two of these deal entirely with psychotic or autistic children. However, the principles remain the same for all children. The first stage is to find out what the child does without any rewards. Then arrange things so that the child can switch on vibration or light every time he moves his arm or makes a "please" sign or whatever response has been chosen. Three of the studies use a lever to switch on either vibration or light or some sort of sound (Ferrari & Harris, 1981; Byrne & Stevens, 1980; Rincover et al, (1977).

Since Byrne and Stevens refer specifically to visually impaired, multiply handicapped children, it is worth looking at their results more closely. Essentially, they found that there was a significant relationship between the scores of the children on the Fairview Self-Help Scale and their responses to vibration or light as a reinforcement for lever pressing. Specifically, the more able children tended to have preferences for light rather than for vibration. However, there were a few children who behaved very differently from the others in that they preferred vibration although they were quite able. From the practical point of view, this means that one cannot assume that less able children will automatically prefer vibration, although in many cases this will be true. In particular autistic-like children often prefer vibration while being advanced in other respects.

More recently Hogg (1983) has investigated the effects of music, praise, or vibration on a multiply profoundly handicapped child. This study illustrates the careful attention to detail that is required if a useful assessment is to be made. The only behaviour that the child showed spontaneously was turning the head. Every time head-turning was seen, it was recorded. Although Hogg was able to use an electrical recorder, most people should be able to use paper and pencil to record this. One can then draw a graph of the number of responses for vibration or sound or praise and compare them. Hogg recorded the child's behaviour over many short periods, as did Byrne and Stevens (1980). This too is important since it increases the chances that the differences you observe are the true ones. Short sessions are important because in that way the child does not become tired and hence will continue to respond to the stimuli.

It is possible therefore to describe an assessment as consisting of a number of short sessions in which the children are given the opportunity to work for vibration, or some other possible reward such as praise or music. There should be a number of these sessions; up to about 10 with each type of reward. The behaviours of the child need to be carefully recorded and then drawn up on a graph so that it is easy to see how well the child responds for each type of reward.

Teaching and Treatment Using Vibration

In this section we will briefly consider how vibration has been used both as reward for performing certain activities, but also how vibration has been used to improve the chances of learning anything at all. These two uses may be distinguished by the fact that vibration may be given as a form of stimulation of behaviour, in other words before the behaviour, or vibration may be given as a form of reward or reinforcer after the behaviour. We shall start by considering vibration used before behaviour occurs.

In theory at least vibration could be used both as a signal that something was about to happen or it can be used as a method of initiating or enabling behaviour. In practice only the latter use appears to be described in the literature. Jones (1979) describes the use of vibration both as an enabling method and as a method of eliciting changes in behaviour. It has long been known to physiotherapists that the use of vibration enables greater mobility of the joints of both cerebral palsied and normal people. The paper by Jones also describes the use of vibration to prevent recurrent chest infections in a profoundly handicapped child. While the prevention of infection undoubtedly improves the physical condition of the child and hence the probability of learning, my concern is with the greater range of activity that may be possible with vibration-induced joint mobility. In the case described by Jones, the vibration induces almost double the extension seen when the person is resting. Enabling movement in this way allows not only for easier care of the child but also more opportunities for learning adaptive responses. It is not yet clear whether there are long-term effects, although Jones (1980) reports some improvements in another case that lasted beyond the period of vibration. It should be noted that the whole body of both people was vibrated, thanks to the use of a vibrating chair and a vibrating pad.

Jones (1980) also describes the facilitatory effects of vibration in the sense that vibration may cause a child to be more active. For the particular case described, very short periods of vibration (two minutes) caused movements of the head, fingers, eyes, neck and vocal chords. Myrvang (1973) also describes similar facilitatory effects on a profoundly handicapped child, although it is not clear from her paper that any of the children were visually handicapped.

Before using vibration to facilitate or to cause voluntary movements, it is important to ensure that no undesirable or potentially harmful movements are elicited. For this reason it is recommended that a physiotherapist be consulted.

Vibration as a reward

The use of vibration as a means of teaching new behaviours, rather than enabling behaviour to occur has been more thoroughly investigated. Vibration may be used either to increase or to reduce the rate of occurrence of certain behaviours.

Myrvang (1973) reports the use of vibration as a reinforcer for four profoundly handicapped children in order to increase the rate of vocalisation. Ten 15-minute training sessions resulted in an eight-fold increase in the number of vocalisations. The use of non-contingent vibration (an important control) resulted in only a five-fold increase.

Jones' (1979) paper again provides further clear evidence of the effectiveness of vibration as a reward. In this study he taught a blind physically and mentally handicapped girl to hold a cup for up to 70 seconds at a time. Jones reports that subsequently this girl learned to explore certain objects, and to hold her spoon at meal times.

Lest these results seem to present too one-sided a story, a study by Hogg (1983) demonstrated that vibration was ineffective in promoting head-turning in a profoundly handicapped child.

Goodall et al (1982) report the use of vibration and social reinforcement to teach four children with visual and multiple handicaps to place shapes in a form board. However, some children still failed to learn the task. Another paper by Goodall & Corbett (1982) recorded the effects of sensory stimuli on stereotyped behaviours. No increases in stereotyped behaviour were found with vibration, and in fact for some children, stereotyped behaviours decreased.

Mary Sheridan Unit Experience

Thanks to the generosity of Niagara Therapy we have been able to experiment with the use of vibration, and as a result we feel able to offer the children much greater opportunities for learning. A few examples of the type of learning that may be achieved should suffice to indicate the type of work we do.

Ideally, when children are assessed at the Mary Sheridan Unit, we check whether they will learn to press a switch or make some other voluntary movement in order to obtain sensory reinforcement. Although all children admitted for assessment are tested, this is often done informally rather than through the procedures outlined in the first part of this account. Vibration is often found to be the most effective reward for the multiply handicapped child admitted to the Unit.

At the same time, as we establish that a child will work for vibration, we also carry out a thorough assessment of the child's needs. This forms the basis for a teaching programme in which the goal and the rewards are clearly specified.

We have used vibration to teach walking, standing, toileting, elements of sign language and manipulative skills. One of the children who was deaf and partially sighted (rubella handicapped) learned to reproduce 20 signs from the Paget-Gorman sign system by being systematically rewarded with vibration for closer and closer approximations to the correct hand movements. In order to get her to do the signs, her hands had to be held for a lot of the time that this type of teaching was going on. In its turn this required one-to-one and as a result it could only take place during very short sessions of about 10 minutes at a time.

Another younger child, also deaf and partially sighted due to maternal rubella, was taught 'food', 'drink' and 'please', using the same methods. However, in addition to producing the signs, he also showed less interest in his otherwise constant eye poking.

Perhaps our most effective use of vibration has been for teaching standing and walking. This has been achieved at least in part due to the development of automatic apparatus which only vibrates if a step forward is taken. Steps backwards or small jumps do not receive any vibration. In this way we have taught a number of children, some of whom were physically handicapped, to take forward steps. The basis of the device is a long wooden platform with pressure-sensitive switches incorporated under a carpet. Thanks to some electronic circuits, the pressure switches are only activated in one direction. When used for teaching walking, handrails are provided which slot into the platform. However, it can also be used to teach crawling if it is made into a tunnel with an inverted U-shaped top. We have also used a set of steps and a slide on the same base unit to teach climbing. This apparatus has not been sufficiently evaluated for us to claim any great superiority of effect.

In conclusion, we would like first of all to say that although vibration is a useful and adaptable tool, both for eliciting behaviour and for rewarding it, it should not be considered the universal panacea. Some children will not be motivated by vibration any more than some children respond to praise. It is very important, therefore, to assess what a child responds to before drawing up teaching programmes, or buying expensive equipment. Even when vibration has been shown to be effective with a child, we often train the child to accept social rewards as well. This is done by ensuring that both vibration and a cuddle or praise are given simultaneously. In this way the cuddle or praise becomes motivating for the child. Therefore, we are able to use more normal rewards with that child, with all the advantages that go with them.

Equipment

Any object that "buzzes" probably vibrates. Hence it is possible to use electric toothbrushes, old electric razors (not Phillips type) or electric facial massage kits as small handheld vibrators. As far as more powerful vibrators are concerned, the Niagara Therapy vibrators are supplied by Vibro-Medico at 20 Church Road, Hadleigh, Essex SS7 2DQ. There may be other sources of such equipment since some of the reports in the literature imply that they have built their own vibrating motors. For further ideas on equipment it is recommended that one should read the article by Woods & Parry (1981) and Goodall et al, (1981) where a number of developments are described.

Select Bibliography

'Mentally Handicapped Children's Responses to Vibro-Tactile and Other Stimuli as Evidence for the Existence of a Sensory Hierarchy' Byrne & Stevens

Apex, Journal of British Institute of Mental Handicap vol. 8 no. 3 December 1980

'Sensory Stimulation and Stereotyped Behaviour in Rubella and Severely Handicapped Children' Goodall. E.

Conference for Provision for the Deaf/Blind - National Association for Deaf/Blind and Rubella 1981

'The Uses of Mechanical Vibration with the Severely Mentally Handicapped' Jones. C.

Apex, Journal of British Institute of Mental Handicap vol.7 1979 & vol.8 1980

Issue 9, July 1983

The mannerisms of blind children

By Heather Jones and Roger Hinds, then RNIB Education Advisers. Heather has now retired and Roger Hinds is Manager of the RNIB Specialist Employment Unit.

You have only to watch a politician or a member of your family to realise that we all have mannerisms. There are, however, certain behaviours common the world over to those born with little or no sight which can become so obsessive that they interfere with the learning situation or actually cause damage to the head or eyes. Eye poking, gyrating on the spot, head-banging or shaking, biting the hands, are a worry to parents and teachers. The following notes were put together following a day's discussion between Mrs. Heather Jones, Senior Education Adviser for the RNIB and Roger Hinds, a member of the Information Exchange team who has had very little vision since birth. There are no programmes to reduce undesirable behaviours: the aim is to initiate a change of attitude in the care-giver at the detailed planning stage of such a programme. What are these mannerisms? We are not thinking so much of hyperactivity or tantrums, fits or tics or compulsive muscle activity.

Eye-Poking

This occurs in some blind and weak-sighted children developmentally at the time the hands have found the face and mouth. Presumably, without vision-created desire to reach for objects and people out there in the world, and without visual-monitoring of manual reaching and grasping, the youngster finds his reward in stimulating his own body. He must get some primitive visual stimulation from poking and moving the eye-ball. Abler children can confirm this and talk of seeing colours or a silver ring in the poked eye. One can hardly design a programme to eliminate such a pleasure without offering a substitute, and it must be understood that the intervention must take place close to the child's face and eyes and the hands must be slowly lured away out into the nearby space. Music, glitter, another human being, all have a place, depending upon the needs and the circumstances of the individual case.

Finger-Flapping

Again, such behaviours have their origin at the time when the hands fail to move out into space from the mouth and eyes. It is as if the finger movements are dictated by the eye's need to see movement or changes of light/darkness patterns. There also seems to be an element of creating airflows on the face. In our experience, such finger-flapping can indicate the presence of a little vision, except that the habits may have been formed at an earlier age before the loss of sight. Where there is a little sight, intervention must offer, again close to the face, a vision-stimulation programme which has bright colour, movement and changing light intensities as its ingredients so that the needs of the retinal cells are satisfied. Perhaps the TV screen and appropriate animated colour pattern from the micro can play a part here. Teachers of the visually handicapped, however, have a vast range of ingenious toys and apparatus to offer you.

Other Light-Play

There are many records of children seeking out particular places where they play with sun-beams or other chinks of light by moving their heads or bodies somewhat repetitively and strangely. Some are simply drawn to look up at the light, at the window or in the ceiling. Such habits derive from a time when their weak vision was only able to feast on such light-sources and they could not, or cannot, see further visually-rewarding detail in their environment.

The Dangers

Obviously, it is in no way desirable to look directly at the sun or a strong light but it is agreed by the experts that no harm will come to the eyes if looking is encouraged greatly in ordinary circumstances. Our children need to sit close to a TV screen which may need to be clear and coloured. The point about the odd light behaviours is that they are socially unacceptable and, if repetitive, they preclude new vision learning situations. All issues of Information Exchange contain tips on vision stimulation, and we are beginning to gather suggestions for activities for the totally blind child. The golden rule is that people, in their willingness to romp and closely interact, are the best toys and learning aids.

In brief

The following points seemed worthy of a mention for those readers who are new to blind or weak-sighted children:

1. Intelligent blind people have similar mannerisms but can be aware enough to eradicate them or at least keep them private. The behaviours are in evidence throughout the world and are more likely in "deprived" conditions. No one should be blamed, least of all parents.

2. It is not wise to think in terms of a cure, although an enriched environment close to the face at the time of origin could form the best prevention. Some of us have found that worse behaviours can follow a shallow attempt to eliminate a mannerism without adequate substitution for what could be a biological need.

3. Scientific Exploration - we felt that it is vital to give children the benefit of any doubt and bear in mind that any seemingly odd behaviour may well serve a scientific exploratory function for that child, even at a primitive level of development. A few examples will illustrate what we mean:

Hand-clapping, clicking of the tongue, apparently inappropriate vocalizations etc. may be serving the purpose of echo-location; i.e. the child may be sounding off the walls about him and judging his whereabouts in space.

Head positions may appear odd but the child may be just getting himself into the right position to see best what he wants to; he will not be aware that he looks odd. If sight is confined to the bottom or to the sides of the eyes, the head will need to be eccentrically held high or to one side. This type of deviant posture is often in fact labelled "eccentric viewing".

With growing awareness of his own identity as a person amongst others, the blind child can demonstrate a reduction of mannerisms.

As with so much of our knowledge of human beings, we will learn most by observation: only by keeping detailed records of when and where and the time and the place of the behaviours, will we begin to understand their function and origin for the child. If there is a real problem, a specialist teacher of the visually handicapped and/or a psychologist can help you with the wider perspective.

References

Jan E. et al. (Eds) 1977: Visual Impairment in Children and Adolescents. Grune and Stratton, New York.

Baumeister A.A. and A.A. 1978: Suppression of Repetitive Self-Injurious Behaviours by Contingent Inhalation of Aromatic Ammonia. The Journal of Autism and Schizophrenia vol.8.

Burlington D. 1972: Psychoanalytic Studies of The Sighted and the Blind: International University Press.

Issue 10, December 1983

Approaches to curriculum (I)

By David Bethell and Judy Bell, then Peripatetic Teachers of the Visually Handicapped, Walsall. David Bethell is currently Statements Officer, Walsall and Judy Bell is Team Leader for Visual Impairment in the Wolverhampton Special Needs Support Service.

1. Is there an accepted, proven curriculum for SLD children?

We think not. They have only been considered 'educable' since 1970, and since then we have tended to offer them a mixture of care-giving, 'rich' environments that are intended to stimulate but leave a good deal to maturation and chance, and the use of 'behavioural technology' in getting them to learn specific skills. We recognise the importance of the environment, we agree that the behavioural approach has proved very powerful and useful in raising children's skill levels and controlling their behaviour, and we know that there is a whole range of exciting new work being done in the SLD field. However, most people would agree that we have not got a fully developed SLD curriculum yet, and that there are many shortcomings in what we offer these children. We make some suggestions about this in the next sections.

2. What are the main goals that the SLD curriculum should help a child reach?

We would argue that a curriculum for these children should have two main aims: to help them to some understanding of the environment, thus some control over it and some degree of autonomy; and to help them respond and relate as individually as possible to other people. We are not convinced that the present tendency to stress the mastery of specific skills - a stress on products and outcomes that may be useful, but are not necessarily generalisable - is the best or only way to help children get an understanding of objects and events around them. Such skills may help a child get information, but they may not be enough to help him order it or solve the problems it poses. We think that skills training needs to be complemented by sustained efforts to make the patterns, relationships and procedures of the child's world more accessible and intelligible to him. And we think that the imposition of skills by behavioural techniques tends to relegate 'interactive' teaching, in which we build on the child's initiatives, to a less important role than it deserves, thus decreasing his chances, perhaps, of developing identity and autonomy, and of forming any but dependent relationships with others.

(In this connection you may like to read, or re-read, R. McConkey's article 'Education without Understanding?' in Special Education: Forward Trends, VIII:3, Sept.'81).

3. Should the goals for a visually handicapped SLD child be different from these?

We do not think so, but we should say here that we prefer to think in terms of individual needs rather than of categories of disability within the SLD range. It seems clear that for a child who has little or no sight, the goals we talked about earlier are especially relevant and especially hard to reach because he will find it extra difficult to get information about his world, and to integrate and make sense of what he does get. Of course, such a child is going to need some special compensatory skills and some special teaching techniques and emphases.

4. How can you help a child towards a better grasp of his environment and a less passive, dependent relationship with others?

We do not have a definite answer, but we would like you to consider the following suggestions.

We think that in many schools, wards etc., the SLD VH child will get some specific skills training in general areas of development and, probably, in special 'VH' skills, some therapy, some outings, and a good deal of very dedicated but perhaps rather unstimulating care. However, it is often the case that the environment and its systems, patterns and procedures are informed by the organisational requirements of the school or hospital, by skills-teaching programmes and timetables and the ticking of their record sheets, and at worst, by staff interests that are peripheral or irrelevant to the needs of the children. You may say we are exaggerating, but ask yourself honestly:

• if you taped a whole day's talk in your class, how much of it would be with the children, intelligible to them or even relevant to them?
• how often during the school day is a child given a choice of materials, activities etc. rather than having them imposed on him?
• how positively do staff or visiting adults respond to initiatives from children?
• what proportion of the activities your children are involved in are 'artificial', i.e. polish a skill and evoke a 'Good Girl' or other reward, but have no 'real life' antecedent, motivation or outcome?
• how often, and for how long is a child, especially a VH one, left uninvolved, unstimulated, immobile?
• how valid is the 'scale of importance' that you present to the child by the measure of praise or blame you allot to his different actions and responses?

Perhaps you have an entirely clear conscience, but your answers may suggest to you that you are not doing enough to make the people and events of the child's world more real, relevant and accessible to him, to use opportunities for informal learning in naturally occurring situations, and to encourage him in interaction with other children and adults.

We think, simplistically perhaps, that if a child does not have some grasp of his individual identity in relation to other people and objects, the basic patterns of time, space and causality, it is impossible for him to behave 'intentionally', i.e. he cannot hold an aim in his mind, and recall and order information so as to act to reach this aim. To enable a child to have some autonomy, we have to try to help him follow and understand at least some of the patterns, systems and relationships in which he is caught up, by, for example:

1. simplifying, routinising and differentiating the stages of all activities in the classroom, giving children active roles in them if possible, and using any means to make the connections, e.g. between cause and effect, as obvious as may be;

2. trying, by the way we talk with, touch, and present things to the child, to make it easier for him to remember and thus anticipate events in a known sequence, and so to be able to plan and act even in the smallest, simplest way to take some control over these events;

3. having a firm policy of 'interactivity', so that any contact or activity initiated by the child is followed up by a teacher or aide, who tries to build on the communication or play that the child starts, without taking control over it; and that visitors to the class do not just talk to the staff, but relate to each child individually;

4. using the routine positioning and moving of children constructively, to help them understand spatial relationships;

5. using real situations and events for informal learning and for generalising formally taught skills;

6. letting children choose whenever possible, not simply in contrived discrimination exercises, but in the natural course of the day's events;

7. cutting down on extraneous noise, adult 'chat', and other environmental 'clutter';

8. making efforts to 'explain' things that happen in terms of causation, time sequence etc., by talking them through and acting them out to involve the child;

9. making differences (and perhaps similarities) between people and between. objects more marked by accentuating appearance, voice tone, texture, smell and so on;

10. at all times, showing that affection, sympathy, appreciation and other 'affective' behaviour is as important or more so than the development of a skills repertoire.

This may seem vague and more to do with classroom management than curriculum, but what we are trying to suggest is a full-time, whole-day, carefully planned endeavour to use all the activities in which the child is involved, not just as the infrastructure for skills training and care giving, but as a continuous opportunity to practise skills, to gain some understanding of the environment - some self-regulatory behaviour, if you like - and to grow in the affective domain, which for some very disabled children may offer the most satisfying and productive experiences. Don't get us wrong; we value structured, formal teaching to precise objectives very highly. But we do think it needs to be supported and enhanced by the 'complementary curriculum' we have outlined, which, we believe, is the most effective way to use all our resources for the benefit of the children in our care.

5. How does this complementary curriculum work out in practice?

In this section we have tried to identify some of the routine activities and organisational procedures of every school day which offer scope as learning activities in their own right, and we have tried to elaborate on the ten points we made in the previous section.

Arrival at School

DO

• have a specific welcome routine for each child;
• speak his name, touch his face;
• make up an individualised welcome song, perhaps always get the same person to sing it;
• give the child a sense that he has a separate identity from those around and that he can be treated in a unique way; give him the idea that arrival at school marks the beginning of the school day.

DON'T

• talk incessantly to other adults about things of interest only to you (last night's TV, husband/wife's snoring, etc.);
• speak a child's name in passing (if he can't see, how can he know who you are or if you are talking to or about him);
• treat children collectively so that they have no sense of the individual.

(The same points also apply to a child's departure from school.)

Dressing and Undressing

(outdoor clothes, for PE, swimming, toileting, changing time):

DO

• talk to the child about what or why he is getting dressed or undressed;
• encourage him to do as much as possible himself, and where impossible, physically guide him through the actions even if you know there is no hope of him ever learning the skill;
• help him feel the different textures of his clothes;
• give him some idea of the sequences involved; say, 'this comes off first, but before that comes off we've got to undo the buttons etc';
• give him some degree of choice, e.g. in whether or not he wants his jumper on.

DON'T

• pull the child's clothes off or on with him making no contribution;
• talk to other people whilst you are helping him with his clothes;
• ignore the naturally occurring needs for dressing and undressing only to concentrate on the skills in a carefully structured one-to-one programme (great if this is possible as well - but try to give the child a reason for doing it),

Provision of mid-morning drink:

DO

• tell the child what is going to happen;
• if 'squash' is on the 'menu', take him to the tap so that he can turn it on to dilute the drink (for a VH child this will make the source of the sound of running water identifiable and give him a chance to make the cause/effect connection);
• let him feel his cup or feeder;
• shake it so that he can feel the liquid moving inside;
• let him smell the liquid to help with identification;
• give him a chance to accept or refuse a particular drink (you can do this even with a very profoundly handicapped child by holding the feeder so that it only just touches his lips);
• give him a choice between two drinks (you are given the choice of tea or coffee in the staffroom!);
• tell him when the liquid is almost gone and you are going to withdraw the cup from his mouth.

DON'T

• suddenly thrust a cup or feeder in or out of a child's mouth without prior warning (the event should be related to what comes before and after);
• hold the cup/feeder for the child without guiding him through the actions;
• make him drink at your pace instead of his own.

Toileting/changing

DO

• tell the child what is happening and why it is being done (if he doesn't understand the words 'wet nappy', let him feel the wetness with his hand);
• encourage him to hold the flannel used for washing;
• allow him to smell the talcum powder - perhaps have a different fragrance for each child for individuality;
• allow him to flush the toilet and listen to the resulting sound;
• allow the child the right to individual attention and personal dignity by only dealing with him and not six others at the same time.

DON'T

• screech, shout, and make disgusted noises if he has an accident;
• hurry through the whole process as quickly as possible (it may be unpleasant, but in the long term self-regulation may be achieved more readily if care is taken to make the proceedings understandable to the child);
• leave the child unattended on the toilet for long periods (if successful he needs to be told how clever he is straight away, not ten minutes later);
• treat all children as though their toileting needs are the same;
• allow one person to take a group of children en masse to the toilet.

Mealtimes

Many of the do's and don't's already discussed under the heading of the mid-morning break apply here. In addition -

DO

• prepare a child for mealtime by having a set sequence of events, washing hands, putting on apron, for example;
• take him to the dinner trolley, or if possible to the kitchen to (see) smell the food and its preparation before it is presented to him on his plate;
• tell him about the different foods available;
• keep the different foods separate on his plate so that there is some chance of him seeing the differences in colour and texture (he may eventually be able to discriminate between e.g. potatoes and meat);
• use an unpatterned, contrasting plate so that his residual vision can be used to distinguish the food;
• if he is totally blind, allow him to feel the food with his fingers - at least in the early stages of schooling;
• talk him through each mouthful telling him what he has in his mouth - if possible, allow him some choice over this.

DON'T

• mix all his food up together so that every meal is an amorphous mess with no special visual or gustatory identity (if this happens he will have no reason to look at his food because it will always look the same);
• talk to other adults as he is eating;
• allow the food to get cold 'because it might burn him';
• feed more than one child at once - it must be an individual process with plenty of opportunities for interaction;
• be in a tearing hurry - it's a school, not a fast-food restaurant! (What happens at the meal is probably more important than what happens afterwards).

Visits by therapists and/or specialist teachers

Each child may receive several visits during the course of the day, so

DO

• ask visiting professionals to adopt a unique greeting for each child which they will always use;
• emphasise the differences between people by encouraging the child to feel their hair, beard, face, or distinctive clothing;
• ask whether visitors could always use the same perfume, aftershave, etc, to accentuate their 'sameness' over time but also individuality;
• always get visitors to explain to the child what is going to happen in their period of therapy.

DON'T

m

• allow visitors to grab Children without greeting or warning;
• allow professionals to use a child as an illustration for an impromptu lecture or demonstration (especially if the child is required to do something out of situational and temporal context).

'Free' Activity: (i.e. when there is no set timetabled activity)

DO

• provide the child with a choice of things to do and make sure he is given the means to make that choice;
• make sure there is one member of staff who has special responsibility for the child during this time.

DON'T

• leave the child unattended for long periods with nothing but 'canned' music to listen to. At best he will go to sleep, at worst it will drown environmental sounds and teach him that sounds are unrelated to the events going on around him.

Movement between activities

It is generally accepted that mobility is important for VH children - but how often do we consider helping it through non-timetabled activities?

DO

• tell the child where he is going;
• encourage or prompt him to feel his way along the wall, touch pieces of furniture as he passes them, feel the door handle and the door itself as he passes through it and listen to it slam as he pushes it shut (if he can't see and is incapable of independent movement, this is going to be one of the few ways in which he can learn about space, his passage through it, and the relationship between himself and 'fixed' objects);
• put up different textured tactile strips as route markers between familiar places to help him find his way if he is mobile;

DON'T

• push or drag a child passively along from one area to another;
• expect him to find his own way if left in the middle of a large area with no tactile or auditory reference points.

Positioninq of pupils for different activities

DO

• have a plan of where each child should sit/lie at different periods of the day - if necessary, pin it on the wall where everyone can refer to it;
• make sure the child sees and 'hears' the room from different directions and angles - sometimes facing the door, sometimes with his back to it, sometimes in the sun, sometimes in the shade. If he is blind, he should have the opportunity to hear environmental sounds coming from different directions;
• ensure that children do not always sit in the middle of the room - sometimes, especially if they are VH, restrict their space by sitting them in a corner where they can feel the boundaries of their world;
• vary the kind of surface they sit on (lino, carpet, beanbag, resonating platform, rubber mat, lap etc..);

,DON'T

• always sit the child in the same place (or in the same position relative to other children);
• when you are working with a child, always sit facing him - try him next to you, on your lap, lying alongside you.

Structured skill training

We emphasise that this is vitally important for most SLD children, but we think its effects must be maximised and generalised by taking opportunities to embed formally taught skills in the 'complementary' curriculum. For example, (a), if the objective of a behavioural programme is 'the child is able to sort objects into two groups according to function', we try to further his understanding of object classification by getting him to sort out all those chairs that have to be stacked before home time; or after lunch, to collect plates (or forks or knives) so that they are sorted for washing up; or (b), a child who is withdrawn for visual skill training of, say, tracking, can be encouraged in the ordinary classroom to track something motivating like the lunch trolley. (More on this point in section 6).

Wasted opportunities

In addition to the specific examples we have given, we feel there are a number of events that go on in and around school which do not usually impinge on the children at all. Whether or not they can be incorporated into the 'complementary' curriculum depends on the circumstances of schools and the willingness of non-teaching staff. We suggest that such activities as:

• doing the washing in the washroom;
• helping the caretaker sweep up leaves;
• helping him fill the splash pool;
• helping the cook with the preparation of lunch;

offer very valuable lessons in co-operating, in the understanding of sequences (After I've messed up my clothes they have to be washed! Before I eat my lunch it has to be prepared and cooked) and in cause and effect. Similarly, infrequent and unexpected events can be made accessible to the child, as when the delivery truck comes and is heard in the classroom, the child can be taken out to feel the heat and vibration of the bonnet, to sit in the driver's seat, rather than being kept 'on task' at the inset jigsaw.

A note on staff organisation

The approach we are advocating is essentially one based on the importance of individual and interpersonal interaction. As some of our children may have to cope with a multiple caregiver regime outside the school, we think it important to develop specific relationships within the classroom. For this reason, we think it would help if, as far as possible, responsibility for particular children was allotted to staff with a particular liking for them. Thus, children may have a greater chance of developing relationships with staff and staff have an increased chance of interpreting the child's attempts at initiation and communication, than if staff are constantly changed around. If a child likes and responds well to a member of staff, joint activities which would otherwise not be reinforcing for the child may be turned into an enjoyable and motivating experience.

Clear staff organisation is important in this approach. We feel it may be necessary to timetable frequent short breaks and discussion periods so that there is time for planning and co-ordination - and for some relaxing adult chat away from the children.

6. How do you set about organising a curriculum for the individual visually handicapped child?

We'll use a diagram here, but if you don't take kindly to such things, skip on to the explanation below it.

• 

Explanation

Stage 1: Getting information

You'll have the usual general data about the child. In addition to this you will need the special 'VH' information, as follows:

• something about the management of VH (the RNIB booklet 'Guidelines for Teachers and Parents...' advice from your peri teacher etc.);
• What ophthalmological information can you get from the child's eye specialist, or (often the best source), his orthoptist? Often medical information is unavailable or non-commital or misleading, but it can be a great help, e.g. in prognosis.
• absolutely essential, an assessment of the child's functional vision. You may be able to get-a specialist VH teacher to do this for you or with you, or you may have to do it alone, but you must have it. (See published assessment guides such as the Peabody Functional Vision Inventory for the Multiple and Severely Handicapped). You must at least know if the child has useful vision or not, if his vision may be improved, what the optimal conditions for his use of sight are, and so on. More precise details of his acuity, field, colour preferences etc. will be very helpful.

Stage 2: Analysing the information and setting aims and objectives for the child.

We can't give you a step-by-step guide to this critical and difficult stage; you probably have experience in doing something similar already. Here are a few points:

• Usually, the accepted basic skills categories are appropriate for the VH child, with programme modifications for those with poor but useful sight, and some deletions and special additions for those who don't use sight at all; […]
• Vision has to be very severely down before a child stops using it as the preferred mode for getting information and for integrating the information received from all senses, so it's nearly always worth trying to 'train up' a child's vision;
• The SLD child who can't see (or doesn't respond at all to visual stimuli) is in a very bad way. Lack of sight will compound his disabilities over almost the whole range of development; he will have difficulty in getting and integrating basic information about himself and his world, and although special compensatory VH skills teaching may help him, he will be in especial need of the 'complementary curriculum' we have described, and the empathic and common-sense approach that goes with it.
• Have high but realistic expectations. It may be wiser - dare we say it? - to help a very profoundly handicapped child to have some enjoyment and to make progress in relating positively to other people, rather than to continue fruitless efforts to improve his cognitive skills (although obviously the two are related);
• It will be much easier to set precise, assessable objectives for the child in the area of specific skills than in the back-up area of the complementary curriculum. This, perhaps, is why we usually neglect it. We could say that the goals in this area subsume the objectives of the skills programmes, reflecting them in deliberate but informal, real-life practice, correlating them in broader contexts, and emphasising that they need to be learned and used in interactive rather than imposed relationships. For instance, if in fine-motor skill training a child is learning to unscrew tops, we make sure the actual skill practice is woven into the day's events, when we make coffee, open the sweet jar and so on, and try to interpose it in activity sequences where the manual skill is subordinate to other goals to do with choosing, acting on the environment and so on; and similarly if we are training a child to give attention, hold his head up, or in other attempts to control behaviour at as basic level, we would try to complement it sympathetically by building a relationship with the child that allows his initiative to take over from our imposition as soon as possible;
• If your L.E.A. maintains careful and well-composed statements on special-needs children, they may help you. They, and the advice on which they are based, should list goals and objectives for the child, describe his difficulties, and give details of the help that is to be provided for him.

Stage 3: Specifying curriculum to meet the goals and objectives.

The school curriculum is your starting point. Some objectives will be reached through 'ordinary' programmes, some through modified programmes which take account of sight loss, some through special VI programmes. You must have a functional vision assessment. Its results (e.g. can the child see small objects (1cm. diam.) at arm's length? does he respond better to orange than red? can he recognise people visually across the room? which is his dominant eye? over what arc can he track moving objects? etc.etc.) coupled with your own commonsense, will enable you to choose, and if necessary, adapt programmes to suit the child who has useful residual vision. The child who is not using vision will need an emphasis on the compensatory skill programmes (usually, sense stimulation and training - kinaesthetic, hearing, smell, touch, taste, sight - some information on these in back copies of IE) - and most importantly, on an overall endeavour to help him get information and make sense of it. This would entail especially finely graduated programmes, your imagination and ingenuity in helping the child build up concepts and the correlations between them, and particular stress on the approach we are trying to outline. As you decide on programmes, you should try to 'embed' them in the complementary curriculum. This is a great deal easier said than done, of course. Four important factors will be:

• careful consideration of the ways in which you would like the skills the child is learning to become generalised;
• a detailed analysis of a day's/week's activities;
• timetabled time for planning and co-ordination;
• the involvement and commitment of all staff concerned with the children (even dinner ladies and coach escorts) in this sort of approach.

Stage 4: Evaluation and feedback.

Standard procedures for evaluating skills objectives. The success or otherwise of wider goals will be reflected in the skills results and in the general progress of the child rather than in any specific gain, but one would hope to see improvement - it would probably have to be subjectively judged - in the child's autonomy and responsiveness to others.

The best criterion may be your own satisfaction - your conviction that you are not wasting any of the time or opportunities the child so badly needs to make progress.

You would expect to make an almost continuous assessment of the process, modifying it as necessary.

Issue 11, March 1984

Approaches to curriculum (II)

By Judy Bell and David Bethell, then Peripatetic Teachers of the Visually Handicapped, Walsall. David Bethell is currently Statements Officer, Walsall and Judy Bell is Team Leader for Visual Impairment in the Special Needs Support Service in Wolverhampton.

Some Ideas on the Adaptation of Curricula for Visually, Mentally Handicapped Children

Perhaps the first, rather obvious thing to say is that if a curriculum is to be adapted it has to be done on an individual basis. A child who is totally blind is going to have different needs from one who has some useful residual vision. So, if any additions are to be carried out you should already know:

a) which senses the child is using to gain information; and

b) the extent to which any other handicaps affect his abilities and needs.

In spite of the disagreements about what the curriculum actually is, most people agree that certain areas of development, e.g. language and communication, motor skills and self-help should be included. Usually they are incorporated in a written curriculum in the form of developmental checklists with small steps between each clearly specified skill. However, quite often certain steps are partly, if not wholly, inappropriate for children with a severe visual handicap. We think that, according to the individual's degree of sight loss, adaptations will have to be made by deleting, modifying, substituting or adding to the skills taught, materials used, time scale adopted and teaching procedures employed.

We realise that this is probably a gross over-simplification of the processes involved in adapting a written curriculum and, to some, it may seem that we are merely stating the obvious. However, we feel that it does offer an organising structure which is simple enough to be usable, but flexible enough to be applicable to a wide variety of different types of curriculum checklist.

In the following section we have tried to look at each of the elements we have identified (skills, materials, procedures, time scales) and have given examples of how these might be adapted in practice. Wherever possible, we have devised examples which we feel are typical of many SLD school curricula, although we have not used that of any school in particular. Of necessity much has been left out and in some cases artificial distinctions have been made for the sake of clarity. Please forgive us for this.

Adaptations involving materials

Perhaps the most obvious - this is why we have listed it first.

1. Many curricula include skills involving colour discrimination tasks. These are inappropriate (not to say impossible) for totally blind children. If the skill is not to be dropped altogether, materials would have to be modified to incorporate different textures, weights or possibly smells so that discrimination could take place using these parameters instead of colour.

2. In the early stages of motor programmes a child is often required to turn his head in response to a visual stimulus. Sound, smell or possibly taste could be substituted here.

3. Non-visually handicapped children may experience some problems in developing a sense of position in space, but these are likely to be less severe than for the visually handicapped multiply handicapped (VHMH) child who cannot see the floor, walls and ceiling of the room. There will be particular problems if a physical handicap precludes independent movement. Additional specialised equipment may have to be devised and built to give such a child even the most basic concept of finite space. An artificially confined space or box (similar to that advocated by Lilli Nielsen) may have to be used in which the child is placed for short periods so that he can feel the boundaries of the 'world' outside his own body.

4. Obviously, any material which depends purely on its visual interest will be inappropriate for the seriously visually handicapped child. In particular, language programmes may contain material incorporating complex pictures. These would have to be drastically modified or possibly dropped altogether. For example, a severely visually handicapped child would be unlikely to be able to describe the actions going on in a complicated, full-colour picture or to say whether something was in front or behind something else in the picture if he was never able to see anything more than six inches from his own nose.

Adaptations involving teaching procedures

1. Many schools who have adopted a fairly strict behavioural approach use techniques of prompting and fading to teach skills specified in their checklists. Usually this involves the use of gestural prompting as a half-way stage between physical and verbal prompting and verbal prompting alone. If a child can't see the teacher's hand and arm movements, then gestural prompting is clearly superfluous and the intermediate stage would have to be missed out. Perhaps, the fading of physical prompting would have to be more finely graded so that, for example, the final physical prompt in getting a child to do up a button would be for the teacher to lightly click on the button and then to touch lightly the child's fingers.

2. A common and very valuable teaching procedure is that of encouraging children to learn through imitation. There is little hope that blind or severely partially sighted children will be able to learn much in this way. In fact, it is often quoted as a main area of concern for teachers of blind pupils of normal ability. The only alternative to deleting this procedure altogether is to physically prompt the child through every desired action or skill. This does have some fairly major drawbacks, however. Have you ever tried to prompt a 10 stone VHMH child through the process of skipping or climbing a rope?

3. Just as imitation is a very useful tool for the teacher, so too is language. You may have to modify the kind of language you use in teaching a severely visually handicapped child by making it far more specific. The instruction "Go over there" accompanied by a point in the desired direction will have little meaning whereas, "Go and stand next to the door of the store-cupboard" may give rather more clues as to meaning.

Adaptations involving skills taught

Severe loss of sight or total blindness means that a whole range of skills which are either unnecessary or of only very marginal concern for the fully sighted mentally handicapped child have to be taught. We have only managed to list a few of these below.

1. Skills relating to mobility - finding the way around - are likely to be particularly important for the VHMH child. Probably entirely new programmes will have to be added to the curriculum to enable the child to find his own way around: a) the classroom; b) the school; c) the playground; d) his home

2. Extra skills may have to be taught in sequences designed for the fully sighted. For example, in a teeth-cleaning programme it may be necessary to teach a child strategies for locating the toothpaste and toothbrush before getting on with the business of unscrewing the cap, squeezing the tube and scrubbing the teeth.

3. Skills of order and neatness assume especial importance over and above those normally demanded for the sake of social acceptability. If a visually handicapped child is taught to take off his clothes he must also be taught to pile them neatly and in a set order so that time is not then spent in hunting for lost clothes or in trying to work out the identity of a carelessly thrown down garment.

4. Many schools include in their programmes the skill of identifying objects by their sound - usually as an early part of their receptive language scale. This, together with the location of sound sources and the recognition of individuals by their voices, represents a vital skill area for children with little or no sight.

Adaptations involving time scale and sequencing

Though the eventual aim of education for VHMH children will be the same as for those with good sight, the sequencing of the objectives adopted to reach this aim and the time spent at various stages of learning will have to be adapted.

1. Adequate understanding of language may have to be established before a blind child can be expected to attempt certain motor skills. The lack of ability to imitate will, as already mentioned, preclude the copying of movements. These might therefore have to be described to a child in inevitably fairly complex language.

2. Children with very low vision may need far more assurance before attempting certain motor skills. Leaping off boxes becomes very difficult if you can't see where you are going and don't know when you're going to land. There needs to be a lot of trust in the adult requesting the action - and trust needs time to develop. Perhaps there needs to be a particularly heavy emphasis on the effective side of the curriculum for these children.

3. Finger-feeding may be considered to be either a non-desirable or a very transitory stage in a self-feeding programme for a sighted mentally handicapped child. However, a blind child may need to finger-feed for a much longer period in order to learn about the properties of food, the relationship between food and the dish it is on and between food and his mouth.

In what we have written above, we haven't really mentioned the area of language and concept development. In the last section we have made the point that language is vital as a pre-cursor to many skills which a blind mentally handicapped child will be expected to learn. Yet the very teaching of language and related concept development may be particularly problematic and require a special curricular emphasis. Much care and planning will be needed to get even the simplest of concepts across in some sort of order rather than as isolated bits of information. The teacher will have to be involved in highly structured formalized and planned out work which will have to include not only the set programmed work, but also in everything which goes on in the classroom. For example, an apparently simple concept such as 'a chair' may be thought by a mentally handicapped visually handicapped child as 'the action of me sitting down', ‘my own wheelchair', 'anything you can sit on', 'something which is hot, uncomfortable and pokes me in the back' or perhaps 'something which moves me from place to place'.

Issue 12, September 1984

‘Deaf-blind’ children

by Peggy Freeman, teacher of multiply handicapped children, founder of the National Deaf/Blind and Rubella children's Association (Sense) and author of a number of specialist books and articles.

Firstly, I believe we should be aware of exactly what being blind or partially sighted as well as being deaf or partially hearing means to the child himself. It is easy to say 'He is blind' or 'He doesn't see well' or 'He hears only loud sounds' and so on, and to have a concept of what this means to us. But how often do we stop to spell out in so many words the extent to which this double disability affects the child's ability to learn and therefore the development of his true potential? A visual handicap combined with an auditory one means that the child misses those vital early clues to making the relationships with his fellow human beings, clues about the environment in which he has to live and act and which he has the potential to influence. He misses visual clues about the way people behave and therefore of what is socially acceptable or not, how it is perfectly natural to become an independent being.

None of us gathers information randomly - we seek for that which we want to see to satisfy and realise an objective. Sighted children easily learn to discriminate objects because they are usually within a framework and can be expected to remain there; if the partially sighted child sees only in part or hazily and has no verbal prompts to help sort out what he sees, his world may well be chaotic; he lacks the security that follows from knowing that things generally stay in the same place.

Hearing allows us to develop communication with others, to store information efficiently, through language to think, express ourselves in words and in writing it enables us to share the thoughts of others through conversation and reading, which in turn influences the way we think and behave. Where a hearing loss is further complicated by poor vision the road to achieving all this is long and few deaf/blind children make it. A normal child learns much by eavesdropping but you cannot eavesdrop on signs. Hearing is the only sense that can literally bend round corners allowing us access to several inputs at the same time - it comforts the baby to hear his mother about the house even though he cannot see her - when the mother of a deaf/blind child leaves her baby alone, he is truly on his own. The baby moves to touch what he sees - his mother's voice warns him when to move is unsafe. He sees us walk, jump, dance and he sees both the joys and the benefits of being able to move. A deaf/blind child's world is as far as his arms will reach - beyond this lies the unknown. Toys that encourage fine motor control in the normal child have no meaning for him, they do not relate to the world as it seems to him.

No child is born ready to learn for himself - he reaches this stage only as a result of going through sets of recognised skills acquired naturally during the first few years of life - we cannot take it for granted that the deaf/blind child will also acquire these without help. For instance, if he has some residual hearing, we nearly always have to teach him to use it - that means first learning to listen, to be aware of sound and no sound, to discriminate between different pitches, speed, rhythm and to associate sound with its source so that it acquires meaning - unless he has these skills we cannot assume that he will use residual vision - we shall have to be certain he possesses such skills as fixating, tracking, focusing, etc. We have to observe and check whether he has these skills and if not, this is where we must begin his training. These are the assets of which he must make the fullest use. His greatest asset is the sense of touch and of this too he must make the fullest use.

Body contact is a form of communication of relationship and therefore of socialising. Temperature affects the way we feel and a child who is uncomfortable is not a receptive one. Pressure provides a wealth of information, and can be an efficient way of remembering things: for instance, if you are on the receiving end a slap conveys a very different message from that of a caress! The way we differ in handling a child, in terms of firmness, intensity, position; or if we are tense, angry or frustrated, provides useful clues to people's identity and feelings. If we are not consciously aware of the importance of conveying these things to the deaf/blind child we shall deprive him of much that could be valuable to him. We cannot assume that the deaf/blind child will automatically develop an enhanced sense of touch - there are skills involved in using touch for information which we may have to train him to use.

Touch is, therefore, not a minor sense nor confined to exploration by the hands as often as tends to be thought. Every part of his body will gather useful information; but only if we emphasise those things which can be received in this way; it cannot be left to chance. He will not learn to explore efficiently with his hands unless we first show him how and provide appropriate experiences -shape, texture, weight and so on. Whether or not there is a possibility of useful vision and/or hearing developing after training, I feel that all children with the dual disability should be encouraged to develop tactile skills. In this way those who can eventually learn through sight and hearing will have come to no harm - but for those who cannot go this far, we will not have lost valuable time.

In examining the effect of the dual handicap on the child himself, his needs become that much clearer. This child needs someone to interpret his environment for him - if we can think of ourselves as 'intervenors' rather than teachers, this states clearly what we must do. Our hands become his ears and eyes - we do not stand face to face to teach him, we stand behind him with our hands on his to guide him, we do not lead him, we go with him. We call this method 'hands on'.

We must also discard the idea that we are going to 'teach this child to communicate' and 'by such and such a method'. As intervenors, we come between the child and his environment, passing on to him the information he cannot get for himself - to do this we have to communicate with him. In other words communication is not taught but used, it is a medium by which this child learns and he learns by using it. He will not communicate with us until we have communicated with him; he will not communicate until he has something to communicate about, and this depends on the information we provide for him. Nor, incidentally, will he communicate with us until we have shown him how to respond to us. Too often in the past we have shown these children how to receive information but failed to show them how to respond - without this they may not realise they can or should respond.

So the position we take - whether it is for information about an object, or showing him how to do something or communicating with him to tell him something - is with the child's back to us. Not only do our hands guide him more accurately this way, but in addition he gets clues as to how to position the rest of his body from the position of body holds. This way you convey far more information than when working from the front, you direct the child in the activity at the natural angle which is more comfortable for him and more likely to get his co-operation. You also have greater control over him - you can use your body to cut out things which might distract his attention and also to direct his head to where you want him to look. You are in the best possible position to speak directly into the child's ear or within a distance from his hearing aid.

Of course, when the child is still small, you can work with him on your lap, later putting him between your legs whilst you sit on the floor or behind his high chair or at a small table. Gradually you can move to a position at his side but still with the ability to guide both his hands from behind for learning a new task or to prompt him when necessary in a task he is beginning to master.

'Hands on'

The deaf/blind child needs us to help him identify those features or objects which will enable him to recognise and remember them. For instance, the hollowness which is common to all things from which we can drink; the shape - long, low, with a bump at one end - which identifies all beds and makes them different from things on which you sit such as chairs, stools and settees (what is common to these?); the roundness that is common to balls, plates, saucers, wheels etc., and the differences which determine how each of these round things is used. He needs us to show him how to do things with his hands – self-care activities such as feeding, dressing, washing and so on; fine motor actions such as banging, squeezing, pushing, threading, working wind-up toys, etc, should all be demonstrated in the 'hands on' position. We continue to do this until such time as, through our hands, we feel the child developing an anticipation of what has to be done next, and this is the stage where we can begin to lessen our guidance and encourage him to do it for himself.

Generally, it is best to encourage him to do the last part of an activity by himself, for instance to pull off the sock we have together pulled down the leg and over the heel already. When he can do this, we encourage him to do the last two parts and so on - back-chaining. It is important that we never do for the deaf/blind child what he can do for himself. It is also important that we do not just show a child how to do something and then forget to draw his attention to the effect of what he has done. He must understand what has been achieved by what he has done, whether this is good, bad or an absolute disaster!

I find that it helps when working 'hands on' if you regard the activity you are sharing with the child as a sequence of movements which together make a pattern. Piaget's theories about how the young child develops random movements and then simple single patterns which can be used in complex sets of patterns depending on different situations, have been helpful to me in working with the deaf/blind. For instance, if you examine the actions required to be made by the child in feeding himself with each mouthful of food, he goes through a sequence of 11 movements. It is by doing the same set of actions again and again that they become established in a sequence as part of his pattern of feeding.

If we can identify the pattern of movements within an activity, we are more likely to convey it in the same sequence each time our hands guide those of the child. We are also then more aware of when the child is becoming ready to take over. This may seem rigid, but when the child has learned to do something for himself, he may add to it his own characteristics or take short cuts as we all do.

Communicating, in the sense of language, is very much a 'hands on' activity, for these children need to use signing. Even if there might be some potential or speech, without the benefit of lipreading, it takes the child so long that he is likely to become frustrated and end up with no means of communicating at all. It is best to provide an alternative right from the start, but at the same time we must always give him the opportunity to hear the spoken word, and 'see' it if this is possible, alongside signing.

Initially, I would use what I call 'signals' rather than signs - the feel of mother's brooch, daddy's moustache, the smell of strong soap before bathing, touching baby's hand to his mouth before a feed, things connected to regular daily routines which allow the child to develop a sense of anticipation of what is going to happen so that life has some form and timing and is not just a series of random happenings. I believe this is essential for deaf/blind children in all situations. In school, try to find clues that will help them anticipate the beginning and the end of an activity and keep the routine strictly the same, until the children have that sense of security which allows them to relax and respond.

Once the child shows recognition of a 'signal', this seems to me to be the place for the first signs to be used. It doesn't matter what signs we begin with, what matters is that it is related to something that you know from observation is meaningful to the child. As the child's understanding and interest in his environment grows, he will show us what signs he needs - we do not chose a list of signs to teach him. Until he has enough information to allow him to think and to make choices of necessity, signs will be tied to things which affect his body. Although I have said 'signs', perhaps I should have said 'using signs to converse' for I firmly believe that we should use sentences and not single signs, modified to begin with as we would for the young normal child.

In fact, hand movements are easier to imitate than the complex movements required for speech. The child receives our message by our manipulating his hands, and just as a normal child must hear words many, many times before he can speak them, so must the deaf/blind child be shown signs many, many times before he can be expected to make them for himself. We must be ready to accept all attempts, however far from the real thing, so that he is encouraged to continue. We must also watch out for his 'signals' - for instance he may show that he wants to go out simply by making an action like that of pulling up a zip - we must be quick to respond to him if we want him to respond to us, and in time we can pair his sign with the commonly used one so that he can learn to use this in place of his own. It is the motoric component of a thing or action which has meaning for the child.

Signs are also patterns of movement and should be thought of as having four parts which have to be made clear to the child if he is to be able to imitate them without the aid of vision. These patterns are:

1. The shape the hands make.

2. The place of the body or space where the sign is made.

3. The movement or flow of movement or actions of the hand(s).

4. The final hand shape in the act of completing the sign.

Remember that in all these aspects of tactile work, the child is 'seeing' through your manipulations. Whilst receiving information tactually requires the use of his hands, a deaf/blind child's knowledge would be very limited if it only referred to those things which we could bring to his notice. He lacks the incentives of the seeing child and he lacks flexibility because he does not turn to look for things or to locate sounds. We may have to show him what movements he can make with the various parts of his body and what can be achieved by making these movements, what freedom he has once he can move on his own.

As intervenors we may have to manipulate the child through the movements until he can do them himself. At first we must not ask him to move into space on his own - we must go with him and share the activity until he feels safe: roll with him, crawl with him, jump and walk with him until he has the feel of it and knows what to do with his body to master the skill and wants to do it because being physically active is both pleasant and useful.

As Dr. Jan van Dijk, the Dutch expert on deaf/blind children says, "As he moves into space the child will learn that things stay in their place and it is he who moves". The child learns to make adjustments in space, (to avoid obstacles) gets a sense of distance and this helps to create an awareness of self - he can say "I go", "I do". A spoon becomes not just a knocking thing but the thing I eat with. He and things assume an identity and the world begins to have shape and form as well as people.

Sources of information

There are three sources of valuable information open to those of us who work with the deaf/blind. First, the child himself is a mine of information and observing him should take up a good deal of our time. Where does he seem to see things? If we know this, we know where to start stimulating his vision. Does he have a preference for a colour? If so, things we want him to recognise should be this colour to begin with. If he is blind, what things does he like to hold and explore? are they hard or soft? and so on.

Work from the child's lead rather than from what we might think he ought to be doing. If we have entered his world we will be more likely to have his confidence and be able to lead him into our world which, after all, is the one in which he is going to have to learn to live and function.

If a child likes light, use it to develop his interest in other things. Little Nana, who came to our Family Centre responded to nothing in a positive way except light - like so many Rubella children, he was obsessed with it. So we darkened a room and lit up a toy - which he would then pick up and move about in the light - we then moved the light source to another toy to which he would crawl and examine in the same way. By the end of the first term, he would come into the playroom (which was kept free of bright light sources) and search for the toy box and handle the toys without the need for the strong light stimulation. If a child likes rocking, rock with him - then pair this with rhythm and music, working to the stage when he can control the taped music himself and make a choice of rhythm. Once he has a concept of self and realises that he can act for himself, we have a basis on which to build.

Secondly, observation of normal children is another valuable source of information for us; we should watch normal children from time to time to note how they explore their environment. Thirdly, if we are to pass on information tactually, we must ourselves become sensitive to tactile experiences. What we may recognise visually as a salient feature may not be so tactually. We must feel for ourselves objects and actions so that we know what it is important to alert the child to in order for the information to be useful to him.

The importance of having a good relationship with the deaf/blind child cannot be overstressed. It is not just a relationship of "I love you", but one which must begin with the child recognising you for the person you are - he needs to know you have long hair, a big smile, round cheeks, a particular scent, that you greet him in a special way and leave him with a special goodbye. All those things that make you an individual enable him to get to know you as different from others who handle him, to know that he can trust you and find pleasure in pleasing you and in communicating with you. Above all, give him time - time to learn and time to respond.

Issue 13, January 1985

Blind children – with reference to those who are also profoundly handicapped in other ways – some thoughts

By Beryl Tierney, then RNIB Education Adviser and now peripatetic teacher for visual impairment in Shropshire.

Introduction

The following are a few thoughts concerning blind children with some reference to those with many handicaps. They cannot be comprehensive within such a short article. I believe I was asked to write this to complement the mass of material which has been produced recently on the subject of maximising the use of residual vision. It would seem that, now, we are in danger of being totally geared into perceiving and encouraging with relevant programmes, the tiniest of visual responses and of building up a stock of visually stimulating resource materials, to the exclusion of others. The result may be that, when we meet that minority of children who really do not have any visual responses at all, we can be less sensitive about observing what they are telling us about themselves and what their needs are, as we interact with them.

Lisa

Recently I spent some time with a totally blind, profoundly mentally handicapped, cerebral palsied little girl without head control. She had been showing little interest in my attempts to "play" with her and, as she lay passively on her back, a very familiar person who often cuddled and played with her, came in and started to talk. Almost imperceptibly, the little girl tilted her head very, very slightly in the person's direction, started to vocalise, but barely noticeably, and lifted her left hand about three inches. She repeated this almost every time the person spoke. Unfortunately, on this occasion, she was not facing towards that person and what I think was an attempt to communicate was not acted upon. However her persistence seemed to suggest that she was usually successful in attracting a response.

The subject of communication seems to me to be pre-eminently important because of its role in helping blind children to achieve self-awareness and mastery over the environment.

Eye contact

In normal sighted infant development we are told that it is not only the mother's role as a care-giver which causes the baby to respond to her in a special way. Rather she is the one who interacts with him, perhaps showing pleasure at his early smiles or by providing more little games for him to react to. Babies can latch on quite quickly to their mother's, delight and begin to show off their prowess by kicking out with arms and legs, or with smiles and vocalisations. They gain in muscle-tone, body awareness and self-esteem, and their mothers delight in their success at parenting. Their repertoire in communication at the pre-verbal levels includes glances, frowns, smiles, gestures, movements, vocalisations and touch. The visually dependent element seems quite considerable.

Blind children and their parents need to find equal success. Parents miss the rewarding experience of eye-contact, or having a smile returned at a time when they may be feeling hurt or inadequate anyway. Somehow they have to take the initiative, as have other care-givers, and become sensitive to the children's unfamiliar signals of, perhaps, stilling as someone approaches or speaks, tiny anticipatory movements of hands, arms or legs, slight inclinations of the head, possibly quivery pleasure movements, and early vocalisations which, without eye contact, do not seem to be addressed to them. They need time to realise these may be manifestations of a child's interest, and be encouraged to fulfil the children's needs for counteraction on their part, by voice or laughter, pleasant touch sensations, or varieties of movement, often becoming quite energetic as children become sturdier. Thus encouraged, blind children start to produce their full repertoire in smiling, laughter, body movements and vocalisations; delighting in their attainments, and parents experience the exhilaration of success, encouraging them to be creative in their parenting, helping them to see their children as children first and blind second.

Life is not always so joyful and discomfort also has to be communicated. It has seemed to me that children without sight, not having the distraction of visually stimulating events to help them move away from their own body sensations, are more aware and distressed by teething pains than the sighted.

Vision stimulates a child in prone to lift his head again and again to observe his environment. Other incentives will be needed for a blind child, if he is not to come to dislike being in that position - important for strengthening neck and trunk. If he does not grow accustomed to it he may not crawl until after he has walked. A "head down" sitting, standing, or walking posture may persist without remediation. Not seeing the floor, or realising that it is a continuous surface, parachute reflexes and saving reactions in all directions may have to be encouraged, perhaps with singing games, as may an appreciation of the advantages of sitting over lying. Lying, he is in a position of safety and more aware of his whole body as it is in contact with the floor. Sitting, he has yet to learn that he can orientate sounds better, and his hands have access to things about, and can work together more effectively in exploratory play.

Hands

At an early age sighted babies will swipe at nearby hanging objects in a general way. As hands are brought into the visual field, they are regarded and brought together in play. More visual and motor control is then exerted in developing and refining hand/eye co-ordination. At first, hands reach out to grab everything within arm's reach. With growing visual interest in detail, finger movements become finer and finer. Playing with hands and fingers, bringing them together in games and routine activities, putting things into a child's hands from the start, and later tapping his hand lightly with a "Here you are" as an object is presented, gently pushing the elbow of the other arm so that the other hand joins the first in examining it, help the early stages of tactile development in a blind child.

Learning permanence of objects without vision to monitor the disappearance of things cast away is more difficult. Directing a hand back down onto a dropped object is helpful and, of course, returning dropped objects. This latter often develops into a time-consuming fun activity. One may have to teach this game if it is developmentally appropriate, but perhaps with older children at this stage, exercise some control by providing a hard surface or tin, upon or in which to drop things. Where children stick at this stage, it may be necessary to move them on to thenext, whilst possibly retaining a throwing game, perhaps with soft objects and a large tin lid or gong as a game in a specific area.

Of course, dropping toys can be a genuine rejection of particular play-things and one has to test out which game is being played, if it is child-initiated.

Many blind children seem to remain longer than the sighted at the mouthing stage. Many additionally-handicapped retain the mouth as the primary touch receptor for a very long time and, for some, it becomes all-important and hinders further progress. It has been suggested that the hand which moves outward from the body may only become the primary sensor when the child begins to have some awareness of himself as an individual. The building of relationships and a structured routine which gives meaning, and appropriate language, are probably as helpful as alternative stimulation and very specific programmes to modify behaviour.

Seeing things beyond his body space encourages a child to move to examine them. Without sight he may be content to sit passively handling the things immediately around him. Without help he may not know what is beyond and how to get there. When he is developmentally nine or ten months, he will reach to sound or move towards a beckoning voice, but sounds are not good motivators for movement until that stage - which has to be encouraged - is reached.

There is a dilemma of needing to achieve a "hands on" approach, with a child who lacks the stimulation to move to get into that kind of learning situation. Hopefully a child will learn a rich variety of movement and become more aware of his body in energetic fun episodes with people. Perhaps, by a close bodily contact at these times, he will have the chance to experience a variety of body movements and find out about the continuity of the floor, or cling laughingly to father's back, squirm around the carpet, or play at moving, or being moved, in a game from one calling person to another. However handicapped, experiencing different positions, being put in different parts of the room, being taken to specific things rather than them being brought to him and being shown around the walls of a room, are all appropriate.

Without vision the various tilt and righting reactions to achieve an awareness of postural uprightness, and eventually standing balance, have to be learned proprioceptively. This is a long process and independent standing and walking are usually delayed. Energetic sessions with other children and adults also help a child gain experience of other planes.

Where there has been no visual awareness of the feet, reaching to find them and taking them to the mouth may have been missed.

A hemiplegia presents greater problems for sitting balance to a child both unable to correct by sight and lacking sound kinaesthetic awareness of part of himself.

Language

Until he gets moving in some fashion, he has much less chance to learn verbal labelling. Sighted children point in a demanding way to things beyond their reach, This may cause care-givers to label them. Blind children do not point. Furthermore they miss the incidental labelling or completely meaningful explanation of visual events enjoyed by the sighted, possibly conversation which is encouraged by eye contact with others.

I know of blind children who have understood something in one situation but not another. For instance, a girl who knew "Go upstairs" only in the context of going to bed, until it was realised, threw a tantrum if asked to do this at any other time.

Without sight, sounds come and go and may appear to be random and without meaning, and are less easy to pinpoint exactly with regard to direction and, especially, distance. It is less easy to discriminate important from unimportant sounds. A blind child may find it less easy to discount less interesting sounds. He has not the distraction of vision and cannot shut his ears. Unknown sounds may be frightening, although, to others the same ones may be fascinating or funny. It is important that we clothe all environmental sounds with meaning, where possible tracking down their source.

Mobile blind children will use environmental sounds to orientate themselves. Some develop an "object " sense, probably depending on sound sensitivity to echoes. Some stamp or shout as they enter an unfamiliar place. They interpret from the echoes, information about space, walls and surfaces. Extraneous sounds from stereos and radios muffle these sounds, which give valuable information. A great variety of activity in a classroom, each with its own sounds, may confuse and inhibit a child from paying attention to his special activity.

Blind children do not have the same opportunities for learning by imitation and often have to be carefully shown many routines normally taken for granted.

Visually one can get an awareness of a whole thing or scene quickly and there is a continuity to visual experience which is easy to keep returning to. Tactile impressions are “bitty” and do not easily span a space larger than one can get one's hands round. A blind child has to learn tactually, which is arduous and time-consuming, and piecing together is an intellectual activity. Impressions have to be internalised for recall because re-examination, done visually in an instant, is hard going tactually. It is important to consider the number of times and the different circumstances in which one looks at things from different angles and has them named, to appreciate how much this may need to be done by hand before a comprehensive understanding is reached. Incidental touches, or knocks, sounds, or communication, are less easy to interpret without sight and children may need to have answered "Who was that?", "What is happening?", "What is going to happen?" and to be reassured about approaching and departing people.

Parents

A child's blindness may be the source of terrible parental emotional distress, initially producing guilt and doubts about parenting ability, possibly fear of handling in case they are doing it wrongly. I say "may" because people react differently. Other care-givers may feel inexplicably frustrated and puzzled by the unaccustomed lack of eye contact, especially when children are handicapped in other ways. Baffled, they may decide that at least the children shall be comfortable and warm, so they muffle them up snugly in clothes right down to their toes. Sometimes children might benefit from having their toes, perhaps much of their body, bare, to feel the surface they lie on, the hands which tend them, the variety of clothes of the people who care for them, the air which wafts in through the window and the varying temperatures as they move. If able, they might like the freedom to kick without encumbrance. They will be in a better position to appreciate the pressures on their skin as they are cuddled, tickled, turned and lifted.

Some blind children have other sensory, intellectual and physical impairments. Some have feeding problems and their parents have not yet enjoyed even the assurance that they are good providers. Some may have difficulty showing basic pleasure reactions when just a fleeting smile would help. Perhaps their body movements are such that care-givers are in doubt as to whether they are only uncontrolled reflexes, or an attempt to communicate, or a struggle to achieve.

Among them are those who remain inconsolably miserable, or, not only wakeful throughout the night, but noisy, and their parents become fraught. Desperate attempts to gain harmony are in danger of resulting in later ongoing poor patterns of behaviour. (There is a theory that confusion of night and day might be influenced by interference in Circadian rhythms, as light is thought to be a strong regulator of these). Persevering with correct "putting to bed" routines is most helpful in the long run, but specialist paediatric advice should be sought for really difficult children.

It seems that some multiply handicapped blind children may never have achieved an initial understanding of their environment and it may be to them a frightening wilderness. Some stick by the familiar, show panic reactions to the novel, rejecting new objects or people. Everything new becomes "old hat" in time, so a gentle approach at increasing horizons and meaning is relevant to them. Some may accept being passively manipulated through a daily routine so long as no demands are made on them. Others find they can achieve what to them are successful interactions and mastery over their environment, by unacceptable and often dramatic activities. Others find their own body can be guaranteed to give satisfaction. Some may not differentiate parts of themselves from the environment and bite or bang themselves as they would objects. Others give themselves up to a safe inner world, building a protective shell around themselves which is hard to break. Some may achieve speech and mobility and some proficiency at self-care, but remain at the stage of repeating speech or have not built the confidence to initiate activities, remaining dependent upon someone to prompt them in play and work.

Overcoming primitive reflexes or movement of any kind for some physically handicapped children with some hand/eye co-ordination, visual stimulation to move and an ability to internalise objectives in language, is such a hard-won struggle that blindness and perhaps mental handicap as well, produces a desperate situation. It is small wonder that children so handicapped may find neither meaning nor motivation to enter into the intense struggle outwards for mastery, and may appear even more mentally handicapped than they are, or be dubbed lazy. Whilst they may need to be relatively passive recipients of our care and therapy, much of the time we must remain alert to the tiny clues they give that they are trying to unlock the door from their side. We must build on opportunities for them to display sparks of individuality and effort, leading to the reward for achievement which they understand.

There has not been space in this article to tackle the day-to-day management and stimulation of blind children. I hope I have pointed adequately to particular areas of development and learning difficulty in blind children in general.

Issue 14, September 1985

Some of our needs (mine, and my teacher’s)

By Sally Silverman, Peripatetic Teacher of visually handicapped children in Avon.

Section A: Needs of the child

Although such a diverse group in age/ability/range and degree of other handicaps, there is a framework of underlying needs which holds true for the visually handicapped population in general and which are fundamental to the children under consideration here.

1. Time to adjust, even to very familiar situations (entering own classroom).

2. Proximity must be placed or allowed to be close to adults, classmates, especially for 'hellos' and 'goodbyes'. Fine for small children to be carried, sat on adult's knee. Proximity encourages state of well-being, security, information (eg texture of adult's clothing, smell of adult... identification).

The children need to be touch and be touched... this builds reassurance and relieves stress.

3. Time and proximity to communicate and to respond to communication.

Closeness to learn through ‘hands on’ methods of communication (Makaton through tactile rather than visual means).

Time to attend to specific sounds

Time to interpret specific sounds

Time to respond to specific sounds

Sounds must be concrete, uncluttered, attached to meaningful events which are likely to be repeated.

5. Time to anticipate

a) the behaviour of others. (As one teacher has put it: 'she cannot anticipate others who are friendly from those who will bite or scratch... as a result she is withdrawn').

b) the behaviour of teachers/therapists, others... needs to have name called, be warned before being picked up. Also told when being left.

c) the sequence of familiar routines... eg the clinking of milk bottles likely to mean a drink is coming.

6. Consistency in approach and way of being handled, - by all - school nurse, dinner ladies, head teacher; educational psychologist, physiotherapist, speech therapist.

Consistency in familiar environment - the way the furniture is placed (if major changes are made, then warnings must be given)

Consistency in placement of familiar toys and objects

Consistency in information given to parents

Consistency in routine

Consistency in 'places' the child is left in a room (soft play area, by the window, by computer etc).

7. Well-considered learning/play environment

As a direct result of low levels of sight:-

Good/imaginative planning is essential if exploratory behaviours are to develop... if voluntary movements are to be rewarded and mobility and orientation skills evolve.

'there is a need for a mentally and physically encompassable setting... within which they can develop out-going exploratory behaviour' (Tobin).

For young and very physically handicapped children a large cardboard box lined with foil and other textured surfaces which has fairy/torch light inserted and which has an exit can be very useful.

Enclosed spaces are also important, as the child's own sounds rebound, do not become lost and are thus likely to be repeated.

Contrast must be given on feely boards, with visual materials presented (figure/ground), moving from outside to the inside, sour and sweet.

Free circulation areas - essential if confidence is to be established with the child who is near to taking those first independent steps... hazards (other wheel chairs, frames etc) must be stored elsewhere.

Uncluttered wall surfaces - a child needs to roll, crawl, shuffle, walk towards wall surfaces and to be helped to gain some idea of the size, shape, landmarks in his/her room.

Knowledge of immediate environment - a child is likely to be familiar with texture/resonance of floor surface (where the draughts are coming from) but will be totally dependent on adult intervention to give him knowledge of where the door handle is, the light switch, the taps, the windows andhis coat hook.

8. Behaviour

Behaviours used for:

• comfort (rocking, masturbation)
• information (tongue clicking, hand clapping)
• pleasure (eye poking, hand waving)
• looking (through spaces between fingers)

These need to be recognised for what they are and understood in relation to the age of the child, home/hospital circumstances etc.

Self-stimulatory behaviours are more than likely to increase when inappropriate or inadequate stimulation is close by.

(Refer to Heather Jones’/Roger Hinds’ article 'Mannerisms' above).

Behaviours such as constant calling out or excessive clinging can be mitigated to some extent if regular verbal and physical 'glances' are given by the teacher.

Integrated approach/additional teaching methods/additional equipment

It is an accepted fact that a fully able-bodied blind child is likely to experience difficulty in linking his/her learning experiences into a unified whole - how much more difficult it is for the children we are considering here.

Integrated approach

The child needs a teacher who is willing and able to provide an Integrated Curriculum, who can say 'listen...' to the flush from the toilet rather than put on a tape of street sounds.

The child does not need a time-table of olfactory/tactile/vision/listening sessions.…

Without an integrated/well-considered approach, information received by the child can become fragmented, repetitive behaviours can follow, and as a result the child be considered to be functioning at a lower level than may really be the case.

10. Additional methods

The visually handicapped child will need to gain more information than his fully sighted peers through his ears, nose, mouth, eyes, and from the temperature and resonance of surfaces around him. For this he will need a learning environment which can provide contrast (light and dark, silence and specific sound) and above all a team of workers who have a sense of direction as to where all this sensory input is leading.

Additional equipment:

For children who have a degree of useful vision, consideration of environmental lighting is important.

Highly polished surfaces (tables, floors) can hinder mobility and exploration and tinted glasses (check with Orthoptist) may be useful in bright summer playgrounds.

Local lighting - eg Anglepoise, can be useful for focusing visual attention for all, including multiply handicapped. Lamps do not have to be used on a table. 'Habitat' do an anglepoise lamp which has an additional standing base. This has been used eg for highlighting a transparent tray full of coloured popcorn which a child was playing with while lying prone over a wedge.

Overhead lighting - White can encourage light gazing and give both staff and children headaches... coloured tubes can be purchased, or safe local lighting set up around different 'work areas'.

Ultra-Violet lighting - Slides/discos/overhead projectors, a range of torches, the computer, can all assist in encouraging the use of residual vision. (See Mark Mabon's article on 'light stimulation' above).

Some children will benefit from tilted work surfaces, typewriters, large-print materials, closed-circuit televisions and low-vision aids.

The same children are also likely to benefit from having other agencies come into school so that they and their teachers get the best out of these materials (as listed under ‘Implications for Head Teacher’ at the very end of this article).

11. Finally. The need for good home/school contact is recognised as being important for all children, but it can be argued to have a particular significance when the child has a severe sensory loss, eg, for the most profoundly visually handicapped, developmentally young children who are not yet aware of time and place.

Daily home/school diaries are important but so is a welcoming attitude on the part of the school and a willingness to listen to and to learn from the parents and so work together for the eventual benefit of the children concerned.

Section B: Needs of the teacher/therapist

Although such a diverse group in age/training/personality, there is a framework of underlying needs which holds true for all those who are working with profoundly handicapped children who are also visually handicapped.

1. Time to adjust, to prepare the room. Time to welcome and settle his/her class group without interruptions from other staff. (Notices should be given out before school, preventing irritability on the part of children and teachers).

2. Proximity must be prepared to give and to receive close physical contact (well-considered, not smothering).

Should not rely on classroom assistants or others to do this alone.

Must be prepared to let him/herself be used as the child's prime educational aid... (climbing-frame, enclosed space, sensory stimulation bank, communication aid, friend).

Implications for Class Teacher: a relaxed unhurried teacher who feels comfortable in herself, as physically fit as possible, is flexible in approach and who has a sense of humour.

Implications for Head Teacher: class groups need to be small in size. Six is plenty when a blind child/children are part of the group… (adding another classroom assistant may not always help...)

The Head needs to ensure class teacher/class assistant have adequate breaks, that they do not have to do excessive lifting, that there is time to discuss the needs of their children (away from the class).

The visually handicapped children concerned should be matched with the most appropriate teacher to help meet their needs.

3. Time, willingness and training

To listen to/observe small hand/mouth movements/changes in body tension which may be clues, signals, methods of communication from the child.

With profoundly handicapped children much teacher satisfaction is gained through eye contact, smiles from the child. With severely handicapped children, satisfaction must be looked for from the methods of communication as stated above.

Time to help a child relax his hands/overcome tactile defensiveness where it exists.

Training in 'hands on' methods...helping child understand processes through hands rather than eye.

4. Awareness of the major significance of sound & listening skills for effective learning.

Awareness of his/her own voice... clarity, pitch, rhythm, volume; use of song (made-up ones about classroom routines, activities).

Awareness of environmental sounds: How to make good use of them, how they need to be controlled.

Make a sound map of the regular classroom sounds, eg door chime, canary, floor surface, toilet flushing, musical mobile area (not taped... a mental sound map for teacher to remember to emphasise those sounds throughout the day to give information to the child... landmarks for orientation).

Awareness of own body sounds... making use of own footsteps (rhythm, volume) to give the child information about distance, direction... time to anticipate teacher movements.

Allow time for response to environmental sounds

Implications:

a) A degree of noise control is essential.

b) Minimal classroom interruptions are essential (avoid a sea of voices, meaningless conversations).

c) Help colleagues to realise that this is the child's learning environment... put a polite notice on the outside door.

d) Small groups are essential...noise levels cannot be controlled when there are 15 children in a group with 2 classroom assistants and 1 teacher.

Training

That sound sources need to be within the child's reach... include teacher's mouth, tape recorders, musical mobiles...

If attention is given to sound control, and to purposeful use of sound, then relaxation... pleasure... information can result and irritability on the part of teacher and child can be kept at bay.

Anticipation

The child's difficulty in anticipating the movements/behaviour of others demands a degree of empathy on the part of the teacher.

Even more important when the child may also be severely physically handicapped and have a strong startle reflex.

Some children will need to be protected from the unpredictable behaviour of others.

Implications for Head Teacher: A balance needs to be made between over- protection due to vulnerability on the one hand and exposure to unfair stress on the other. (Needs a 'Home Base' and to move across school for certain activities?)

6. Consistency implies a degree of awareness and empathy on the part of the teacher. Awareness and empathy for the visually handicapped population as a whole and a particular empathy for the most vulnerable members within that population.

This is essential when the classroom is arranged in the morning and cleared away at night (a 'sound' box, so useful for exploring, can easily become a meaningless jumble when every shaker and rattle is thrown into it at the end of the day. If it is put into the left instead of the right hand side of the storage unit one night then it might not be found again the next day).

The child could have a simple diagram of his physical environment/landmarks on the wall by his other charts. Useful when a supply teacher comes.

Consistency in approach by all staff implies specific input for all staff. Perhaps a 'high profile' week could be held in a school where other agencies (mobility/technical officers, advisers for the visually handicapped) could be invited in to work with the staff and exchange ideas. Implies ongoing support and interest from Head Teacher and Advisory and Support Services.

7. Well-considered play/learning environment

Consistent/enclosed spaces implies that individual teachers have the room and resources to create individual spaces for the child/children concerned.

Other children

Frustrating to create safe/interesting areas for the child concerned if it is likely to be pulled down/destroyed by others in the group. A management problem which will need to be discussed with the Head Teacher.

Free circulation area

Implies having adequate storage space for large equipment. Need to constantly assess when, how, where, how often, a piece of equipment is being used.

Teacher awareness

Of the importance of environmental control especially to mobility. Should have access to relevant literature ('Mobility Ideas' RNIB, 'Making Sense of First Steps'... article from 'Sense', Summer 1985).

Physiotherapist

Needs to contribute ideas to the physical environment and also be aware of the points stated above.

Behaviour

Just one point to keep in mind. Many of the mannerisms that are thought to be the consequence of 'brain damage' in the blind child in the special care unit are also present in blind children with high Iqs, and as one severely visually handicapped Head Teacher freely admits 'I often poke my eyes in private... it gives a lovely circle of light!

Integrated approach/additional teaching methods/additional equipment

A teacher will need additional information, training, support (including financial for additional equipment).

Resources

Additional equipment need not be expensive, eg when purchasing plates, think about the colour (scrambled egg shows up much better on a dark blue plate, green peas better on yellow).

Look up rag-bag ideas from past issues of Information Exchange and Talking Sense and Guidelines for teachers and parents etc.

Implications for head teacher

The class teacher, however experienced and keen, cannot be expected to meet the multiple needs of the VH child in the class on his/her own and must be prepared to invite in other agencies including Advisory teachers for the Visually Handicapped (LEA and RNIB) Mobility and Technical Officers, Orthoptists, Partially Sighted Society, 'Sense', parents.

Issue 15, October 1985

Curriculum [A letter from Lilli Nielsen]

A letter from Lilli Nielsen who has been working with handicapped children for 30 years. Since 1967 she has worked as special education adviser at Refsnaesskolen, National Institute for Blind and Partially Sighted Children and Youth in Denmark.

Dear Information Exchange,

I should like to give you some comments on the subject of curricula for blind mentally retarded children. In my opinion the best curriculum is the one which is done in relation to the level of the child's development.

If the child in all or in some areas is developed to a level under the level of 3 years, I don't think it is possible to teach the child, but I am quite sure that the child is able to learn. To have the possibility to learn what he needs to learn for further development, it is necessary to give the child surroundings for this learning. Therefore, in the classrooms for children developed to a level under the level of 3 years, I would suggest furnishing the classroom with several play-surroundings, so that the teacher during the day can move the children from one of those arrangements to the next and later on to the next and so on. It could be as shown in the drawing.

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Number 1: This could be a basin for playing with the connection between water and toys, water and flannels, water and 4-5 pieces of soap, water and cups and so on. (Without any examination from the teacher).

Number 2: This could be a resonance platform upon which a support bench is placed. The child is placed on his stomach upon the bench and he is given a lot of objects under his hands and feet so that the sounds he is making by pushing or handling the objects can make connection between movements of arms and legs and the use of the muscles of the back. In this way the pupil will develop the ability to sit without support or to sit in such a good way on the floor or on a chair as to be able to handle objects (playing, eating or whatever) in a sitting position. Many of our blind mentally retarded children who are able to sit without support are sitting with such a hunched back that it is almost impossible for them to use arms and hands in a successful way.

Number 3: This could be a resonance platform upon which is placed the material "The Little Room" which, if it is equipped well, will give the child the possibility to achieve connection between reaching behaviour and basic concept of space, connection between touching and space, sounds and space, smell and space and so on.

Number 4: Could be a resonance platform with a lot of objects where the child could push, pick up or play banging-plays in sitting or lying position.

Number 5: Could be a corner of the room where the child could sit with his feet into a Foot Spa (a vibrating material) which could help him to get warm feet or to diminish spastic reactions. The child could also be placed in such a way that he could have his hands into the Foot Spa (with water or marbles or nuts and so on). Some of my children have achieved a better touching ability by playing with this vibrating material.

Number 6: Could be a table for eating or other activities.

When the children arrive at the classroom, each child is placed in one of the arranged surroundings. After that the teacher goes to one of the children to give him attention and to interact with him in what he is doing. The teacher is perhaps together with this particular child for 20-30 minutes. Then the teacher will go to the next child for the next 20-30 minutes, but the teacher is also between the sections, moving all the children from one arrangement to another. At the end of the school day each child has been through the different surroundings and each child has had at least 20-30 minutes of total attention and interaction with an adult.

This is what I would call a frame for a curriculum where the detail of what the child is offered is based upon what the child at every time needs for further development. The questions about what he in fact needs just now could be solved by a very detailed assessment about what he is in fact able to do and a discussion about which kind of surroundings he needs to use this ability as a basis for going through the next step of development.

I think that very often while we are talking about curriculum for these children, we are talking too much about what we will teach and train and too little about what the children are able to do and what they must and can learn by their own activities.

I also believe that a child must be developed to a level of about three years before he can gain from teaching.

I could have given a Iot of other comments, but I have now to continue with all the other works which are waiting.

Yours sincerely

Lilli Nielsen

October 1984

Content author: library@rnib.org.uk

Last updated: 20/11/2008 11:13