Communication issues and strategies for deaf-blind individuals: case studies basic on etiology and language level.

Through the demonstration of appropriate rehabilitative training techniques, methods, and technologies, the Helen Keller National Center for Deaf-Blind Youths and Adults (HKNC) facilitates a national, coordinated effort to meet the social, rehabilitative, and independent living needs of those who are deaf-blind. Communication presents a unique challenge to the deaf-blind individual, family, friends, and all involved in that person's life. This article includes five case studies of adults with dual sensory impairments. Described are various communication strategies, depending on the time in life of the hearing and/or visual loss. Included are: I. Congenital Deafness and Blindness, focusing on those without a formal language system; II. Congenital Deafness with Visual Impairment: Minimal Language Skills, focusing on those with minimal language skills; III. Congenital Deafness with Visual Impairment: No Linguistic Deficits, focusing on those with no linguistic deficits; IV. Congenital Blindness with an Adventious Hearing Loss; and V. Sudden Loss of Vision and Hearing. The accompanying table provides a brief description of communicative methods, aids, and devices that may apply.

I. Congenital Deafness and

Blindness

"C.S.," who is congenitally deaf and blind due to maternal rubella syndrome, came to HKNC at the age of 22. The etiology of maternal rubella syndrome stems from affected tissue development of the newborn of those whose mothers have been exposed to the rubella virus (German measles) during the first trimester of pregnancy Symptoms include "hepatosplenomegaly, interstitial pneumonia, congenital heart defects (patent ductus arteriosus, stenosis of pulmonary trunk), low birth weight, congenital cataracts, purpura, hearing loss, inguinal hernias, mental retardation" (Magalini, 1971, pp. 464).

C.S. spent most of his life in an institutional setting with minimal educational intervention. Upon arrival, he used informal methods of communication. Vocalization and behavior were his primary means of protesting and rejecting activities. For example, he would push away an undesired work task. He was unable to follow formal signed directions, but he was able to respond to tactual cues (i.e., opening a door when his hand was placed on the knob, turning on the water when his hand was placed on the faucet, taking off his coat when a tug was made at the collar).

He used physical manipulation of the "listener" to request specific items (i.e., leading a person to the refrigerator to indicate the desire for something to eat). The need for help or assistance was communicated by extending an item to the "listener" (i.e., a jar or box that could not be opened). He arrived with a limited repertoire of signs. In most cases, these were basic food signs learned for the sole purpose of making a request (coffee, cookie, candy, milk).

The traditional method of "classroom instruction," sitting across a desk from the student), was deemed an inappropriate means of evaluating and providing communication training for C.S. There are no standardized testing procedures or means of assessment for deaf-blind persons, therefore techniques such as "language sampling" and "situational observation" assessment were utilized, such as observing a morning grooming or food preparation routine. Specific communication goals were developed according to his daily needs.

Based on C.S.'s demonstrated ability to make an internal "connection" between activities or items and "signs," and his ability to copy new signs, training in basic functional sign language was deemed appropriate. The initial sign lexicon was developed for him incorporating the following guidelines:

* Signs were taught for frequently occurring items and activities to give more opportunity for daily use of these signs; i.e., eating and food, grooming, everyday work, and leisure activities.

* Iconic signs were utilized; i.e., signs that look like what they represent. These signs incorporate the natural body movement of the referent. This facilitated the paired association between the item or activity and its corresponding sign; for example, brush teeth comb hair," "food/eat," "bed/sleep," "come (here)," "stir." Please note, however, that what is iconic to a hearing/sighted person may not be for the deaf/blind individual; for example, the sign for "drive" (steering motion) may have no meaning to a congenitally blind person who has never experienced that motion.

* Symmetrical signs were used as opposed to asymmetrical signs. The formation of the hands in the same shape was motorically easier; i.e., the sign for "more" versus "again."

* "On the body" signs were chosen as opposed to signs formed "out in space" (i.e., "eat" versus "shop"). This provided more tactual feedback for the learner.

* Two signs formed within close proximity of each other were not taught simultaneously, to avoid confusion (e.g., "eat" and "drink").

* Signs were taught to be used for more than labeling or requesting. The use of the sign was expanded for more communicative functions (i.e., commenting, expressing a choice, offering).

* Learned signs were generalized over a domain of similar items or activities: i.e., the sign for "paper" to include letters, envelopes, inserts, etc., and the sign for "work" to include assembly, sorting, other work activities.

The reader should bear in mind that all of the above guidelines were not adhered to strictly and simultaneously. This would have greatly limited the repertoire of signs chosen for initial instruction. However, once this initial sign lexicon was established, additional signs were introduced expanding the realm of these guidelines.

In teaching initial signs, it was also important to incorporate gestures. For example, when teaching the sign for "sit" the instructor paired this with the natural body movement of sitting down as the learner's hands were placed on the shoulders of the instructor as well as feeling the chair.

As a means of documentation of learned signs, HKNC utilizes Signs of Success. This book, developed and edited in 1985 by Laura G. Cummings and sponsored by The Illinois Deaf/Blind Service Center, is a progressive sign language manual particularly developed to meet the communication needs of deaf/blind and multihandicapped individuals. In addition, because of its workbook format, the unique communication system of an individual can be recorded and expanded as the individual's sign vocabulary grows.

In other cases, when the paired association between the item or activity and sign may not be achievable, sign language may not be the appropriate method of communication, and tangible symbols may provide a more concrete means of communication. Tangible symbols may include the actual object, portions of the object, one shared feature, or an associated or arbitrary object to represent a specific item or activity. These objects or symbols are attached to square backings in order to cue the learner for an item or activity.

Tangible symbols are representations, not the actual object to be used. For example, an empty toothpaste tube may be attached to a cardboard back" to cue the learner to the activity of brushing teeth. When appropriate, this tangible symbol can also be paired with the sign. These symbols may be used in a specific sequence that is repeated daily to facilitate their association. For example, a "sequence box" or schedule may be established in which the learner takes each tangible symbol from the box in a sequenced order. Once the activity is completed, the symbol is placed in a "finished" box. As these tangible symbols are established, the learner may expand to use these expressively; i.e., extending the symbol to the listener to make a request or indicate a need or choice.

"During the initial stages of concrete symbol use, ... symbols would be selected that can be used frequently throughout the day within a small array and that are related functionally or perceptually to their referents" (Goetz, Guess, and Stremel-Campbell, 1987, pp. 58). Examples include: a spoon to indicate mealtime, a seatbelt buckle to indicate going out in a car, a ping-pong ball to represent any "ball" activity, or a chlorine scented towel to represent swimming. These tangible symbols, in the order listed, reflect a decreasing degree of iconicity; each is chosen depending on the individual needs of the learner.

Abstract tangible symbols are randomly chosen. The individual learns to make the association through consistent presentation of the symbol. For example, a three dimensional wood block may represent the end or completion of all activities.

The key to effective communication training is to pair beginning signs and/or tangible symbols within natural functional environments. Information about personalized systems are forwarded with the individual to future living and/or work placements.

II. Congenital Deafness with

Visual Impairment:

Minimal Language Skills

"M.E." is congenitally deaf and visually impaired as a result of maternal rubella syndrome. Unlike C.S., M.E. appeared to have a basis of a formal linguistic system. He arrived at HKNC with an extensive repertoire of single formal signs. His residual vision allowed him to discriminate pictures and line drawings, and he was able to print the alphabet and could pair the letters with the fingerspelled manual alphabet. He could print and fingerspell his first name, and he demonstrated a comprehension of basic signed directions, such as "get your coat," "go bathroom," "eat more." He readily "copied" new signs and/or accepted physical assistance to form new signs.

He did not use formal signs to request items, make choices, indicate needs, or answer questions. Language training was provided during functional settings to expand his formal repertoire of signs and the use of the above mentioned communicative functions. A personalized communication book was developed for him that included categorized picture/word pairs in relation to his daily routine and activities. For example, his morning grooming routine was displayed in sequential order with Polaroid photos, which were paired with signed directions as a means of prompting him throughout the routine. His daily schedule of activities was also presented in a similar fashion: arts and crafts was represented by a drawing of a pair of scissors and the printed word "ART," a work activity was represented by a time card and the printed word "WORK," and mealtime was represented by a drawing of a place setting and the printed word "EAT." He was prompted to look at this schedule at the beginning and end of each activity. This was also paired with the corresponding formal sign and the sign "finished," when appropriate.

Because group activities provided natural opportunities for him to enhance his expressive communication - requesting items, gaining the attention of others, asking for assistance, and indicating choices - M.E. was involved in a daily socialization peer group using natural interactive communication. Techniques were used to elicit language and expand his range of signs, both receptively and expressively.

His communication book also included pictures/words for community based activities. Since he enjoyed trips to a local fast food restaurant, his book contained pictures of preferred food items. He was encouraged to point to the desired food item (hamburger or chicken nuggets) as he interacted with the restaurant staff. The final page in this section of the book contained a picture of a dollar bill as a prompt for him to take out his money for payment.

Communication books vary to accommodate each person. Participation and involvement from the individual is encouraged in the construction and content of these books, as this provides more meaning and understanding of their purpose. These books may contain sections for shopping, recreational activities, work activities, time telling and calendar skills, and banking and money management. Communication books may be constructed to match the individual's sensory needs and language level; i.e., using objects, pictures, large print or raised print (see table), words, braille, or any combination of the above.

III. Congenital Deafness with

Visual Impairment:

No Linguistic Deficits

"R.D." was born deaf and educated in residential schools for the deaf. In her late teens, as her vision deteriorated, the medical diagnosis was Retinitis Pigmentosa (RP). This, in conjunction with deafness, is labeled Usher syndrome (Type I). Usher syndrome is usually marked with deafness at birth or "during childhood a progressive hearing loss (evident at age 4 to 6) and secondary lack of speech development. Usually a few years later (average age 9) progressively poor night vision, degeneration of peripheral visual fields, tunnel vision, (and/or) blindness" (Magalini, 1971, pp. 532).

R.D. used American Sign Language (ASL) as her primary mode of communication. ASL, a formal linguistic system, "... is not based on, nor is it derived from English" (Humphries, Padden, and O'Rourke, 1980, p. 1). It has its own syntax, grammar, structure, and idioms.

Due to R.D.'s visual condition, modifications were necessary for receptive communication: the signing partner needed to wear dark clothing for contrast; care was taken to limit the glare of light; the distance between her and the partner needed to be increased; the "signing space," or spacial area in which signs are formed, needed to be decreased due to visual field restrictions; and some signs needed to be modified, e.g., the sign for "Russia" was fingerspelled as the formal sign is made at waistline level and could not be seen by R.D. when focusing on the facial area of the signing partner. R.D., on occasion, found it necessary to manually "track" the signer. This involved holding the signer's wrist and following the movements. Because RP is a progressive visual condition, training focused on tactual sign language (see table). This training included the use of a blindfold.

English may be considered a second language for congenitally deaf ASL users. R.D. was able to communicate effectively with the general public using notewriting, although there were errors in English grammar and syntax. Her vocational and educational aspirations justified training in written English composition. Commercial programs utilized by HKNC include The Apple Tree Series (A Patterned Program of Linguist Expansion Through Reinforced Experiences and Evaluations by Anderson, Boren, Caniglia, and Krohn, 1975/1980) and The Gallaudet Step Series (Structured Tasks for English Practice), Gallaudet University Press, 1975).

Training was provided in reading and writing for everyday living, which included the development of a personalized language resource/reference book. Categories in this book focused on the individual needs for future living independence. Examples of categories include: medical terms and prescription labels, application terminology, banking and budgeting terms and procedures, public transportation schedules, newspaper advertisements and listings, and emergency procedures.

This reference book was also used to develop and enhance R.D.'s English vocabulary. For example, under the banking and budgeting category, the unfamiliar word "deposit" may be listed with the definition of "money in the bank" and "endorse" may be defined as "sign name." This may also include sentence models to help the individual compose notes when accessing the community; for example, "I would like a _____ (one way, round trip) ticket to _____ (name of town). How much, please?" Training took place both in the classroom setting and in the community to provide opportunities for the functional use of material covered in the reference book.

Dependent upon the individual's future goals, plans, and reading comprehension level, the instruction of braille may be considered. For the avid reader and/or writer, Grade II Braille may be taught. This is an intensive program of advanced contractions and abbreviations for someone whose literary realm may include books, magazines, or newspapers. In other cases where extensive reading may not be a viable personal or vocational goal, Grade I Braille instruction may be more appropriate. This includes the alphabet and basic punctuation. Both the above mentioned braille programs include a method of writing braille, using either a slate and stylus and/or the Perkins Brailler (see table).

For those whose reading and writing would be limited, a method of using raised tactual printed letters may be used for identification and labeling of personal items and articles. The Large Print Label Machine makes large letters on vinyl or magnetic tape that can be read tactually by those with a knowledge of the printed alphabet and can be used for basic communication when attached to index cards and to label such items as closets and drawers, food items, and appliances. A braille label machine is also available.

Other means of communicating with the nonsigning public may be with prepared notes, perhaps on index cards, that can be presented to the public. These may be in the form of large print, raised print, or braille. The user needs only to identify a specific word on the card to recognize the content. An appropriate complete English translation would be written below for the general public to read. For example, a card may have the brailled word "coffee" paired with the printed sentence: "Please, I would like a cup of coffee with milk sugar." Receptive communication from the public may be accomplished such methods as notewriting, Print On Palm (P.O.P), Tellatouch, or alphabet plates (see table).

Additional aids and devices that may be appropriate include writing guides, the Large Display Telecommunication Device for the Deaf (TDD), TeleBraille, and an alerting device for the home (see table).

IV. Congenital Blindness with

Hearing Loss

"H.P.," who is congenitally blind, educated and graduated from schools for the blind. At the approximate age of 25, he noticed a progressive loss, and within 10 years it was enough to warrant the use of amplification, so he was fitted with a hearing aid. He came to HKNC "to rebuild confidence and [improve] his ability to communicate and be effective in the community...."

H.P.'s speech remained as his main expressive mode of communication. With the use of hearing aids, he was at times able to understand loud, slow, clear speech. However, his hearing fluctuated and it was evident that an alternative method of communication was necessary. The first mode taught to him was the fingerspelled manual alphabet. As he had no knowledge of the printed alphabet, P.O.P. was deemed inappropriate. H.P. had learned braille a young age and, therefore, the braille alphabet was then paired with the corresponding fingerspelled manual alphabet letters. He expressed a desire learn the cursive letters included in his name for his signature.

The next step was instruction in tactual sign language. This did not focus on ASL, because it is a visual language, incorporating facial expressions and use of space, and as English was H.P.'s linguistic basis, and he had no visual referent, ASL was not his language tactual sign language, which follows an English structure and word order.

Because H.P. was proficient in the reading and writing of braille, this enabled him to have access to many other means of communication. The Telebraille (see table) was used often, in the Face-to-Face Mode, for one-on-one conversations. H.P. also accessed large group meetings through a typing interpreter with use of the Telebraille. This device also enabled him to access the telephone and computer for vocational goals.

For receptive communication with the general public, the more portable Tellatouch and/or braille alphabet cards were used (see table). He continued to use his voice expressively and his speech remained within the normal limits of intelligibility. However, as he was no longer able to monitor his speech auditorily, training and feedback regarding articulation and volume were provided as a means of speech maintenance.

Also recommended for this group of individuals would be an alerting device for the home environment (see table).

V. Sudden Loss of Vision and

Hearing

"J.H." had normal speech, language, hearing, and vision, until his midthirties, when he experienced a complete and sudden loss of vision and hearing resulting from Meningitis. His speech remained intact as his expressive method of communication, but he was shut out from all incoming and receptive information.

As he retained a visual memory of the printed alphabet, the first stages of receptive communication were accomplished with P.O.P. For those who may experience difficulty distinguishing letters on the palm, this method may be altered; i.e., taking the person's index finger and guiding him/her to print the letter on a table, or printing the letter on the person's back.

Once P.O.P. had been established, this was then paired with the fingerspelled manual alphabet. This was viewed as a faster and more efficient method and provided him with an introduction to his most likely future primary modes of receptive communication: fingerspelling and sign language.

Expansion into the realm of the manual alphabet and sign language was a slow process for J.H. First, much time was needed for personal and mental adjustment to his sudden sensory losses. As he accepted sign language as a possible means of receiving communication, the following initial signs were taught and guidelines considered:

The signs for "yes" and "no," giving J.H. the opportunity to ask questions and receive feedback quickly and efficiently.

Signs involving his immediate surroundings; i.e.,"hospital," "bathroom," "nurse," "bed," "eat/food," "school," "home," etc.

Basic question or signs for the "wh" sound; i.e., "who," "what," "where," "when," "why."

"Name signs" were given to the people in his immediate surroundings. Name signs consisted of abbreviations or short forms of people's names, usually utilizing the initial letter (manual alphabet) of that name. This facilitated conversational references to those frequently interacting with him.

Basic time-related signs: "yesterday," "today," "tomorrow," days of the week, "month," "year," etc.

Social signs; "again," "please," "sorry," "thank you," etc.

The method of P.O.P. and the above mentioned initial sign lexicon, including the fingerspelled manual alphabet, gave J.H. an immediate opportunity to open channels of communication. Once this was established and he was aware of future expectations and plans, the focus of sign language became instructional as he would need this method as his main mode of receptive and, possibly, expressive communication. As in the case of H.P., the sign language most likely used by J.H. would be in accordance with an English structure and word order, being that this was his natural linguistic basis.

Planning for J.H.'s future, outside of the instructional environment in which many or most are familiar with sign language, we can list four appropriate communication methods for use with the general public: P.O.P., alphabet plates, the Telletouch, and the Tactile Speech Indicator for emergency telephone calls (see table).

As mentioned previously, the instruction of braille may be considered. Dependent upon the individual's future goals and plans, Grade I, Grade-II, or a modified/limited braille program may be instructed.

Other aids and devices that may be appropriate include writing guides, the TeleBraille II, and an alerting device for the home (see table).

When interacting with any deaf-blind person, adaptations must be made to meet that individual's needs. Communication provides a means of accessing, understanding, and relating to the environment and to others. The challenge of communication is met by patience, creativity, and the exploration of all possible means, methods, and adaptive measures.

Methods of Communication, Aids, and Devices

(compiled by Couslin, Dooley, and Godfrey, 1992)

* Alert/Signal Vibrating Systems - wireless paging systems that transmit basic lifeline information such as doorbell, telephone, fire alarm, smoke detector, or baby cry signals. Included are transmitters and receivers to identify each sound source. The transmitter sends out signals that are felt as vibrations by the deaf-blind person carrying or wearing the receiver.

Available from: VibraCall, Silent Call Corp., PO Box 868, Clarkston, MI 48347

* Alphabet Plates - pocket sized plastic cards which have the alphabet in either raised print letters or braille (matched with the printed alphabet). Words can be spelled out using the deaf-blind person's finger as a pointer.

* Fingerspelling, Visual - message is spelled out using the manual alphabet.

* Fingerspelling, Tactual - message is spelled out into the receiver's palm using the manual alphabet.

* FM System - used in conjunction with hearing aids. Sound is transmitted by radio waves through a microphone held by the speaker, the transmitter transmits the sound to the receiver, which magnifies the sound of the speaker's voice louder than other noise in the room.

* Interpreting - deaf or deaf-blind person utilizing a hearing person to receive information conveyed in the appropriate form of communication for the individual for whom they are interpreting. The interpreter in turn conveys the message from the deaf-blind consumer into voice.

* Interpreting, Relay - utilizing a deaf interpreter in 3-way communication. The deaf interpreter receives information from a hearing interpreter. He/she will then shadow or modify the message into the appropriate form of communication for the individual for whom they are interpreting. The deaf interpreter will also receive information from the consumer and sign to the hearing interpreter who will then voice.

* Loop System - used in conjunction with hearing aids. Based on the same principle as the FM system using electro-magnetic energy to transmit sound.

* Label Machine (large print and braille) - embossing device that makes large print or braille labels on vinyl or magnetic tape that is read tactually and/or visually.

Available from: Independent Living Aids, 27 East Mall, Plainview, NY 11803; and MAXI Aids, PO Box 3209, Farmingdale, NY 11735.

* Oral - oral transmission of the auditory and/or visual message into the visual mode of lipreading, accompanied by facial expressions and body language.

* Perkins Brailler - braille typewriting device. It has six major keys which correlate to the six - dot braille cell. The braillist pushes different combinations of these keys to form a braille letter or word. Extension keys are also available for individuals who have limited use of their hands or have use of only one hand. The machines can either be manual or electric.

Available from: Howe Press, Perkins School for the Blind, 175 N. Beacon St., Watertown, MA 02172.

Print On Palm (P.O.P.) - block letters are printed on the open palm of the receiver using the index finger, one at a time, on the same palm area, pausing slightly after each word.

* Sign Language, Visual - acquisition of spoken information by a visual-gestural mode. Be aware of the distance and signing space required for visually impaired individuals.

* Sign Language, Tactual - the receiver places his/her hands on top of the interpreter's in order to track the signs thereby receiving the information. Some signs may need to be modified or fingerspelled.

Tactile Speech Indicator - telephone device for receiving sound through tactile cues by means of vibration. The deaf-blind individual must be capable of using speech to express a message. As a simple yes/no question is asked, the received answer is then distinguish tactually by the basic code of: "no" (1 vibration), "yes-yes" (2 vibrations) and "I don't understand/know" (3 vibrations).

Available from: Greg Verity, 53 Haven Ave., Port Washington, NY 11050.

* Tadoma - method of oral communication whereby the receiver places his/her thumb over the lips of the interpreter, allowing for tactual lipreading. The index and middle fingers are placed along the jaw, the ring finger and pinky are placed along the throat, thereby receiving the vibrations of the vocal cords.

* Teletypewriter/Telecommunication Device for the Deaf (TTY/TDD) - portable device used mainly to communicate over the phone with another TDD user or Relay Service. Fashioned with a typewriter-like keyboard and two couplers on top for the phone handset, messages are typed back and forth and appear on a small screen. Tones are transmitted over the phone wires and converted into a printed message.

Available from: Ultratec, Inc., University Research Park, 450 Science Dr., Madison, WI 53711.

* Large Print Display TTY/TDD - a large print display when attached to a specific TDD produces letters approximately 2 inches in height. It can be used over the phone and in interpreting situations.

Available from: Ultratec, Inc., University Research Park, 450 Science Dr., Madison, WI 53711.

* TeleBraille II - a TTY/TDD with a braille display attached. Messages are typed and produced both in print and in braille. The braille component has braille keys which allow the braille user to type, and the message is printed on the screen of the TDD and vice versa. This device can be used both by two participants sitting next to each other ("Face-to-Face Mode"), as a telephone device and an answering machine. It can access a computer, a braille embosser, and/or a printer output. It is used by fluent braille readers; the speed of the message can be adjusted to receive a small grouping of words at a time or continuously.

Available from: TeleSensory Systems Inc., 455 North Bernardo, PO Box 7455, Mountainview, CA 94043.

Telletouch - a portable device with both typewriting and braille keyboards on one side and a braille cell on the back. Letters are typed and felt one at a time. Effective with an individual who uses speech.

Available from: American Foundation for the Blind, Product Center, 100 Enterprise Place, PO Box 7044, Dover, DE 19903.

Total Communication - a method which incorporates sign language, mouthing of the words, body language, and/or hearing aids. Using whatever means available to communicate the information. This method is primarily used as a teaching method in the schools for the deaf or for individuals whose first language is English.

Writing Guides - enable a blind or deaf-blind person to write/print tactually. These are available in several different forms: 1) a board with a metal (or flexible) horizontal bar which assists a person to write within a confined area on a straight line; 2) pocket size plastic, metal, or cardboard, with a single space cut-out for one's signature; and 3) plastic bank check or envelope guides.

Available from: Independent Living Aids, 27 East Mall, Plainview, NY 11803.

(1.) Anderson, M., Boren, N.J., Caniglia, J., & Krohn, E. (1975). A Patterned Program of Linguistic Expansion Through Reinforced Experiences and Evaluations. Dormac, Inc. Beaverton, Oregon. (2.) Cummings, L. (1985). Signs of Success: A Progressive Sign Language Manual. The Illinois Deaf/Blind Service Center: Glen Ellyn, Illinois. (3.) Gallaudet University Press. Structured Tasks for English Practice. Washington, D.C. (4.) Goetz, L., Guess, D., & Stremmel-Campbell, K. (1987). Innovative Program Design for Individuals with Dual Sensory Impairments. Paul H. Brookes Publishing Co., Baltimore-London. (5.) Humphries, T., Padden, C., & O'Rourke, T. A Basic Course In American Sign Language. (1980). T.J. Publishers: Silver Spring, Maryland. (6.) Magalini, Sergio (1971). Dictionary of Medical Syndromes. J.B. Lippincott Co., Philadelphia-Toronto.

Ms. Godfrey is Supervisor and Ms. Costello is a Speech Language Pathologist at the Communications Learning Center, Helen Keller National Center for Deaf-Blind Youth and Adults, Sands Point, NY.