Orientation and mobility for deaf-blind people.

Very few programs specifically serve people who have both a visual and a hearing impairment, even though this combination produces unique situations requiring unique strategies and solutions. Instead, people who are deaf-blind must seek services from programs that serve deaf people or blind people and which usually have staff who are prepared only to serve one or the other. The frustrations and fears that this situation causes both professionals and deaf-blind people are legion.

Orientation and mobility (O&M) specialists are no exception. Even though, at one time or another, most of them will work with people who are both blind and deaf, many feel inadequate about doing so. I remember the first time a deaf-blind person was referred to me. I told the counselor that because I had not been trained to work with such a person, he should refer her somewhere else. Fortunately, the counselor convinced me that I had the skills needed to work with this woman. Indeed, teaching O&M to her was one of the most rewarding experiences of my professional career, inspiring me to become more involved and to work more with deaf-blind people.

O&M specialists can rest assured that if they know the O&M skills needed by people who are visually impaired or blind, they already know most of the O&M skills that are needed by people who are also deaf. To teach those skills and provide appropriate services to their deaf-blind clients, O&M specialists need to know: (1) strategies for communicating with that client (such as using an interpreter); (2) how to teach that client to communicate with and interact with the public; and (3) street-crossing strategies for clients who cannot hear the traffic adequately.

Communication with the Client

Knowing how to communicate with a deaf-blind client involves much more than just knowing a communication system such as fingerspelling or signs. Without knowing about the client's background and culture, the O&M specialist won't even know what language that client may be using, much less what communication strategies would be appropriate for him or her.

There are some deaf-blind people who have no formal language because they were never exposed to a language in a mode that they can perceive, or they have a cognitive impairment that prevents them from being able to process language, or both. More information about communicating and working with people who have minimal language skills can be found in Baumgart, Johnson, and Helmstetter (1990), Godfrey and Costello (1995), and Huebner, Prickett, Welch, and Joffee (1995).

In general, however, the primary language of Americans who are deaf or deaf-blind is either American Sign Language (ASL) or English. ASL is the primary language for many people who are born deaf. By this I don't mean that they use a visual mode, such as signs or written notes, to communicate in English, but rather that their native language is ASL, which has its own grammar and sentence structure. They may or may not be skilled in the use of the English language itself, regardless of whether it is written or spelled out, conveyed with signs, or spoken, because English is a second language for them.

Because ASL and English are different languages, a person whose language is English (such as most American O&M specialists) and one whose language is ASL (such as many congenitally deaf, visually impaired Americans) may have difficulty understanding each other. For example, to someone who understands only ASL, the English sentence, "John will teach Bill after they eat their lunch," may be understood to mean that they will have the lesson before lunch. Conversely, that same sentence in ASL, "Lunch finish; Bill John teach," may be confusing to someone whose only language is English.

Deaf people whose language is ASL vary in their level of comfort and skill using English. For some, English that is spelled, written out, spoken, or signed will be adequately clear and understood; for others, it will lead to confusion and misunderstandings. Thus, it is important to know whether the client is congenitally deaf and, if so, in what language(s) he or she is proficient. If the client is proficient only in ASL and the O&M specialist's only language is English, an interpreter will be necessary in order to provide clear, full communication.

Whether the deaf-blind client's language is ASL or English or neither, there is a wide variety of communication techniques and devices that are available. The choice of which technique should be used with a given client, and whether that client will best perceive the communication tactually, visually, or auditorally, will depend on the client's vision, hearing, primary language, experience, skills, and preferences. The best way to find out which would be best is to ask the client. Some of the available techniques include signs, symbols, signals, fingerspelling, Braille, written notes, speaking, and lipreading; however, if the client does not understand English well, all but the first three techniques would be inappropriate. There are many communication devices that can be used, including the teletouch and Telebraille (on which the speaker types messages that the deaf-blind person can read in braille); homemade cards or commercial plates, such as the Brailtalk, which have Braille and print letters to which the speaker can point or place the deaf-blind person's finger; commercial or homemade "communication boards" with pictures and/or symbols and accompanying print notes to which deaf-blind people can point or on which their finger can be placed, and so on. There are a number of sources of information about communication techniques and strategies to use with deaf-blind people, including College for Continuing Education (1995), Godfrey and Costello (1995), Kates (1980), Sauerburger (1993), and Smith (1994). Whether the communication will be provided by the O&M specialist or an interpreter will depend on the instructor's skills with the method and language of choice.

When an interpreter is used, the O&M specialist and the client communicate with each other rather than with the interpreter; the skilled interpreter will then convey the messages accurately to the other person. The interpreter should be skilled in the communication methods and languages being used and, just as important, he or she should be impartial. Because it is difficult or impossible for most family members and friends to remain impartial, it is strongly advised not to use them as interpreters. Another issue to consider is that interpreters who are skilled working with deaf sighted people may need to learn how to convey the communication tactually or accommodate for the visual needs of deaf-blind people; it cannot be over-stated how important it is to convey visual information to the client, such as describing the environment and what is happening around them, facial and body expressions of the speaker, and so on. Several good sources of information about using interpreters with deaf-blind people are Bourquin (1996), Raistrick (1995), and Sauerburger (1993).

Communication and Interaction of the Client with the Public

An important part of most O&M programs is teaching people to interact with the public for soliciting aid, shopping, dealing with over-solicitous strangers, and so forth. This aspect of O&M is a challenge when working with deaf-blind people for several reasons: the methods that deaf-blind people need to use to successfully communicate with the public are often unfamiliar to the O&M specialist (and often to the client as well); the public's reaction to people who have a hearing impairment in addition to a visual impairment is not always the same as it is to those who are only visually impaired; and deaf-blind people are often less able than hearing blind people to understand what is going on around them. This difficulty with understanding what is happening can lead to confusion and misunderstanding, an inappropriate distrust of the public, and a subsequent unwillingness to travel independently wherever there might be any interaction with strangers.

The creative and skillful O&M specialist can help prevent this unfortunate situation by helping deaf-blind clients prepare to communicate with methods that the public will feel comfortable using; helping them realize that the public is usually bewildered and the importance of being persistent and patient to help the public learn how to communicate with them; and providing them with feedback after their experiences with the public. This feedback, if accurate and informative, can help deaf-blind clients learn to interact and understand what may be happening around them at some point in the future when they are alone.

To prepare the deaf-blind client to communicate with the public, the O&M specialist and the client can brainstorm to choose techniques that might be effective and then practice those techniques until the client is proficient. The instructor may not know any more than the client which strategies would be best for which situation; the client and instructor can only guess which might be best, and then try them. If these methods don't work for that person in that situation, then others need to be tried. Because no system is ever successful with every person in every situation, the more techniques with which the client is proficient, the more likely the interaction will be successful; if one attempt fails, the client who is proficient in several techniques can try another approach.

Many clients are tempted to rely on communication techniques with which they are familiar and skilled, but they will instead need to choose and become proficient with techniques which the public will understand and, perhaps as important, with which the public will be comfortable. Such techniques include using gestures which other people will understand, notes and cards, voice (if the deaf-blind person's voice is understandable), recorded messages (devices such as the Attention, Getter can record several messages which can each be played repeatedly with the touch of a button), and pictures and symbols. The public can be asked to respond by giving a signal, such as tapping the deaf-blind person, squeezing his or her hand, nodding their head "yes" or "no," or tapping the deaf-blind person's hand twice for "yes" and once for "no"; using their finger to print letters on the deaf-blind person's palm ("print on palm"); spelling out messages or pointing to pictures and messages with the deaf-blind person's communication device; speaking, if the client can understand speech; writing notes, if the client has enough vision to read them, and so on.

Once the client has chosen which methods seem best, he or she will need to become proficient before trying them with the public. Print on palm, like most communication methods, requires practice, and clients can often perceive the print better if they place their hand lightly on the hand of the speller (most strangers do not mind this). People with minimal language skills who are using pictures, symbols, or prewritten notes and cards need to understand what those pictures, symbols, and cards mean. For example, the client who is taught to point to the note next to the picture or symbol of the hamburger needs to understand that it means he or she is requesting a hamburger. People who are taught that when they are lost they are to find an appropriate person to whom they can give their special emergency card need to understand how to use that card and to wait for help to arrive.

The client also needs to understand that the public will need the client's help and patience in order to facilitate communication. Many deaf-blind people assume that the public understands that they are deaf and knows how to communicate with them. When the public fails to cooperate, these clients--not realizing that the people did not understand what to do--will instead assume that the people are purposely being rude or hateful, and the client may give up in disgust. Other clients whose attempts to communicate fail will wait passively, or continue to use the same communication method for long periods of time without trying another method. The deaf-blind client needs to understand that he or she may need to be persistent and try several ways of explaining to the public such things as how they can communicate or help, and that he or she is deaf as well as blind.

Whether the deaf-blind traveler is using a card, voice, or recording, if the first message is that he or she is deaf-blind, many people will become be-wildered or suspicious and will move away without investigating further. Thus, it is helpful to first explain what the traveler needs (e.g., "I want to cross the street," or "I need to know when the bus arrives at Fifth and Maple"). The deaf-blind traveler also needs to decide exactly how he or she wants the public to respond in order to help or communicate, and should explain this clearly immediately after the need is explained ("Please tap me if you can help," "Please hand me this card when the bus arrives," or "Please guide me to the door," etc.). After this information is conveyed, the visual and hearing impairments can be explained ("I am deaf and can't see well," or "I am blind and hard of hearing"). Examples of effective messages are: "Please help me find the bus stop; tap me if you can help because I am blind and can't hear well." "I need to find a salesperson; please print letters on my palm with your finger because I am both deaf and blind."

After clients have become proficient with as many communication techniques as possible and understand the need to be patient and persistent with the public, they are ready to try to communicate and interact with them. At this point, the O&M specialist's role is to step back and observe the interaction unobtrusively. If the public realizes that the instructor is with the client, they will not behave normally and the clients will never learn whether their strategies are effective or not.

It is relatively easy for instructors to be unobtrusive while observing clients who have learned to travel independently and who are trying their skills in new areas where their instructor has not been observed teaching them. However, instructors who work at rehabilitation centers or who have been working intensely with their client to orient him or her to that area will be challenged to find places to teach the client to interact where the public is not familiar with their role as an instructor, and to observe what happens without being noticed. It may be necessary in some cases to have the interaction observed by an assistant who is unknown to the public, or to observe from a distance, perhaps using a hidden microphone which can enable the instructor to hear what is going on.

After each interaction, the O&M specialist and client debrief the experience. The client needs to learn what the instructor observed, and judge whether it was successful or not. If it wasn't, the client can brainstorm with the O&M specialist to think of strategies that might be more successful and to try them, again, with observation and feedback.

Street-Crossing Strategies

The fact that the deaf-blind client cannot hear well, or at all, can require the O&M specialist to adjust the techniques that are taught, but I have found those adjustments to be minimal in all areas except that of street-crossing strategies. We O&M specialists have learned to teach people to cross streets primarily using their hearing (although many also use their remaining vision effectively), and it often requires some readjustment on the part of the O&M specialist to consider strategies to evaluate and teach people how to cross streets when they are deaf as well as blind or visually impaired.

Basically, the O&M specialist will need to help deaf-blind clients 1) evaluate when they cannot hear and/or see well enough to know when it's clear to cross; 2) decide in which situations where they cannot detect the traffic they are willing to take the risk of crossing alone; 3) learn strategies for getting assistance or planning alternate routes for those situations where they do not want to risk crossing alone; and 4) learn how to judge when it is safe to cross and how to complete the crossing safely at intersections with traffic signals where they can hear or see the traffic well enough or see or feel the traffic signal.

At intersections with traffic signals, it is relatively easy for the experienced O&M specialist to evaluate whether clients can observe the traffic flow or traffic signal well enough to recognize when it is their turn to cross. Because the instructor will not be with the clients during their entire lives, it is also necessary for the clients to be able to evaluate whether they can cross safely or not in a variety of conditions at intersections with traffic signals.

At situations where the street being crossed has no traffic signal or stop sign to control the traffic, the O&M specialist can evaluate (and teach the clients to judge) whether or not they can detect the traffic well enough to know when it's clear to cross by using the Timing Method for the Detection of Vehicles (Sauerburger, 1989, 1995). O&M specialists can also help clients who can see the traffic at a distance to evaluate their ability to judge when it is slow enough or far enough for them to cross safely by using the Timing Method for Assessing the Speed and Distance of Traffic (Sauerburger, 1989, 1995). Again, it is imperative that all clients, including those who have both visual and hearing impairments, be able to judge for themselves whether they can detect or judge the speed and distance of the traffic well enough to know when it is safe to cross.

People who cannot hear or see the traffic well enough to know when it's clear to cross have to decide whether the risk of crossing there alone is acceptable or not. For example, most deaf-blind people who travel independently consider the risk of crossing their neighbors' driveways to be acceptable and they do so without assistance, but at busy streets when they cannot hear or see the traffic, most consider the risk to be too great to cross alone. The range of risks involved for crossing anything from quiet driveways to busy highways is considerable, and clients will vary in how much risk they feel comfortable taking. For example, some deaf-blind people will cross residential, dead-end streets where there are never more than two or three cars passing each hour, but others would not willingly take that risk.

The O&M specialists' role is to help their deaf-blind clients understand what risk there is by describing the situation and helping them "observe" the traffic during different times of the day. This can be done by having the client place his/her hand on the hand of the instructor or a friend who points to the cars passing by, or by giving the client a signal whenever a car passes. The instructor needs to also explain how visible the client is to drivers and how the drivers react to the client. After getting all the information, clients will decide whether or not they want to risk crossing there alone. If they do, they will increase their safety by warning any drivers who might potentially be passing (e.g., by moving their cane forward before stepping out).

If the client decides not to risk crossing there alone, the O&M specialist can help him or her come up with alternatives, such as getting assistance to cross; planning an alternative route; using paratransit or a car pool; and so on. If the street must be crossed to reach a bus stop, the crossing might be avoided by riding the bus to the end of the line and back.

If the client decides to get assistance, many of the same strategies for communicating with the public that were discussed earlier would be effective here. Some deaf-blind people rely on gestures to indicate they need help to cross, some use a card and/or their voice or recorded message to ask for assistance, and some get attention by using a whistle. If the person stands facing the street while trying to get assistance, people are more likely to realize he or she wants help to cross rather than for something else. For places where few pedestrians pass by, deaf-blind people have been very effective at getting assistance from store and business personnel and neighbors, sometimes calling them ahead of time (using an accessible TTY and relay service) to ask the helper to watch for them. Also, they have successfully gotten drivers to stop their car, get out, and guide them across streets by holding up a large sign where the drivers can see it, with large letters asking for help to CROSS STREET.

At intersections with traffic signals, deaf clients who can see the traffic and/or see the traffic signal or feel its vibrations (if a tactile traffic signal was installed) well enough to know when it's their turn to cross need to know how to avoid the traffic that turns into their path. If they are relying on their remaining vision, they need to know, for example, that when they start to cross with the parallel street on their right

they must first glance to the left to be sure no one is turning right on red. As they approach the middle of the street, they must look over their right shoulder to see if anyone is turning left from behind them on the parallel street and forward to see if anyone is turning right. It is important to be sure they understand this concept, because it is surprising how many visually impaired people, both deaf and hearing, don't understand these principles and will look toward the left when any traffic that could endanger them at that point would be coming from the right.

Conclusion

Teaching O&M to people who have both hearing and visual impairments can be challenging but very rewarding. The O&M specialist who accommodates to provide clear, comfortable communication and who is creative and flexible enough to adapt the O&M techniques as needed for the person who cannot hear can provide a very effective, successful O&M program for these clients.

Bibliography 

[1.] Baumgart, D., Johnson, J., & Helmstetter, E. (1990). Augmentative and Alternative Communication Systems for Persons with Moderate and Severe Disabilities. Paul H. Brookes Publishing Company, Baltimore, MD.

[2.] Bourquin, E. (1996). Using interpreters with deaf-blind clients: What professional service providers should know. RE:view, 27, (4), 149-154. Heldref Publications, Washington, DC.

[3.] College for Continuing Education (1995). Being in touch: Communication and other issues in the lives of people who are deaf-blind. Gallaudet University Press, Washington, DC.

[4.] Godfrey, N., & Costello, M. (1995). Communication issues and strategies for deaf-blind individuals: Case studies basic on etiology and language level. American Rehabilitation, 21, (2), 19-22. Rehabilitation Services Administration, Washington, DC.

[5.] Huebner, K., Prickett, J., Welch, T., & Joffee, E. (Eds), (1995). Hand in hand: Essentials of communication and orientation and mobility for your students who are deaf-blind. American Foundation for the Blind, NY.

[6.] Kates, L., and Schein, J. (1980). A complete guide to communication with deaf-blind persons. National Association of the Deaf, Silver Spring, MD.

[7.] Raistrick, K. (1995). Hiring interpreters for individuals who are deaf-blind. American Rehabilitation, 21, (2), 19-22. Rehabilitation Services Administration, Washington, DC.

[8.] Sauerburger, D. (1989). To cross or not to cross: Objective timing methods of assessing street crossings without traffic controls. RE:view. 21, (3), 153-161.

[9.] Sauerburger, D. (1993). Independence without sight or sound: Suggestions for practitioners working with deaf-blind adults. American Foundation for the Blind, NY.

[10.] Sauerburger, D. (1995). Safety awareness for crossing streets with no traffic control. Journal of Visual Impairment and Blindness, 89, (5), 423-431.

[11.] Smith, T. (1994). Guidelines: Practical tips for working and socializing with deaf-blind people. Sign Media, Burtonsville, MD.

Ms. Sauerburger is an orientation and mobility specialist in Gambrills, MD.