Early intervention for infants with deaf-blindness.

Early intervention for infants with deaf-blindness. ABSTRACT: Few individuals labeled deaf-blind are, in fact, totallydeaf and totally blind. Many of these individuals have residual sightand hearing, but may not receive adequate early training in using thesesenses effectively. Effective early sensory training with infantsentails the use of consistent reinforcement methods in natural socialcontexts. Preservice and inservice teachers must become knowledgeablein high-quality programming components in which the goal is to increasethe abilities of students with dual sensory impairments--in bothmobility and communication--and to help them become independent,responsible adults. In recent years, educators and researchers have directed theirattention to early childhood and early intervention ear��ly interventionn. Abbr. EIA process of assessment and therapy provided to children, especially those younger than age 6, to facilitate normal cognitive and emotional development and to prevent developmental disability or delay. programs for infantswith severe disabilities (Bickman & Weatherford, 1986; Ramey,Trohanis, & Hostler, 1982). Specifically, this focus has resulted inan increase of interest in services and programs for infants with dualsensory impairments (Freeman, 1985; McInnes & Treffrey, 1982). Inrelation to early intervention and deaf-blindness, however, there is aneed for improvement in university-level pre-service training programs,development of better identification and educational placementprocedures, and the establishment of research-based interventionprogramming. In this article, we briefly discuss the effects that definitions ofdeaf-blindness may have on educational placements and services forinfants with dual sensory impairments and on the training of pre-serviceuniversity students interested in becoming professionals in this area.Several intervention theories and their effects on current specialeducation practices are also presented. In essence, we argue that theestablishment of appropriate early intervention programs entails methodsthat address the use of residual sight and hearing, as well as thedevelopment of other senses. Thus, much of our focus in programming ison assessment and training in the use of vision and audition. EFFECTS OF DEFINITION ON PROGRAMS AND TRAINING Problems in the development of effective intervention programmingand the training of professionals have resulted from the range ofinterpretations for the federal government's educational definitionof deaf-blindness (Baldwin, V., 1986; Bullis & Bull, 1986). Ingeneral, the federal definition does not suggest the multiplicity ofservices and the types of professional training needed to support theseindividuals with such diverse characteristics. Many students with dual sensory impairments are categorized asmultihandicapped (D'Zamko & Hampton, 1985). Their sensoryimpairments are not recognized as primary disabilities. Thus, thesestudents may be placed in programs that lack sufficient supportive andconsistent services to meet their needs effectively (Fredericks &Baldwin, 1987). For example, most teachers of students with severe ormultiple disabilities may not be familiar with vision and auditoryassessments; residual visual-training and auditory-training methods;coactive, cooperative, and reactive learning techniques (Van Dijk van Dijk can refer to: Arjan van Dijk (born 1987 in Utrecht(, dutch football player Bill van Dijk (born 1947 in Rotterdam), dutch singer Bryan van Dijk (born 1981), dutch judoka Dick van Dijk (born 1946 in Gouda), dutch football player , 1965;1968); and alternative modes of communication (e.g., communicationboards, American Sign Language). In general, these teachers may havelittle or no knowledge of programming for students with dual sensoryimpairments. Even some universities may not be equipped to provide preservicestudents with necessary skills to deal with the multiplicity ofprogramming needs for teaching children with deaf-blindness (Baldwin,V., 1986; Bullis & Bull, 1986; Covert & Fredericks, 1987). Forexample, some preservice training programs for certification inmultihandicaps or severe handicaps do not address functional visual orauditory training and assessment. In many states that offercertification for multihandicaps, the requirements are so generic theydo not specify the skills necessary for dealing effectively withindividuals who are deaf with additional handicapping conditions (Curtis& Tweedie, 1985; D'Zamko & Hampton, 1985). FUNCTIONAL INTERPRETATION OF DEAF-BLINDNESS The number of persons with deaf-blindness has not increasedsubstantially since 1974; however, interpretations of the definition ofthe population have changed drastically. The need for quality servicesand qualified personnel, both in education and in adult services, hasbeen recognized (Barrett, 1987). Commendably, recent adult servicedelivery definitions have included more functional interpretations ofthe term deaf-blind (Konar & Rice, 1982). For example, individualscategorized as having deaf-blindness can represent any of the following:(a) those with moderate-to-profound auditory and visual impairments,with or without other educationally disabling conditions, who needservices to increase independence; (b) those with central-processingproblems that result in cortical blindness or central auditorydysfunction; and (c) those with progressive sensory impairments such asUsher's syndrome. The formulation of more recent functionalinterpretations, such as category a, have allowed some states to includechildren with functional impairments and other children whose primarydisability is mental retardation mental retardation,below average level of intellectual functioning, usually defined by an IQ of below 70 to 75, combined with limitations in the skills necessary for daily living. (K. Arnold, personal communication,December 1987). Regardless of the categories of dual sensory impairments,approximately 94% of these children have either residual hearing orresidual sight (Fredericks & Baldwin, 1987; Ouellette, 1984). Thus,intervention programming and university-level preservice training shouldconsider auditory and visual assessment and training, as well as othersensory training techniques (e.g., tactile, olfactory olfactory/ol��fac��to��ry/ (ol-fak��ter-e) pertaining to the sense of smell. ol��fac��to��ryadj.Of, relating to, or contributing to the sense of smell. , and kinesthetic kin��es��the��sia?n.The sense that detects bodily position, weight, or movement of the muscles, tendons, and joints.[Greek k )and innovative communication strategies (Barraga & Morris, 1982;Goetz, Utley, Gee, Baldwin, & Sailor, 1981; Siegal-Causey &Downing, 1987). These areas should also be considered in developingearly intervention theories and programs for infants withdeaf-blindness. INTERVENTION THEORIES Several theories have provided the philosophical underpinnings ofcurrent intervention practices. Biological-developmental theorists havedescribed psychological growth in holistic, interactionist terms (Lewin,1951; Piaget, 1952; Vygotsky, 1962). These theorists argued that, frombirth, organisms use, assimilate, and construct conceptions. Cognitivegrowth results from communicative interactions. On the other hand, radical behaviorists assert that the mind is amachine that is formulated by stimulus input from birth and thatreflects the accumulation of this learning by the output of behavior(Skinner, 1953). Behavior is explained by a causal mechanism that doesnot depend on the functional value of the behavior. Determinism is oneof the basic tenets of behaviorism behaviorism,school of psychology which seeks to explain animal and human behavior entirely in terms of observable and measurable responses to environmental stimuli. Behaviorism was introduced (1913) by the American psychologist John B. (Baldwin, A., 1980). Special education programs seem to be influenced by educationalideologies such as environmental transmission, which parallelsbehaviorism, and a combination of romanticism and progressivism.Romanticism emphasizes the value of childhood, the discovery of an innerself, and interaction with others. Progressivism, which parallels thedevelopmental theory of Piaget, also emphasizes interaction with others,as well as interaction with the environment. It is based on the Hegelianbelief that development is a progression through stages and thatknowledge is an active change in patterns of thought influenced byproblem-solving situations (Baldwin, A., 1980). In other words Adv. 1. in other words - otherwise stated; "in other words, we are broke"put differently ,organisms are proactive in constructing their own developmental progressfrom birth throughout life. It seems that intervention programs for high-risk infants,including those with dual sensory impairments, lack a firm theoreticalbase. The development of these programs may be the result of theaccumulation of nontheoretical research data (Walker & Crawley,1983). Most curricula for infants with disabilities, however, tend toadhere to adhere toverb 1. follow, keep, maintain, respect, observe, be true, fulfil, obey, heed, keep to, abide by, be loyal, mind, be constant, be faithful2. the tenets of a biological-developmental orcognitive-developmental approach (Bailey, Jens, & Johnson, 1983).That is, developmental milestones are emphasized, and skills must bedeveloped in a specific hierarchical order regardless of the ages ofchildren with disabilities. The developmental order of skillscorresponds to what has been observed in younger children withoutdisabilities (Bailey et al., 1983). On the other hand, some programs use curricula that emphasizefunctional (i.e., ecological or environmental learning) approaches inwhich instructional practices rely on task-analysis of functional andchronological age-appropriate activities, analysis of discrepanciesbetween needed skills and previously acquired skills, and the use ofoperant-conditioning methods. Bailey et al. (1983) analyzed 15 curriculafor infants with disabilities and found that only 3 curricula employed afunctional approach. In general, the functional approach was used inconjunction with principles from 1 of the developmental approaches. Only 1 of these 15 curricula for infants has been field tested. Inaddition, very few data are available on the effectiveness of thevarious theoretical approaches. It has been argued that principles fromseveral theories can be combined in curriculum and instruction of earlyintervention programs (Bailey et al., 1983). We think that a creativeapproach, using aspects of both the environmental-learning theories andthe cognitive-developmental theories, is appropriate for infants,especially infants with dual sensory impairments. Specifically werecommend the incorporation of systematic training in the area ofauditory and visual development in natural settings and usingage-appropriate materials. It has also been documented that the use ofinstructional operant-conditioning methods in these natural, meaningfulsettings can increase residual sense function and generalization ofacquired skills (Barraga & Morris, 1982; Goetz & Gee, 1987;Lundervold, Lewin, & Irwin, 1987). EARLY INTERVENTION Early intervention is the establishment of educational and supportservices support servicesPsychology Non-health care-related ancillary services–eg, transportation, financial aid, support groups, homemaker services, respite services, and other services for children, age 3 and younger, with or at risk fordisabilities, and their families. The importance of early interventionfor children with handicapping conditions has been widely documented(Bronfenbrenner, 1975; Hayden, 1979; McInnes & Treffrey, 1982;Peterson, 1983). In the case of infants with two or more handicappingconditions, such as deaf-blindness, the need for early intervention isgreater. The senses of vision and audition are dynamically andneurologically linked, and both senses should be addressed on aconsistent, systematic basis to prevent problems in cognitive,linguistic, and social-emotional development. Identification The methods for identifying infants are case finding, registries,and screening. To provide appropriate and crucial intervention servicesto infants and families, it is vital that the identification process beimproved. States should be encouraged to establish registries thatinclude (a) functional tracking (i.e., description of a child'splacement and intervention methods), (b) directional services (i.e.,services that direct families to available programs), and (c) listing ofprogramming options for children with dual sensory impairments and theirfamilies. Firm connections should be established with the appropriatepersonnel within the medical community such as obstetricians,neonatologists, and pediatricians to facilitate the identificationprocess. This should enable agencies to assist families in findingappropriate services for their children (Michael, Arnold, &Niswander, 1988; Watson, Barrett, & Brown, 1984). Early Intervention for Infants with Deaf-Blindness Early intervention programming may need to be eclectic, usingtechniques that emphasize, at least, the development of motor andfunctional communication skills, and particularly, the distance senses(vision and audition) (Fredericks & Baldwin, 1987; Goetz & Gee,1987). Classroom teachers need to know how to interpret the results ofboth clinical and functional assessments and improve the sensoryfunctional abilities of infants (Curtis & Tweedie, 1985;D'Zamko & Hampton, 1985). Adequate assessment, followed by acomprehensive intervention program, should lead to improvement in aninfant's use of residual senses for communication and mobilityskills (Freeman, 1985; McInnes & Treffrey, 1982). Relatively few data are available concerning the enhancement ofresidual vision and hearing functions, using sequential, simultaneous,or contingent methods, in infants with deaf-blindness. Some methodsfocus on the functional use of one sense or the other; however, theyhave been designed to aid classroom teachers of older children (Goetz& Gee, 1987; Goetz et al., 1981; Smith & Cote, 1982). Inaddition, these methods have not specifically focused on the developmentof residual senses in relation to communication, mobility or self-imagein infants. Given the available information, we present some effectivevisual and auditory tests and examples of training for infants with dualsensory impairments. These examples can be incorporated into programmingby classroom or home-bound teachers. A transdisciplinary team, whichincludes eye (e.g., optometrists) and ear (e.g., audiologists)specialists, should help interpret formal test results and providedirections in determining appropriate adaptations for each child'sspecific needs. DEVELOPMENT OF RESIDUAL VISION Visual Assessment Visual assessment and subsequent intervention are critical forinfants with dual sensory impairments for two main reasons: efficientvision use is important for learning, and visual function can improve(Goetz & Gee, 1987; Lundervold et al., 1987). Developing a formalvision-training program may require great effort from members of thetransdisciplinary team. For example, the team must conduct a battery ofboth clinical and functional tests over a period of time to determinevisual effectiveness and subsequent curricular planning andinstructional intervention. Cress (1989) suggested that assessments befollowed by ongoing observation and recording of children's visualbehaviors during activities in natural, meaningful environments. To planaccurately for intervention, teachers of children with dual sensoryimpairments need to have the ability to interpret clinical findings,perform functional assessments, and record ongoing data of thechild's performance. A child who does not respond to conventional testing may be acandidate for several physiological tests that focus on visual acuity visual acuityn.Sharpness of vision, especially as tested with a Snellen chart. Normal visual acuity based on the Snellen chart is 20/20.Visual acuityThe ability to distinguish details and shapes of objects. .These formal tests should be administered by qualified clinical ormedical personnel. The tests include the Visually Evoked Response e��voked responsen.An alteration in the electrical activity of a particular part of the nervous system as a result of receiving a sensory stimulus. (VER Verpersonification; portrayed as infantile and tender. [Rom. Myth.: LLEI, I: 322]See : Spring ),also known as Visually Evoked Potential Evoked potentialA test of nerve response that uses electrodes placed on the scalp to measure brain reaction to a stimulus such as a touch.Mentioned in: Spinal Stenosisevoked potential,n (VEP VEPvisual evoked potential. ), and the Electroretinogram e��lec��tro��ret��i��no��gramn. Abbr. ERG A graphic record of the electrical activity of the retina.electroretinogramthe record obtained by electroretinography; abbreviated ERG. (ERG). The VER has been used extensively to determine the visual acuityof infants (Baraldi, Ferrari, Fonda, & Penne, 1981) and childrenwith neurological handicaps (Mohn & Van Hol-Van Duin, 1983). The ERGyields useful information about the functioning level of the retina. Functional tests assess the visual behavior of the individualrather than just the physiological condition Noun 1. physiological condition - the condition or state of the body or bodily functionsphysical condition, physiological statewakefulness - a periodic state during which you are conscious and aware of the world; "consciousness during wakefulness in a sane of the eyes. That is, thesetests assess the ability to track objects, use visual fields, developeye-hand coordination, and perform other functions that reflect visualdevelopment. The tests are portable and can be administered by trainedpersonnel, such as teachers. Functional vision assessments have been developed both forindividuals with visual impairments only and for those with multiplehandicaps. Some assessments developed for clients with multiplehandicaps include Functional Vision Inventory for the Multiple andSeverely Handiapped-(Langley, 1980) and the Visual Assessment Manual(Sailor, Utley, Goetz, Gee, & Baldwin, 1982). Since neither of thetwo assessments have reported reliability or validity data, nocomparisons on their applicability and effectiveness can be made (Cress,1985). The Opkinetic Nystaqmx (OKN OKN Okmulgee Northern Railway Company ) provides information on the acuitythreshold of the infant through the use of spinning cards to determinefixation ability. The Forced Preferential Looking Test (FPL), based onFantz's work (1963) with infants, is another test that seemspromising for infants up to 6 months old and for difficult-to-testchildren such as those with dual sensory impairments. The Operant operant/op��er��ant/ (op��er-ant) in psychology, any response that is not elicited by specific external stimuli but that recurs at a given rate in a particular set of circumstances. op��er��antadj. Preferential Looking Test (OPL OPL Open Publication LicenseOPL Olympus Product Line (Sun)OPL outer plexiform layerOPL Organiser Programming Language (PSION)OPL On-Premise LaundryOPL Optical Path LengthOPL Open Public License ), which pairs a discerned reinforcingconsequence with the behavior of fixation, is specifically geared towardinfants over the age of 6 months Telter, 1979), but has producedpromising results for individuals with multiple disabilities (Duchman& Selenow, 1983; Mohn & Van Hol-Van Duin, 1983). The TellerAcuity Card Technique, normed on 0-to-3-year-old children withoutdisabilities, has been shown to be effective for children who aredevelopmentally delayed or at risk for this condition (Cress, 1989; Mohn& Van Hol-Van Duin, 1983; Teller, McDonald, Preston, Sebris, &Dobson, 1986). In addition, this procedure is useful for mass screeningof infants. In sum, to obtain accurate data on the visual functioning level ofinfants with dual sensory impairments, one must use a variety ofclinical and functional tests over a certain period of time. It may benecessary to provide visual training to young children to improve theirability to be assessed (Cress, Johnson, Spellman, Sizemore, &Shores, 1982). For example, some children can be trained to fixate To close. The term often refers to closing a track-at-once session on a CD-R disc. See disc fixation. visually through operant conditioning operant conditioningn.A process of behavior modification in which a subject is encouraged to behave in a desired manner through positive or negative reinforcement, so that the subject comes to associate the pleasure or displeasure of the . The infant's need forlow-vision aides (e.g., eyeglasses) should be determined as early aspossible. Methods for adapting the classroom and home environments,positioning the child, and enhancing optimal vision use should resultfrom the assessments and be part of the programming (Courtwright, Mihok,& Jose, 1975; Jose, 1983). One must complete an assessment batterybefore developing a training program. Visual Training In our view, a vision training program should follow a functional,hierarchical sequence, using activities similar to those outlined, forexample, in the manual Look at Me (Smith & Cote, 1982) or in thearticle "Functional Vision Programming" (Goetz & Gee,1987). For each visual skill listed here, a separate instructionalstrategy package should be implemented for each infant when appropriate.Implementation begins in natural, meaningful contexts (e.g., going tothe store, mealtimes) after decisions are made on the targeted visualskills to be learned to enhance participation. 1. Awareness of light (orient to presence of stimulus). 2. Attention to light fixation either bifoveal or monofoveal). 3. Localization Customizing software and documentation for a particular country. It includes the translation of menus and messages into the native spoken language as well as changes in the user interface to accommodate different alphabets and culture. See internationalization and l10n. of light source in various areas of the visualfield (awareness and attention). 4. Light tracking. 5. Awareness of presence or absence of light. 6. Visual tracking of objects or persons. 7. Attention to presence or absence of light. 8. Localization of objects (scanning). 9. Use of peripheral vision peripheral visionn.Vision produced by light rays falling on areas of the retina beyond the macula. Also called indirect vision.Peripheral vision. These components can be systematically taught via prompting methodse.g., see Sailor et al., 1982), and continuous loop strategies (Goetz& Gee, 1987). The target visual behavior must be performedconsistently before proceeding to the next behavior. Contingentreinforcement is used, as well as a pairing of the visual objective to afunctional skill that requires the use of the target visual skill. Forexample, a functional skill for infants, such as grasping a bottle, ispaired with the visual objective of fixation. Older or more skilledinfants may be expected to locate visually an article of clothing suchas their shoe or to discriminate between two desired objects and chooseone. Event recording techniques can be used to measure the targetedvisual behavior during the observation periods. In general, infants with dual sensory impairments progress veryslowly. Parents should be shown, through modeling, procedures andstrategies for achieving objectives step by step. They should beencouraged to incorporate the activities into their normal day-to-dayroutines with their infants at home. An example of one level of thistraining is presented as follows. Level 1: Awareness of light (orient to presence of stimulus). Rationale: In training very young children to be aware of light,there may be a need to orient them to the presence of a stimulus, andthen pair the preferred stimulus with the stimulus of light. Whenchildren become aware of various stimuli in their environment, this isthe first step in their reaction to the outside world. Objective: The purpose is to build awareness of a sensory stimulusby orienting behaviors toward the stimulus. The reactions of childrenshould be monitored. Target Behaviors: 1 .Head turn. 2. Gaze shift. 3. Brief fixation. 4. Ability to respond consistently to light stimulus. Activity: Child will perform target behavior selected when blindsin the home are opened in the morning. DEVELOPMENT OF RESIDUAL HEARING Auditory Assessment As in vision assessment, a variety of clinical and functionalhearing tests should be administered to infants with dual sensoryimpairments over a period of time before establishing an interventionprogram. Hearing should be assessed to (a) determine the extent anddegree of impairment; (b) evaluate the effects of medical treatment orthe use of prosthetic pros��thet��icadj.1. Serving as or relating to a prosthesis.2. Of or relating to prosthetics.prostheticserving as a substitute; pertaining to prostheses or to prosthetics. devices, such as hearing aids Hearing AidsDefinitionA hearing aid is a device that can amplify sound waves in order to help a deaf or hard-of-hearing person hear sounds more clearly. ; and (c) provideindividual, appropriate educational programming (e.g., Erber, 1982;Sanders, 1982). As discussed previously, early intervention,particularly amplification and auditory training, is important becauseof the pervasive effects of hearing impairment hearing impairmentn.A reduction or defect in the ability to perceive sound. on the child'scognitive, linguistic, and socioemotional development. In the assessment of middle ear function, the three major objectivemeasures that involve physiological responses to auditory stimuli auditory stimuli,n.pl in dentistry, the irregularities or deposits on the surface of a tooth that may be detected by ear of both patient and clinician during examination and probing. andrequire no instructed behavior responses are static compliance,tympanometry, and acoustic reflex The acoustic reflex (or stapedius reflex) is an involuntary muscle contraction that occurs in the middle ear of mammals in response to high-intensity sound stimuli. evaluation (Orchik & MacKimmie,1984). These tests have been useful with some special-needs populations,such as children with behavioral disturbances, language delays, andmental retardation. For children under 1 year of age, standardimmittance ImmittanceThe impedance or admittance of an alternating-current circuit. It is sometimes convenient to use the term immittance when referring to a complex number which may be either the impedance (ratio of voltage to current) or the admittance (ratio of audiometry is not feasible; however, a technique known asacoustic otoscopy or acoustic reflectometry can be used for thesedifficult-to-test children (Teele & Teele, 1984). Another useful andefficient test is the Sensitivity Prediction Acoustic Reflex (SPAR)method (Niswander, 1988). Behavioral hearing assessments require overt behavioral responsesto auditory stimuli. Traditional methods are inappropriate for childrenwith dual sensory impairments (Niswander, 1987). Many of these childrendo not have the necessary cooperative and receptive language skills toparticipate. It seems that effective testing programs involve thepairing of visual/tactile and auditory stimuli, and then fading thesestimuli so that the level of auditory response can be determined. For infants without the use of efficient vision, there seem to beno best testing procedures available that are supported by research. TheAuditory Brainstem Response Auditory brainstem response (ABR) is an electrical signal evoked from the brainstem of a human or other mammal by the presentation of a sound such as a click.Auditory brainstem response audiometry (ABR (1) (AutoBaud Rate detect) The analysis of the first characters of a message to determine its transmission speed and number of start and stop bits.(2) (Available Bit R ) and Behavior Observation Audiometric au��di��om��e��ter?n.An instrument for measuring hearing activity for pure tones of normally audible frequencies. Also called sonometer.au (BOA) methods are recommended for hard-to-test individuals; however,they are not always accurate in determining auditory function (Hecox,Gerber, & Mendel, 1983; Niswander, 1987; Spradlin, 1985). Forexample, in BOA procedures, the child is placed in a soundproof sound��proof?adj.Not penetrable by audible sound.soundproof v. testbooth. The audiologist AudiologistA person with a degree and/or certification in the areas of identification and measurement of hearing impairments and rehabilitation of those with hearing problems. presents stimuli and observes changes in thechild's behavior such as eye blinks, startle startle/star��tle/ (stahr��tl)1. to make a quick involuntary movement as in alarm, surprise, or fright.2. to become alarmed, surprised, or frightened. reactions, andcessation or increase in activity. Other behavioral audiometric procedures that have been adapted foruse with hard-to-test children include the use of classical and operantconditioning to train responses. For example, visual stimuli may be usedto reinforce correct localization responses (Goetz, Gee, & Sailor,1985). This classical conditioning Classical conditioningThe memory system that links perceptual information to the proper motor response. For example, Ivan Pavlov conditioned a dog to salivate when a bell was rung. testing is named the VisualReinforcement Audiometry (VRA VRA Visual Resources AssociationVRA Voting Rights Act of 1965VRA Volta River AuthorityVRA Veterans Recruitment AppointmentVRA Virginia Recycling AssociationVRA Volunteer Rescue Association ( Australia)VRA Voice Risk Analysis ). Adaptations for individuals who arevisually impaired may include the use of vibrotactile reinforcement(Spradlin, 1985). An example of operant conditioning testing is TangibleReinforcement Operant Conditioning Audiometry (TROCA). This highlystructured test originally was developed for assessing children withmental retardation (Lloyd, Spradlin, & Reid, 1968). Typically, candyor little toys are dispensed if a child depresses a button on a boxafter hearing a sound. If a visual reinforcer reinforcer/re��in��forc��er/ (-in-for��ser) any stimulus that produces reinforcement, a positive r. being a desirable event strengthening responses preceding its occurrence and a negative r. is used, this test islabeled Visual Reinforcement Operant Conditioning Audiometry (VROCA). In most cases, children with dual sensory impairments need to betrained to make reliable responses to auditory stimuli. TROCA and otheralternative procedures can be used to train children before formalaudiological evaluations are made. Because of children's varyingabilities, no one procedure is appropriate for all children. As statedaptly by Cress (1989): A knowledge of the specific child's response capabilities andreinforcer preferences is crucial in selecting one of the trainingprocedures described above. Even more crucial, perhaps, is a commitmentby service providers to devote the time necessary to accomplish thistraining. (pp. 16-17) Cress also has argued that training children to respond to auditorystimuli rarely occurs in instructional practices with young childrenwith dual sensory impairments. In addition to interpreting the results of formal audiologicalmeasures, classroom teachers should be able to conduct informalassessments of their students' hearing. in general, informal testsinvolve presenting various auditory stimuli to students and recordingreliable changes in behaviors. These tests are important because formaltest results do not provide information about how well students usetheir residual hearing; that is, the functional use of hearing in theclassroom (Erber, 1982; Sanders, 1982). In essence, the findings offormal and informal tests can be used to establish instructionalprograms that help students to improve skills, such as localizing anddiscriminating sounds, and to train students for subsequent formalaudiological assessments. Several factors should be considered in evaluating students'responses to sounds (e.g., Sailor et al., 1982). These include (a)students' characteristics, such as age and capabilities; (b) theuse of a natural, meaningful setting (e.g., in the home); (c) the natureof the auditory test stimuli; and (d) the range of response modes,particularly in students with severe disabilities. We recommend thatseveral test stimuli be selected from each of three general categories:speech (e.g., child's name, name of favorite toy, babbling babblingNeurology Quasi-random vocalizations in infants that precede language acquisition. See Lalling stage. ),environmental sounds (e.g., water pouring, door slam), and noise makers(drum, telephone, toys) (Erber, 1982; Sailor et al., 1982; Sanders,1982). Test stimuli should use sounds with a wide range of frequenciesto increase the possibility of obtaining responses. To obtain reliableresults, the selected sounds should be placed on a tape for testingpurposes. Depending on age and ability, students can be required todetect sounds (presence or absence), discriminate between them (same ordifferent), identify them (pointing to labels or pictures), orcomprehend them (e.g., reacting or responding to requests, commands,questions) (e.g., see Erber, 1982). Auditory Training There are a number of approaches for the development of audition,ranging from unisensory (i.e., audition only) to multisensory (e.g.,vision, audition, and taction tac��tion?n.The act of touching; contact.[Latin tcti ) (Calvert, 1986; Ling, 1984). Someapproaches include a strong speech component. Because of varyingcharacteristics and abilities of students, there is no auditory trainingprogram that will work for all children with dual sensory impairments.Some fundamentals are the involvement of parents or caregivers(especially for language development); the use of natural, meaningfulenvironments; the use of age-appropriate activities; and adherence to adevelopmental sequence. Whether the normal development sequences of auditory behavior alsoapply to people with severe disabilities is an open question (e.g.,Sailor et al., 1982). Although the developmental sequence may not beobserved precisely for every student, it should provide a generalframework for understanding auditory functioning and for establishing anintervention program. For example, from birth to age 3 months, theinfant's responses to sound are largely reflexive and may include astartle response Noun 1. startle response - a complicated involuntary reaction to a sudden unexpected stimulus (especially a loud noise); involves flexion of most skeletal muscles and a variety of visceral reactionsstartle reaction , widening or blinking of the eyes, or a sudden changein activity. Typically, infants respond to gross sounds (e.g., doorslamming); however, they will also respond to speech. The use offamiliar sounds, such as speech, might be effective in eliciting earlyattending responses (e.g., see Northern & Downs, 1984). Auditoryfeedback emerges around the 4th month. Subsequently, the child'sbabbling becomes more like speech and he or she begins to monitorproductions of sounds. At 9 months of age, the child can accuratelyidentify the location of sound sources at all angles from the ear(Northern & Downs, 1984). The association of particular sounds andtheir sources to meaning occurs during the last 3 months of the 1st yearof life. Early intervention programming for children with severedisabilities should contain the major aspects of the normal acquisitionprocess, that is, detection, awareness, attention, discrimination,feedback, self-monitoring, identification, and associating sounds withmeaning (see discussions in Erber, 1982; Ling, 1984; Mischook &Cole, 1986). The auditory process is inseparable from speech and languagedevelopment (e.g., Ling & Ling, 1978; Pollack, 1985). For example,in associating sounds with meaning, the child begins to realize whichacoustic cues are significant. Several factors contribute to achild's capacity to learn auditorially, for example, earlyidentification of hearing loss; early and consistent use ofamplification systems, such as group and individual hearing aids; theextent, severity, and etiology of the hearing loss; the quantity andquality of auditory stimulation; an intact capacity to learn; andinterrelations among parents and specialists (Ling, 1984). Althoughseveral auditory training and learning programs exist (e.g., Erber,1982; Sanders, 1982), it may be beneficial if a program follows afunctional sequence that correlates to what has been observed in infantswithout disabilities, deviating only in the time of achievement of thevarious targeted behaviors. Boothroyd (1982) has outlined seven targetbehaviors that should be components of a successful program: 1 .Attend to sounds. 2. Attend to differences among sounds (discrimination). 3. Recognize objects and events from the sounds they make. 4. Be alerted to sounds. 5. Use hearing for the perception of space (pertinent for a childwith severe visual loss). 6. Use hearing for the perception of speech. 7. Use hearing to control the production of speech. Boothroyd's sequence of behaviors can serve as a conceptualframework For the concept in aesthetics and art criticism, see .A conceptual framework is used in research to outline possible courses of action or to present a preferred approach to a system analysis project. for the training components of an auditory-training program.An example of one level is as follows: Level 1: Develop an awareness of sounds (attend without meaning). Rationale: The initial cognitive level to be achieved is a basicawareness of the presence and dimensions of sound without any necessaryrecognition of this auditory stimulus. Objective: To provide very young children with a knowledge of thepresence of sound. Some suggested target behaviors include the following (Michael etal., 1988, pp. 13-14): 1. Eye-widening (eyebrow movement). 2. Eye-blinking. 3 .Startle. 4. Stirring or arousal from sleep. 5 .Cessation of movement. 6. Slight head turn toward the sound. 7. Any combination of the above behaviors. Activity: Child will perform target behavior when the radio isturned on in the crib. INTEGRATED SENSORY APPROACH Among researchers on deafness, there is no clear consensus that anintegrated multisensory approach (i.e., involving both sensessimultaneously) is better than a unisensory approach that focuses ononly one sense i.e., audition), especially for language development(Ling, 1984). There is agreement, however, that an integrated sensory approachshould be used and should offer opportunities for children to formulateideas about the environment. That an integrated approach is important,especially for children with dual sensory impairments, is supported byresearchers in the field of perception who are concerned with the notionof cross-modal transfer (McKenzie & Day, 1987). As with other approaches, there is no one best integrated sensoryapproach that will work for all children with dual sensory impairments.The following example is adapted from a qualitative report involving an8-month-old child considered cortically blind who eventually saw himselfin the mirror after a period of several months (J. Miller, personalcommunication, April 1989). Target behavior: To assist the child in learning to fixate on hisor her own face in the mirror. Preliminary target behaviors: Awareness of light, fixation onlight, attention to light. Items needed: Large plastic mirror, penlight pen��light?n.A small flashlight having the size and shape of a fountain pen.Noun 1. penlight - a small flashlight resembling a fountain penflashlight, torch - a small portable battery-powered electric lamp , and optical aids. Training: 1 .Position infant so that he or she is facing mirror, shine lighton mirror, and tap behind the mirror where the light is shining. Lookfor changes in infant's behavior, such as cessation or increase ofmovement and increased vocalization. 2. Turn off light and stop tapping. Look for changes in behavior. 3. Repeat until response of looking at mirror is paired with light. 4. Slowly fade light back in line with infant's face, but keeptapping at previous location of light on mirror. 5. Fade out tapping. 6. Fade out light. CONCLUSION Programming for infants and children with dual sensory impairmentsshould be designed to fulfill the needs of these individuals regardlessof how they are categorized or where they are placed. Children with dualsensory impairments should receive specialized services, such asalternative modes of communication, functional sensory training, andorientation and mobility. We have emphasized effective programming,rather than programs, to highlight the necessity of fulfillingspecialized needs. Infants and children with dual sensory impairmentsare found in a variety of program settings. Thus, it is crucial thatsupplemental information and instruction be available to the direct careproviders, including family members, for the further development of theabilities of the children. RECOMMENDATIONS 1 .There is a need for adequate programming in sense utilizationfor young children with dual sensory impairments. 2. The development of appropriate preservice training is important,not only in the management of auditory and visual impairments, but alsoin methods of instruction to increase ability. 3. More research is needed to determine the best methods forhelping children acquire functional sensory skills to become moreindependent. 4. Parents or caregivers and other members of the family should beinvolved as early as possible in creating communicative environments that stress the use of residual senses. REFERENCES Bailey, D., Jens, K., & Johnson, N. (1983). Curricula forhandicapped infants. In S. Garwood & R. Fewell, Educatinghandicapped infants: Issues in development and intervention (pp.387-415). Rockville, MD: Aspen. Baldwin, A. (1980). Theories of child development. New York New York, state, United StatesNew York,Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of : Wiley. Baldwin, V. (1986). Prevalence of students with deaf-blindness alProject Report). Washington, DC: Office of Special Education and Rehabilitation, Special EducationPrograms, U.S. Department of Education. Baraldi, P., Ferrari, B., Fonda, S., & Penne, A. (1981).Vision in the neonate neonate/neo��nate/ (ne��o-nat) newborn infant. ne��o��naten.A neonatal infant.neonatea newborn animal. full term and premature): Preliminary result ofthe application of some testing methods. Documenta Opthalmologica, 51,101-112. Barraga, N., & Morris, J. (1982). Program to develop efficiencyin visual functioning. Louisville, KY: American Printing House for theBlind. Barrett, S. (1987). Trends and issues in developing communityliving programs for young adults who are deaf-blind and profoundlyhandicapped: In response to Lyle T. Romar. In A. Covert & B.Fredericks (Eds.), Transition for persons with deaf-blindness and otherprofound handicaps (pp. 39-50). Monmouth, OR: Teaching ResearchPublication. Bickman, L., & Weatherford, D. (1986). Evaluating earlyintervention programs for severely handicapped children and theirfamilies. Austin, TX: PRO-ED. Boothroyd, A. (1982). Hearing impairments in young children.Englewood Cliffs, NJ: Prentice-Hall Bronfenbrenner, U. (1975). Is earlyintervention effective? A report on longitudinal evaluation ofpreschool programs. (DHEW DHEW Department of Health, Education, & Welfare Publication No. [OHD OHD Oregon Health DivisionOHD Overhead DoorOHD Ohrid, Macedonia - Ohrid (Airport Code)OHD Organic Heart DiseaseOHD Off-Hook DelayOHD Over-the-Horizon DetectionOHD Online Hard Drive ] 74-25, Vol. 2).Washington, DC: U.S. Government Printing Office. Bullis, M., & Bull, B. (1986). Review of research onadolescents and adults with deaf-blindness. Washington, DC: The CatholicUniversity, National Rehabilitation Center. Calvert, D. (1986). Speech in perspective. In D. Luterman (Ed.),Deafness in perspective (pp. 167-19 1). San Diego San Diego(săn dēā`gō), city (1990 pop. 1,110,549), seat of San Diego co., S Calif., on San Diego Bay; inc. 1850. San Diego includes the unincorporated communities of La Jolla and Spring Valley. Coronado is across the bay. , CA: College-Hill. Courtwright, G., Mihok, T., & Jose, R. (1975). Reading stands:A nonoptical aid. Optometric Weekly, 66, 449-451. Covert, A., & Fredericks, H. (1987). Introduction. In A. Covertand H. Fredericks (Eds.), Transition for persons with deaf-blindness andother profound handicaps: State-of-the-art (pp. 1-3). Monmouth, OR:Teaching Research Publication. Cress, P. (1985). Visual assessment. In M. Bullis (Ed.),Communication development in young children with deaf-blindness:Literature Review I (pp. 31-59). Monmouth, OR: Teaching ResearchPublication. Cress, P. (1989). Sensory assessment manual. Lawrence:University of Kansas The University of Kansas (often referred to as KU or just Kansas) is an institution of higher learning in Lawrence, Kansas. The main campus resides atop Mount Oread. , Bureau of Child Research, Parsons Research Center. Cress, P., Johnson, J., Spellman, C., Sizemore, A., & Shores,R. (1982). The development of a visual acuity test Visual acuity testAn eye examination that determines sharpness of vision, typically performed by identifying objects and/or letters on an eye chart.Mentioned in: Optic Neuritis for persons withsevere handicaps. Journal of Special Education Technology, 5, 11-19. Curtis, W., & Tweedie, D. (1985). Content and process incurriculum planning. In E. Cherow, N. Matkin, & R. Trybus (Eds.),Hearing-impaired children and youth with developmental disabilities (pp.246-270). Washington, DC: Gallaudet College Press. Duchman, R., & Selenow, A. (1983). Use of forced preferentiallooking for measurement of visual activity in a population ofneurologically impaired children. American Journal of Optometry optometry(ŏptŏm`ətrē), eye-care specialty concerned with eye examination, determination of visual abilities, diagnosis of eye diseases and conditions, and the prescription of lenses and other corrective measures. andPhysiological Optics, 60, 817-821. D'Zamko, M., & Hampton, 1. 1985). Personnel preparationfor multihandicapped hearing-impaired students: A review of theliterature. American Annals of the Deaf, 32, 9-11. Erber, N. i 982). Auditory training. Washington, DC: AlexanderGraham Bell Graham Bell could refer to: Alexander Graham Bell (1847–1922), recognized inventor of the telephone, however is disputed to be the second inventor of the telephone, after Antonio Meucci or maybe Philipp Reis Association for the Deaf. Fantz, R. (1963). Pattern visionin newborn infants. Science, 140, 296-297. Fredericks, H., & Baldwin, V. (1987). Individuals with sensoryimpairments: Who are they? In L. Goetz, D. Guess, & K.Stremel-Campbell (Eds.), Innovative program design for individuals withdual sensory impairments (pp. 3-15). Baltimore, MD: Brookes'Freeman, P. (1985). The deaf-blind baby: A program of care. London,England: William Heinemann William Heinemann (18 May 1863 – 5 October 1920) was the founder of the Heinemann publishing house in London.He was born in 1863, in Surbiton, Surrey. In his early life he wanted to be a musician, either as a performer or a composer, but, realising that he lacked the Medical Books. Goetz, L., & Gee, K. (1987). Functional vision programming: Amodel for teaching visual behaviors in natural contexts.. In L. Goetz,D. Guess, & K. Stremel-Campbell (Eds.), Innovative program designfor individuals with dual-sensory impairments (pp. 76-97). Baltimore,MD: Brookes. Goetz, L., Gee, K,, & Sailor, W. (1985). Using a behavior chaininterruption strategy to teach communication skills to students withsevere disabilities. The Journal of the Association for Persons withSevere Handicaps, 10,21-30. Goetz, L., Utley, B., Gee, K., Baldwin, M., & Sailor, W.(1981). Auditory assessment and program manual for severely handicappeddeaf-blind students. (San Francisco State University ••[ , Bay Area SeverelyHandicapped Deaf-Blind Project. U.S. Department of Education 300780038).Washington, DC: U.S. Government Printing Office. Hayden, A. 1979). Handicapped children, birth to 3, ExceptionalChildren, 45, 5 10-516. Hecox, K., Gerber, S., & Mendel, M. (1983). Development ofauditory brainstem responses. In S. Gerber & G. Mencher (Eds.), Thedevelopment of auditory behavior (pp. 70-90). New York: Grune &Stratton. Jose, R. (1983). Understanding low vision. New York: AmericanFoundation for the Blind. Konar, V., & Rice, D. (1982). Strategies for serving deaf-blindclients. Hot Springs: Arkansas Research and Training in VocationalRehabilitation. Langley, M. (1980). Functional vision inventory for multiple andseverely handicapped. Chicago: Stoelting. Lewin, K. (1951). Field theory in social science. New York: Harper& Row. Ling, D. (Ed.). (1984). Earlyintervention for hearing impairedchildren: Oral options. San Diego, CA: College-Hill. Ling, D., & Ling, A. (1978). Aural habilitation: Thefoundations of verbal learning in hearing-impaired children. Washington,DC: Alexander Graham Bell Association for the Deaf. Lloyd, L., Spradlin, J., & Reid, M. 1968). An operantaudiometric procedure for difficult-to-test patients. Journal of Speechand Hearing Disorders, 33, 236-245. Lundervold, D., Lewin, L., &Irwin, L. 1987). Rehabilitation of visual impairments: A criticalreview. Critical Psychology Review, 7, 169-185. McInnes, J., &Treffrey, J. (1982). Deaf-blind infants and children: A developmentguide. Buffalo, NY: University of Toronto Research at the University of Toronto has been responsible for the world's first electronic heart pacemaker, artificial larynx, single-lung transplant, nerve transplant, artificial pancreas, chemical laser, G-suit, the first practical electron microscope, the first cloning of T-cells, Press. McKenzie, B., & Day, R. (Eds.). (1987). Perceptual developmentin early infancy: Problems and issues. Hillsdale, NJ: Lawrence Erlbaum. Michael, M., Arnold, K., & Niswander, P. 1988). A study Ifthe differential effects of providing functional vision and auditorytraining to very young children who are deaf-blind. Ohio StateUniversity Ohio State University,main campus at Columbus; land-grant and state supported; coeducational; chartered 1870, opened 1873 as Ohio Agricultural and Mechanical College, renamed 1878. There are also campuses at Lima, Mansfield, Marion, and Newark. , Great Lakes Great Lakes,group of five freshwater lakes, central North America, creating a natural border between the United States and Canada and forming the largest body of freshwater in the world, with a combined surface area of c.95,000 sq mi (246,050 sq km). Area Regional Center for Deaf-Blind Education.Grant proposal submitted to Office of Special Education andRehabilitation Services (OSERS OSERS Office of Special Education and Rehabilitative Services ). Mischook, M., & Cole, E. (1986). Auditory learning Auditory learning is a style of learning in which a person learns most effectively by listening to information delivered orally, in lectures, speeches, and oral sessions. Auditory learners make up about 25% of the population. and teachingof hearing-impaired infants. Volta Review, 88, 5, 67-81. [SpecialIssue]. Mohn, G., & Van Hol-Van Duin, J. (1983). Behavioral andelectrophysiological measure of visual functions in children withneurological disorders. Behavioral Brain Research, 10, 177-187. Niswander, P. (1987). Audiometric assessment and management. In L.Goetz, D. Guess, & K. Stremel-Campbell (Eds.), Innovative programdesign for individuals with dual sensory impairments pp. 99-127).Baltimore, MD: Brookes. Niswander, P. (1988). Audiological assessment of thedifficult-to-test child. Unpublished manuscript, Ohio State University,Nisonger Center. Northern, J., & Downs, M. (1984). Hearing in children (3rded.). Baltimore, MD: Williams & Wilkins. Orchik, D., &MacKimmie, K. (1984). Immittance audiometry. In J. Jerger (Ed.),Pediatric pediatric/pe��di��at��ric/ (pe?de-at��rik) pertaining to the health of children. pe��di��at��ricadj.Of or relating to pediatrics. audiometry (pp. 45-70). San Diego, CA: College-Hill. Ouellette, S. (1984). Deaf-blind population estimates. In D.Watson, S. Barrett, & R. Brown (Eds.), A model service deliverysystem for deaf-blind persons (pp. 7-10). Little Rock: University ofArkansas The University of Arkansas strives to be known as a "nationally competitive, student-centered research university serving Arkansas and the world." The school recently completed its "Campaign for the 21st Century," in which the university raised more than $1 billion for the school, used . Peterson, N. (1983). Early intervention with the handicapped. In E.Meyer (Ed.), Exceptional children (pp. 94-143). Denver, CO: LovePublishing. Piaget, J. (1952). The origins of intelligence in children. NewYork: Norton. Pollack, D. (1985). Educational audiology audiology/au��di��ol��o��gy/ (aw?de-ol��ah-je) the study of impaired hearing that cannot be improved by medication or surgical therapy. au��di��ol��o��gyn. for the limited-hearinginfant and preschooler pre��school��er?n.1. A child who is not old enough to attend kindergarten.2. A child who is enrolled in a preschool.Noun 1. (2nd ed.). Springfield, IL: Charles C Thomas. Ramey, C., Trohanis, P., & Hostler, S. 1982). An introduction.In C. Ramey & P. Trohanis (Eds.), Finding and educating high-riskand handicapped infants (pp. 1-18). Baltimore, MD: University ParkPress. Sailor, W., Utley, B., Goetz, L., Gee, K., & Baldwin, M.,(1982). Vision assessment and program manual for severely handicappedand/or deaf-blind students. (San Francisco State University, Bay AreaSeverely Handicapped Deaf-blind Project. U.S. Department of Education300780038). Washington, DC: U.S Government Printing Office. Sanders, D. (1982). Aural rehabilitatioti.- A management model(2nd ed.). Englewood Cliffs, NJ: Prentice-Hall. Siegal-Causey, E., & Downing, J. (1987). Nonsymboliccommunication development: Theoretical concepts and educationalstrategies. In L. Goetz, D. Guess, & K. Stremel-Campbell (Eds.),Innovative program design for individuals with dual-sensory impairments(pp. 15-48). Baltimore, MD: Brookes. Skinner, B. F. (1953). Science andhuman behavior. New York: Free Press. Smith, A., & Cote, K. (1982). Look at me. Philadelphia: ThePennsylvania College of Optometry The Pennsylvania College of Optometry (PCO) is one of the oldest optometry schools and throughout most of the 20th century has been a leader in both training and research. It was the first school in the United States to confer the Doctor of Optometry degree after a four-year . Spradlin, J. (1985). Auditory evaluation. In M. Bullis (Ed.),Communication development in young children with deaf-blindness:Literature review I pp. 49-61). Monmouth, OR: Teaching ResearchPublications. Teele, D., & Teele, J. (1984). Detection of middle eareffusion effusion/ef��fu��sion/ (e-fu��zhun)1. escape of a fluid into a part; exudation or transudation.2. effused material; an exudate or transudate. by acoustic reflectometry. Pediatrics, 104, 832-838. Teller, D. 1979). The forced-choice preferential lookingprocedure: A psychophysical psychophysical/psy��cho��phys��i��cal/ (-fiz��i-k'l) pertaining to the mind and its relation to physical manifestations. psy��cho��phys��i��caladj.1. Of or relating to psychophysics. technique for use with human infants.Infants Behavior Development, 2, 135. Teller, D., McDonald, M., Preston, K., Sebris, S., & Dobson, V.(1986). Assessment of visual acuity in infants and children: The acuitycard procedure. Developmental Medicine and Child Neurology, 28,779-789. Van Dijk, J. (1965). The first steps of the deaf/blind child towardlanguage. Proceednigs of the conference on the deaf/blind. Refsns,Denmark (pp. 47-50). Boston, MA: Perkins School for the Blind Perkins School for the Blind,at Watertown, Mass.; chartered 1829, opened 1832 in South Boston as the New England Asylum for the Blind, with Samuel G. Howe as its director; moved 1912. . Van Dijk, J. (1968). Movement and communication with rubella rubellaor German measles,acute infectious disease of children and young adults. It is caused by a filterable virus that is spread by droplet spray from the respiratory tract of an infected individual. children., Paper presented at the annual meeting of the NationalAssociation for Deaf-Blind and Rubella Children, St. Michielsgestel,Netherlands. Vygotsky,L. (1962). Thought and language. Cambridge, MA:Massachusetts Institute of Technology Press. Walker, J., & Crawley, S. (1983). Conceptual and methodologicalissues in studying the handicapped infant. In S. Garwood & R.Fewell, Educating handincapped infants (pp. 158-209). Rockville, MD:Aspen. Watson, D., Barrett, S., & Brown, R. (Eds.), (1984). A modelservice delivery system for deaf-blind persons. Little Rock, AR: Research & Training Center on Deafness. ABOUT THE AUTHORS MARTHA G. MICHAEL is a Program Manager at the Center for SpecialNeeds Populations, College of Education; and PETER V. PAUL is anAssociate Professor in the Department of Educational Services andResearch at The Ohio State University, Columbus. Manuscript received December 1988; revision accepted June 1989. Exceptional Children, Vol. 57, No. 3, pp. 200-210. [c]1990 TheCouncil for Exceptional Children.