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Blind and Multiply Handicapped

by Doris M. Willoughby

Editor's Note: The following article is an excerpt from Chapter 12 of the Handbook for Itinerant and Resource Teachers of the Blind and Visually Impaired. Written by Doris M. Willoughby and Sharon L. Duffy in 1989 and published by the National Federation of the Blind, this excellent resource book is as valuable to parents as it is to professionals. The book is available from the NFB Materials Center for $23 (shipping and handling included). To order, send check and request to NFB Materials Center, 1800 Johnson Street, Baltimore, Maryland 21230. Calls for information or credit card purchases are taken between 12:30 p.m. and 5:00 p.m. Eastern Standard Time at (410) 659-9314.

Although the term multiply handicapped has been largely replaced by the term multiply disabled, I have elected to make no editorial changes in when and how those terms are used in this document. Regardless of terminology, the content of the following material can stand up to the toughest scrutiny for soundness in philosophy, attitudes, and practical application. However, I have replaced referecences to the federal special education law (at one time commonly known as P.L. 94-142) with the current designation, IDEA (Individuals with Disabilities Education Act).

When a student has more than one disability, it is extremely important to examine the situation individually. Each disability should be carefully analyzed, both separately and as it may interact with the other disability or disabilities.

Either or both of two opposite errors on the part of educators (or medical personnel) may cause unnecessary problems: (a) the assumption that anyone with a multiple handicap necessarily will have great difficulty in education and in life; and (b) failure to consider how two disabilities may interact and interfere with customary compensations for each. The former error is the more common.

Lori has a moderate problem with asthma. She also wears a brace on one leg, and climbs stairs slowly. If she were not blind, relatively little fuss would be made over these problems. An asthmatic child's teachers are advised of any restrictions, and medicine is kept available. The child who walks with a brace may have adapted physical education. However, if the child is also blind, some educators may immediately assume that she cannot achieve normally in any respect an exaggeration that is unconscionable and in conflict with IDEA. Or, the student and her family may believe any and all problems are due to the various handicaps.

Michael is not so fortunate as Lori. He is barely able to walk, cannot control his hands well, and has a moderate hearing loss in addition to blindness. Michael clearly needs a great deal of special help. Nevertheless, it should not be categorically assumed that Michael couldn't do anything in a regular class at the usual pace.

Each Situation Is Different

Look for clear reasons whenever a child is not keeping up with his age group and work hard to develop the abilities he has. Be sure that an expert in each disability is on the scene, working cooperatively with others. The team approach (with the parents always included) really shows its value with multiply handicapped children. Different specialists working alone can ruin one another's efforts. Two or more disabilities can interact in ways that may not be obvious without consultation. For example, the teacher of the blind may not realize that even mild cerebral palsy can cause much difficulty with typing. At the same time, the occupational therapist may not realize the importance of typing to a blind child, and may fail to explore ways to make it possible. If various specialists work closely with one another and with the parents, they can find an appropriate approach to each need.

Regardless of the severity of problems, expect progress and work toward it. Virtually everything in this Handbook is applicable whether or not the child has other handicaps. Methods and ideas need merely to be adapted for the other disability.

Other chapters in this book explain that alternative techniques (methods which do not rely on sight at all) often are not taught to students who should have learned them. This problem may be even more common with multiply handicapped children. For example, children regarded as having low general ability are sometimes not taught Braille at all, even though they actually could benefit greatly from a vocabulary suited to their needs.

Carefully analyze priorities in working toward independence, and seek the best means available for meeting them.

When any child has a behavior or adjustment problem, it can be hard to determine the precise cause. If the child has one or more disabilities, it becomes especially complicated. Does Matt have tantrums because he is at the age of the terrible two's, because of losing more sight, or because of the neglect he suffered before he was adopted? Does Elaine cry so easily because her heart medications need adjustment, because some classmates teased her about blindness, because of the tensions of the teen years, or for some other reason?

Knowledge about specific problems can be very helpful, but sometimes it is impossible to be sure of the cause(s). It is often best to deal with the behavioral difficulty and not worry about the cause. Whatever the cause may be, the student still needs to learn more appropriate behavior

Beware of the tendency to blame everything on blindness. Because of public attitudes, parents and others tend to believe that blindness is more devastating than almost any other handicap. A typical result is the incorrect belief that the blind child with, say, mild mental disability, cannot succeed nearly as well as others with mild mental disability. Another common result is preoccupation with futile attempts to develop a very small amount of sight, to the detriment of alternative techniques and general skills, which have much more potential.

Blindness and Physical Disabilities

A physical disability may be a problem so slight that it shows up only in certain sports, at one extreme, or near-total paralysis at the other extreme. This seems obvious, but is often ignored by unwise generalizations.

Mild orthopedic problems generally should be accommodated wherever the student would be otherwise. Consider these examples:

A five-year-old has had surgery to straighten his foot. He has trouble running and climbing stairs. But none of this rules out his starting to use a long white cane. The cane is, in fact, increasing his confidence on stairs.

A twelve-year-old uses leg braces and walks with difficulty. Her class schedule is arranged so that she need not walk a long distance in a short time. However, except for Adaptive Physical Education, no alterations are made in the classes themselves.

A first grader has very little use of his right arm. He cannot read Braille with conventional two-handed motion. However, his teacher is helping him develop his own style, and he is moving right along in the Patterns books. His Perkins Brailler has the adaptation for one-handed use.

Any problems involving the hands will usually affect typing skill. Consult an occupational therapist. Adapted fingering patterns exist to accommodate missing or useless fingers. If a child with poor muscle control keeps striking unwanted letters, the occupational therapist can add a keyboard shield, so that each key is in a small depression. Exercises can develop finger strength and coordination.

Although some physical disabilities affect how the hands move in reading Braille, general procedures usually need not be changed. As long as some fingers are usable, Braille can be learned. Do not assume, furthermore, that a physical disability necessarily slows down pacing it depends on the individual. Even if the sense of touch is believed to be damaged, it may develop surprisingly well with constant practice.

Physical education is most often affected by a physical handicap. Work closely with the Adaptive P.E specialist for the best arrangement of regular and/or modified activities. Don't let the student be left out of archery because the Adaptive P.E. teacher doesn't know about audible goal locators (devices which make a sound at the target or goal) and failed to consult you. Don't let the student be excluded from all running because you don't know how to teach him and you failed to ask for help. Also be sure everyone is using the same language a bowling rail for the blind is totally different from the bowling aid for people in wheelchairs.

If the student can walk fairly well, and has the use of at least one hand, then he can learn to travel with a long white cane. A mild orthopedic handicap should have little effect on how quickly the student learns to travel well. Even some people who appear to have poor balance will walk better with a long white cane, as they no longer need to shuffle their feet and fear obstacles ahead. (Of course, the long white cane cannot actually improve balance as such.) A greater physical involvement may cause more difficulty, but need not rule out cane travel.

One student had an artificial leg. She blamed her inability to keep in step on that handicap, until the teacher explained that all students, with very few exceptions, have difficulty keeping in step at first. Once this was explained, the student mastered this aspect of travel as quickly as everyone else.

Even for people using wheelchairs there is increasing use of white canes. One-handed steering of the chair is necessary, to leave the other hand free for the cane. A telescoping cane may be desirable for storage on the chair. Even limited independent mobility can be very important for employment and personal freedom.

Height may not be commonly thought of as a physical handicap, but it can be. Very short stature can prevent reaching drinking fountains, locker shelves, etc., and make it hard to find a suitable desk. As the student moves along in school he will have trouble with foot pedals in sewing, high tables in science, etc. Often a simple aid such as a footstool is sufficient. However, for extremely short stature a specialist (Adaptive P.E. teacher, physical therapist, etc.) should be consulted. He/she may have suggestions not readily thought of by others, and will lend weight to requests for special furniture. In the case of very tall stature, as occasionally occurs with early-maturing children, desk size is the main consideration.

With any extreme, give careful attention to the student's feeling of self-worth teasing is common from other students and even adults. Note that abnormal growth hormones can cause early puberty, or delayed or incomplete puberty.

Blindness and Hearing Loss

A mild hearing loss need not keep a student from learning in essentially the usual ways. It is very important, however even more so than for the sighted child with a mild hearing loss that careful attention be given to the compensations he does need. When a sighted hard-of-hearing child (or a sighted child with normal hearing who is temporarily disadvantaged by poor acoustics) cannot hear the teacher well, he will nevertheless receive visual cues. The blind child who cannot hear the teacher well may be totally at a loss.

Work closely with the audiologist to examine the environment. Sometimes even a minor change in furnishings can make a great deal of difference. Especially helpful improvements include:

Carpeting

Acoustical ceiling tile

Dropped ceiling

Cork or other absorbent material on walls

If hearing aids are needed, urge that binaural hearing (in both ears together) be emphasized, even though this may mean two aids instead of one. Otherwise the child may hear a sound but not be able to tell where it is coming from a disastrous problem for a blind child. Develop and use the hearing in each ear to the maximum extent possible. Also note that the type of aid called CROS (Contra Lateral Routing of Signals) makes it possible for one ear to hear sound as coming from two directions, thus encouraging sound localization.

Different hearing aids amplify particular frequencies to varying degrees. The importance of environmental sounds to a blind person may be relevant in the choice of an aid.

In some cases an auditory trainer (actually a specialized FM radio) may be worn by the child for greater amplification. Used with a special microphone worn by the classroom teacher, it helps eliminate extraneous noise. A switch selects reception for the teacher's microphone only or reception for the classroom in general.

A hearing loss can make it difficult to orient oneself to traffic and other environmental sounds. It can interfere with using the sound of the tapping cane to locate doorways, parked cars, hallways, etc., as one passes them. Nevertheless, try to help your student develop these skills, rather than assuming it is impossible perhaps it is possible to some extent. Also note that the identification aspect of a white cane is especially important.

Headphones may be helpful in listening to recorded material.

Lew Needed Help

Lew was visually impaired; however the preschool teacher had said he could see all of their materials OK. He also had a hearing impairment, but his speech communication was good. It was expected that he would do well in regular kindergarten. However, he failed to learn the names of the alphabet letters, often ignored the teacher's directions, and generally had severe difficulty.

Ms. Pirtle, the itinerant teacher of the visually impaired, believed that not enough attention had been given to the hearing impairment. She insisted that a teacher of the hearing-impaired attend the spring IEP conference.

I wonder if Lew should have a Phonic Ear, commented Ms. Pirtle (using the brand name for one kind of auditory trainer). Sometimes we think he really doesn't hear the teacher's directions. And I wonder if he really hears the difference between the letter names b, d, and so on. His vision really isn't good enough to see gestures clearly or do any lip reading at all.

We usually don't suggest a Phonic Ear for children with this much hearing, replied the teacher of the hearing-impaired. But you may be right. Let's put it in the IEP as a trial arrangement.

In first grade with his Phonic Ear, Lew's achievement and adjustment improved rapidly. He quickly learned the letter names, now that he heard each one reliably. He no longer needed repeated explanations and reminders. Impressed with this improvement, the parents also decided to agree to include Braille in the next IEP; Lew had great difficulty seeing ink print letters near the end of the day.

I didn't realize, said the teacher of the hearing-impaired at the next meeting, how much the low vision interfered with the compensations which other hearing-impaired children make almost automatically. Because Lew could see pictures and letters at close range, almost everyone had made this error. Lew himself, never having experienced good hearing, had no understanding of the problem. (If asked, Can you hear me? he would usually answer Yes, not realizing what he had been missing.)

Deaf-Blind Students

If the student has very little hearing, and also little or no vision, a specialist in the education of the deaf-blind should be involved. Detail about the education of the deaf-blind is beyond the scope of this book. However, the importance of three key skills will be pointed out: Braille, typing, and mobility.

Braille is vital for all the usual reasons, plus several others. Talking books and live readers are not usable. It is difficult to keep up with the news when one cannot use the newspaper, radio, or TV; the American Brotherhood for the Blind doing business as the American Action Fund for Blind Children and Adults publishes the Hot Line for Deaf-Blind, a weekly Braille newsmagazine.

Although manual sign language can be used by the blind (in a version contained within the hand of the listener), written language is essential for spelling, grammar, and precise meaning. Standard English may actually be a second language as compared to the sign language used.

Furthermore, for the deaf-blind Braille is a major channel for personal conversation. The Tellatouch, manufactured by the American Foundation for the Blind, enables almost anyone to communicate with a deaf-blind person. By using either the keys of a regular typing keyboard or keys like a Perkins Brailler, the speaker can raise pins to form Braille under the listener's fingertips. The Tellatouch is probably the most versatile and efficient communication aid for the deaf-blind. The keyboard can be used by almost anyone, with virtually no training necessary; the listener need only know standard Braille, or even just Grade I Braille; and the device is not extremely expensive.

Another device is a glove with the letters of the alphabet printed in locations, which the wearer has memorized. The speaker touches letters in turn, to spell out a message.

Newer devices, much more complex and expensive, may enable conversation in either direction or even over the telephone.

In communicating with a sighted person who is not present, typing skill is valuable for the deaf-blind as well as others. In addition, the deaf-blind person whose speech is not easily understood will find a typewriter to be a handy, inexpensive way to communicate in person.

A person without sight and hearing may be limited in mobility. However, there is no reason why a deaf-blind person cannot use a cane at school, in the workplace, and elsewhere with appropriate arrangements.

General Health Problems

When a medical condition affects a student's general health, a primary problem is deciding how much to expect. Can tension bring on an attack or seizure? Does the health condition truly limit stamina or general ability? If so, how hard do we dare to press for achievement in school?

Solid decision-making is based on a clear medical statement from a doctor, usually with interpretation by the school nurse. Ask the nurse for written specific guidelines, to be distributed to all teachers. (Example: One student was severely bothered by heat, but the school was not air-conditioned. Every fall and spring there was much debate as to how much he couldn't stand. The boy took advantage of this by avoiding assignments. Finally the nurse analyzed the temperature at which he began to have real trouble, and a thermometer was placed in each of his classrooms. When a room reached the problem level, the boy took his work to the air-conditioned office for that class period. On very hot days he worked at home. In no case was the boy excused from assignments.)

A policy of written guidelines also prevents phantom diseases. One girl was thought to have mononucleosis, but actually was overdoing her musical activities. Another girl, after fully recovering from a severe infection, had to fight for years a reputation of being sickly. Blind children, whom society tends to believe are frail anyway, are especially vulnerable to such misjudgments.

It is wise to check about food prohibitions for all students, especially those with health problems. Any child may have allergies. The diabetic child has a very strict regimen. Don't forget that small treats are food too.

The Emotionally Disturbed Child

Too often, the emotional problems of a blind or visually impaired person are blamed on the visual disability itself or on irrelevant factors, when the real problem is inadequate skills or incorrect assumptions about blindness.

Carol achieved excellent grades in high school, and received an award as an outstanding blind student. After graduation, however, she became more and more frightened at the prospect of college and a job. She became afraid to leave the house alone.

Carol talked with a psychiatrist, who believed that she had a typical reaction to the trauma of blindness, and concentrated on helping her adjust to restricted circumstances. Later a second psychiatrist, while counseling Carol to build up her confidence, strongly urged her to attend the adult Orientation Center for the blind. Finally Carol agreed. She also joined the National Federation of the Blind and met successful blind people from all walks of life. Soon she was delighted with her improved practical skills, and came to realize that it is respectable to be blind. No longer feeling that blindness meant inferiority, Carol went on to college a few months later.

Carol's high school teachers had helped her to achieve well academically, but had not succeeded in teaching her real self-respect and confidence as a blind person.

Fortunately Carol lived in a state with an exceptionally good adult Orientation Center. In many states she would have received little positive help after high school. The National Federation of the Blind, however, provides a positive influence throughout the country.

Some blind children, of course, really do have emotional problems as such. Consult the psychologist or other expert if a student is destructive toward himself or others, loses or gains a great deal of weight without medical explanation, or has major behavioral changes (examples: increased withdrawal and avoidance of personal contact; increasing aggression; increased avoidance of responsibility; marked indifference to personal appearance or to things in general).

As with any other multiple disability, specialists must work together. The psychologist might be unaware of the real problems of blindness, just as you may not know how to treat serious depression.

When a blind child truly has psychological problems, it is no less important that he be taught good techniques and positive attitudes regarding blindness. He does not need the additional burden of believing that blindness means inferiority. Whenever a blind child seems to have severe behavioral problems always consider all of these possibilities:

(a) a true psychological disorder

(b) low expectations due to an exaggerated view of the limitations of blindness

(c) lack of skills (mobility, social interaction, etc.) or the opportunities to use them

(d) two or more of these together

Following are several examples of apparent psychological problems, which turned out to be something else. In each case, if the described solution had not worked, psychological causes should have been investigated. (Caution: Often in such cases, the problem related to blindness is handled poorly, and a psychological cause is still wrongly assumed.)

A seventh-grade girl seemed withdrawn, not talking with any of her classmates. A sympathetic classroom teacher found that she knew almost no one, and lacked experience in making friends. This teacher coached her in how to get acquainted. She also recruited three girls to go to lunch with her.

A partially sighted tenth grader refused to go shopping or walk to the pizza

shop. If she did go out in public, she clung to someone's arm. I'm afraid of crowds, she said, and the psychologist wondered if she had agoraphobia (extreme fear of open places). Finally her parents realized that the girl could not really tell the difference between a step-down and a mere change in pavement coloring. Also, they realized she really could not judge traffic motion. They insisted that the mobility teacher give her cane travel instruction with sleep shades, even though he had said this was unnecessary. After a few weeks the girl was shopping happily all over town, with newfound freedom and confidence.

A third-grade boy continually poked and pushed his classmates. The counselor found that, like the seventh grade girl above, this boy did not know how to make friends. Also, some of the boys had teased him about his heavy glasses. The counselor included this student in group counseling, to help him make some real friends and to teach him social skills. This small group often played together at recess, providing an additional opportunity for normal social interaction.

An eighth grade girl, rather thin, never ate lunch at school. By 2:00 p.m. she was tired and listless. The nurse feared she had an eating disorder.

I'm just afraid I'll make a fool of myself, the girl finally confided. Those school lunches have gravy and soup and whatever, and I know I'll make an awful mess. And don't tell me to bring a sack lunch. My mom doesn't have time to make one.

The nurse arranged several sessions of eating hot lunch privately with coaching. She also helped the family teach the girl to pack her own sack lunch.

His behavior is bizarre, said the first grade teacher. He waves his arms in circles, just any old time. And he keeps poking his fingers in his eyes.

The resource teacher explained that these habits, while very undesirable, are not unusual in blind children and may not mean psychological disturbance. The psychologist helped the teachers work out a behavior modification plan, with simple rewards for avoidance of these habits.

An eleventh grade girl was very unhappy. Everyone assumed that this was because of losing more and more sight. Finally, however, her mother realized that the breakup with her first real boyfriend was the current crisis. Several heart-to-heart talks revived interest in school dances and other activities. At the same time, the counselor and the resource teacher reexamined the program of alternative techniques to cope with decreasing sight.

A senior boy seemed deeply depressed. The psychologist found a strong fear of spending life in a rocking chair, like an elderly blind neighbor.

Although this boy had met some other blind people, he had never really talked with them about their jobs. It was arranged for him to visit two blind people at work and to receive cassettes from Job Opportunities for the Blind. Soon he was happily examining several career choices at the Community College.

He must be autistic, said the kindergarten teacher. If you leave him alone, all he does is whirl around and around.

The itinerant teacher redoubled her efforts to teach the child cane travel for increased mobility. She urged the kindergarten teacher to correct him sternly whenever he started whirling. If it's a class session, insist he sit down and pay attention, just as you would any other child. If it's free play, move him physically to something interesting, such as the clay table or the swing, and insist that he do something constructive.

Pseudo-diagnosis of supposed psychological problems is very common, due to the mistaken belief that blindness necessarily causes psychological difficulties, and due to inadequate teaching of techniques and skills. However, as with any student, a psychologist should be consulted if solutions such as those above do not work, or if the behavior is dangerous. Always consider also whether a medical condition (possibly undiagnosed) might be affecting behavior.

Mild Mental Disability

Most students classified as mildly mentally disabled can lead an essentially normal life, and do not appear obviously different. Regular social interaction and integration into some regular classes are appropriate. Modification is usually necessary for heavily academic work.

For the older student, emphasis is placed on vocational skills for appropriate jobs. Often high school students have a part-time job in the community with school supervision restaurant work, farm work, cleaning, stocking shelves, etc. These students reasonably expect to marry, to raise families, and to hold jobs in competitive employment at a level appropriate to their ability. In short, they blend into the general population.

Mild mental disability is generally defined by a score of 55 to 70 on an intelligence test. Those scoring slightly above this are often called slow learners and may need somewhat similar help.

There is no reason why mildly mentally disabled blind students cannot learn the same alternative techniques as others Braille, cane travel, typing, abacus, etc. Extra explanation, practice, and repetition may be needed, but basically the education of a mildly mentally disabled blind student is similar to that for others.

However, mislabeling a visually impaired child is a common problem. Sara had always been regarded as mentally disabled. However, when a new itinerant teacher started an assertive program of alternative techniques (despite previous assumptions that Sara could not benefit from them because of retardation, or did not need them because she had some vision), Sara bloomed. By graduation, it was obviously doubtful whether Sara really was mentally disabled at all.

Blindness aside, there is much controversy as to whether intelligence tests really measure general ability. For blind students there are additional problems with such tests, as discussed in the chapter on testing. As provided in IDEA, no single test should be used to classify a student. Use more than one measure, including general behavior and achievement.

Moderate Mental Disability

This degree of disability is generally defined by a score of 40-55 on an intelligence test. These students have difficulty with social conventions and life skills, and have very low ability for academic work. The student generally can learn to dress himself, eat normally, and handle most self-help skills, but some supervision will probably always be needed. (For example, a person may learn to dress himself and to do laundry, but not be able to handle repairing or replacing garments.)

Typically, moderately mentally disabled persons achieve partial self-support in sheltered employment. Some, however, do hold regular competitive jobs.

Many blind students with this degree of disability read Braille with a limited vocabulary, just as their sighted counterparts do in print. If there is uncertainty whether reading instruction is appropriate, a good indicator is the degree to which the student can grasp concepts. Can he make comparisons? Draw conclusions? Carry on a logical conversation? If it seems at all reasonable, reading instruction should be attempted. Even a few symbols can be useful for labeling, for simple messages, etc.

For pre-reading skills, provide materials similar to those used with preschool children. If the student is really beginning to read, someone who knows Braille should work directly with him.

Most moderately disabled persons are able to learn cane travel, sometimes doing better than one might expect. Without a cane, the person is more limited than is really necessary.

For older students, independent living skills and vocational education are emphasized. Instruct the student and/or his teacher in alternative techniques for such things as:

Personal cleanliness

Cooking

Laundry and very simple mending

Housecleaning

Shopping

Industrial janitor work

Sorting and assembling

Collating, stapling, etc. (You may need to explain techniques for keeping track of which papers are which. They may be boxed, labeled, kept in a certain place, etc.)

The role of the resource/itinerant teacher of the blind will depend on the student's age and individual abilities. If a skill such as cane travel or Braille were being intensively taught, you would work directly with the student. But if much repetitive practice is needed, someone else will probably help in between your lessons. Often you will mainly provide information to other teachers and to the family.

Severe/Profound Mental Disabilites

These students have intelligence scores of under 40. Many will never walk. A sheltered living situation will be needed in adulthood.

Lessons for a Severely/Profoundly Handicapped Student

When a student is mildly mentally handicapped, working with him is basically the same as with others, but at a slower pace. Working with a school-aged student who is moderately handicapped is much like working with a preschooler or kindergartner, though there usually are complicating problems. But when a teacher is first asked to work with a severely/profoundly handicapped individual, it may be very hard to imagine how to proceed. This chapter will offer a number of suggestions.

Unless you are employed by a special school, your role probably will not usually include direct instruction. Daily contact is necessary to achieve rapport. Progress occurs at a pace so slow as to be outside many teachers experience. Academic work is not appropriate. For these reasons the itinerant/resource teacher of the blind will most often provide suggestions and materials. But in order to do this one must understand what the program for such a student is like.

Why is it so important for that boy to shake a rattle? I once asked a friend who worked at the State Hospital-School. Is his hand coordination so poor?

That is part of it, she replied. He can't do much with his hands yet. But our main goal on this is to get him to sit at a table. If we can get him to sit up and rattle something, then he'll be in a normal position instead of sprawled. This will also help him hold his head up. And if he gets used to really sitting at the table, consider all the things that can lead to eating more normally, putting objects in containers, even starting to work a simple puzzle.

My friend was helping me think about early developmental skills. It can be hard to think in those terms when the chronological age is 12.

Following are some typical skills, which (with much more specific wording) may be in the IEP:

Turn head toward something interesting

Reach for an object on command

Recognize familiar objects

Distinguish between colors

Roll a ball

Place a ball in a box

Follow a simple command, such as Stand up

Wash hands

Wash face

For the severely/profoundly handicapped student, it is necessary to break skills down into very small steps, each of which must be taught by much repetition. Consider a sequence for a student learning to wash her face:

(1) Reach for washcloth

(2) Pick up washcloth

(3) Find faucet

(4) Turn on water

(5) Hold washcloth under water

(6) Wring or squeeze cloth

(7) Put cloth to face

(8) Move cloth around on face

This sequence actually is only a part of the procedure, because after each new step is learned, all steps to that point must be practiced before adding another. Also, the above sequence does not include soap. That may need to begin with: Examine soap and understand it is not to be eaten.

Teaching a severely/profoundly handicapped student to wash her face, with daily lessons, can easily take many months.

Most Blind Students Do Not Need This

Breaking a task down into small steps, as above, is necessary for students who have great difficulty. To a lesser extent, breaking a task into smaller steps is also done routinely by all teachers.

Blindness in itself does not require more of this kind of thing than is necessary for sighted students. However, unfortunately, some publications seem to make that very assumption. For example, A Step-By-Step Guide to Personal Management for Blind Persons gives incredibly detailed directions for taking a bath e.g., As towel gets damp, shift to a dry section. This widely circulated book ought to be entitled: A Step-By-Step Guide to Personal Management, for Blind Persons With Special Learning Problems.

Its text should carefully explain that such detailed help is not needed for the vast majority of blind persons. In this way the book could be helpful for those who really need it, without encouraging the false belief that all blind persons are unable to follow ordinary directions or grasp general concepts.

In 'To Man the Barricades' (see References), Kenneth Jernigan explains in detail the severe damage caused by the assumption that all blind people need the help which is appropriate for those who learn very slowly.

Helping Teachers Make Lessons Appropriate

In teaching a skill to a severely/profoundly handicapped student, it is usually necessary to move the student through it physically many times, gradually giving less and less help. For example, at first the teacher might hold the student's fingers on the washcloth and raise the student's arm to the face; later the teacher might just touch the fingers and raise the child's arms slightly as a reminder. This is called physical prompting and is especially important with a blind student.

Emphasis should be on skills for functioning as independently as possible in an appropriate (very sheltered) environment.

You may need to provide ideas for alternative techniques, and to help teachers realize that planning for a blind student is basically the same as planning for other students. Ask, What is she doing now? and What would you be doing if she were sighted? Teachers of the mentally disabled will know what is appropriate for each developmental level, and how to break things down into small steps. After some consultation and experience, they will usually be able to plan their own modifications for a blind student. Give plenty of encouragement and compliments for the teacher's work.

Let us return to the list of typical skills and note how they can easily be made appropriate for a blind child:

Turn head toward something interesting: Use an interesting sound. If there is some sight, sometimes use a flashing light or a bright-colored shiny surface.

Reach for an object on command: Associate a sound with the object, or use something very bright if that is appropriate.

Recognize familiar objects: Make sure the objects are consistent and easily distinguished tactually.

Distinguish colors: If the child has quite a bit of sight, this may be achieved with bright, clear colors. Distinguishing textures is an appropriate alternative.

Roll a ball: Use a ball that makes a sound. Provide plenty of appropriate feedback (for example, the teacher might clap his hands when the child rolls the ball a certain distance.)

Place a ball in a box: Use a stable container that will not move around easily. Help the child to examine the ball and the container with her hands, before she tries to put the ball in.

Follow a simple command: such as Stand up. Use physical prompting.

Wash hands or face: Washcloth, soap, faucet, etc., can all be found by touch. It is helpful if (at least at first) such things are always in the same place in relation to the student. Help the student examine and understand each thing (including the water itself) before starting to work on what to do with it. For example, help her to turn on the faucet with one hand while her other hand is underneath, so that she feels the stream come on.

Keeping Vision In Perspective

Avoid being pushed into overemphasizing visual development. On the one hand, especially with the younger child, it may be hard to tell how much he really can see, and therefore some effort to develop the use of his sight may be warranted. On the other hand, parents and teachers often overdo the visual emphasis, in a futile attempt to improve vision that is not really there, and with the erroneous idea that better vision would bring better general ability.

Encourage everyone to note what (if anything) interests the child visually. Will he turn toward a light? Does he respond to the general room lighting being turned on or off? To a flashlight? To shiny surfaces? To blinking lights? To lights of certain colors? Red and green are often favored. Also, black light may be especially effective (a kind of ultraviolet light which cannot itself be seen by the human eye, but which can give interesting fluorescent effects).

[Caution: Some lighting effects, especially blinking lights, may bring on seizures in certain children.]

If the developmental level is early infancy, remember that development of the use of vision will not exceed mental and physiological development.

For a child with very low awareness, it may help to pair something visual with something else to which the child already responds, and gradually encourage the child to notice the visual attraction alone. For example, if the child already responds to music, a bright red ball might be shown each time the music is started. This may help the child learn to respond just to seeing the ball.

Keep vision in perspective by working to develop all senses. This approach helps to determine the child's general ability as well as his visual ability. Emphasize the integration of sense that is, how the senses work together. Any child with useful sight (including the fully sighted) requires practice in order to know what visual information means. After he has felt a ball many times, he comes to understand when his eyes are seeing a round object.

Following are a few typical activities that help develop the sense of touch, smell, and/or taste, along with vision if it is present:

* Peanut butter is placed on the fingertip and may be licked off.

* The child examines various textures (velvet, corduroy, hay, feathers, etc.) and gently rubs his arms and legs with each.

* Cornstarch is moistened to form a ball with interesting characteristics. When held in the hand it melts, but upon leaving the hand it coagulates again.

* Water play has endless possibilities.

Conclusion

What kind of educational setting does this student need? In answering this question, carefully consider which disability most affects education as a whole. If mental ability is essentially normal, then the regular curriculum is appropriate, with only as much special help as is genuinely needed. If the student is severely mentally handicapped, then the mental disability and not the blindness is most relevant; a setting appropriate for severely mentally disabled students is preferable to one for merely blind children.

Placement should always be decided on an individual basis, however. Rigid categories are not an appropriate way to plan education.

The following chapters in this book are especially relevant for students with more than one disability: Early Childhood, Orientation and Mobility (Under Age 8 and Special Problems), Teaching Braille (Second Grade and Below), Dealing With Medical Matters, Placement Options and Decisions, and Working With Other Agencies and Organizations. See also References.

Many people with multiple handicaps complete their education, raise families, and succeed in vocations of their choice. Treat each student as an individual, emphasizing the strengths he has, not permitting him to be regarded only as part of a vague lump called the multiply handicapped.

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