Karen Levin, Ph.D Speech Therapist, Johannesburg

Speech therapy and blindness

 

Most blind or visually impaired people develop perfectly adequate speech and language skills! Learning is different, perhaps slower, and accessing the world to learn is more challenging. However, just as all children are at risk of communication impairments, so too are blind and visually impaired children.

 

 

Not much is known about how blind or visually impaired children develop speech and language.

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I was asked, many moons ago, to develop and teach a course to speech-language therapy students on what was known then as "multiple handicaps". Few therapists knew how to work with blind or visually impaired people or with people who were blind/visually impaired and lived with other impairments, and at that stage there were no university programs in South Africa that addressed this area.  Particularly challenging for the speech-language therapist is therapy for people who are deafblind or people who have severe physical impairments and sensory impairments, such as people with cerebral palsy and deafblindness. I was a little fazed (to put it mildly) by having the responsibility of introducing this course at a university level. I developed the course based on my clinical experience and coupled it with a wide range of sources of information.  Despite the challenges, the course was developed over time, and intervention for individuals who are blind/visually impaired and those who are blind with other impairments is taught in most university programmes in South Africa today.

 

However, despite the fact that speech therapists know about speech and language development and learning,  almost nothing is written on how to carry out  speech-language intervention with people who are visually-impaired, blind, or have cerebral visual impairments  - when I first taught the course in about 1999 there was very little literature, and that is true still today.

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A bit about blindness and visual impairment

Most people who are  visually impaired have some degree of sight. But there are some people who have absolutely no sight whatsoever.

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What causes blindness or visual impairment? Some people's visual problems are a result of some condition that affects the eyes themselves; others have visual problems because the neural tracts that take the information from the eyes to the brain are damaged - this is what is called CVI (cerebral visual blindness). The information on this page relates to all levels of visual impairment, but there are some very special things that can be done with people who have CVI. This information is not included on this page.

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• Like all children, blind or visually impaired children can have a range of associated problems such as language impairments, childhood apraxia of speech, cleft lip and/or palate, learning disorders, or intellectual disorders. They can also have hearing losses. They can have Down's Syndrome or any other syndrome that is associated with, or not associated with, blindness. 

• Blindness or visual impairment can be acquired such as as a result of facial or head injuries from a car accident, or from a disease such as cancer of the eye or complications of diabetes.

• Children who are born prematurely are at risk of developing Retinopathy of Prematurity. Abnormal blood vessels grow in the retina. ROP can also develop in premmies from receiving too much oxygen or developing infections.  

• There can be genetic reasons for visual impairment.

 

Language is critically important for individuals who are blind or visually impaired.

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It is really a whole lot easier for blind or visually impaired people to cope in the world if they can use language to mediate their learning and to negotiate the world. We use language to tell the child about what is in the world. We use language to explain the environment to blind children. We use language to tell the child about our minds - they cannot read our facial expressions, and cannot work out context sometimes because they cannot see it.

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It is difficult for low-vision, CVI, or blind children to learn about things they cannot see or touch. So talk to them, and let them learn through touch and hearing.

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The child will not associate barking with a dog unless someone tells him it's a dog.

 

Here is a doggie. He is barking.

 

He will not know that the thing he picks up while sitting on the grass is a stick. 

 

Here is a stick. Feel it.

 

He might not know that the noise of the car engine comes from a car if he cannot see the car.

 

Can you hear the car?

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The child needs to learn to get around in the space that he cannot see so we use language to help

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Put your right hand out. Can you feel the door? Okay, Walk a little to the left and you will

                                                                                 get to the handle. There you go!

 

 

We need to help blind/visually impaired young children to be precocious language learners.

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We have to teach very young blind/visually impaired children as much language as early as possible. I start to teach children under the age of 3 years of age 'left' and 'right' and words about space and movement (e.g.  here, over there, higher up, closer to you, far away, three steps more, near your elbow, etc.) so that we can use language to help them to get around.

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Language and speech development children with visual impairments

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Speech production of blind and/or visually impaired children.

 

Many children who are blind or have visual impairments present with speech sound disorders. For example, they continue to muddle up 'f 'and' th' for a long time. However, in my experience - I don't have much literature to guide me - most children who are blind learn all their speech sounds very well and easily if their cognition is intact and if their ears hear perfectly. I am not sure how much vision plays a part in learning speech sounds. I don't think much - after all, most speech sounds are not visible! That is why it is so very hard to lip read.

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The problem is that many children with visual impairments have other problems too -and it seems that these other problems interfere with learning speech sounds. So, for me, the main issue in speech sound production is coming up with ways to teach sound production that do not depend on the child looking at how and where sounds are made, but rather by  facilitating the learning of speech sounds through feeling and hearing the sounds, and by listening to what to do from very carefully worded instructions.

 

Language impairments and visual impairments

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There are basically two approaches to looking at the development of language in blind or visually impaired children: one is to compare their learning to that of typically developing sighted children. By doing this, we create what we call a 'deficit' model - we claim that in the absence of vision, there is a deficit which must impact learning. It's not a good approach because it locates the problem in the individual and ignores the role of everything else the child encounters in the world which may contribute to the problem.

 

The other way to consider the language development of blind or visually impaired children  is a 'difference' model  which means that that we understand and acknowledge that the children learn in a different way. The route that they take to learning is different; the behaviours that they demonstrate are different; and sometimes their ways of speaking are different. We have to be very sensitive to the behaviours of the child or we will under-estimate their skills. For example, blind children may repeat what we have said (echolalia) a lot - is it a problem? Some people say so and work to STOP the children from using echolalia.  Others disagree and point out that blind children use imitation as a means of communicating and to work with language. Similarly, blind children may use vocalizations and tactile handling where sighted children use gestures - the behaviours achieve the same goals in different ways. 

 

But does 'different' just mean that they will learn in a different way with the same end-process competencies as sighted children? I am not sure!

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AAC and blind/visually impaired children

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Many children who are blind/visually impaired  experience very significant speech and/or language problems that make it very difficult for them to learn language or to communicate with others. Speech therapists use what we call "alternative and augmentative communication" with people with such difficulties. It can be difficult to provide blind or visually impaired people with AAC but it is not impossible! There are all kinds of things that we can do. Please go to my AAC page.

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Understanding how blind/visually impaired babies learn and what to do with a blind baby in the first year of life

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Make the world an auditory and tactile one, with a bit of smell too

 

Immediately after birth, babies are highly alert. They focus their eyes as far as the distance from their faces to their mom's faces when they are held in the crook of the mom's arms. They look intently at the mom. It is this very, very early eye contact in the first hours after birth that helps to form that bond between the baby and the mom. We hear moms greeting their babies while looking into their eyes.

 

Hello baby. Look at you. Welcome to the world.

 

We also know that parents and grandparents comment on the colour of a newborn baby's eyes, which most often is not the colour that they will be when they grow up, but they are commented on nonetheless.

 

Hence, this early visual contact is important to the mom and others in the baby's life.

 

We know that the first thing that babies respond to visually is a face. In experiments where babies are shown various shapes, it is well known that they choose to look at ovals more than any other shape. They also like to look more at ovals that have some resemblance to a face than ovals with other shapes in them.  So, babies seem pre-wired to look at faces. 

 

Blind/visually impaired babies can't. So what do we do to help them to connect?

 

Use the auditory: We have to encourage them to respond to voices. Talk to the baby all the time. Blind/visually impaired babies cannot see you walk into the room, so you need to alert them to the fact that you are approaching them. They need to hear you open the door, they need to hear your footsteps and they need to hear your voice. You don't have to "stomp" around, but be very aware of making your presence known.

 

Use the tactile: And we have to let them touch our faces, right from the start. They cannot do it themselves ... a newborn cannot reach up and stroke a face...but the mom can take the baby's hand and run it over her face.

Some blind babies need a very small and distinct tactile sign for recognition, so let the baby touch - or take the baby's hand to touch - something distinctive about a person such as granny's ring, grandpa's beard, big sister's hair. That way, they learn to recognise people.

 

Use smell: Blind/visually impaired babies also learn to use smell for recognition, so don't use a different perfume every time...try to 'smell consistent'.  You do not need to use perfume - babies learn the smell of people.

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Babies who are blind/visually impaired have to be encouraged to move in response to tactile and auditory stimuli. 

 

Typically developing children start to lift their heads up and a little later, turn their heads, in response to auditory and visual stimuli. Blind/visually impaired babies sometimes do not lift their heads up because there is nothing in their visual field to respond to.

 

Blind/visually impaired babies have to be encouraged to lift their heads in response to auditory stimuli. Bring things that make a noise near the baby while the baby is on its tummy. Make a noise with something on the right, then something on the left, then something in front... the baby will learn to turn to the source of sound he or she is rewarded for doing so (a sighted child's reward is seeing what they were looking for) - and the reward is making the sound again and providing a social response like "yes, it's here". Then do some more  sound-seeking - make a noise with something on the left, wait for a seeking behaviour and give a reward, and then make a noise with  something in front. Keep doing this to encourage the baby to lift his or her head in response to a noise.

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Later, at around 6 to 9 months, the baby may start to reach for the source of the noise - so encourage this. You can help the baby by taking his or her arm to reach.

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Blind/visually impaired  babies generally do not explore the environment because they cannot see what there is to explore, so you need to take them to explore.

 

They cannot see the edge of the room, so you need to take them there - pick them up, hold out their hand, and walk towards the wall, then put the baby's hand on the wall. Help them to feel all around the cot. They don't know that there are barriers all around or that they are lying in a rectangular shaped bed. Start to use "orientation and mobility" principles from under a year of age. Use language to describe the environment. Don't underestimate how much babies get to understand under one year of age. Put different kinds of carpet on the floor or put masking tape along the edge of doorways so they can feel where they are as they start to crawl around. 

 

Blind/visually impaired  babies may have delayed physical development such as sitting later than sighted babies.

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You can encourage this development. Please consult with a physiotherapist if your child's physical development is delayed.

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Don't be scared to put your child in a variety of positions throughout the day -  on his tummy, on the floor, in his cot, in a safe baby chair, and in a high chair safely (strapped and always in your sight). 

 

Encourage movement using tactile, auditory and olfactory sensory input. He or she will learn to reach out for things and will explore things.

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At around 6 months of age, typically developing babies sit, and then use their hands. They reach out for things. They hold them in their hands. Then they start to move them from one hand to another. Then they put them in their mouths. They look at the objects. Then they start to explore them.

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This is what you need to encourage the blind/visually impaired baby to do - but you need to help. The blind/visually impaired baby needs to be attracted to things so make them tactile. A sighted baby looks at a range of things and chooses which one to go for. The blind/visually impaired baby needs the choice too. So give him or her a variety of toys, placed close to him or her, or touching.

 

A wrap around mat is useful. This is a u-shaped mat that you can make out of carboard, carpeting, or thick plastic. The child sits in the U, so that there is a strip on his left, on his right and in front of him. You can attach toys with velcro or they can be placed on the mat.  The reason for using the mat is that the child may feel the mat and will then know that there are toys all around him because you have taught him that by using the mat.  When you first start using it, take his/her hand and let the child feel the mat in front and on the sides. Then put a few toys on and let him/her feel for the toys. After a while, when he feels the mat, s/he will know there are toys to play with.

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You can even further once he knows about the mat. You can put the toys in boxes with lids or in jars with screw-on lids, or a small washing bag with a zip or a make-up bag with a press-stud, so that he or she is encouraged to seek toys.

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Put the child's toys in a toybox that is always in the same place and teach the child to go to the box to find toys. You may want to put a strip of masking tape on the ground or a piece of carpet to help to guide the child to the box. You can control the number of toys in  the box by selecting which ones you want and leaving the other packed away somewhere else.

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The toys must have interesting textures (e.g. a ball covered in tin foil, fabric, cotton wool, or a ball made with a textured covering). The items can also be constructed to make noise (e.g. a match box with a bit of sand in it;  or a cookie box with a toy inside) (NB NB Never use little things that the child can choke on if the small item comes out of the box!). A rattle, a teething ring, a plastic drinking bottle - anything that the child can hold, explore, listen to, or feel.

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Teaching object permanence is critical for language development.

 

Object permanence means that the child knows that when something is out of their hands - when they can no longer feel it or hear it - it still exists. Typically developing babies learn this over time - months in fact. By the age of 9 months, they have developed this understanding. If you do not have this understanding, you will not learn that a word stands for something that is not necessarily there. Blind/visually impaired babies may take more time to learn object permanence because they cannot see that the objects still exist if you take them away or if they drop them. Babies who are blind/visually impaired need to feel rather than see that objects that have 'disappeared', still exist. They cannot see them, but you can show them by telling them, or by taking them to where the object is.

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Some blind/visually impaired children throw things. The problem is that they do not see them and are not taught that they do not disappear. Always encourage the development of object permanence - that if they throw them, they do not disappear.

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Blind/visually impaired babies need to learn about cause effect.

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This means that they learn that if we do something, there is an effect.  Provide them with many opportunities - if they press a button, the toy makes a noise. If they open a bottle, the water is there. If they throw a ball, it makes a noise. If they shake the box (with the toy in it), it makes a noise. If they smile, they are spoken to and so on.

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Blind/ visually impaired babies need to learn about joint attention.

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This means that two people are interested in the same topic. Typically developing babies will look at something that you look at. Later, they will turn to look at what you are looking at. They will look at a toy and you will talk about that toy. This is the beginning of language - we have to have something that we are BOTH interested in so that we can have a TOPIC to talk about.

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We have to teach joint attention to blind/visually impaired babies in a tactile and auditory way. I have found that the best way is by touching what the baby is touching, in such a way that they baby can FEEL that I am also touching it.

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Mediate their learning with language. You can talk about the joint topic. "We are both playing with the elephant. I am also touching the elephant"

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Blind/visually impaired babies need to learn to explore toys.

 

This is how they learn about the world. How big things are. If they open and shut. What happens if they do something with the toy. How to release toys. What happens if they throw toys and so on and so on. Playing with toys is all about endless amounts of learning.

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They can't see the toys so always make sure you bring the toys (and the environment) to them!

 

Adapt toys.  Most modern toys are made of plastic in primary colours. So the orange ball and the purple ball, as well as the black one and the pink one all feel the same. Blind/visually impaired children need to play with different toys and need to learn to identify difference (that is the beginning of 'comparing and contrasting', a crucial cognitive skill).   BUT if the purple one is a bit rough (because we dotted bits of glue all over it) and the pink one is furry (because we stuck little bits of cotton wool on it), and the black one is rough (because we stuck river sand on it with glue), then they are all (1) different and (2) interesting.

 

You really do not need to spend money on ready-made sensory toys. This is especially relevant in South Africa where imported toys cost the earth. Make a sensory board .. . go to the hardware shop and buy all kinds of hinges and locks. Stick them on a piece of chipboard and you have a board of things to feel. And language to learn:

 

What's this?

It's hard

It's made of metal

It's made of plastic

It feels cold

This one feels sticky

This one is easy to open

This one does not feel easy to open

This one opens and closes.

Pull it

Push this

Touch that

Do it fast

Do it slowly

Up and down

In and out

 

Go to the cupboard and take out those clothes that don't fit or have faded, or that you have not worn in ages.  Cut off the pocket with the button, the zip still attached to material, a press stud on fabric and you have all kinds of things to play with.

 

let's play with this.

it's a zip.

open and close

zzzziiiipppp - can you hear the noise it makes

a long zip and a short zip

open it fast

close it slowly

 

 Much language can be learned through the tactile world.

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The environment is crucial

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Conti Ramsden and Perez-Perreira state this in their book (Language Development and Social Interaction in Blind Children). Blind/visually impaired children are not surrounded by the visual environment like sighted children are. Sighted people  ignore most of what we see - - the blue sky, the grass, the walls, the pylons, trees, cups -  - but if we want to take note of something, we do - a child might ask on seeing something, "What's that, Mommy?" A blind or visually impaired child will not comment on or ask about things that are invisible to them so it's our job to tell him or her about them

 

• We must talk about the the broader environment.

We are in a garden. We are standing on the grass, and there are trees and flowers all around us. The trees are big..."

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• We also have to talk about the specific environment

We are going to the car. It is parked in the driveway. Let's count the steps until we get there. The driveway is made of brick and it feels hard when we walk on it.

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• We have to help the child to generalise about the environment - they do not know that my driveway and your driveway are both driveways, and that houses have them and shops have them.

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• Give the child a sense of where s/he is by using touch and language:  Take the child around the room by the hand and talk to him or her about where the room begins and ends, where everything is situated in the room (e.g. the table is next to the door; the carpet ends here; the chairs are on your left) - even from a very young age!  The child cannot see the environment - you need to show him or her where s/he is, where the boundaries are - even when sitting at a table, let the child feel the edges so the child knows he or she is sitting at a small or big table; that the edge is close or near etc.

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• Use the child's own body to talk about things like height, depth, distance, size

e.g. the plane goes high up in the sky....Put your arm up, Peter...the plane is higher than your arm, its so high that no one can touch it

 

e.g. The tree is tall , even taller than me. Ok, lets make a line on the wall (with tape) to show how tall you are. Now let's do how tall  I am.  ... Pick the child up so s/he can feel the tape running from the floor to your marker and compare it to his own marker on the wall by feeling the distance from the floor to his or her own marker on the wall by feeling the distance from the floor to his or her own marker.

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Blind/visually-impaired children need to read and be read to!

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Book reading is a powerful way that children learn language ... vocabulary, grammar, narratives and scripts (e.g. beginning, middle and end). They learn about predicting (what is going to happen on the next page or at the end); they learn to infer. They learn about literacy ... that there are sounds, words, sentences, punctuation. The list of what we learn through being read to and through reading is endless. Margaret Mead once said that the greatest thing to happen to the human mind is  learning to read because the world of learning is then infinite.

 

Book reading is a powerful way for visually impaired children to learn.  They can be any published book, they can be tactile books, and home made ones.  10 pieces of cardboard stapled together makes a book.

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You can make early books. For example, page one is a ball - round piece of felt. The child has a ball covered in felt so when he feels the round  ball in the book, it feels like his round ball. Page 2 is a block - a square piece of tin foil. The child has a block covered in foil so when he feels his foil block in the book it kind of feels like the tin foil covered block in his toy box. Page 3 is a button - stuck on with glue. Page 4 is a stick - a toothpick and so on.  These early books are like first books - the pictures (in this case, the tactile stimuli - the things I can l "tactile pictures") are tactile real things, representations, or part of real things.

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Cover the books. Blind children cannot see them or the illustrations. I cover books in different papers and fabrics. Sometimes I stick a tactile "picture" on the cover e.g., a button for a face - e.g., for Goldilocks, put three things in increasing size on the cover , or a small wheel from a toy car if it's a book about a car.  You may want to cover a book in velvet-like material if it's a comforting book, or a rough piece of hessian if it's about the sandy place (e.g., rural road, beach, or sandpit).

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Use tactile pictures. Blind/visually impaired children don't need pictures - but they need their attention to be kept in other ways.

Visually intact children love to look at pictures, visually impaired children need something as attractive as pictures. .

 

So, stick things into ordinary children's books. Yes, we were all taught not to write in books, or damage them but it's a load of rubbish...books are there to be read and used, not preserved! Stick a moon into Goodnight Moon. Put hair on Goldilocks. Put egg shells on Humpty Dumpty. And grass where there is grass.

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Use "objects of reference" (i.e., an objects box).. These are boxes with objects that are included in the story. You have to prepare these beforehand. So, some will be lifelike (e.g. a doll for Goldilocks, an apple for the poisoned apple; even a sharp pin for the spinning wheel needle - just be careful); some will be "parts of" such as  a lock of hair for Rapunzel's hair), and some will be representations (e.g. a handful of leaves for the forest; a key to represent the locked door) - be imaginative!!!

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The child can be given the real toy bear to hold while a story of a bear is being read.  Or a moon and a star when Goodnight Moon is read.  

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Audiobooks are wonderful, but cannot replace being read to in an interactive way by an adult who asks questions, points things out, laughs with a child, repeats the pages, changes the scripts, adds his or her own little touches, makes funny voices and accents.

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The use of toys with visually impaired children

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All children learn through play. We start by looking at toys and exploring them, moving them from hand to hand. And we sit in our high chairs and throw them - someone will pick them up and so we learn object permanence (and of course, when someone has to pick up the toy a hundred times, we learn we can manipulate people and laugh with them too). We find and lose them. We mouth them, mess them up, treasure them, and hug them, and we also become attached to them. We share them, and don't share them. We hide them and bury them. They help our emotional development, our social development, and our language development.

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We learn concepts  and then words through playing with toys - big/little; heavy/light; far away and close; few and more and less and some; here and there; mine and yours and ours; what things in the world do and who does them; that toys are symbols and stand for something else; that games can have goals; there are winners and losers .... so, visually impaired children also need to play with toys! A lot!

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One of the best tings to do with a visually impaired child is to co-create toys. We build them together. Use cardboard, glue, different types of tape, paint, etc.

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Make the world tactile. Here are some examples of toys I've made.

 

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