A Child-Centered Approach to Education
Chapter 2: Designing the Educational Program: A Team Approach
Section I I
Developing Strategies for Active Learning
Chapter 3: Language and Cognition
Chapter 5: Motor Development: Gross and Fine Motor Skills
Chapter 6: Functional Academics
Chapter 7: Vocational Training for All Ages
Chapter 8: Daily Living Skills
Chapter 9: Independent Living Skills
Section I I I
Integrating the Educational Program
Chapter 10: Sensory Integration (excerpt)
Chapter 11: Developmental Music
Chapter 12: Toys: Tools for Learning
Chapter13: Games: An Educational Alternative
Chapter 14: Leisure Time Activities
Chapter 15: Cooking
Addressing the Special Needs of Students with Multiple Disabilities
Chapter 16: Orientation and Mobility
Chapter 17: Enhancing the Use of Functional Vision
Chapter 18: Adaptive Technology: Handmade Solutions for Unique Problems
Chapter 19: Augmentative Communication
Chapter 20: Techniques for Lifting Students Safely: Body Mechanics and Transfers
Chapter 21: Assistive Devices and Equipment
Appendix I: Resources
Appendix II: Glossary
Kathy Heydt, RPT, holds a B.S. in Physical Therapy from Russell Sage College and an M.Ed. in Orientation and Mobility from Boston College. Ms. Heydt has worked as a physical therapist for seventeen years, and as an orientation and mobility specialist for eleven years. She currently divides her time between these two positions at Perkins School for the Blind. In addition, Ms. Heydt has worked as adjunct faculty at the Boston College Visually Handicapped Studies Program for the past five years, and has lectured at a wide variety of in-service training workshops throughout New England.
Mary Jane Clark holds a B.S. in Special Education for the Visually Impaired and Elementary Education from Kutztown State College, and has worked in the field of visual impairment and blindness for the past ten years. She also holds certification in repair and final assembly of the Perkins Brailler. In addition to her position as teacher of the visually impaired at Perkins School for the Blind, Ms. Clark has participated in international training in the repair of the Perkins Brailler.
Charlotte Cushman holds a B.A. from Bowdoin College and an M.Ed. in Special Education from Lesley College. She has worked as a teacher of the blind and visually impaired at Perkins School for the Blind for nine years. During a sabbatical leave from her work at Perkins School for the Blind, Ms. Cushman worked with visually impaired children as a volunteer with Mother Theresa's Missionaries of Charity in Calcutta. She has won international recognition for her work in designing adaptive toys for children with visual impairments.
Susan Edwards holds a B.S. in Elementary and Special Education from Keene State College and an M.Ed. in Evaluations and Consulting from Lesley College. Ms. Edwards has worked in the field of visual impairment and multiple disabilities for eight years. Her experience includes working as a houseparent, teaching daily living skills, and classroom teaching. She is currently employed as an Educational Consultant for Perkins School for the Blind. In addition, Ms. Edwards conducts workshops for parents on toy selection and play.
Monica Allon, OTR/L, holds a B.A. in Art Education/Art Therapy from Queens College and an M.S. in Occupational Therapy from Boston University's Sargent College of Allied Health Professions. She has worked in the field of visual impairment and blindness for the past twelve years. She has held the position of Occupational Therapist in the Lower School Program at Perkins School for the Blind.
Judith E. Bevans, MT-BC, holds a B.S. in Music from the University of Rochester, an M. Ed. from Harvard University, and an M.M. in Performance of Early Music from the New England Conservatory of Music. She has worked in the field for twenty-eight years in the United States and the Middle East, and is employed as Music Therapist in the Lower School Program at Perkins School for the Blind. Ms. Bevans has published extensively on music education, music therapy, and music braille, and has conducted in-service and university training in the areas of music education and music therapy.
Dennis Lolli holds a B.A. from St. Anselm College, an M.Ed. in Orientation and Mobility from Boston College, and a CAGS in Educational Administration from Boston State College. He has worked in the field of orientation and mobility with deaf-blind students for twenty years, and in the area of low vision for the past three years. Additionally, Mr. Lolli has written extensively in the areas of low vision and orientation and mobility, and has made presentations at numerous regional and national conferences on these topics.
Vickie R. Brennan holds a B.A. from the College of Wooster, an M.Ed. in Orientation and Mobility from Boston College, and an M.S. in Vision Rehabilitation from the Pennsylvania College of Optometry. She has worked in the fields of orientation and mobility and low vision for eleven years. Ms. Brennan currently holds the position of Coordinator of Low Vision Services at Perkins School for the Blind. She has also worked as project administrator of a federal grant providing low vision services to deaf-blind children in New England, and has provided in-service training regionally, nationally, and internationally.
Flo Ryu holds a B.S. from Boston University, an M.Ed. in Multi-handicapped/ Deaf-Blind Education from Boston College, and a postgraduate certificate in Low Vision from Pennsylvania College of Optometry. Ms. Ryu has worked in the field of deaf-blind education for seven years, and is currently employed as a Low Vision Outreach Specialist for deaf-blind children in New England.
Alex Truesdell holds a B.S. in Special Education from Lesley College and an M.Ed. as a Teacher of the Visually Impaired from Boston College. She has worked in the field of education of young children with visual impairments and deaf-blindness for eleven years, and is currently employed as an Educational Consultant in the area of Assistive Devices at Perkins School for the Blind. Ms. Truesdell has lectured extensively throughout New England on the topic of developing education environments and assistive devices for children with visual and multiple disabilities.
Marianne Riggio holds a B.A. from Boston College and an M.Ed. in Deaf-Blind Education from Boston College. She has worked in the field of Deaf-Blind Education for sixteen years. Ms. Riggio is employed as National Educational Consultant for the Hilton/Perkins Program of Perkins School for the Blind. She has also worked as Coordinating Consultant for the New England Center for Deaf-Blind Services and as Teaching Coordinator of Deaf-Blind/Multihandicapped Services for New Hampshire Educational Services for the Visually Handicapped.
The education of children with visual and multiple disabilities is an exceedingly complex process. Accepted methods of education used for one disability are not necessarily compatible with those used for another. This process is even more complex when several disabilities are present. Moreover, degrees of severity vary within identified disabilities, and the result is a compounded and very unique challenge for educators. It is difficult to generalize regarding the correct approach to use, and it is imperative that everyone working with a child be part of a focused, interdisciplinary team. Each team member must be dedicated to contributing his or her knowledge and energy to the growth of each individual child.
During the past two decades, as the students at Perkins have manifested more complex needs, we have come to realize that if we are going to make a significant difference in their lives we must pool our resources, energy, and experience. We have considerable experience providing comprehensive and multidisciplinary services wherein children are evaluated, educated, challenged, and supported. The process is ongoing and includes the active participation of parents and family members.
This publication is the result of many years of work in developing techniques and methods for working with children who are blind with additional multiple disabilities. The authors and contributors are the same tireless, innovative educators whom visitors to Perkins see as they observe our Lower School Program. Visitors from around the world have said, "You should be sharing this with the rest of us," or "Why don't you write a book on what you are doing here?"
Our research has shown that there are no comprehensive publications on the education of the elementary-age child with visual and multiple disabilities. Hopefully, this publication, representing countless hours of work by the authors, and including the ideas and support of our entire staff, will fill a need for thousands of parents and educators.
All of us at Perkins School for the Blind extend our gratitude to the Conrad N. Hilton Foundation, whose generous financial support has made the Perkins Activity and Resource Guide possible. Through the support of the Conrad N. Hilton Foundation and the Hilton/Perkins National and International Program, this publication is now a reality. Over the next few years, the Perkins Activity and Resource Guide will be translated into a variety of languages, thus enabling educators and parents throughout the world to better prepare children with visual and multiple disabilities to become productive members of society.
Kevin J. Lessard
Lawrence J. Melander
Supervisor of Lower School
by Charlotte Cushman
Who Is This Book For?
This book is intended to be used as a resource for a range of professionals, parents, and other caregivers who are working with children with visual and multiple disabilities.
Those who might benefit from this book include some of the following:
Every part of this book will not apply to all students or adults, but rather will offer general guidelines and resources to be used as a springboard for teaching.
What Population of Students Does This Book Address?
This book has been written to address the educational needs of school-age children with moderate visual and multiple disabilities. This population encompasses an extremely wide range of needs and abilities, ranging from students who may be able to read and learn braille to others who will need a much more functional lifeskills approach. The combination of multihandicapping conditions is unique to each student: the degree of cognitive, physical, visual, and emotional impairments is different in each individual learner. For example, some nonverbal students may excel in motor skills while some academically oriented children may be held back by their lack of self-esteem. There is not one single "type" of student with multiple handicaps and visual disabilities.
Why Was This Book Written?
There is a great deal of literature available written for students with multiple disabilities and much written about students with singular visual impairment. There is, however, little written about students with visual and multiple disabilities. It is our hope that this publication will help to fill this gap.
How Is the Book Organized?
Children with multiple disabilities often present a broad range of needs, including medical, visual, and educational concerns. In the next chapter, Designing the Educational Program, we will briefly examine the roles of many professionals involved in a multidisciplinary team, as well as the importance of home and school collaboration, in designing and implementing an individual educational plan. In the following section, Developing Strategies for Active Learning, we will focus on specific activities and resources within central areas of development. Integrating the Educational Program presents further ideas and resources for reinforcing basic educational objectives in a variety of activities. Addressing the Special Needs of Students with Visual and Multiple Disabilities examines specialized considerations. Additional Resources and a general Glossary are included at the end of the book.
What Information Is Included in Most of the Chapters?
What Is the Educational Philosophy Behind This Book?
We all believe that a functional, child-centered approach to education is the ideal model for which we strive. Realistically, however, many teachers and professionals must work within the constraints of a particular school or budget. Many students with visual and multiple disabilities have great difficulty generalizing skills to other settings and, thus, any "real" setting is preferable to a simulated one. While community integration may be the goal, the fact is that most teachers are still working within a more traditional classroom setting where activities may be isolated. Not all of the activities included here are functional in and of themselves, but they are important prerequisites to the development of other more functional skills. We have included functional applications in most activities to reinforce critical skills in other settings.
This book presents a wide range of information, designed to address diverse educational needs, but it is not meant to be an all-inclusive document. Each activity should be viewed as a springboard for ideas, rather than as a rigid pedagogical formula. Specific variations will depend upon the physical and educational needs of each individual learner.
Independence Is the Goal
The primary goal in educating any child is to help her to function as independently as possible in the world. For some students, independence may be achieved with the help of special equipment, such as a wheelchair, an augmentative communication device, or braille materials. For many students with multiple disabilities, however, gaining independence requires enormous energy, creativity, and patience on the part of all those who work with them. It is often easier to do something for a child than to teach her to do it for herself, but this is ultimately a disservice to the child. It is important to structure situations so that the child can complete tasks independently. For example, select simple clothing without fasteners so that she can dress herself, or place tactile markers on the student's coat hook so that she can find it without assistance. Create opportunities for success!
Be an Advocate for the Child
Because most children with multiple disabilities may not be able to be their own advocates, it is essential that all of those who come into contact with them respect their rights as individuals.
Encourage everyone to be aware of the child's privacy and avoid discussing the child when she is present. Just because she cannot see does not mean that she cannot hear. Similarly, even if she is not verbal, she may still understand what is being said around her.
Allow the child to have the dignity of taking appropriate risks: let her try to do whatever she can for herself, even if it may be slightly inconvenient for others. For example, let her order her own meal at a restaurant and choose her own clothes when getting dressed, if possible.
Help the child choose activities and materials which are appropriate to her chronological age. Even though a child may be functioning at a developmental level well below her actual age, she should still be encouraged to dress and act in a way that is "age appropriate." For example, if a teenager loves to listen to music, expose her to popular music rather than just children's songs.
Teach Skills that Are Functional
It may take a long time for individuals with visual and multiple disabilities to acquire new skills. Therefore, it is best to teach only those skills which are functional. Before introducing a new skill, think about what the value is for the student. Why should she learn this skill? Is it important in and of itself? Does it lead to the development of other important skills? Is it an educational priority? Does it promote independence? Sometimes the answer may be self-evident, for example, teaching a child to use the toilet is clearly a priority in and of itself. Other skills, such as sorting and matching objects, may not be functional at the moment, but may lead to functional goals in the child's future (e.g., sorting silverware or matching socks). Other skills, however, may be taught simply because "everyone always teaches them," but not because they have any true value to a child with multiple disabilities. For example, is it necessary to teach an adolescent to pass a ball or stack blocks or string beads? These skills are often taught in early childhood settings because they are valuable for young children. Re-examine the priorities for older students or for students who are more severely handicapped.
As stated previously, the ultimate goal is to teach skills that are functional. While all activities may not appear to be functional in and of themselves, many are prerequisites necessary to the acquisition of later skills. In addition, many school settings do not have the flexibility to teach students in the "real" setting due to lack of staffing or other constraints. We have, therefore, presented many activities which can be taught within a classroom and included functional applications for teaching those skills in natural settings whenever possible.
Teach Skills in the Natural Setting
Not only does it take a long time for many students with visual and multiple disabilities to develop new skills, but it is often difficult for them to generalize known skills to other settings. It is, therefore, essential to teach functional skills in a natural setting. Do not assume that by teaching a child one task that she will be able to apply this knowledge to a similar task in a different setting. For example, just because a student learns to put pegs in a pegboard does not mean that she will automatically be able to put cups in a rack or envelopes in mailboxes. Similarly, if a child learns to fasten a snap on a doll, this does not mean that she will be able to snap her own pants, especially because she will have learned to snap in reverse. Teach skills that are functional in the setting in which they occur whenever possible.
Break Task Down into Individual Steps
Most students will not be able to acquire a new skill all at once. Therefore, tasks should be broken down into small steps. This process, called task analysis, involves looking at each sequential step in an activity. If a child is learning to brush her teeth, for example, she may begin by just tolerating having the toothbrush in her mouth at first. Later, when the child is ready, other steps can be added, such as finding the toothpaste, removing the cap, squeezing it onto the brush, etc. It may be helpful to write down all of the steps when teaching a new or complex skill.
Provide Assistance as Needed
As we have said, the ultimate goal is for the child to be as independent as possible. In order to achieve that goal, however, she will need adult assistance while she is learning new skills. The following list describes the different levels of intervention.
Provide Repeated Opportunities to Practice Skills
Most students will not be able to learn a new skill in a single session, but need repetition in order to master new concepts. Give them the opportunity to practice these skills in structured lessons, as well as in the natural setting during the course of the day. If a student works on coin identification during a math lesson, she should be encouraged to apply this knowledge throughout the day, for example, when counting lunch money or buying a soda. This repetition will help to reinforce new skills, as well as to generalize that knowledge to new situations.
Speak to Students Using Normal Voice and Language
It is important to speak clearly and concisely, using words that students can understand. Speak in a normal tone of voice that is not high-pitched, too loud, or singsong. In general, use words that refer to visual concepts or attributes of color and seeing as you would ordinarily. Phrases such as "see you later," "do you see what I mean," are part of normal speech. Similarly, words like "watch" and "look" can be used with blind students to refer to their own style of looking. For example, if you ask a student to "watch" where she is going, she will learn that you mean to pay attention, or if you ask a blind child to "look" at something, she will learn that you want her to feel it.
Use Real Objects
Students with multiple disabilities, particularly those who are blind, may not understand symbolic representations at first. The only resemblance which most representations have to the real thing is their visual similarity. For example, sighted children may find a teddy bear visually appealing or delight in a small plastic cow that looks just like the real thing. Proudly, we bring these items to school because we are teaching about animals. We are then disappointed because the child does not recognize these tiny animals. Think about this from the perspective of a young, inexperienced blind child who also happens to be developmentally delayed. These items mean nothing to her because she does not even know what a real cow looks, feels, or smells like. By taking the child to a farm she can first learn about real items, and, later, when she is developmentally ready, real objects may be paired with representations that are visual or tactual.
A Multisensory Approach Is Best
It is essential to use a multisensory approach when teaching children with sensory impairments, particularly if they are also developmentally delayed. It has been estimated that 75 percent of learning is visual, but, clearly, a blind child cannot learn through the visual mode which is the basis of most standard curricula. Nor is it effective to simply transcribe print text into braille for many multihandicapped children. Such students benefit most from a direct hands-on approach that fosters the development of other senses. Tactile experience is crucial to blind children since much of the information that they gain about the world is acquired through touch. Auditory channels are equally important; helping children to interpret and make sense of what they hear is indispensable to their ability to function in the world. In addition, the senses of taste and smell can also help children to develop a deeper understanding of their environment. Furthermore, it is important to note that more than 80 percent of students labeled as legally blind have some visual potential. For students with low vision, the use of colors, lights, and materials with high contrast are desirable. Ideally, each of the senses should be incorporated into an integrated teaching approach to encourage children to explore the world around them.
Take Advantage of the "Teachable Moment"
It is no secret that we all learn best when we are interested and motivated. Make the most of those moments, which are often completely unplanned, but when the student is drawn toward a particular item or idea. For example, a teacher may have prepared a classroom lesson on following directions, but while on the playground, an opportunity arises to apply the concepts of the lesson. The student is enjoying swinging and is reluctant to come inside. The same skills can be taught outside by having the student "stop" and "go" or swing "fast" and "slow." It is important to be flexible and to take advantage of these moments since a child may ultimately learn more from these spontaneous interludes than from a structured lesson.
Whenever possible, try to incorporate materials that are of interest to the student. For example, if a child loves musical instruments, but the goal of the lesson is to teach sorting skills, have her sort small jingle bells and shakers. Similarly, in a counting lesson, have the student count cassette tapes if that is what motivates her. Be aware, however, that some students may perseverate on particular topics or materials in an inappropriate manner. Familiar materials or "enticers" may be phased out or replaced eventually with some students. The educational team will need to decide how to balance the introduction of new topics to broaden a student's interests, with the use of familiar, motivating materials that can help to develop new concepts.
Know the Student's Medical History and Physical Restrictions
Many students with multiple disabilities have extremely complicated medical histories. Before working with a student, it is absolutely imperative to research her medical background and condition. Be sure that you find out the following information:
Students should learn to communicate as much of this information as possible. They can carry special cards or wear medical alert bracelets if their condition warrants.
Make Adaptations to Meet the Student's Physical Needs
Children with multiple disabilities often have difficulty gaining access to the world around them. A lack of vision, motor skills, or cognitive development can greatly affect their ability to explore their environment. With a little imagination, teachers and parents can make simple adaptations to toys, games, and other materials to make them accessible to all children. Textures, for example, can be added to many toys to help a child to identify different parts of the toy or to locate the on/off switch. Similarly, the placement of textures on a child's chair or bedroom door may help her to travel more independently around the house or school. See the Adaptive Technology chapter for more ideas.
Create an Environment that Encourages Optimal Functioning
It is important to structure the physical environment in such a way that students can function at their full potential. Most children with multiple disabilities cannot organize their surroundings in a meaningful way and thus, are dependent on others to structure the environment for them. When setting up a space for these children, consider factors such as acoustics and lighting, as well as physical layout. See Enhancing the Use of Functional Vision for suggestions for children with low vision.
Many multihandicapped children have difficulty screening relevant information from the environment, and the noise of a busy room may be overstimulating. While it is important to help students to develop coping mechanisms, it is also necessary to minimize auditory distractions so that they can focus on the immediate situation.
Within a workspace, it is essential to present materials in an organized manner. Use trays, boxes, and dividers to define space and help children to organize their work.
The physical layout of a classroom or living area also has an effect on an individual's ability to function independently. The environment should be free of unnecessary obstacles or clutter so that a child can move about freely. Materials should be left in consistent, easily accessible locations so that a child can find them independently. See the Orientation and Mobility chapter for further suggestions.
The following principles are meant to provide general guidelines. A behavior specialist should be consulted for specific concerns.
Be Clear and Consistent
Many children with multiple disabilities rely heavily on the predictability of their routines in order to make sense of the world. Although we want them to be flexible and to learn to adapt to an ever-changing world, it is also important to provide a routine in which the expectations are clear and consistent. If they are to acquire a sense of responsibility, children should have clear limits set and should be aware of the consequences of their actions. The ultimate goal is to teach an individual to monitor her own behavior.
Accentuate the Positive
Be enthusiastic! Your attitude will set the tone for the student. Often, the use of a cheerful, though natural, voice will positively affect the way that a child approaches a given task. Begin a structured lesson with a familiar activity that the child can do so that she can feel successful. If the child starts out with a sense of accomplishment and praise, chances are that she will be motivated to try a new activity.
When we, as teachers and caregivers, are tired and stressed, it is all too easy to focus on what the child is not doing or is doing wrong. It is very important, however, both for the child and the adult, to remember to praise the child for things she does well and not just to reprimand her for her transgressions. For example, if a child is playing with the materials instead of using them appropriately, say, "Oh, good, Ellen, you found the penny. Now can you put it in the bank?" In this manner, the child will be praised for what she has done correctly while also being gently reminded of your expectations.
Redirect Students When Necessary
If a student is doing something which is generally considered to be inappropriate, be sure that she understands what is expected of her. Model acceptable behavior and praise the student whenever her behavior is socially appropriate. If the negative behavior persists, try to ignore it at first, and praise others for their good work. If the child continues to exhibit negative behavior, redirect her to the desired behavior. For example, if it is time to sit down at the table for circle time, but one student refuses to sit with the group, try to redirect her interest. Drawing her attention to the positive often works best; for example, say, "Let's find out what day it is today. Look, Julie, I've got your chair waiting right here so that you can help us with the calendar." This type of approach is often more successful than a direct negative comment, such as, "Julie, I told you to sit down!" Students often feel more in control when they are redirected because they do not perceive your comments to be a direct request.
Reward Desired Behavior
It is very important to let students know when you are pleased with their performance. Be sure to praise them when they have stayed on task and followed directions. Make it clear exactly what behavior you liked, or did not like; for example, say, "Ben, I'm glad you remembered to wait quietly at the table when you were finished. That was great!" or "It's too bad you didn't follow directions. Now you won't be able to earn free time." Simply saying "good job" or "good boy" does not give the student enough information. In addition, when behavior is specifically labeled, it can be a model to other students too.
Establish Meaningful Consequences for Behavior
Choose consequences that will be meaningful to the individual student. Consider a child's developmental level, her physical abilities, and her interests when deciding upon a consequence. For example, a child who is totally blind may not be motivated by earning a sticker. Similarly, a student who would rather talk to herself than participate in group activities will probably not feel "punished" if she is removed from the group for negative behavior. Moreover, a child who cannot see may not even realize that she has been pulled away from the group or that her chair has been turned around.
Many multihandicapped students need immediate consequences which are directly related to their behavior at the time. For example, if a child misbehaves in swimming on Monday morning, it would not be appropriate to tell her that she will not be able to go on the class field trip on Friday afternoon. First of all, Friday is too far away, and, second, the field trip has nothing to do with the pool. A more appropriate consequence may be having to get out of the pool early. It is necessary to analyze meaningful consequences for each learner (for example, getting out of the pool early may actually be desirable for some).
Follow Through with Consequences
Do not threaten students with consequences that you do not plan to enforce. A student will learn quickly if an adult repeatedly says, "This is your very last warning" and does nothing when the student persists in the behavior. In addition, it is usually best to deal with any situation yourself, rather than to threaten with a third party who is not present. For example, if a student acts up and the teacher says, "Do I need to call your mother and tell her about this?" the student is getting the message that the teacher is not able to handle her behavior. Although there may, of course, be times when a parent should be informed of a child's behavior, telling parents should not replace dealing with the child directly when a conflict occurs.
This book is meant to be a model for others to use as a springboard to develop ideas and create activities for their own students. No rigid formula is appropriate for all students, and each student's individual needs must be the focus of any educational program. Although specific methods and materials may vary, the ultimate goal is the same: to teach students functional skills that will enable them to be as independent as possible in the world.
For additional information, refer to the General Annotated Bibliography in the Resources chapter.
Special thanks to the following individuals who read this chapter and offered ideas, information, and helpful criticism: Mary Talbot, Priscilla Chapin, Judy Bevans, Alex Truesdell, and Kimberly Carey.
Critical Skills Chart
Developing Play Skills
What Is Play?
Special Considerations for Development of Play Skills in Children with Visual and Multiple Disabilities
Structured Play as an Educational Tool
Early Awareness of Self and Others
Games and Songs for Developing Social Interaction
Developing Community Awareness
Introduction to Critical Thinking
Developmental Screening Checklist
Tools for Assessment
Social development is an integral part of a comprehensive educational program. In addition to incorporating skills from all domains, it is an essential area of development in and of itself: social development is the basis for living, working, and functioning within the community. Interaction with others increases language development while play provides an enjoyable way to develop fine and gross motor skills. Games are an excellent way to practice functional cognitive skills, such as following directions, imitation, and problem solving. As children get older, social skills are essential in helping them to make the transition from school to work. Students must have acceptable social behavior in order to function in a work environment. Good work skills alone are not enough to ensure success without the necessary accompaniment of appropriate social skills.
Socially acceptable behavior is learned by watching others. By observing and imitating the norm, a set of behaviors emerges which is deemed to be appropriate by society at large. A student with visual impairment does not have the benefit of nonverbal cues, such as body language. To complicate matters further, the student with significant developmental delays may not be able to determine just what behavior is deviant. As unfair as it may be, we are all judged by our appearance and behavior. In order for students with multiple disabilities to be as fully integrated as possible into the mainstream, they need to learn what behavior is, and is not, socially acceptable.
In order to encourage socially acceptable behavior, all activities, toys, materials, clothing, etc., should be age appropriate and resemble that which is found in mainstream society. An individual will appear more handicapped if he is using materials designed for someone below his age level. Similarly, differences are accentuated by ill-fitting, unclean, or outdated clothing. By providing materials and clothing appropriate to a child's chronological age, we can help him to be viewed by society in a more positive light.
All children should be taught good manners and an awareness of hygiene, but this is especially true for individuals who may need years of practice to learn a simple skill. It is important to help our students learn to respect other people's space and property. Students need to grasp the concept of public versus private space. This is crucial to gaining independence and helps to avoid offending others in daily interactions. It also helps the student to protect himself.
Certain physical mannerisms which are characteristic of this population may stigmatize its members in society. "Blind mannerisms," which include behaviors such as rocking, eye poking, light gazing, and other self-stimulatory behavior, such as arm flapping or any constant repetitive motion, are common in multihandicapped children. Researchers in the field have been debating whether this indicates a behavioral problem or a need for increased stimulation. In either case, it is important to offer appropriate alternative behavior.
Social skills that are acquired naturally by most children must be specifically taught to many students who are multihandicapped. These students need adult intervention at all levels of social development, from the earliest stages of self-awareness, to the development of simple interactive skills, and, finally, to an active participation in the community. Appropriate social skills should be modeled for students at all levels, and students should have ample opportunity to practice functional skills in a variety of settings.
In this chapter, we will examine various aspects of social development, as well as some of the ways in which social skills reinforce concepts in other domains. The first section, Developing Play Skills, discusses the value of play, as well as some specific activities for developing play skills. Early Awareness of Self and Others looks at activities for simple name recognition. Games and Songs for Developing Social Interaction looks at some strategies for increasing interaction with adults and peers. Cooperative Skills provides ideas for activities that encourage students to work together. Developing Community Awareness presents activities that encourage interaction with the community. The last section, Introduction to Critical Thinking, challenges students to develop problem-solving skills in real-life situations.
For related information refer to the Toys, Games, and Leisure Time Activities chapters.
The following chart identifies essential skills or concepts in social development and activities that focus on the acquisition of these skills. This format promotes easy access to appropriate activities to develop these basic skills.
What Is Play?
It is important to remember that play is a way in which children can learn and grow in all areas. The research on children's play indicates that cognition, language, gross motor, fine motor, and social development can all be enhanced through play. In order for play to be meaningful, toys and activities must offer an appropriate level of challenge.
The stages of development in play skills have been observed and outlined in able-bodied (Piaget, 1962; Garvey, 1977), visually impaired (Fraiberg, 1977), and multihandicapped children (Musselwhite, 1986). Although the stages of play may be labeled differently, they tend to follow a common sequence. Not all children will progress through all stages of play, but it is important to understand that play follows a developmental sequence.
Sensorimotor Play (also called "exploratory play") The child explores objects and experiments with his own body. At this stage children often mouth, squeeze, and bang objects to discover their various properties. As they begin to manipulate objects in a more systematic manner, children start to develop an understanding of cause and effect (i.e., the child learns that he can produce a certain result by performing a given action), and object permanence (i.e., the object continues to exist even when the child can no longer see or touch it). See the Language and Cognition chapter for related information.
Solitary Play (also called "independent" or "isolate" play) The child plays appropriately with simple toys and materials by himself.
Parallel Play The child engages in his own activity next to a peer, but does not actually play with the peer.
Associative Play The child begins to approach a peer through brief physical contact or eye contact.
Cooperative Play The child begins to initiate simple interactions with others, and an element of mutual participation is introduced.
Symbolic Play (also called "pretend" or "representational" play) The child begins to make believe and act out familiar events using props. This stage can be broken down still further, beginning with functional play, in which a child acts out functional activities, such as eating, sleeping, cooking, and cleaning. Children begin by using real objects as props, such as real dishes at a pretend tea party or an actual pillow when pretending to go to sleep. In representational play children learn to represent an object with a model (miniature car or furniture) or with a completely different material (a piece of cardboard becomes a plate). Children in this stage enjoy role-playing, or acting out various situations, such as going shopping, going to the doctor, and playing house. Again, they begin by using real people (themselves) to act out these situations, and later learn to substitute dolls or puppets as the primary characters in their play. As they become more sophisticated in their play, children learn to sequence steps in a given play situation (e.g., getting in the car, driving to the store, selecting an item to purchase, paying for the item, and returning home in the car).
Special Considerations for Development of Play Skills in Children with Visual and Multiple Disabilities
We traditionally think of play as being inherently pleasurable and self-motivating to all children, but this is not always the case for children with visual and multiple disabilities. Because of early medical experience, physical disabilities, and learning environments that may not have encouraged exploration, many children with multiple disabilities do not automatically explore their surroundings. Others may actively investigate the world around them but may need help interpreting their discoveries and generalizing their experiences to new situations.
Children with special needs may not be able to play spontaneously at first. What comes naturally to most children will, most likely, have to be specifically taught to blind, multihandicapped children. Many normal play activities are learned through observation and imitation, much of which is visual. Most non-disabled children imitate their parents' daily activities (such as housecleaning, driving a car, using a telephone) and engage in parallel play with their peers. While many multi-impaired children can learn to enjoy playing, it may be unrealistic to expect them to play alone without adult guidance at first.
Teachers and parents often complain that children with multiple disabilities play with toys in inappropriate ways. For example, when given a truck, the child may want to spin the wheels instead of "driving" it on the floor. Other children may continually mouth a toy without exploring its special characteristics. These behaviors may indicate that the child is in an earlier stage of play (such as sensorimotor play) and that he may actually be making important discoveries at his own level about cause and effect and the various properties of different materials. If a child's play appears to be self-stimulating and nonproductive, it is often because he needs to be taught new strategies for interacting with a toy.
Because cognitive development and motor abilities affect a child's level of play, not all children will progress through all of the stages of play. Children cannot play at a more advanced stage until they have developed the necessary cognitive skills. However, adults can help to structure play to make it more appropriate for the child's chronological age even if his cognitive development is at a lower level. For example, if a ten-year-old child is still functioning at the sensorimotor level, he might be given musical instruments to blow and tap in a way that would be socially appropriate.
A common problem for many students with multiple disabilities is learning to grasp the symbolic representation of objects. It may be difficult for them to comprehend that a small plastic representation can stand for a real object. For example, puppets and dolls or miniature plastic animals or furniture will be meaningless at first to blind children. It is crucial to have as much experience as possible exploring and playing with real objects before being introduced to pretend models.
Structured Play as an Educational Tool
Play is becoming more widely accepted as an appropriate method for education and therapy because of its proven value in developing skills in all domains. As such, it is a crucial part of any integrated educational program for students with multiple disabilities. Furthermore, as parents and educators, we can learn an enormous amount about a child by watching him play. Children express what they know about the world through their play, therefore, observing a child at play is an excellent means of informal assessment.
It is important for adults to determine what degree of intervention each child needs in developing play skills. Play can and should have an element of spontaneity but should also encourage growth through new experiences. In the early stages of development, most activities include at least some element of play. Adults can structure the environment in such a way that children can enjoy the pleasure of exploration and discovery while developing important skills. By acting as facilitators, adults can model enjoyable activities while providing an environment which is safe and predictable and toys which offer an appropriate level of challenge.
Variety of preferred toys, objects, or edible treats
Students should be given the chance to make choices in all areas of daily functioning. Mealtime and free time usually include an element of choice, but almost any activity can be structured in a way that offers some choice (e.g., which work task would you like to do first, which item of clothing would you like to put on next, etc.). Decision making skills should be reinforced throughout the student's day.
Choose a simple sound-producing toy that each student enjoys and is able to operate with minimal assistance. It is best to choose a toy with a definite cycle that will clearly mark the end of a turn, such as a music box, electronic toy, or jack-in-the-box.
Encourage students to take turns during leisure time activities.
Stages of play occur in a developmental progression and, therefore, not all students are ready for representational play. (Refer to the introduction of this section.) Students who are not ready for this stage might be confused by time and orientation conceptswondering why they are lying down to go to sleep in mid-morning in a place other than bed.
Expand on role-playing to prepare for various interactions. For example, practice role-playing a trip to the store before going shopping (put items in a cart, unload cart at register, greet cashier, pay cashier, carry bags out of the store). Repeated opportunities to use these skills in a variety of settings will help students to generalize their knowledge to new situations.
While there are many parallels between the social development of non-handicapped, sighted children and their peers with visual and multiple disabilities, there are also some crucial differences. From the earliest months of life, a blind infant does not have the ability to use vision to interact with his environment. Sighted babies are able to make eye contact with their parents and see them smile. In addition, they develop body concepts and an understanding of cause and effect by watching their own hands and feet and discovering what happens as they move. Without the benefit of sight, it takes blind and visually impaired infants longer to develop these same concepts. Furthermore, when a child is born with additional handicaps, such as developmental delays or physical disabilities, it is even more difficult for him to explore his surroundings in a meaningful way. Early intervention and constant stimulation are crucial in helping a multihandicapped child develop interaction and exploration skills.
Because of the limitations of their early interactions with people and the environment, many multihandicapped students are delayed in learning about themselves and the world around them. The activities in this section focus on simple awareness of self and others.
For related activities refer to the Developmental Music chapter.
Motivating toy or other reinforcer
Stand on the opposite side of the room from student with a preferred toy or edible treat in your hand. Cue him to call your name and then dramatically run to him, saying "Here I am! You called my name. What would you like?" Cue student to name reinforcer, but using your name to frame the request (e.g., model the request, "Mark, I want the music box, please.") Give him the object after he requests it.
Note: When a student is just learning to name familiar adults, this activity is best introduced when there are two adults present. One adult can cue the student, while the named adult waits to be called.
Encourage students to call familiar adults by name throughout the day, when appropriatefor example, at snacktime, or free time, when they need help, when greeting a friend, and when making a request. Model the appropriate phrases for them, as necessary.
Form a circle with students and explain that each person should stand up when he hears his name. Ring a bell and call a name. Give student time to stand up, with prompting as necessary. Reinforce him with lots of praise. After student is seated again, ring the bell and call another name.
See "People" in the Developmental Music chapter.
Take attendance each morning as part of the daily routine. Ask students to say, "I'm here," or to wave "hello" if they are unable to speak, when they hear their names.
One student stands in the middle while others circle around him and sing to the tune of "Ring Around the Rosie":
Ring around ___
All around ___
Clap hands, clap hands,
We all clap for ___
Repeat the activity until everyone has had a chance to stand in the middle.
Have student in the middle choose the next person to be in the center of the circle.
Encourage students to call their peers by name as appropriate throughout the day. Provide a verbal model, if necessary.
This section builds upon the previous section, Early Awareness of Self and Others. The focus here is on increasing interaction with peers and adults in structured games. These activities encourage group participation and taking turns. The songs included in this section are sung to familiar tunes. For related activities refer to the Developmental Music chapter.
To emphasize group participation
Circle time is often an important part of the daily routine in many classrooms. It can be designed to focus on a variety of different levels of development, using either songs and simple games or a structured ritual of opening exercises. Some basic components include:
"Hello Song" where each student is greeted and, in turn, greets others. See theDevelopmental Music chapter for words, music, and related songs. Older students may prefer simply to greet each other verbally, without a song.
Students can take turns calling each other's names and finding out who is there. This is a good opportunity for students to identify their classmates.
Talk about the day of the week, the date, month, year, and season. Discuss time concepts, such as "yesterday, today, and tomorrow." Reinforce math skills by having a "calendar count-up" where the group counts in unison to the date. Practice left-to right progression by having students place the dates in tactilely defined boxes (e.g., using raised lines). See "Daily Calendar" in the Functional Academics chapter.
This may be done verbally or with a special weather chart where students hang up words, pictures, tactile symbols, or real objects to tell about the weather.
What are you wearing?
This goes well with a discussion about the weather (e.g., "What do you wear when it's cold, raining," etc.) Students can describe what they are wearing in as much detail as they are able. They can also take turns asking each other what they are wearing. See "What Are You Wearing?" in the Language and Cognition chapter and "Clothing Selection" in the Independent Living Skills chapter.
This may be done individually or as a group. This is a good time to make announcements or to discuss special upcoming events. See "Schedule Boxes" in the Language and Cognition chapter.
For younger students, choose an activity from this chapter or the Developmental Music chapter. For older students, try a simple discussion. See "Conversation Skills" in the Language and Cognition chapter.
SPECIAL CONSIDERATION FOR VISUALLY IMPAIRED STUDENTS
As a general rule, try to design charts and calendars that are meaningful to the group. For example, some blind students may benefit from exposure to braille or some tactile representation. Keep in mind, however, that symbolic representations which may be obvious to a sighted person are often meaningless to multihandicapped, blind children. For example, a card with cotton balls representing clouds may mean nothing, but a real umbrella representing rain may have an association they readily understand. In addition, using an actual umbrella to illustrate the weather helps to reinforce a functional skill.
Encourage students to tell where they put everyday objects; for example, "Sam, I put your radio on top of your desk."
Ask students to find items throughout the day, such as lunch money in their front pocket, hat in the outer section of their backpack, etc.
A variety of hats, such as a wool cap, a baseball hat, a helmet, and a straw hat
Students sit in a circle and one person puts on a hat. Everyone sings to the tune of "The Farmer in the Dell":
___ has the hat.
What do you think of that?
What do you think he'll do?
He'll take it off and give it to ___
The student with the hat chooses the next person to wear the hat and puts that person's name in the blank. The game continues until everyone has had a turn wearing the hat. The final verse ends: "He'll take it off and put it away."
Play the game using a variety of clothes, such as shoes, coats, mittens, shirts, and socks.
Be aware of sanitary issues when sharing clothing. If necessary, each student can have his own hat and set of clothes to use. Be sure to wash the hat and clothes periodically.
Reinforce dressing/undressing skills throughout the course of the day: put on a jacket to go outside, apron for cooking, smock for crafts, etc. For younger students, the song could be used as motivation by changing the words to fit the situation; for example,
Philip has the coat.
What do you think of that?
What do you think he'll do?
He'll take it off and hang it on his hook.
Students take turns singing in dialogue with teacher or the entire class. Responses can be standard or individualized, depending upon the group. Sing to the tune of "Frere Jacques":
Where is Ellen? (everyone sings)
Where is Ellen?
Here I am! (answers Ellen)
Here I am!
How are you today? (everyone sings)
How are you today?
1 am fine. (Ellen responds)
I am fine.
Repeat the song until everyone has had a turn.
Have student vary his response to the question, "How are you today?" ("I am tired" or "I am hungry.")
Encourage students to respond to simple greetings and questions in the natural setting.
Encourage students to search for familiar people as independently as possible.
Special thanks to the following individuals who read this chapter and offered ideas, information, and helpful criticism: Fran Honan, OTR, Lori Vaughan, RPT, Linda Butterworth-Till, Mary Goodwin.
Critical Skills Chart
The Tactile System: General Guidelines for Working with Students with Tactile Defensiveness
The Vestibular System: Gravitational Insecurity
Gross and Fine Motor Coordination
Developmental Screening Checklist
Tools for Assessment
Sensory integration is the ability to take in, sort out, and organize information from the body and the world around us. All of this takes place automatically in the central nervous system (nerves, spinal cord, and brain). Information is received by the nervous system through the sensesvision, touch, hearing, taste, and smell. The nervous system also includes lesser known systems for processing the effects of gravity, body position in space, and sequencing motor patterns.
The major part of the brain responsible for processing sensory integration is the brainstem. When a sensory integrative dysfunction is present, the brainstem may not be fully mature. Therefore, the higher level of the brain, the cortex, tries to assume the function of the brainstem. Since the cortex is the thinking area of the brain, the student has difficulty performing automatic motor functions. Movements may appear slow, choppy, and clumsy. To further complicate the situation, the cortex is necessary for concentration and learning. Since the cortex is occupied with the movement functions of the brainstem, it is not available to attend fully to school activities.
Sensory integrative theory and its practical applications were developed by A. Jean Ayres, Ph.D. They have been used by occupational and physical therapists for over 25 years. Individuals who specialize in this area have undergone education and training in the field of sensory integration. It is important to note that this theory continues to have ongoing research with resulting modifications.
Using a sensory integration approach may promote maturation of the brainstem. This will allow the brainstem to function properly and movement may become more automatic. In addition, the cortex will be free to concentrate on school activities, so advances in educational goals will be evident.
Students who have difficulty processing sensory information may have trouble learning at school. These students may have a short attention span, difficulty staying at their seats, and problems in concentration.
If a visual impairment is present in addition to a sensory integration dysfunction, it is extremely important for a student to further develop his ability to use sensory information to function effectively in his environment. If the system has not refined the ability to collect, interpret, and react to sensory information, the student will continue to have difficulty in all areas of learning.
A detailed Developmental Screening Checklist has been included in this chapter. Upon completion of the checklist, you may suspect the student has a sensory integration problem. Direct consultation with a qualified occupational or physical therapist will be necessary for a complete evaluation. The results of the evaluation will determine if a sensory integration dysfunction is present. If specific problem areas are identified, an individual treatment plan will be established for the student. This treatment plan should also include classroom and home activities for daily carry over.
The activities included in this chapter are general activities appropriate for class-room and home use. They emphasize the three major treatment areas: tactile (sense of touch), vestibular (sense of balance), and proprioception (input from muscles and joints). To achieve the best results, provide a variety of activities from the different outlined areas in this chapter. The activities in each section are arranged from simple to more complex.