This selection of Frequently Asked Questions is based on the questions from and discussions with families and service providers who participated in project activities and workshops. The answers are drawn from the review of the literature and from the clinical judgment and experiences of service providers and professionals who have worked with children who have significant and multiple disabilities.

Sensory Input

1. How do I determine which types of sensory input (visual, auditory, tactile) provide the most useful information to a nonverbal child who has low vision and has other disabilities?

Carefully observe the child’s response to various sensory input in different situations to see how the child responds and what he or she seems to understand. Although a child has some vision and hearing, he or she may benefit from tactile input at specific times (e.g., if the environment is dark or noisy). Some children’s ability to use vision may vary according to the their level of alertness, health, and the context (e.g., children with cortical visual impairment). A child may need to use touch to help confirm or clarify what he or she sees. It is helpful to collect data on the child’s responses to different modes of sensory input in various situations. Also, functional vision and hearing assessments should be used to determine how the child is using these senses.

2. Should I use tactile strategies when the child has some vision?

There are many reasons why the use of tactile strategies may benefit a child with multiple disabilities. All children learn through a combination of input from their senses. When children have multiple disabilities and subtle responses to visual stimuli, it may be difficult to determine whether the child has a clear understanding of what is being presented or communicated through visual means. Tactile information will supplement visual input or clarify other sensory input because it is very concrete.

3. Will the use of tactile strategies interfere with the child learning to use his or her vision?

In our experience, the use of tactile strategies will not inhibit or prevent a child from learning to use his or her vision. Appropriate modifications (e.g., positioning, color, contrast, lighting) of materials and the environment must also be made to encourage the child’s use of functional vision. In fact, increased active participation in interaction and activities should motivate a child to learn to look. Some children with cortical visual impairments have difficulty looking and reaching or manipulating an object at the same time. They may look then look away and reach or tactilely examine the object. It is important for family members and service providers to agree on the strategies that they will use with a child. For example, objects may be first presented visually to a child, then after several seconds, provide an opportunity for the child to touch and handle the object. In this way, what the child feels will confirm or clarify what he or she sees.

Tactile Strategies

4. Is there a sequence for beginning to use tactile strategies with a young child?

There is no single sequence for using tactile strategies that fits every child who has multiple disabilities. Each situation is different, and tactile strategies need to be selected accordingly. Mutual tactile attention is a place to begin establishing interaction and supporting the child’s communication development. As discussed in the manual, every child needs both a means to receive communication and a way to express himself or herself. Begin by carefully observing the child in familiar activities with preferred people. What are the features of preferred objects? What situations seem to be the most motivating for the child? Note how the child uses the sense of touch to explore and interact with others and how he or she responds to tactile input from others.

5. How do we decide which tactile communication strategies (e.g., coactive signs, sign on body, tactile signs, touch cues, object cues, textured symbols) to use with a child who is deaf-blind?

First, identify the child’s receptive and expressive communication behaviors. Next, consider the child’s motor and cognitive abilities. Use techniques that the child will easily understand so that he or she will experience immediate reinforcement and pleasure for effort during interactions. If there is little or no response from the child, try a strategy that provides more concrete information (e.g., whole objects that are familiar to the child). Be sure that any strategy that is used with the child is integrated in natural, respectful, and enjoyable conversations that involve turn taking and shared attention. Over time, a child may progress to more abstract and complex communication modes.

6. How do we determine whether to use a textured symbol or an object cue?

Object cues are easily understood because of their obvious relationship to their referents (e.g., a cup to represent drink). When it is difficult or inconvenient to use an object cue (e.g., to represent “let’s go outside and play on the lawn”), then a more abstract communication mode, such as a textured symbol, may be needed. See previous discussions on object cues and textured symbols. What an object cue or textured symbol represents must be made immediately apparent to a child (i.e., by giving the child the item, beginning an activity, or going to the place) so that he or she will understand its meaning.

7. What should I do to help the child understand what textured symbol or object cue means?

The key to helping a child understand the meaning of any communication cue or symbol is to link it closely to its referent (mutual tactile attention within conversations will support this) and to use it consistently within meaningful activities in a variety of settings. The child needs to learn that a particular textured card or object stands for a particular activity or object. When the child touches the textured card or object, he or she must receive or experience the referent immediately.

8. How can a child who is blind differentiate between a touch cue and a sign made on his or her body?

Initially, the child may perceive the sign made on his or her body as a touch cue having a very fixed meaning within a specific context. Through consistent exposure to the sign (i.e., by encouraging the child to feel the signer’s hands and by using coactive and tactile signs) and its referents (objects, people, or activities), he or she may gradually recognize a sign that is produced on his or her body (e.g., if the signer places his or her hand on the child’s mouth to sign EAT, the child will feel the placement of the touch on his or her mouth and not perceive the flat “O” hand shape that is a feature of EAT) has the same meaning when it produced coactively or signed tactilely in different situations.

9. I get confused between coactive signing and tactile signing. How are they different?

Tactile signing is a means of receptive communication. The child tactilely perceives or reads the signs by keeping his or her hand over the signer’s hand. Coactive signing is used for instructional purposes, to teach a child how to produce a new sign in the appropriate situation, or to help a child to produce signs to convey a message that he or she wants to express. Use tactile signing when you want to send the child a message and coactive signing when the child wants to communicate something. Just as listening precedes speaking in children who can see and hear, understanding tactile signs (receptive language) precedes the production of signs (expressive language) by children who have a hearing loss and no vision.

10. How can I develop some concrete way to let the child know that he has completed a particular activity rather than my just signing FINISHED?

Often children who are blind and nonverbal may not know how long an activity will last or understand our expectations for a particular task. They may be quite startled by a sign for FINISH that seems to come out of nowhere. It is important to make the message and expectation very concrete and easy to understand. One simple way is to tell the child how many times he or she is expected to do a task and make that expectation apparent from the materials that are available. For example, in a block and container play activity, put out 5 blocks for the child and say use key tactile signs “PUT BLOCKS IN BUCKET, 1,2,3,4,5, FINISH.”

Similarly, at “clean up time,” you can specify how many things and the names of the things that the child needs to locate and put away. This is helpful if the child cannot see whether or not the whole area is cleaned up. For example, “Jimmy, find the car and the hat and put them away.” You can let children know when there is “Five more minutes of playtime.” Introduction to number and time concepts within everyday activities will build on the child’s early literacy skills. At music or circle time, provide a tray or container with objects or other tactile representations of songs and activities, so children can make a choice and also learn that when the tray is empty the activity will end. Again, telling the child “One more song and then we are finished” is also important. A modified timer may also be useful if the child can hear the buzzer or bell.

Challenges

11. What can I do if a child is tactilely defensive and hates to touch things?

First of all, do not force the child to touch and handle the things that he or she rejects. Very often, the term“tactilely defensive” is misused by service providers to label a child who does not want to touch or handle certain materials. It is most important to consult with an occupational therapist that has expertise in sensory integration. He or she will have specific procedures for identifying whether a child’s responses are indicative of tactile defensiveness, some other sensory defensiveness or hyper-responsiveness to certain sensory stimuli. If the occupational therapist determines that the child has a sensory modulation dysfunction, then he or she will recommend certain activities to address this neurologically-based problem. If the child’s reluctance to touch and handle certain materials is based on unpleasant experiences, take time to develop a trusting relationship, make your hands quietly available to the child, use mutual tactile attention, tactile modeling, and hand-under-hand guidance to gradually offer opportunities to touch, explore, and handle preferred objects without forcing the child to do so. Provide anticipatory cues and expand the child’s communication and understanding of activities.

12. How can I encourage service providers to be more consistent in the use of selected tactile strategies for a particular child?

Children who have multiple disabilities are likely to interact with many different service providers during their school programs. It will be very confusing for the child if each person uses a different method of communication and has conflicting expectations. The child’s communication options should be noted in the IFSP/IEP. It is very important to have a team meeting with family members and service providers who interact most frequently with the child to identify and agree on tactile strategies that will be used consistently. Practicing selected strategies and viewing videos of the child’s interactions are very helpful procedures. Once strategies are selected and agreed upon, methods for sharing information, documenting practice, and planning for follow up are needed. Written guides on the use of cues and signs should be available in easily accessible places. Data collection sheets, communication notes, or e-mail are ways to document practice and share information. Short, regularly scheduled meetings facilitate opportunities for data analysis, evaluation of current strategies, and agreements on any changes that need to be made.

13. When interacting with my child I have realized that I pay more attention to his facial expression and body movements but not to his hands. How can I become more aware of my child’s hands to engage in tactile conversations?

First, become more aware on how you use your hands when interacting with your child. Use the Self Awareness Questions in the SALUTE manual to think about your own body language. Next, carefully observe your child’s hands while he or she is interacting with objects and people. Become familiar with his or her hand movements. Practice focusing on the child’s hands as well as facial expressions and body movements during interactions. Try closing your eyes during touch conversations between your hands and the child’s hands. This will help you become aware of how your hands receive tactile information from the child.

14. What should I do if a child persists in putting objects in his mouth rather than touch them with his hands?

Safety is a priority, so children must not be allowed to put small objects or other health hazards in their mouths. Young children without disabilities vary in the age at which they no longer put things in their mouths (Juberg, Alfano, Coughlin & Thompson, 2001), but this mouthing behavior does not inhibit their hand use. Children who are blind may use mouthing as a way to maintain contact with and obtain information about an object. If so, objects should be washed for hygienic purposes. Children usually decrease their mouthing of objects as they increase their hand use. Play activities that involve throwing in appropriate situations (e.g., throwing beanbags onto a big drum) may promote outward hand movements that will help separate the child’s hand from his or her mouth. If mouthing is a concern, then professionals of relevant disciplines (e.g., occupational therapy, visual impairment, nursing) should develop a working hypothesis about the function of the mouthing behavior. What sorts of objects are mouthed? Does the child seem to discriminate between certain sizes, shapes, or textures through mouthing? How does the child use his or her hands? When and how does he touch and handle objects? Will the child touch and handle objects if something is in his or her mouth (e.g., a pacifier for a toddler)? Through a comprehensive interdisciplinary analysis, an appropriate approach can be developed to encourage the child’s manual exploration.

15. What can I do if a child rejects my efforts to interact with him and seems more interested in engaging in self-stimulatory behaviors (e.g., patting self or objects)?

Remember that a child needs to “see” an activity before he or she will want to participate. Concentrate on providing opportunities for the child to touch your hands and objects without the expectation that he or she participates in a certain way. Spend time just making your hands available to the child and see what he or she does. Have fun making “conversations with hands” by imitating the child’s hand movements in a gentle and playful way. It takes time to establish a relationship and to develop an understanding of the child’s experience and perspective. Carefully observe the child’s actions and identify when you might join in his actions. For example, if a child persists in patting an object, you could gently place your hand beside his hand and imitate his patting action, thus communicating “I see what you are doing, let’s pat together”(mutual tactile attention). Once the child accepts your imitative tactile interaction, try to introduce other activity involving a different hand movement (e.g., varying the tapping rhythm) or object (e.g., a drum). This will provide a basis for developing other kinds of social games and interactions.

16. My child dislikes having his hands touched or manipulated. How can we interact with him in a more acceptable way?

Do not manipulate the child’s hands or force him or her to touch something that he resists. Consult with an occupational therapist regarding the child’s hand use and responses to tactile input, and to obtain suggestions. Use tactile strategies that allow the child to maintain control over his or her own hands (see the previous discussions on mutual tactile attention, hand-under-hand and hierarchy of prompts). Create playful interactions involving hand games or finger plays that you both enjoy (e.g., pat-a-cake for a young child and “High Fives” for an older one) and follow the child’s lead by imitating his manual actions (e.g., clapping hands, tapping a tambourine, or playing a keyboard).

17. My child is totally blind and has some hearing and poor muscle strength (very low tone). He doesn’t like to manipulate or explore objects. I have to manipulate his hands to help him with everything. How can I help my child participate without continuously moving his hands?

Discuss your concern with your child’s teacher and physical or occupational therapist to determine the best way to help your child. Depending on your child’s motor ability, they may suggest some simple adaptations to materials (e.g., Velcro or built-up handles on objects to help your child grasp them), ways to increase the child’s attention (e.g., by tactile kinesthetic play) as well as ways to gradually decrease his dependence on your total physical assistance. Begin with activities that your child enjoys so that he is motivated to participate. Instead of using hand-over-hand guidance, try supporting him at the wrist or elbow to see how he responds to those physical prompts. See how he responds to hand-under-hand guidance when you introduce your hand under his. Will he keep his hand on top of yours if you touch his hand with your finger?

18. My child is blind and has severe cerebral palsy. He has very limited hand and arm movement and tends to keep his hands in fists. What kind of tactile strategies can I use?

Ask to meet with your child’s educational team to discuss your questions. The physical or occupational therapist can explain your child’s motor abilities and optimal positioning needs; and may suggest ways to help decrease your child’s tone to help him open his hands. The speech and language therapist and teacher will have suggestions about adaptive switches or other communication devices to support your child’s communication. Together you can determine what tactile strategies to try first and how your child uses and responds to tactile information and interactions.

19. How do you know what a child is learning (e.g., understands language/communication input)? How do you determine the next step?

Evaluating whether an instructional strategy is effective for a particular child must be a priority in teaching all children who have disabilities. Otherwise we would not be providing the most appropriate educational opportunities. It’s a challenge to determine what a child is learning if the child has significant and multiple disabilities that influence his or her behaviors. The child’s responses may be extremely subtle or atypical. Careful observation, systematic interaction, data collection, and analysis of the child’s behaviors are essential in determining what a child is learning. How does the child respond to a “delay” or “interruption” of a very predictable sequence in an activity? How does the child react when he is given the object cue for a certain activity? Videotape an interaction or routine when the child is first learning about it, and then do so again later on when he or she has become more familiar with the activity. Comparing the child’s behaviors on these tapes may be helpful in identifying subtle changes in his or her quality of responses.

20. How can I encourage other children to use tactile strategies with the child who is deaf-blind?

It is very important to encourage these interactions because most children like and learn from peers. Moreover, many children with significant disabilities have limited opportunities to interact with other children unless adults provide sufficient support. Similarly, children without disabilities need to learn how to interact effectively with a child who is deaf-blind. You can use your own interactions as a model. Help children follow the interest and lead of the child who is deaf-blind rather than manipulating his or her hands. Teach them how to adapt signs appropriately for the individual child who is deaf-blind. Show them simple strategies such as offering an object under or to the side of the child’s hand rather than physically moving his or her hand to the object. Discuss the importance of waiting for the child to respond by allowing enough time. Help children practice tactile strategies with each other or an adult. Encourage them to interpret the behavioral responses of the child who is deaf-blind and respond appropriately.