Future Reflections          Fall 2007

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Functions of the Cane
and the Bottom-Up Approach to O&M for Children

Excerpts from
Independent Movement and Travel in Blind Children: A Promotion Model
A Volume in Critical Concerns in Blindness
by Joseph Cutter

Introduction and Review
by Barbara Cheadle, Editor, Future Reflections
President, National Organization of Parents of Blind Children

Independent Movement and Travel in Blind Children: A Promotion Model
A Volume in Critical Concerns in Blindness
by Joseph Cutter
Includes bibliographical references
Copyright 2007 IAP--Information Age Publishing, Inc.
ISBN 13: 978-1-59311-603-3 (paperback)
ISBN 978-1-59311-604-0 (hardcover)
331 pages, large print font, black and white photos.

Hardback and paperback editions are available for purchase from IAP at <www.infoagepub.com> (search by author, Cutter). Paperback copies are also available from the NFB Independence Market: <[email protected]>, fax (410) 685-2340, phone (410) 659-9314, extension 2216.

Joe Cutter has finally done it. He�s written a book with answers to the questions that parents have been asking ever since the NFB revolutionized orientation and mobility (O&M) for blind kids by being the first to produce and promote kid-size canes for toddlers on up. For years, parents have been asking: When is a child ready for a cane? What kind of cane should she use? How long should the cane be? What if my child has additional disabilities? Our traditionally trained O&M instructor is using techniques and strategies that don�t work with our three-year-old; is she just too young or is there a different approach that will work?

The last question is key to understanding the unique breakthrough that Cutter�s book represents. This is more than a book about cane techniques and teaching strategies (although there is enough of that to satisfy the most detail-oriented parent or instructor), it is a guide that lays out a whole new way to think about and approach the facilitating of normal--yes, normal--movement and independence in young blind children.

That�s what has made it so hard to select a segment to reprint from the book. If we only print the practical tips and strategies, then the reader will not fully understand the vital conceptual underpinnings; and if we only print segments about principles and philosophy, then we lose the practical-minded who are looking for specifics. So, as editor, I determined that to do this properly, it required printing a segment from two different sections of the book. Going in reverse order, the first segment is reprinted from chapter 4, �Cane Travel for the Blind Child--From the Bottom Up.� This is a very practical discussion of the specific functions, uses, and characteristics of the cane, with special attention to its functionality and adaptations for the very young child. Last is a segment reprinted from chapter 1, �The Promotion Model.� This segment is a short explanation of the philosophy behind the practices that are described in the book, with specific attention to the bottom-up concept that Joe Cutter has pioneered in the development of the Promotion Model.

Having said all this, it still does not do justice to the importance of this book. Since movement is essential to all aspects of development and growth for every blind and visually impaired child, the value and scope of this book goes far beyond questions related to the use of the white cane. In fact, I can say--without hesitation--that if the parents, caregivers, or instructors of blind/visually impaired children between the developmental ages of birth to kindergarten could only have one book or one resource to consult--this is the one they must have.

With permission of IAP--Information Age Publishing, here are pages 149-160 as reprinted from Independent Movement and Travel in Blind Children: A Promotion Model:

Functions of the Cane

The cane is a handheld tool used for independent movement and travel. It performs many functions. Under the blind child�s direction, it can inform, explore, inspect, detect, protect, and most of all, facilitate getting to know and moving in the world.

To illustrate, the cane is more than a windshield wiper on the world. It is the steering wheel that can be manipulated to where the traveler wants to go and gives direction for whenever the traveler wants to circumvent an obstacle. It is the headlights giving preview of what�s ahead. It is the bumper protecting from unexpected encounters. It is the antennae receiving resonance information about the sound space world. It is the tires, adjusting to the terrain and providing a smoother safe ride. Like the car, the cane is as effective as the driver who must obey the laws of the road. The cane gets children where they want to go.

Below is a list of the basic functions of the cane.

• Tool Usage: In the progression of tool usage, the cane is used intelligently by the child to reach off his/her body and touch the world. It is a handheld tool. With practice, the cane increases the safety, confidence, effectiveness, and efficiency of the child moving about in the world.
• Protector, Detector, and Previewer: The cane conducts information through its shaft into the blind child�s hand. This is often referred to as feedback. The child, as a traveler, then uses this information to decide how and where to go and what to do to get there. Like vision, the cane tells the child what is ahead, detects what is to be avoided or approached, and gives general preview, not only of where the traveler will be stepping next but also echolocation information of objects further away.
• Tool for Action and Sensory Integration: The cane is a tool for active movement. It gathers information. Sensory integration is what children do with sensory information. The cane facilitates sensory integration, as it is a handheld tool used by the upper body that connects to the ground, and this connection affects the movements of the lower body. Occupational and physical therapists who work with blind children can be given guidance to incorporate the cane into their therapy activities. When this is done therapists find that the use of the cane facilitates sensory integration of information. This occurs because the cane conducts information to the child�s hand that travels up the arm into the child�s brain.
  
  The cane decreases the need for self-stimulation by increasing the active movement of the blind child in a purposeful and satisfying way. Therapists agree that the less the child needs to think about the movement, the more automatically it will be done. I can think of no other tool that affords such facilitation of the goal of automatic movement with a handheld tool than the cane.

• Tool for Normalizing Posture and Gait: Use of the long cane assists with the child�s development of normal gait patterns and posture. The research on movement in blind children typically reported a wide-based stance, abnormal gait patterns, poor posture, and constriction of the body when moving. These abnormalities were thought to be due to blindness. We now know otherwise: they were due to lack of opportunity to use the cane. The lack of opportunity for the blind child to use the appropriate tool at the appropriate developmental time caused the abnormalities in posture and gait to occur. With the long cane the child can stand relaxed and erect, develop typical gait patterns, and move faster and more confidently.
• Tool for Play: Initially, the cane is used and enjoyed by blind children in their play. The child has fun with it, poking it in snow and bushes or exploring a playground. The child taps it on different surfaces for the fun of hearing echoes. In an amusing, fun way the cane introduces the child to the world beyond the fingertips. Use of the cane stimulates the creative and imaginative nature of the child.
• Low Vision Aid: The cane can be used by partially sighted children to look where their eyes cannot see; for example, the cane looks down or to the side so they can look up. It touches the world for children, offering the possibility that they may want to visually view what it touched. The use of the cane as a low vision aid was covered more extensively in chapter 3 in the section titled �Succeeding with Partial Sight.�
• Tool for Confidence and Self-Esteem: O&M is a confidence-based skill and the early use of the cane introduces the blind child to experiences that increase self-confidence. When introduced early in life, the cane affirms who the blind child is and what must be done to be independent. The child develops confidence earlier in the what and how of independent travel. Such confidence integrates into the personality of the child.
• Tool for Freedom of Movement: The cane affords the opportunities for freedom of movement and joy of movement that is every child�s right. With it children decide where and when to go, and how fast or how slow. The cane facilitates awareness of the child�s movement and this increases attention span while moving and traveling in the environment.
• Tool for Cognitive Development: The cane is a tool that provides opportunities for children to use intelligence in thinking about self-directed movement, making decisions, developing good judgment, and learning to problem-solve. Through self-monitoring the child directs the movement of the cane to satisfy curiosity and understand the requirements of safe and effective travel. Driven by cognitive interests, the cane is a tool to learn about the environment. Its use facilitates the formation of basic concepts about the environment and prepares the child for learning more advanced O&M concepts and skills.
• Puts the Blind Child at an Advantage When Traveling: The use of the cane has so many functions that it places the child at a real advantage in learning about the world and in moving and traveling in it. Through everyday experiences with the cane, blind children learn through their own orientation and mobility to view themselves as independent travelers. To not get an early start on cane travel for the blind child is to place the child at a disadvantage and all of the aforementioned �functions of the cane� are not a possibility; instead limitations will be developed by the passive movement that following someone�s lead engenders. The child�s cognitive development, freedom of movement, and confidence to travel independently is also at risk of not developing. Make sure the blind child in your care is given all the advantages.

Characteristics of the Cane

The characteristics of the cane can affect the safety, effectiveness, and efficiency of the traveler. As travelers, blind children and blind adults have the same requirements for the characteristics of the cane. These main characteristics that need to be considered when choosing a cane are: composition, weight, length, grip, tip, flexibility of the shaft, resonance affordability, and one piece or folding.

As blind children mature and develop appropriate posture, balance, hand-functioning, height, and size, they will use a proportionately larger cane. Over the years, I have experimented with a variety of types of canes, grips, and tips. I have found that the straight, hollow, flexible, lightweight, metal-tipped canes, such as those available through the National Federation of the Blind, possess the most advantages for the blind traveler. These canes start at about 24 inches and, as their length increases, the overall proportions of the cane are scaled larger. The design of the cane is not altered. This creates a seamless continuity for the child and makes it unnecessary to adapt to a different type of cane.

The characteristics of the long cane can either afford the traveler advantages in use of this handheld tool or not. Below is a list with a brief explanation of the characteristics that have the most significant effect on the independent movement and travel of blind children.

• Composition: Canes can be made of metal, fiberglass, carbon fiber, and wood. What is important for blind children is that the material used is lightweight and flexible and is a superior conductor of resonance and tactile information. I have found the materials that facilitate the child�s travel most to be fiberglass and carbon fiber.
• Weight: Remembering that a cane is a handheld tool, the lighter cane has an advantage over a heavier cane because children can more easily manipulate the use of it with the hand. A cane that is too heavy will compromise hand-functioning. The lighter cane approach to travel places children at an advantage.
  
  With a heavier cane the blind child usually drags it behind or keeps it to the side. This leaves the child vulnerable in front, as the cane is not always clearing ahead. Canes that are too heavy will reduce the control that the child has to manipulate the cane at the wrist, hand, and fingers. Easy manipulation of the cane will be reduced. The heavier canes restrict the possibility of a longer cane for younger blind children who need the extra length to compensate for lack of extension of the arm and walking in-step as older blind children and blind adults can do.

• Length of Cane: A lightweight cane introduces the possibility for a longer cane to be introduced to the child. The O&M specialist must take into account the fact that the blind child will not extend the arm forward and not be able to walk in-step. These are developmentally advanced skills beyond the capability of the young child. Therefore, a child-centered measurement would be around the mouth-to-nose area. This gives the child more time to react to an object when contacted.
  
  The conventional approach of sternum/breastbone area as a marker for length is based on the adult skill of walking in-step, adult reaction-time capability, and other adult-based factors. When working with the bottom-up approach, it is understood that the child will not have these same capabilities. Therefore, this rationale for conventional measurement of length of the cane is inadequate.
  
• Grip of the Cane: It is important that blind children be able to place their child-sized hands comfortably around the shaft of the cane. An adult-sized cane that is cut down may be the correct length for the child, but the grip circumference is often too big. Consequently the child cannot grip the cane properly. In addition, some types of child-sized canes on the market have a sponge or rubber type material around the shaft with a section notched out for the pointer finger. In my work with blind babies and cane use, they would often try to bite this material. This, of course, was not safe, as the material is not meant to be chewed and digested.
  
  A cylinder-shaped cane grip makes it easier for the child to �grasp and go,� whether the child is right- or left-handed. A grip that has one flat side is obtrusive to the child�s natural inclination to hold the cane. In addition, the flat surface is for isolating the index finger, which the younger blind child is not usually ready to do. Also, isolating the index finger is a conventional O&M grip protocol, which is not necessary to hold and use the cane proficiently, as there are alternative grip positions. These are discussed later in this chapter.
  
• Tip of the Cane: The best type of tip for the cane is a metal tip. The tips of the NFB-type canes are metal surrounded by rubber and have a certain amount of flexibility. This way, the blind child can get the crisp, clear information from the metal tip cane and is less likely to get stuck in cracks in the sidewalk, as the child gains experience in handling the various types of terrain. The cane can come with many different types of tips. For example, the marshmallow (rolling and non-rolling), mushroom, and teardrop tips (made of plastic/plastic-type materials) were developed because it was assumed that gliding over uneven surfaces more easily would be a good thing for blind children.
  
  My experience has been the opposite, however. By easily gliding or rolling over the ground, these tips reduce the texture information and details of the ground surface. From the bottom-up, blind children need to understand about cracks in the sidewalk, uneven terrain, and the more subtle texture differences in ground surfaces. They need to easily identify where the sidewalk, grass, and driveway differentiate. A cane tip that subdues this information is not affording clear information. In addition, these types of tips distort the resonance (sound feedback) that the cane should afford the child.
  
• Flexibility of the Cane Shaft: It is important for the composition of the cane to have flexibility as it contacts the environment. Fiberglass canes have a certain amount of give and take and can bend and go back to their original shape. Metal canes are easily bent and once bent they do not regain their original shape. Metal folding canes are the most frequently dispensed canes in O&M instruction even though they easily lose their shape and become deformed at the joint-fit.
  
  In addition, there is the added factor of getting hurt. When moving with the cane, blind children are learning about speed, confronting an object, and reaction time with the cane. Earlier on in learning to use the cane, children can hit an object and continue forward. This results in the cane being pushed into their stomach or groin area. A more flexible cane results in less of a push and a more user-friendly understanding of contacting the object world.
  
• Resonance and Tactile Feedback Potential of the Cane: The importance of the resonance capability of the cane cannot be overstated. The blind child will learn to use resonance for information and orientation, as in echolocation. The importance of tactile feedback is also essential. It gives very useful information about ground surfaces and assists in identifying what type of surface is ahead. Therefore, hollow, one-piece canes made of fiberglass are superior conductors of resonance and tactile information. In contrast, folding canes have elastic running down the shaft that distorts and dampens resonance and tactile information, thereby providing much less information to the child.
• One Piece Hollow Design: A cane made of a one piece, hollow construction facilitates vibration and tactile information, as well as resonance for echolocation use, in a superior way that folding canes do not. For the first-time traveler it is best to use a one-piece, hollow-design cane. In addition to facilitating these aforementioned characteristics, such a cane affords the opportunity for the child to learn how to store the cane in the classroom, cafeteria, and the car. When children are given a folding cane, they do not have an opportunity to learn to store a one-piece cane.
• Folding and Telescopic Canes: Folding canes should never be used as the blind child�s first cane. Folding canes embody many negative characteristics for blind children. Here are some reasons why:
  
  1. The elastic running down the shaft of a folding cane dampens and distorts resonance information.
  
  2. Folding canes add weight and this will reduce the increased length of the cane that the child can handle without compromising hand functioning.
  
  3. Folding canes increase dependence because many young blind children in early intervention and pre-school cannot fold or unfold their cane; they must rely on someone else to do it for them. This does not facilitate independence.
  
  4. Folding canes convey negative messages about the cane. What message do we send blind children when we ask them to fold their cane? Is the cane in the way? Should it not be seen? It is subtle negative messages about the cane that result in blind children developing poor self-esteem and negative thoughts about the use the cane.
  
  5. Telescoping canes have the advantage of having a hollow center and no elastic running down the staff to distort resonance, but they don�t offer the stability of the one-piece cane. These canes tend to telescope in when they hit an object. Young blind children may not be ready to react quickly enough should this happen and it could bring them in harm�s way.

Eventually, a telescoping or folding cane might be an option as a back-up cane, or when the child has developed efficient reaction time and a light touch with using the cane. However, in the early movement of blind children, adults must promote what is known to be best to facilitate independent movement and travel, and which affords a rich and valuable experience in using the cane.

When these characteristics of the cane are considered carefully, we are more likely to choose a cane that places the blind child at an advantage. The bottom line is this: any cane is better than no cane. However, if we are to promote the independent movement and travel of blind children, we should consider the characteristics outlined above. We should be placing blind children at an advantage by using what we know has worked successfully when learning to use the cane.

When these characteristics are considered and built into a cane, this becomes the cane of choice for the blind child. There are blind adults who use this cane of choice every day and blind children should have the opportunity to use it too. The Resources chapter gives contact information for purchasing this cane through the National Federation of the Blind.

Ideas for Adapting the Cane for the Child

To better meet the needs of the child, it may be necessary to adapt the cane. The cane may need to be adapted for various reasons--hand and finger functioning, keeping the tip oriented down, and differences in the child�s developmental level to grip and use the cane. Below are some ways to adapt the cane.

• For some children �building up� a cane grip is needed for better hand-functioning. Usually these blind children are working with an occupational therapist. The therapist can assist in finding a grip for the cane that will be more functional. The adaptation might be similar to what is used by the child to hold eating utensils. Consider using a sponge taped down with duct tape and a bicycle grip slipped over the shaft of the cane.
• For the child who has not yet learned to keep the cane down, weight can be added. For example, tape a fish weight at the end of the cane, just above the tip. This will not distort the resonance as much as the large plastic tips discussed previously. For some children who need a heavier downward orientation, a three to six inch piece of metal plumbing pipe may be added, depending on how high the child is lifting the cane off the ground when walking. Put the cane tip end through the hollow pipe, taking the cane tip off first and then putting the cane tip back on and taping down the pipe.
• Velcro and therapy putty can be used to attach the cane to the child�s desk vertically if placing it underneath the desk or table is not an option. Velcro can also be used as a marker for where to hold the cane for going up stairs or the shorten-position for navigating through crowded areas, as discussed later in this chapter.
• Some children like the feeling of an edge at the end of the cane that they can feel in the palm of their hand. A rubber band twisted around the grip end can provide such an edging or a piece of Velcro taped to the end.
• Some children prefer a different feeling on the grip, perhaps a material that is softer. Taping over a thin sponge can create such a cushioned feeling.

These modifications can be removed as the child develops more advanced hand-functioning and control over inadvertently lifting the cane, or when personal preferences for griping the cane change.

[The following segment is reprinted from chapter one, pages 10-12, of Independent Movement and Travel in Blind Children--A Promotion Model, with permission of IAP--Information Age Publishing.]

The Building Blocks of the Promotion Model

Below are the building blocks of the Promotion Model. First, the philosophy, which is its essence and spirit. Second, the principles, which are the foundational truths that support the model. Third, the developmental perspectives, which are the fundamental beliefs to fuel and guide the model. Fourth, the strategies, which put the philosophy, principles, and developmental perspectives into a plan for action. And fifth, the practices and techniques, which facilitate and put the strategies into action in the everyday learning and development of life skills for the independent movement and travel of blind children.

The Philosophy

Philosophically, we must acknowledge that child development is built on gain and not loss. The adult-centered approach of conventional O&M gives significant consideration to the loss of vision that adults experience later in life. When looking at child development, however, the Promotion Model recognizes that loss of vision does not factor significantly in the developmental gains that children make every day. Children born blind or who lose vision in the first years of life do not experience the type of loss associated with adults who lose vision. These children have not acquired years of developing visual skills nor do they possess a visual orientation to the world that has a long-standing integration into their personality.

For blind children, success is not measured by how much vision they have, but rather is built on how many skills are developed for independent movement and travel. With one skill built upon another, the goal of development is mastery over the environment to move and travel safely, confidently, and independently.

In the Promotion Model, the child leads the way, and if we are willing to learn from the child, many possibilities emerge. As an O&M professional service provider, I have connected with parents of blind children, incorporated them into my service delivery plan, and learned much from their experiences with their blind children. I have partnered with the organized blind that have provided me with positive, skilled blind role models for independent movement and travel. The building blocks of the Promotion Model have been developed from years of such learning from blind children, their parents, and skilled blind adults (the organized blind). Together, they form the fabric of the �nature and nurture� of independent movement and travel. Together, they present a formidable, alternative program of O&M to promote the independent movement and travel of blind children.

Bottom-Up

The child is not born with concepts of the world. The baby is born with sensory systems, like �fingers of the brain,� that gather information. With sensory and motor experiences the child matures over time and gives purposeful thought to what is experienced. One way to describe this process is bottom-up, which means that out of the experience comes the concept. If the experiences we give blind children are developmentally sound they will experience independent movement and travel age/stage appropriately. Blind children will develop the concept or self-perception of themselves as travelers.

Historically, conventional O&M was developed as an adult-centered approach. Its protocols were developed from an adult point of view for adult learners. For instance, the adult was given the concept of a new skill and the skill demonstrated for him/her. Then the newly blinded adult would perform the skill. This can be described as a top-down approach, which means that out of the concept comes the experience. This is a very different approach than bottom-up, which is the perspective of the Promotion Model.

Bottom-up is driven by the sensory and motor experiences of the child, and top-down driven by the cognitive concepts directing the movements of the adult. For example, when blind children under three years of age are learning to use the cane, they will need to be amused, explore, and have fun with their cane. Their movements will be more exaggerated and less refined. On the other hand, these are not the behaviors or the goal of the adult learning cane travel for the first time; adults will be ready to perform at a different cognitive level of understanding.

When promoting independent movement and travel in blind children we need to approach skill acquisition from the bottom-up, making sure our intervention and practice is suited to the developmental ability of the child. Imposing a top-down approach at a developmentally inappropriate level will meet with frustration and disappointment for both the child and the teacher. As a result, the conventional O&M instructor often assesses that the child is not ready for O&M instruction or ready for using a cane. In the latter case a pre-cane device is often used. Within the Promotion Model, however, the blind child is ready for instruction, just not from the top-down but rather from the bottom-up.

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