Occupational
Therapy For Young Children With Visual Impairments and Additional
Disabilities
by
Jill Brody, M.A., O.T.R.
Background
I am an occupational therapist who has been
privileged to work with young children with multiple challenges
for many years. I am especially interested in infants and
preschoolers who have visual impairments as well as other
disabilities. I was also a consultant for children with hearing
loss in the home, at preschool, and in public school settings
for three years.
Currently,
I work with a little boy who has both visual and auditory
impairments and a diagnosis of Charge Syndrome. He has limited
vision in only one eye and a profound hearing loss, with a
possibility of some hearing in one ear. I have seen him during
weekly home visits since he was 6 months old and when he attends
a center-based infant program twice a week. Figuring out the
best ways to help him and other children with multiple sensory
and/or physical impairments to understand their environments
and learn how to communicate this understanding to others
is absolutely fascinating!
At
the Blind Childrens Center in Los Angeles, I work with a team
of professionals including teachers, speech therapists, and
orientation and mobility instructors to provide the best possible
interventions for children who are enrolled in the center.
Of course, the most important team members are the children’s
parents and family.
Role
of Occupational Therapists
Occupational
therapy is a profession and a discipline that studies the
development and activities of human beings from birth to old
age. Pediatric occupational therapists (O.T.s) analyze and
focus on behaviors that support a child’s play, self-care,
and other "occupations" of childhood. Occupation
does not mean a Job but how people
in different stages of life spend their time in meaningful
and functional activities.
O.T.s
evaluate a young child’s overall development and plan
activities that support learning and help the child interact
successfully with his or her immediate environment. For example,
if a child is not able to sit independently but is beginning
to reach for toys, an O.T. would suggest a way for the child
to sit safely and supported so that he or she can manipulate
and explore toys without having to work on trunk control or
balance at the same time. The child can be helped to grasp,
explore, or manipulate toys that are easy to grasp. Some youngsters
are able to move their legs more effectively and can operate
toys with their feet! If a child has some use of his or her
hands or has head control, adaptations of simple "low-tech"
devices or more sophisticated augmentative alternative communication
devices (e.g., switches with voice enhancement) can be made.
This way the child can activate the switch by hand or with
a head stick to request a toy or attention.
The
process of assessment in occupational therapy includes observing
the child with his or her parents or caregivers, presenting
a variety of play materials to see how he or she interacts
with them, placing the child in different body positions to
get information about mobility and muscle tone, and obtaining
information from the family. Evaluations focus on children’s
responses to a variety of sensory stimuli, such as different
sounds, textures, or movements.
Depending on a child’s age and ability, different kinds
of toys are introduced and the child’s responses are
observed. The child is also usually placed in a variety of
positions and encouraged or assisted, if necessary, in transitioning
to a different position (e.g., sitting to standing). Many
children do not like being handled by unfamiliar people; in
that case a caregiver can be asked to position and interact
with the child while the O.T. observes.
An
occupational therapy assessment determines what a child is
able to do, both independently and with assistance, what kinds
of activities he or she enjoys, avoids, and finds comforting
when upset. Sometimes standardized assessments may be used
as a starting point but typically they are not very useful
for children with multiple disabilities or sensory impairments.
When
a child has a severe visual impairment in addition to other
disabilities, the evaluation process is more complicated because
it is necessary to determine how much the child’s vision
problems contribute to overall functioning. Some materials
commonly used for assessment are not appropriate for children
with visual impairments, as they rely primarily on visual
responses, e.g., tracking or reaching for objects. Assessment
can be compared to trying to solve a puzzle: what factors
inhibit the child’s effective interaction with the environment
and what can be done to meet the child’s individual learning
needs?
After
a comprehensive assessment and in conjunction with the child’s
family and other professionals working with the child, the
O.T works as a member of the team to develop interventions
that address the individual child’s learning needs. The
choice of therapeutic tools in occupational therapy needs
to be highly individualized for each child. Addressing the
family’s concerns and priorities and what they would
like to achieve through interactions with various professionals
is of critical importance.
Definitions
Like
all disciplines, occupational therapy has its own language,
e.g., the terms "sensory integration," "sensory
processing" and "sensory diet." The following
are definitions for terms commonly used by occupational therapists:
Sensory integration is a therapeutic
approach frequently used by O.T.s. It refers to the awareness
of and organization of sensory input followed by actions that
reflect this awareness. (Ayres, 1979). Sensory input is gained
from our bodies and our environment through many different
senses (e.g., vision, hearing, touch, smell, and taste).
Sensory processing refers to
the ways in which a child indicates awareness of and responds
to information received through a variety of sensory channels,
including tactile, visual, auditory, proprioceptive, and vestibular.
Assessing sensory processing is different and more complex
than observing how a child receives or responds to visual
or auditory stimuli because of a visual impairment or hearing
loss.
Tactile
processing refers to the awareness of
touch through receptors in the skin. Some children show significant
aversions to touching different textures and are labeled as
"tactilely defensive" or "tactilely over-responsive
or hyper-reactive." Current early intervention literature
(Williamson & Anzalone, 2001) suggests that the terms
"over-responsive or hyper-reactive" may be preferable
to "defensive." These children demonstrate their
over-responsiveness by avoiding, moving away from, crying,
or even gagging, to touching items that others enjoy, e.g.,
stuffed animals, play dough, Jello or even different clothing
fabrics.
Proprioception
refers to the perception of sensation of the muscles and joints
enabling the brain to know where each part of the body is
and how it is moving. Children with significant proprioceptive
needs and decreased awareness of their bodies’ movements
often seek out activities that provide them with increased
awareness, such as grasping objects very tightly, jumping
vigorously for long periods, or "crashing" into
pillows or furniture. They seem to need extra impact in order
to process information about their body positions in space.
Vestibular
processing refers to a child’s
ability to respond to body movements through space, including
swinging. It indicates whether a child is receiving adequate
information to develop balance and equilibrium responses and
whether the child is comfortable when his or her balance is
challenged. A child may be placed on a platform swing and
then gently moved from side to side at first to observe reactions.
Then, if the child is able to tolerate it, more vigorous swinging
is attempted.
Effective
sensory processing involves integrating all this input
to produce what is called an "adaptive response"
to the world. An adaptive response
is an appropriate action or reaction to what is being perceived,
such as quickly removing one’s hand from a hot stove.
In order for children to learn optimally, effective sensory
processing is critical.
Some
children are tactilely over-responsive, keep their hands fisted
to avoid touching anything but hard plastic toys and are difficult
to engage in tactile exploration activities. Others may not
seem to be aware of being touched (i.e., under-responsive).
Intervention
Strategies
The
child’s preferences should always
be respected. However, helping the child to become more comfortable
with a variety of sensory experiences is very important for
learning. Most children seem to respond better to firm touch,
rather than light, because it gives their bodies information
about where they are being touched and what is expected of
them in terms of movement.
When
a preferred activity has been found, items that are less acceptable
can be introduced, e.g., if a child enjoys swinging, a variety
of textured materials (less preferred objects) can be introduced
during vestibular stimulation. Balls with different textures
can be used interactively while in a swing. If the child likes
water play, this experience can be expanded with toys, soap
bubbles, sponges, and even cornstarch or flour added to the
water. Crawling on different surfaces in pursuit of desired
toys provides tactile input to the body, as does playing "peek-a-boo"
with textured cloths.
If
a child has significant sensory processing problems, the family
can be helped to create a "sensory diet" for their
child at home. A sensory diet
is a therapist-designed plan that incorporates meaningful
activities with sensory stimuli to encourage appropriate adaptive
responses to daily activities (Wilbarger, 1991). If a child
exhibits decreased discrimination of vestibular and/or proprioceptive
information, for example, the opportunity to engage in these
activities can be built into the daily schedule. Swinging
on the playground, playing in a bath, and rough housing with
caregivers are natural activities for young children that
families can build into their routine. In contrast, children
who become overwhelmed by activities in the environment should
have areas where they can withdraw until they are more comfortable,
e.g., beanbag chairs, play tents, a favorite blanket in a
quiet area, or even a favorite video can be used to help children
who need time to themselves.
Occupational
therapy support needs to be meaningful for the child through
communication. Simply presenting sensory experiences without
relevance to the child’s interest and learning needs
is not beneficial. The following are considerations for selecting
object cues; touch cues, signing on the body, and coactive
signs:
