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Early intervention for infants with deaf-blindness.

ABSTRACT: Few individuals labeled deaf-blind are, in fact, totally deaf and totally blind. Many of these individuals have residual sight and hearing, but may not receive adequate early training in using these senses effectively. Effective early sensory training with infants entails the use of consistent reinforcement methods in natural social contexts. Preservice and inservice teachers must become knowledgeable in high-quality programming components in which the goal is to increase the abilities of students with dual sensory impairments--in both mobility and communication--and to help them become independent, responsible adults.

In recent years, educators and researchers have directed their attention to early childhood and early intervention programs for infants with severe disabilities (Bickman & Weatherford, 1986; Ramey, Trohanis, & Hostler, 1982). Specifically, this focus has resulted in an increase of interest in services and programs for infants with dual sensory impairments (Freeman, 1985; McInnes & Treffrey, 1982). In relation to early intervention and deaf-blindness, however, there is a need for improvement in university-level pre-service training programs, development of better identification and educational placement procedures, and the establishment of research-based intervention programming.

In this article, we briefly discuss the effects that definitions of deaf-blindness may have on educational placements and services for infants with dual sensory impairments and on the training of pre-service university students interested in becoming professionals in this area. Several intervention theories and their effects on current special education practices are also presented. In essence, we argue that the establishment of appropriate early intervention programs entails methods that address the use of residual sight and hearing, as well as the development of other senses. Thus, much of our focus in programming is on assessment and training in the use of vision and audition.

EFFECTS OF DEFINITION ON PROGRAMS AND TRAINING

Problems in the development of effective intervention programming and the training of professionals have resulted from the range of interpretations for the federal government's educational definition of deaf-blindness (Baldwin, V., 1986; Bullis & Bull, 1986). In general, the federal definition does not suggest the multiplicity of services and the types of professional training needed to support these individuals with such diverse characteristics.

Many students with dual sensory impairments are categorized as multihandicapped (D'Zamko & Hampton, 1985). Their sensory impairments are not recognized as primary disabilities. Thus, these students may be placed in programs that lack sufficient supportive and consistent services to meet their needs effectively (Fredericks & Baldwin, 1987). For example, most teachers of students with severe or multiple disabilities may not be familiar with vision and auditory assessments; residual visual-training and auditory-training methods; coactive, cooperative, and reactive learning techniques (Van Dijk, 1965; 1968); and alternative modes of communication (e.g., communication boards, American Sign Language). In general, these teachers may have little or no knowledge of programming for students with dual sensory impairments.

Even some universities may not be equipped to provide preservice students with necessary skills to deal with the multiplicity of programming needs for teaching children with deaf-blindness (Baldwin, V., 1986; Bullis & Bull, 1986; Covert & Fredericks, 1987). For example, some preservice training programs for certification in multihandicaps or severe handicaps do not address functional visual or auditory training and assessment. In many states that offer certification for multihandicaps, the requirements are so generic they do not specify the skills necessary for dealing effectively with individuals who are deaf with additional handicapping conditions (Curtis & Tweedie, 1985; D'Zamko & Hampton, 1985).

FUNCTIONAL INTERPRETATION OF DEAF-BLINDNESS

The number of persons with deaf-blindness has not increased substantially since 1974; however, interpretations of the definition of the population have changed drastically. The need for quality services and qualified personnel, both in education and in adult services, has been recognized (Barrett, 1987). Commendably, recent adult service delivery definitions have included more functional interpretations of the term deaf-blind (Konar & Rice, 1982). For example, individuals categorized as having deaf-blindness can represent any of the following: (a) those with moderate-to-profound auditory and visual impairments, with or without other educationally disabling conditions, who need services to increase independence; (b) those with central-processing problems that result in cortical blindness or central auditory dysfunction; and (c) those with progressive sensory impairments such as Usher's syndrome. The formulation of more recent functional interpretations, such as category a, have allowed some states to include children with functional impairments and other children whose primary disability is mental retardation (K. Arnold, personal communication, December 1987).

Regardless of the categories of dual sensory impairments, approximately 94% of these children have either residual hearing or residual sight (Fredericks & Baldwin, 1987; Ouellette, 1984). Thus, intervention programming and university-level preservice training should consider auditory and visual assessment and training, as well as other sensory training techniques (e.g., tactile, olfactory, and kinesthetic) and innovative communication strategies (Barraga & Morris, 1982; Goetz, Utley, Gee, Baldwin, & Sailor, 1981; Siegal-Causey & Downing, 1987). These areas should also be considered in developing early intervention theories and programs for infants with deaf-blindness.

INTERVENTION THEORIES

Several theories have provided the philosophical underpinnings of current intervention practices. Biological-developmental theorists have described psychological growth in holistic, interactionist terms (Lewin, 1951; Piaget, 1952; Vygotsky, 1962). These theorists argued that, from birth, organisms use, assimilate, and construct conceptions. Cognitive growth results from communicative interactions.

On the other hand, radical behaviorists assert that the mind is a machine that is formulated by stimulus input from birth and that reflects the accumulation of this learning by the output of behavior (Skinner, 1953). Behavior is explained by a causal mechanism that does not depend on the functional value of the behavior. Determinism is one of the basic tenets of behaviorism (Baldwin, A., 1980).

Special education programs seem to be influenced by educational ideologies such as environmental transmission, which parallels behaviorism, and a combination of romanticism and progressivism. Romanticism emphasizes the value of childhood, the discovery of an inner self, and interaction with others. Progressivism, which parallels the developmental theory of Piaget, also emphasizes interaction with others, as well as interaction with the environment. It is based on the Hegelian belief that development is a progression through stages and that knowledge is an active change in patterns of thought influenced by problem-solving situations (Baldwin, A., 1980). In other words, organisms are proactive in constructing their own developmental progress from birth throughout life.

It seems that intervention programs for high-risk infants, including those with dual sensory impairments, lack a firm theoretical base. The development of these programs may be the result of the accumulation of nontheoretical research data (Walker & Crawley, 1983). Most curricula for infants with disabilities, however, tend to adhere to the tenets of a biological-developmental or cognitive-developmental approach (Bailey, Jens, & Johnson, 1983). That is, developmental milestones are emphasized, and skills must be developed in a specific hierarchical order regardless of the ages of children with disabilities. The developmental order of skills corresponds to what has been observed in younger children without disabilities (Bailey et al., 1983).

On the other hand, some programs use curricula that emphasize functional (i.e., ecological or environmental learning) approaches in which instructional practices rely on task-analysis of functional and chronological age-appropriate activities, analysis of discrepancies between needed skills and previously acquired skills, and the use of operant-conditioning methods. Bailey et al. (1983) analyzed 15 curricula for infants with disabilities and found that only 3 curricula employed a functional approach. In general, the functional approach was used in conjunction with principles from 1 of the developmental approaches.

Only 1 of these 15 curricula for infants has been field tested. In addition, very few data are available on the effectiveness of the various theoretical approaches. It has been argued that principles from several theories can be combined in curriculum and instruction of early intervention programs (Bailey et al., 1983). We think that a creative approach, using aspects of both the environmental-learning theories and the cognitive-developmental theories, is appropriate for infants, especially infants with dual sensory impairments. Specifically we recommend the incorporation of systematic training in the area of auditory and visual development in natural settings and using age-appropriate materials. It has also been documented that the use of instructional operant-conditioning methods in these natural, meaningful settings can increase residual sense function and generalization of acquired skills (Barraga & Morris, 1982; Goetz & Gee, 1987; Lundervold, Lewin, & Irwin, 1987).

EARLY INTERVENTION

Early intervention is the establishment of educational and support services for children, age 3 and younger, with or at risk for disabilities, and their families. The importance of early intervention for children with handicapping conditions has been widely documented (Bronfenbrenner, 1975; Hayden, 1979; McInnes & Treffrey, 1982; Peterson, 1983). In the case of infants with two or more handicapping conditions, such as deaf-blindness, the need for early intervention is greater. The senses of vision and audition are dynamically and neurologically linked, and both senses should be addressed on a consistent, systematic basis to prevent problems in cognitive, linguistic, and social-emotional development.

Identification

The methods for identifying infants are case finding, registries, and screening. To provide appropriate and crucial intervention services to infants and families, it is vital that the identification process be improved. States should be encouraged to establish registries that include (a) functional tracking (i.e., description of a child's placement and intervention methods), (b) directional services (i.e., services that direct families to available programs), and (c) listing of programming options for children with dual sensory impairments and their families. Firm connections should be established with the appropriate personnel within the medical community such as obstetricians, neonatologists, and pediatricians to facilitate the identification process. This should enable agencies to assist families in finding appropriate services for their children (Michael, Arnold, & Niswander, 1988; Watson, Barrett, & Brown, 1984).

Early Intervention for Infants with Deaf-Blindness

Early intervention programming may need to be eclectic, using techniques that emphasize, at least, the development of motor and functional communication skills, and particularly, the distance senses (vision and audition) (Fredericks & Baldwin, 1987; Goetz & Gee, 1987). Classroom teachers need to know how to interpret the results of both clinical and functional assessments and improve the sensory functional abilities of infants (Curtis & Tweedie, 1985; D'Zamko & Hampton, 1985). Adequate assessment, followed by a comprehensive intervention program, should lead to improvement in an infant's use of residual senses for communication and mobility skills (Freeman, 1985; McInnes & Treffrey, 1982).

Relatively few data are available concerning the enhancement of residual vision and hearing functions, using sequential, simultaneous, or contingent methods, in infants with deaf-blindness. Some methods focus on the functional use of one sense or the other; however, they have been designed to aid classroom teachers of older children (Goetz & Gee, 1987; Goetz et al., 1981; Smith & Cote, 1982). In addition, these methods have not specifically focused on the development of residual senses in relation to communication, mobility or self-image in infants. Given the available information, we present some effective visual and auditory tests and examples of training for infants with dual sensory impairments. These examples can be incorporated into programming by classroom or home-bound teachers. A transdisciplinary team, which includes eye (e.g., optometrists) and ear (e.g., audiologists) specialists, should help interpret formal test results and provide directions in determining appropriate adaptations for each child's specific needs.

DEVELOPMENT OF RESIDUAL VISION

Visual Assessment

Visual assessment and subsequent intervention are critical for infants with dual sensory impairments for two main reasons: efficient vision use is important for learning, and visual function can improve (Goetz & Gee, 1987; Lundervold et al., 1987). Developing a formal vision-training program may require great effort from members of the transdisciplinary team. For example, the team must conduct a battery of both clinical and functional tests over a period of time to determine visual effectiveness and subsequent curricular planning and instructional intervention. Cress (1989) suggested that assessments be followed by ongoing observation and recording of children's visual behaviors during activities in natural, meaningful environments. To plan accurately for intervention, teachers of children with dual sensory impairments need to have the ability to interpret clinical findings, perform functional assessments, and record ongoing data of the child's performance.

A child who does not respond to conventional testing may be a candidate for several physiological tests that focus on visual acuity. These formal tests should be administered by qualified clinical or medical personnel. The tests include the Visually Evoked Response (VER), also known as Visually Evoked Potential (VEP), and the Electroretinogram (ERG). The VER has been used extensively to determine the visual acuity of infants (Baraldi, Ferrari, Fonda, & Penne, 1981) and children with neurological handicaps (Mohn & Van Hol-Van Duin, 1983). The ERG yields useful information about the functioning level of the retina.

Functional tests assess the visual behavior of the individual rather than just the physiological condition of the eyes. That is, these tests assess the ability to track objects, use visual fields, develop eye-hand coordination, and perform other functions that reflect visual development. The tests are portable and can be administered by trained personnel, such as teachers.

Functional vision assessments have been developed both for individuals with visual impairments only and for those with multiple handicaps. Some assessments developed for clients with multiple handicaps include Functional Vision Inventory for the Multiple and Severely Handiapped-(Langley, 1980) and the Visual Assessment Manual (Sailor, Utley, Goetz, Gee, & Baldwin, 1982). Since neither of the two assessments have reported reliability or validity data, no comparisons on their applicability and effectiveness can be made (Cress, 1985).

The Opkinetic Nystaqmx (OKN) provides information on the acuity threshold of the infant through the use of spinning cards to determine fixation ability. The Forced Preferential Looking Test (FPL), based on Fantz's work (1963) with infants, is another test that seems promising for infants up to 6 months old and for difficult-to-test children such as those with dual sensory impairments. The Operant Preferential Looking Test (OPL), which pairs a discerned reinforcing consequence with the behavior of fixation, is specifically geared toward infants over the age of 6 months Telter, 1979), but has produced promising results for individuals with multiple disabilities (Duchman & Selenow, 1983; Mohn & Van Hol-Van Duin, 1983). The Teller Acuity Card Technique, normed on 0-to-3-year-old children without disabilities, has been shown to be effective for children who are developmentally delayed or at risk for this condition (Cress, 1989; Mohn & Van Hol-Van Duin, 1983; Teller, McDonald, Preston, Sebris, & Dobson, 1986). In addition, this procedure is useful for mass screening of infants.

In sum, to obtain accurate data on the visual functioning level of infants with dual sensory impairments, one must use a variety of clinical and functional tests over a certain period of time. It may be necessary to provide visual training to young children to improve their ability to be assessed (Cress, Johnson, Spellman, Sizemore, & Shores, 1982). For example, some children can be trained to fixate visually through operant conditioning. The infant's need for low-vision aides (e.g., eyeglasses) should be determined as early as possible. Methods for adapting the classroom and home environments, positioning the child, and enhancing optimal vision use should result from the assessments and be part of the programming (Courtwright, Mihok, & Jose, 1975; Jose, 1983). One must complete an assessment battery before developing a training program.

Visual Training

In our view, a vision training program should follow a functional, hierarchical sequence, using activities similar to those outlined, for example, in the manual Look at Me (Smith & Cote, 1982) or in the article "Functional Vision Programming" (Goetz & Gee, 1987). For each visual skill listed here, a separate instructional strategy package should be implemented for each infant when appropriate. Implementation begins in natural, meaningful contexts (e.g., going to the store, mealtimes) after decisions are made on the targeted visual skills to be learned to enhance participation.

1. Awareness of light (orient to presence of stimulus).

2. Attention to light fixation either bifoveal or monofoveal).

3. Localization of light source in various areas of the visual field (awareness and attention).

4. Light tracking.

5. Awareness of presence or absence of light.

6. Visual tracking of objects or persons.

7. Attention to presence or absence of light.

8. Localization of objects (scanning).

9. Use of peripheral vision.

These components can be systematically taught via prompting methods e.g., see Sailor et al., 1982), and continuous loop strategies (Goetz & Gee, 1987). The target visual behavior must be performed consistently before proceeding to the next behavior. Contingent reinforcement is used, as well as a pairing of the visual objective to a functional skill that requires the use of the target visual skill. For example, a functional skill for infants, such as grasping a bottle, is paired with the visual objective of fixation. Older or more skilled infants may be expected to locate visually an article of clothing such as their shoe or to discriminate between two desired objects and choose one. Event recording techniques can be used to measure the targeted visual behavior during the observation periods.

In general, infants with dual sensory impairments progress very slowly. Parents should be shown, through modeling, procedures and strategies for achieving objectives step by step. They should be encouraged to incorporate the activities into their normal day-to-day routines with their infants at home. An example of one level of this training is presented as follows.

Level 1: Awareness of light (orient to presence of stimulus).

Rationale: In training very young children to be aware of light, there may be a need to orient them to the presence of a stimulus, and then pair the preferred stimulus with the stimulus of light. When children become aware of various stimuli in their environment, this is the first step in their reaction to the outside world.

Objective: The purpose is to build awareness of a sensory stimulus by orienting behaviors toward the stimulus. The reactions of children should be monitored.

Target Behaviors:

1 .Head turn.

2. Gaze shift.

3. Brief fixation.

4. Ability to respond consistently to light stimulus.

Activity: Child will perform target behavior selected when blinds in the home are opened in the morning.

DEVELOPMENT OF RESIDUAL HEARING

Auditory Assessment

As in vision assessment, a variety of clinical and functional hearing tests should be administered to infants with dual sensory impairments over a period of time before establishing an intervention program. Hearing should be assessed to (a) determine the extent and degree of impairment; (b) evaluate the effects of medical treatment or the use of prosthetic devices, such as hearing aids; and (c) provide individual, appropriate educational programming (e.g., Erber, 1982; Sanders, 1982). As discussed previously, early intervention, particularly amplification and auditory training, is important because of the pervasive effects of hearing impairment on the child's cognitive, linguistic, and socioemotional development.

In the assessment of middle ear function, the three major objective measures that involve physiological responses to auditory stimuli and require no instructed behavior responses are static compliance, tympanometry, and acoustic reflex evaluation (Orchik & MacKimmie, 1984). These tests have been useful with some special-needs populations, such as children with behavioral disturbances, language delays, and mental retardation. For children under 1 year of age, standard immittance audiometry is not feasible; however, a technique known as acoustic otoscopy or acoustic reflectometry can be used for these difficult-to-test children (Teele & Teele, 1984). Another useful and efficient test is the Sensitivity Prediction Acoustic Reflex (SPAR) method (Niswander, 1988).

Behavioral hearing assessments require overt behavioral responses to auditory stimuli. Traditional methods are inappropriate for children with dual sensory impairments (Niswander, 1987). Many of these children do not have the necessary cooperative and receptive language skills to participate. It seems that effective testing programs involve the pairing of visual/tactile and auditory stimuli, and then fading these stimuli so that the level of auditory response can be determined.

For infants without the use of efficient vision, there seem to be no best testing procedures available that are supported by research. The Auditory Brainstem Response (ABR) and Behavior Observation Audiometric (BOA) methods are recommended for hard-to-test individuals; however, they are not always accurate in determining auditory function (Hecox, Gerber, & Mendel, 1983; Niswander, 1987; Spradlin, 1985). For example, in BOA procedures, the child is placed in a soundproof test booth. The audiologist presents stimuli and observes changes in the child's behavior such as eye blinks, startle reactions, and cessation or increase in activity.

Other behavioral audiometric procedures that have been adapted for use with hard-to-test children include the use of classical and operant conditioning to train responses. For example, visual stimuli may be used to reinforce correct localization responses (Goetz, Gee, & Sailor, 1985). This classical conditioning testing is named the Visual Reinforcement Audiometry (VRA). Adaptations for individuals who are visually impaired may include the use of vibrotactile reinforcement (Spradlin, 1985). An example of operant conditioning testing is Tangible Reinforcement Operant Conditioning Audiometry (TROCA). This highly structured test originally was developed for assessing children with mental retardation (Lloyd, Spradlin, & Reid, 1968). Typically, candy or little toys are dispensed if a child depresses a button on a box after hearing a sound. If a visual reinforcer is used, this test is labeled Visual Reinforcement Operant Conditioning Audiometry (VROCA).

In most cases, children with dual sensory impairments need to be trained to make reliable responses to auditory stimuli. TROCA and other alternative procedures can be used to train children before formal audiological evaluations are made. Because of children's varying abilities, no one procedure is appropriate for all children. As stated aptly by Cress (1989):

A knowledge of the specific child's response capabilities and reinforcer preferences is crucial in selecting one of the training procedures described above. Even more crucial, perhaps, is a commitment by service providers to devote the time necessary to accomplish this training. (pp. 16-17)

Cress also has argued that training children to respond to auditory stimuli rarely occurs in instructional practices with young children with dual sensory impairments.

In addition to interpreting the results of formal audiological measures, classroom teachers should be able to conduct informal assessments of their students' hearing. in general, informal tests involve presenting various auditory stimuli to students and recording reliable changes in behaviors. These tests are important because formal test results do not provide information about how well students use their residual hearing; that is, the functional use of hearing in the classroom (Erber, 1982; Sanders, 1982). In essence, the findings of formal and informal tests can be used to establish instructional programs that help students to improve skills, such as localizing and discriminating sounds, and to train students for subsequent formal audiological assessments.

Several factors should be considered in evaluating students' responses to sounds (e.g., Sailor et al., 1982). These include (a) students' characteristics, such as age and capabilities; (b) the use of a natural, meaningful setting (e.g., in the home); (c) the nature of the auditory test stimuli; and (d) the range of response modes, particularly in students with severe disabilities. We recommend that several test stimuli be selected from each of three general categories: speech (e.g., child's name, name of favorite toy, babbling), environmental sounds (e.g., water pouring, door slam), and noise makers (drum, telephone, toys) (Erber, 1982; Sailor et al., 1982; Sanders, 1982). Test stimuli should use sounds with a wide range of frequencies to increase the possibility of obtaining responses. To obtain reliable results, the selected sounds should be placed on a tape for testing purposes. Depending on age and ability, students can be required to detect sounds (presence or absence), discriminate between them (same or different), identify them (pointing to labels or pictures), or comprehend them (e.g., reacting or responding to requests, commands, questions) (e.g., see Erber, 1982).

Auditory Training

There are a number of approaches for the development of audition, ranging from unisensory (i.e., audition only) to multisensory (e.g., vision, audition, and taction) (Calvert, 1986; Ling, 1984). Some approaches include a strong speech component. Because of varying characteristics and abilities of students, there is no auditory training program that will work for all children with dual sensory impairments. Some fundamentals are the involvement of parents or caregivers (especially for language development); the use of natural, meaningful environments; the use of age-appropriate activities; and adherence to a developmental sequence.

Whether the normal development sequences of auditory behavior also apply to people with severe disabilities is an open question (e.g., Sailor et al., 1982). Although the developmental sequence may not be observed precisely for every student, it should provide a general framework for understanding auditory functioning and for establishing an intervention program. For example, from birth to age 3 months, the infant's responses to sound are largely reflexive and may include a startle response, widening or blinking of the eyes, or a sudden change in activity. Typically, infants respond to gross sounds (e.g., door slamming); however, they will also respond to speech. The use of familiar sounds, such as speech, might be effective in eliciting early attending responses (e.g., see Northern & Downs, 1984). Auditory feedback emerges around the 4th month. Subsequently, the child's babbling becomes more like speech and he or she begins to monitor productions of sounds. At 9 months of age, the child can accurately identify the location of sound sources at all angles from the ear (Northern & Downs, 1984). The association of particular sounds and their sources to meaning occurs during the last 3 months of the 1st year of life. Early intervention programming for children with severe disabilities should contain the major aspects of the normal acquisition process, that is, detection, awareness, attention, discrimination, feedback, self-monitoring, identification, and associating sounds with meaning (see discussions in Erber, 1982; Ling, 1984; Mischook & Cole, 1986).

The auditory process is inseparable from speech and language development (e.g., Ling & Ling, 1978; Pollack, 1985). For example, in associating sounds with meaning, the child begins to realize which acoustic cues are significant. Several factors contribute to a child's capacity to learn auditorially, for example, early identification of hearing loss; early and consistent use of amplification systems, such as group and individual hearing aids; the extent, severity, and etiology of the hearing loss; the quantity and quality of auditory stimulation; an intact capacity to learn; and interrelations among parents and specialists (Ling, 1984). Although several auditory training and learning programs exist (e.g., Erber, 1982; Sanders, 1982), it may be beneficial if a program follows a functional sequence that correlates to what has been observed in infants without disabilities, deviating only in the time of achievement of the various targeted behaviors. Boothroyd (1982) has outlined seven target behaviors that should be components of a successful program:

1 .Attend to sounds.

2. Attend to differences among sounds (discrimination).

3. Recognize objects and events from the sounds they make.

4. Be alerted to sounds.

5. Use hearing for the perception of space (pertinent for a child with severe visual loss).

6. Use hearing for the perception of speech.

7. Use hearing to control the production of speech.

Boothroyd's sequence of behaviors can serve as a conceptual framework for the training components of an auditory-training program. An example of one level is as follows:

Level 1: Develop an awareness of sounds (attend without meaning).

Rationale: The initial cognitive level to be achieved is a basic awareness of the presence and dimensions of sound without any necessary recognition of this auditory stimulus.

Objective: To provide very young children with a knowledge of the presence of sound.

Some suggested target behaviors include the following (Michael et al., 1988, pp. 13-14):

1. Eye-widening (eyebrow movement).

2. Eye-blinking.

3 .Startle.

4. Stirring or arousal from sleep.

5 .Cessation of movement.

6. Slight head turn toward the sound.

7. Any combination of the above behaviors.

Activity: Child will perform target behavior when the radio is turned on in the crib.

INTEGRATED SENSORY APPROACH

Among researchers on deafness, there is no clear consensus that an integrated multisensory approach (i.e., involving both senses simultaneously) is better than a unisensory approach that focuses on only one sense i.e., audition), especially for language development (Ling, 1984).

There is agreement, however, that an integrated sensory approach should be used and should offer opportunities for children to formulate ideas about the environment. That an integrated approach is important, especially for children with dual sensory impairments, is supported by researchers in the field of perception who are concerned with the notion of cross-modal transfer (McKenzie & Day, 1987).

As with other approaches, there is no one best integrated sensory approach that will work for all children with dual sensory impairments. The following example is adapted from a qualitative report involving an 8-month-old child considered cortically blind who eventually saw himself in the mirror after a period of several months (J. Miller, personal communication, April 1989).

Target behavior: To assist the child in learning to fixate on his or her own face in the mirror.

Preliminary target behaviors: Awareness of light, fixation on light, attention to light.

Items needed: Large plastic mirror, penlight, and optical aids.

Training:

1 .Position infant so that he or she is facing mirror, shine light on mirror, and tap behind the mirror where the light is shining. Look for changes in infant's behavior, such as cessation or increase of movement and increased vocalization.

2. Turn off light and stop tapping. Look for changes in behavior.

3. Repeat until response of looking at mirror is paired with light.

4. Slowly fade light back in line with infant's face, but keep tapping at previous location of light on mirror.

5. Fade out tapping.

6. Fade out light.

CONCLUSION

Programming for infants and children with dual sensory impairments should be designed to fulfill the needs of these individuals regardless of how they are categorized or where they are placed. Children with dual sensory impairments should receive specialized services, such as alternative modes of communication, functional sensory training, and orientation and mobility. We have emphasized effective programming, rather than programs, to highlight the necessity of fulfilling specialized needs. Infants and children with dual sensory impairments are found in a variety of program settings. Thus, it is crucial that supplemental information and instruction be available to the direct care providers, including family members, for the further development of the abilities of the children.

RECOMMENDATIONS

1 .There is a need for adequate programming in sense utilization for young children with dual sensory impairments.

2. The development of appropriate preservice training is important, not only in the management of auditory and visual impairments, but also in methods of instruction to increase ability.

3. More research is needed to determine the best methods for helping children acquire functional sensory skills to become more independent.

4. Parents or caregivers and other members of the family should be involved as early as possible in creating communicative environments

that stress the use of residual senses.

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ABOUT THE AUTHORS

MARTHA G. MICHAEL is a Program Manager at the Center for Special Needs Populations, College of Education; and PETER V. PAUL is an Associate Professor in the Department of Educational Services and Research at The Ohio State University, Columbus.

Manuscript received December 1988; revision accepted June 1989.

Exceptional Children, Vol. 57, No. 3, pp. 200-210. [c]1990 The Council for Exceptional Children.
COPYRIGHT 1990 Council for Exceptional Children
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1990 Gale, Cengage Learning. All rights reserved.

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Date:Dec 1, 1990
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