RNIB supporting blind and partially sighted people
Effective practice guide
Communication: Complex needs
This guide covers developing skills in communicating with children
with complex needs, including the use of communication
technology, touch and objects of reference.
It includes contributions from speech and language therapists and
those by senior lecturers in the Visual Impairment Centre for
Teaching and Research, at the School of Education, University of
Birmingham.
Contents
Part 1: Alternative and augmentative communication (AAC)
Part 2: Objects of Reference
Part 3: Promoting communication in children with complex needs
Part 4: Becoming a sensitive communication partner
Part 5: Using Touch with children with complex needs
Part 6: Further guides
Registered charity number 226227
Part 1: Alternative and augmentative
communication (AAC)
About this part
This part gives explores the use of Communication Technology or
Alternative and Augmentative Communication for children with
severe vision impairment and complex needs. Written by Caroline
Knight, Speech and Language Therapist, this guide looks at how
technological devices can be used to help children learn and
communicate to express their choices.
Contents:
1.1. Communication Technology
1.2. Total Communication
1.3. Developing Switching Skills
1.4. Factors in choosing a switch
1.5. Single message devices
1.6. Sequencing devices
1.7. Making Choices: auditory scanning
1.8. Making choices: direct access
1.1. Communication Technology
Technological devices can help children learn to communicate and
express choices. This is also sometimes referred to as Alternative
and Augmentative Communication (AAC).
For children with a vision impairment and multiple disabilities
(MDVI), the path to effective communication can be very long and
difficult to negotiate. The outcomes rely on the quality of the
interactions of their caregivers, their environment and the
opportunities that they are given.
1.2. Total Communication
Children with MDVI can benefit from a Total Communication
environment, where a variety of means of communication is
available to them. With perseverance, understanding can be
developed and the communication of basic wants and needs can
be established through a variety of channels.
Children with a vision impairment can perceive the world to be
fragmented and chaotic. But technology can provide a constant
and consistent route to communication. Technology can enable the
child to experience control over their environment; it can facilitate
interaction; it can present the child with a means to become an
active communicator; and it can provide opportunities to
communicate with a wider world.
1.3. Developing switching skills
If our ultimate goal is to enable a child to use technology to
enhance their expressive communication, then we must first
consider how the child will gain access to the devices. Typically
this is via a switch.
To ensure that the switch is used meaningfully, we need to
ascertain the most accurate repeatable body movement - with the
least amount of effort - which the child can produce. This will
determine what type of switch should be used. This can be found
by careful observation of how the child moves and interacts with
objects and providing lots of opportunities to practice and refine
skills.
1.4. Factors in choosing a switch
How the switch is activated
Types of switch include:
 simple press switches such as a Jelly Bean or Buddy Button
 flat pad switches which require only a slight touch such as a Pal
Pad or Wolfson Touch Switch
 a String Switch which can be activated by the pull of the string
loop such as by raising an arm
 a Wobble Switch which can be operated by a gross movement
of an arm or leg - no precision needed
 a Tilt Switch which can be attached to the body and reacts to
very small movements
 a tactile overlay on an alternative keyboard such as Intellikeys.
Note that the child's most consistent movement may not be
fingers: children may use, amongst other possibilities, their fist,
back of hand, back of head, side of head, wrist, foot or knee.
It is generally agreed that it is easier for a child to understand they
are in control via the switch if they are able to have direct contact
with it.
Size of the switch
This will depend on how it will be activated and the accuracy of
child's movement.
Positioning of the switch
 Consult the child's Occupational Therapist to ensure that good
movement patterns are established.
 Be consistent so that child does not have to search to locate the
switch each time.
 Have the switch available for prolonged periods, not just when
the adult wants to draw attention to it. The child should
purposefully select to use the switch to achieve an end, and not
because it has suddenly been presented to him. The use of a
mounting arm can lock the switch securely into the required
position.
 Consider using a wireless switch such as the Jelly Beamer so
that there is less to distract the child or for the child to get
caught up in.
 Consider mounting the switch on the child, for example with a
Velcro band around their leg, so that the child is aware of the
position.
Differentiation of the switch
 To help the child distinguish the switch from the rest of their
environment, use switch caps to introduce texture or a
contrasting colour or reflective surface.
 Use different switch covers to help the child distinguish the
different rewards. Or place the different switches in consistent
locations.
Supporting switching
Switching can be cued with verbal prompts such "one, two, press"
(and then faded as the child anticipates and takes control).
Rewards
Provide rewards or outcomes that are motivating to the child and
will have a clear impact on the child, such as a change to their
immediate environment.
Switches using devices such as Battery Switch Adapters and the
AbleNet PowerLink can control both battery and electrical toys and
appliances. These can increase the range of rewards that can be
offered. The following could be considered:
 cool fan (perhaps with streamers added)
 warm hairdryer
 massager
 vibrating cushion
 foot spa
 recordings of novel music or sounds (you could use a site like
FindSounds for this)
 lights
 bubble tube
 computer - patterns on screen, animation.
Presenting switches will help develop and consolidate the child's
understanding of cause and effect. The child becomes active in
their environment and experiences the power of taking control.
These abilities can be developed through individual exploration
and through play with an adult. The skills that are learned and
practiced, such as maintaining attention, anticipation and turn
taking, can be transferred to other areas of the child's
communication.
1.5. Single message devices
Individuals who can use switches purposefully and demonstrate a
need and desire to communicate may benefit from using a Voice
Output Communication Aid (VOCA). Liaise with the child's Speech
and Language Therapist to determine the complexity of language
that is appropriate, eg single words, short phrases or sentences.
Using a single message VOCA, eg the BIGmack, lets the child
build a link between the message and its effect on the
communication partner. In a busy schedule, the adult usually
records the message at the start of the activity. Ideally, the
messages should be recorded by a consistent person - where
possible of the same age and sex as the child, but not known to
them.
Adults should also use the VOCA to model how to use it
appropriately, so the child has experience of hearing a VOCA in
familiar communication exchanges. For example, class staff could
use a VOCA as they greet students and each other in the morning
circle.
Example messages
Messages may be sounds, single words or short phrases. Initially
the child should begin with the switch in a non-time-dependent
context, ie when there is no pressure to use it within any
framework set by the adult.
Examples may include:
 "Hello" - as a general way to gain someone's attention
 "Let's talk" - to initiate an interaction
 "Go away!" - to clear the room person by person
 "Woof woof" - to provide sound effects in a story about a dog.
Adults should reinforce the use of the message by responding as if
the child had spoken the message.
Time dependent messages
Once the child is using the message with meaning and shows an
awareness of the message as a communication to others, then
opportunities that are time dependent can be used.
These may include:
 responding to a greeting in circle time
 a train whistle - to sound whilst the train runs around the track,
 jingling bells or a crashing cymbal to use during a music
session
 saying "Ready, steady, go" to start a game or a song
 saying "Knock it down!" to topple a tower of bricks
 asking for "more" at snack time
 providing a repeated line in a song or story.
1.6. Sequencing devices
Some VOCAs, eg the Step by Step, can offer a sequence of
messages which can give more possibilities for the child to
participate. The child cannot determine the order of the messages
but can control the timing of their delivery.
These can be used in a variety of ways to provide motivating
communicative experiences for the child:
 songs can be played one line at a time
 a list of animals can recorded to be used at the appropriate time
when "Old Macdonald" is being sung
 children's names can be listed and supplied to the teacher a
when a 'volunteer' is needed
 a list of commands can be given for a simplified game of Simon
Says - "clap your hands", "everybody whistle", etc
 a shopping list can be accessed when in the supermarket
 a sequence of commands will allow the child to prompt himself
during an independent activity.
1.7. Making choices: auditory scanning
If the child is unable to access the communication aid physically,
other means can be investigated. It is common practice to give
spoken alternatives in order to elicit a response from a child: for
example, "Do you want yoghurt, banana or custard?" In doing this
we are using a form of auditory scanning.
Technology can replicate and extend this technique by giving the
child a sequence of prompt words or phrases. In its simplest form,
the child activates a switch on hearing the required response, and
the word or phrase is repeated.
A greater number of choices can be made available to the child by
"branching" - using categories that can lead the child to navigate
through multiple layers of vocabulary. For example, the child may
be prompted with "People, Food, Play". If he responds to "People"
he may then be given the choice of "Mum, Dad, Brother, Friend"
etc.
Glennen & Decoste state: "Auditory scanning has elements of
motor and auditory discrimination skills and is cognitively
demanding".
To be successful with this type of system, the user needs to be
able to:
 listen and pay attention
 understand the concept of cause and effect
 listen and activate after a targeted message
 master one consistent motor movement
 demonstrate good comprehension skills
 retain and recall.
If the child is able to cope with this, auditory scanning can offer an
effective means of communication. However, for many MDVI
children, the challenges of this form of communication prove to be
too great.
1.8. Making choices: direct access
By giving auditory feedback and reinforcement, VOCAs offer a
good way to facilitate choice making. The child can be facilitated to
move on from using a single-message VOCA to having a choice of
two.
Initially it can be helpful if one of the choices results in a motivating
outcome and the other is more neutral. (This tactic can sometimes
lead to the child being able to demonstrate previously unknown
preferences, such as a young child who consistently played
Gregorian chant rather than the adults' presumed favourite of a
lively pop hit!)
Simple VOCAs that offer two, four or even eight message cells
could also be introduced gradually. Remember that just because
the device has four cells, you do not have to fill them all. Leaving
some blank spaces may help the child locate those that are in use.
As with the switches mentioned above, the cells need to be
differentiated so that the child can find the desired message.
Different meanings could be denoted by the use of tactile markers,
eg textures, miniature objects, parts of known objects or blocks of
colour, clear photographs or colour. These could be attached
directly onto the switch or cell, or onto an overlay, depending on
the device in use.
Where multiple choices are available, a key guard can often assist
the child in finding the required message without activating
unwanted messages.
Part 2: Objects of Reference
About this part
This part considers the shortcomings of speech and sign and
explores the use of Objects of Reference to aid communication.
Ian Bell is a teacher and speech and language therapist with
considerable experience of children with special needs, including
those with severe vision impairment and complex needs, and
those with autism. Ian is a member of the Visual Impairment and
Autism Project team, looking at the provision for children who have
both severe vision impairment and autistic spectrum conditions.
Contents:
2.1. Shortcomings of speech and sign
2.2. What is an object of reference?
2.3. How can objects of reference help communication?
2.4. Use and misuse of objects of reference
2.5. References
2.1. Shortcomings of speech and sign
Many children with vision impairment and complex needs have
significant difficulties processing and interpreting auditory and
visual information. Spoken words and manual signs are fleeting
and usually bear no direct resemblance to the items they refer to.
Some children with vision impairment and complex needs
frequently move in and out of alertness, and this may be especially
true of those who also have poorly-controlled epilepsy.
In addition, many children with vision impairment and complex
needs have difficulty focusing their attention. It is not surprising,
then, that they often fail to attend to something as brief as a
spoken word or manual sign. Their difficulties continue even if they
do attend. This is because they also process information slowly. By
the time they have interpreted and understood what they have
heard or seen, events may well have moved on, leaving them
confused.
Some children with vision impairment and complex needs find it is
easier to understand when they handle an object. If a child learns
to attach a special meaning to an object, that object is regarded as
an "object of reference".
2.2. What is an Object of Reference?
An object of reference can enable the child to obtain information
from several senses: touch, vision (if they have some useful sight),
smell, taste, and sound (e.g. if they bang it against a surface). This
is more reliable for them than relying only on hearing the spoken
word, even if that is accompanied by a manual sign.
The best way to describe objects of reference is to give a couple of
examples.
Afzal, who had no functional vision, often became distressed in
school when it was time to go home: she did not understand where
she was being taken. Because Afzal always held on to her seatbelt
in the car, it was decided to present her with a piece of seatbelt
webbing immediately before going to the car. It was hoped that this
would help her to understand she was going in the car. Each time
the webbing was presented, the person giving it to her also said
"Afzal; car." After a few days, Afzal relaxed as soon as she was
given the webbing. She had attached the special meaning of "car"
to the webbing and thus it had become a true object of reference
for her; it supported her understanding.
Karl, who had a little useful vision, loved to play with a train set, but
did not have the means to ask for it. It was decided that he should
be taught to hand a section of track to a member of staff who
would then immediately provide him with the train set. Karl soon
got the basic idea and, after a carefully structured programme, he
would spontaneously go to the bottom shelf near the classroom
door, find the track and hand it to a member of staff. Karl had
attached the special meaning of "train set" to the track and thus it
had become a true object of reference for him; it supported his
expressive communication.
2.3. How can objects of reference help
communication?
Objects of reference, then, can play a key part in supporting
communication for a child with vision impairment and complex
needs:
 they can help the child to understand what other people say
 provide a means for the child to express needs and wants.
If you feel an individual child might benefit from objects of
reference, you need to proceed with care at first. It may be
necessary to go through a period of trial and error. This is because
you cannot know for sure whether the child will attach a special
meaning to the object you select.
In addition, it will take time for the child to build up a link between
the object and the item, place, person, event, activity or experience
it refers to.
2.4. Use and misuse of objects of reference
Being child-specific
It is sometimes argued that objects of reference should be
standardised throughout a school. It is very strongly recommended
here that each object of reference is child-specific; for Afzal the
webbing was the correct object of reference for "car" because she
held onto her seatbelt whilst in the car. Thus she could readily
associate the webbing with the experience of going in the car.
However, as soon as Robert got in the car he stretched out his
hand to feel the drop-down table on the back of the front seat. He
showed no interest in the seatbelt, so he would have been unlikely
to attach the special meaning "car" to a piece of webbing; instead,
his object of reference was an identical drop-down table donated
by the local garage.
Another factor to bear in mind is what will happen when the child
moves to another school, or leaves school and goes to college. If
child-specific objects of reference have been used, these can
readily transfer to the new setting with the child. However, if a
standard set has been used in school one, and another, different,
set in school two, communication will break down and the child is
likely to become very bewildered and frustrated.
Location markers
In some schools, objects are employed to mark specific locations.
For example, a spoon is provided at the entrance to the dining hall,
a piece of mat outside the gym. Objects used in this way obviously
have to be standardised for all children. However, rather than
calling them objects of reference, it may be preferable to refer to
them as "location markers".
Activity markers
Objects are also often used to signify the start of activities. For
example, a paint brush signifies an art lesson; a book, a literacy
lesson. Again, it may be preferable not to use the term objects of
reference in this context, but to call them "activity markers". Like
objects of reference, it may be necessary to individualise these: for
example, Leanne likes to use a tambourine in music, but Yaqoob
prefers maracas. Thus, they may not really understand if everyone
is presented with a chime bar beater. In time, activity markers can
be used for some children to inform them of the timetable. They
can be attached in sequence to a vertical board or placed in
horizontally arranged segmented trays.
Choosing objects of reference
Selecting an object of reference for a particular item, place,
person, event, activity or experience is not easy. Remember, an
object of reference is an object to which the child attaches a
special meaning. It is therefore essential to view things from the
individual child's perspective. The object should be something the
individual directly experiences and associates with the particular
item, place, person, event, activity or experience.
Presenting objects of reference
There are some simple rules for presenting an object of reference,
it must be:
 the same object every time
 presented immediately before the item, place, person, event or
activity it represents
 used every time it is needed
 presented in the same manner every time
 presented with the same accompanying speech / signing every
time.
As more objects of reference are introduced, it is essential to
consider the contrasts between them: it is not going to help if the
child becomes confused by objects of reference that are very
similar.
Objects of reference in the classroom
If at all possible, objects of reference should become a means for
the child to express needs and desires, and not just to support
understanding. This means that the child must have access to their
objects of reference so they can select them when necessary. This
can be a major problem for some children, particularly those who
also have a motor impairment.
For the mobile child, objects of reference can be stored on a
section of accessible shelving, on hooks on the wall, or in a box;
wherever they are kept, it is essential to adopt the following rules:
ensure the child knows where they are kept
always return objects of reference to the storage place immediately
after use
allow the child free access to their objects of reference at all times.
For a wheelchair user, it will be preferable, perhaps even
necessary, for the objects of reference to be reduced in size, and
made more abstract (see below). If this is done, it may be possible
for them to be kept in bag attached to the wheel chair, or in a book
which is always kept on the tray.
Moving on with objects of reference
When the child has been using several objects of reference for
some time, it may be appropriate (even necessary) to make them
more abstract:
 initially, they could be reduced in size
 later, part of the object could be used (eg instead of a whole
cup to mean "drink", it may be just the cup handle)
 later still, some objects can be turned into an abstract symbol;
e.g. the cup handle could become a printed or tactile semicircle,
which, eventually could become a printed letter "c", or the Moon
equivalent.
2.5. References
This article is only an introduction to objects of reference. For more
information, refer to Ockleford, A. (2002) Objects of Reference.
London: RNIB.
Part 3: Promoting communication in children
with complex needs
About this part
This part gives explores the challenges of promoting
communication in children with severe vision impairment and
complex needs. Written by Ian Bell, Teacher and Speech and
Language Therapist, Ian has considerable experience of children
with special needs, including those with severe vision impairment
and complex needs, and those with autism. This guide looks at
three helpful communication strategies to allow children with vision
impairment and complex needs to get the most out of their
education.
Contents:
3.1. Three helpful Strategies
3.2. Augmenting speech
3.3. Interacting with the child
3.4. Using objects and events
3.5. Summary
3.1. Three helpful strategies
Promoting communication in children with severe vision
impairment and complex needs is a major challenge. Children in
this group vary so widely with regard to their precise disabilities
and skills that it is really only possible to provide general principles.
Something that works with one child may not work with another.
The strategies for promoting communication can be divided into 3
broad categories:
1. augmenting speech
2. interacting with the child
3. using objects and events.
3.2. Augmenting speech
Augmenting speech is a major topic. It is mentioned here as it is
important to view it alongside interacting with the child and using
objects and events, as being one of the three interdependent
categories of strategies available to us for promoting
communication in children with severe vision impairment and
complex needs.
3.3. Interacting with the child
In our 'Becoming a sensitive communication partner' guide, written
by Caroline Knight, Caroline describes strategies to employ when
interacting with children. This section develops the theme of being
sensitive by describing strategies in which the emphasis is on what
adults do.
Many children with severe vision impairment and complex needs
are rather passive and lack spontaneity. Yet being spontaneous taking the initiative - is essential for communicating effectively.
Caring adults are naturally concerned when a child has few skills,
and often feel the need to provide a lot of stimulation to encourage
development. Unfortunately, when it comes to communication, this
can be counter-productive: the more we stimulate the child, the
less the child is free to take the initiative - to be spontaneous.
To promote spontaneous communication, we need to back off - we
need to "ALLOW":
Always
Look,
Listen,
Observe,
Wait.
Case study
Bob is developmentally very young; he has a little vision, being
able to see a bright object up to 30cm away on his right; and he
has cerebral palsy, and cannot use his hands to manipulate
objects.
His teacher, Sue, provides a wind-up musical toy for Bob, placing it
where he can see it. He smiles and waves his hands while the
music is playing, and stops when the music stops. Bob does
nothing to communicate that he wants it again. However, Sue
interprets Bob's smiling and waving as indicating that he enjoys the
toy. She winds it up again and does this several times over a
period of a few minutes. But she hasn't ALLOWed Bob to
communicate spontaneously.
Sue can do so, however, using the ALLOW approach. When the
toy stops, instead of winding it up again, Sue looks at Bob, and
listens - she observes, and waits. She notices he vocalises quietly
and reaches out slightly towards the toy. Sue interprets that as "I
want the toy again" and winds it up. After a few days, Bob
vocalises louder and reaches better: he is communicating
spontaneously.
Modelling
For children using a symbolic means of expression (eg speech,
sign, or a communication aid), modelling is useful. This strategy
requires two staff to work together, so its use must be agreed in
advance.
For example, Afzal asks Sue, her teacher, for help putting on her
coat by holding it out to someone. Instead of helping the child
herself, Sue involves her assistant, Steve, who is waiting close by.
Sue says "OK, Afzal. Ask Steve - say 'Help'." Steve helps Afzal to
put her coat on.
Sue and Steve also set up other situations in which Afzal needs
help, giving them plenty of opportunities to use the modelling
strategy. Soon, Afzal spontaneously says "Help" in a variety of
situations.
3.4. Using objects and events
This section describes strategies in which the emphasis is on the
use of objects and events.
Sabotage
Sabotage is useful with children who use a symbolic means of
expression (eg speech, sign, or a communication aid).
For example:
 at snack time, give a child who asks for a drink an empty
cup; one who asks for apple some banana; or give an unpeeled banana to a child who cannot peel it;
 in art, give the child some paper and a paintbrush, but no
paint;
 in music, give the child a drum, but no stick.
In each of these situations, ALLOW the child to communicate in
some way before intervening. Sabotage can involve causing an
unexpected event, such as a stack of bricks falling down. Follow
this by ALLOWing the child to comment in some way (for a preverbal child, the comment might be a gesture or vocalisation).
Enticing
Another strategy for children who have some vision is "enticing".
Place a favourite item in view, but just out of reach. In some cases
this will mean placing it in a clear plastic container which the child
cannot open. Again, ALLOW the child to communicate in some
way before intervening.
Interrupting
Routines can be used to promote spontaneous communication by
interrupting them and adopting the ALLOW approach. At first, this
should be tried with a really familiar routine.
For example, Susie has been to the school office many times;
Mike, the administrator, always says "Susie, Hello!" and hands her
a cuddly bear. Susie vocalises "ah". Instead of giving Susie the
bear, Mike says, "Susie, Hello!" and waits. Susie vocalises "ah",
which Mike interprets as a request for the bear and gives it to her.
When the child is familiar with routines being interrupted, sabotage
can be used. For example, Moses enjoys a rocking boat. He
knows the routine: going to the play area, being placed in the
rocker, moving his trunk to make the boat rock, and participating in
the song "Row, row, row your boat". He joins in by chanting "oh,
oh, oh". This routine can be sabotaged by starting another song,
and pausing. The pause ALLOWs Moses to chant "oh, oh, oh",
communicating which song he wants.
Choice
There are many opportunities to provide choice. If the child is using
a symbolic means of expression, a simple question may be
appropriate: "Which instrument do you want?"
At an earlier stage you may need to present alternatives: "Which
instrument do you want? Drum or tambourine?" Beware of children
merely echoing the second option. But, even if you suspect the
child has done so, respect their choice.
For children without symbolic communication, you may need to
demonstrate each option briefly and pause. If the child has no
vision, and so cannot choose using eye gaze, you may need to
judge their choice by interpreting facial expression, arm
movements, or vocalisations.
3.5. Summary
These strategies of ALLOWing, modelling, sabotaging, enticing,
interrupting and offering choice can be very useful. But their
effectiveness relies on them being used by all those who come into
contact with the child, and in all the situations the child regularly
experiences.
Part 4: Becoming a sensitive communication
partner
About this part
This part gives explores how to support a child with complex needs
and visual impairment in developing early communication skills.
Written by Caroline Knight, Speech and Language Therapist, this
guide looks at the impact a vision impairment can have on
communication and focuses on techniques and strategies for
developing communication skills.
Contents:
4.1. Babies, communication and vision
4.2. Communication and vision impairment
4.3. Communication techniques and strategies
4.4. Taking control
4.5. Towards symbolic functioning and speech
4.6. Communicating with a wider circle
4.7. References
4.1. Babies, communication and vision
New babies arrive armed with a wide array of behaviours. Initially
these can be displayed indiscriminately and unintentionally.
Caregivers, however, are drawn in to the infant and typically
respond to these behaviours as if communication is taking place.
They will give meaning to what is taking place and respond
accordingly. An infant that cries is told: "Oh, you are hungry", and
given a feed; one that kicks its legs may hear: "You are excited.
You like your bath", and is then given the opportunity to experience
bath time.
"My behaviours affect others"
With time, the child realizes that their behaviours are affecting
those around them and they start to use the behaviours with the
intention of influencing those around them. The child thus guides
the caregiver with a combination of looks, movements towards
objects, vocalizations etc.
Moving on to speech
The next development sees the child refine skills and use more
systematic and symbolic ways of making their needs known,
typically through speech. Importantly, this takes place within the
context of the development of shared and joint attention, much of
which is dependent on the shared sensory experiences of the
infant and caregiver.
The interactive nature of communication means that the progress
of the child is reliant on access to communication partners.
4.2. Communication and vision impairment
The use of vision plays a key role in these interactions in these
early stages. In the absence of these key visual elements, the child
with vision impairment can struggle to progress with their
communication. How does the child know when their caregiver is
attending to them? How do they develop shared attention when
they have a very limited range of experiences in common with
those around them?
The context as experienced or perceived by the child with vision
impairment and complex needs may not match that of the
caregiver who may not be able to or know how to respond
appropriately.
For example, a sighted child may hear its mother shaking a rattle.
The child may then move, look at the rattle and change its facial
expression. The mother registers her child's interest and attention
and continues to interact with the rattle, watching the baby and
commenting on the reactions of the child. By contrast, a child with
vision impairment may "still" as they attend to a sound and facial
expression may appear passive. The mother interprets these
behaviours as a lack of interest and the interaction is not
continued. This mismatch results in the child, already
disadvantaged by the impact of their disabilities, having access to
fewer and poorer communication exchanges on which to build their
skills.
4.3. Communication techniques and strategies
By adapting and refining our communications, we can support the
child in their communication development.
The following techniques and strategies have been found to be
beneficial when laying down the foundations for communication
and language development in children with complex needs and
vision impairment.
Sharing the moment - multi-sensory interactions
Shared and joint attention are fundamental building blocks to a
child's development. We need to consider what the child without
vision is experiencing. We need to develop other ways of making
and maintaining contact to compensate for the lack of eye contact
and gaze.
Adults should consider the following and use them in their
interactions to engage with the child:
 touch
 movement
 vibration
 rhythm
 smell
 place
 sound - voice, intonation
 sounds - environmental
 air currents.
Cutting out clutter
We need to be aware that stimuli (sound, smell etc) may occur
naturally within the child's environment. While it is not possible or
useful to provide a sterile environment for a child, we do need to
be aware of things competing for the child's attention. They will not
be able to filter them out as we do, or they may be overwhelmed
and shut down.
Creating structure and routine
Develop small routines when interacting with the child. In these
interactions alert the child by using their name and touch in a
consistent manner. Exchanges should include clear signals that
show the beginning and the end.
Going slowly and noticing responses
It cannot be stressed enough that large amounts of time need to
be built into these interactions. The pace should be such that it
allows the child to process what it is experiencing and to organise
a response. The adult also needs time as they will need to look at
a variety of often very subtle responses from the whole child.
The Affective Communication Assessment in "Communication
Before Speech: Development and Assessment" (Coupe, O, Kane,
J. and Goldbart, J. (1998) provides an excellent framework for this.
It enables the identification of reliable responses or behaviours to
events, people or other stimuli and the systematic ways in which a
child responds and affects their environment. The authors also
give guidance on how to reinforce these communication attempts
and facilitate the movement from pre-intentional to intentional
communication.
Intensive Interaction
Another approach, Intensive Interaction, develops pre-speech
fundamentals at these early stages of communication
development. The non-directive approach is built around
interaction sequences that follow the lead of the individual (See
www.intensiveinteraction.co.uk).
Setting the context
It is not just the face-to-face interactions in micro-routines that will
promote a child's communication. Clear daily routines should be
established so that the child can gradually make sense of what
could otherwise be chaotic and fragmented experiences.
Making the patterns, routines and sequences of life explicit to the
child will increase the feeling of security. The child will be able to
understand and learn about his experiences and develop
anticipation of events. They will eventually also learn how to
manage when things do not go as expected.
Using objects and signs
The use of object cues and Objects of Reference can be readily
incorporated into daily routine to give extra information to the child.
By consistently linking an object with an activity the object comes
to represent that activity for the child. For example, a child can be
given a particular spoon to hold and told "it's time to eat" just
before a meal is served. Eventually the child makes the connection
and they begin to anticipate their meal on being handed the spoon.
Early communication through touch can be extended into on-body
signing (see "Learning Together: a creative approach to learning
for children with multiple disabilities and a vision impairment"
(1992). The authors give clear guidance on creating a learning
environment that promotes active exploration and communication.
4.4. Taking control
As the child continues to experience successful communication
with partners who are sensitive to their needs they will begin to
develop intentionality. As the world becomes clearer and more
predictable they will be able to realise that they can also have an
effect on those around them and will begin to take control.
Cause and effect can be explored and practices in many different
ways:
 through work on a resonance board (www.lilliworks.com) in
Intensive Interaction sessions
 making meaningful choices using Objects of Reference
 coactively signing to gain more of something (or perhaps a
more motivating drive) to make something stop
 through technology such as switches.
4.5. Towards symbolic functioning and speech
Symbolic functioning can be developed through various ways.
Exploration and experience with objects can lead to the use of
Objects of Reference as a means of expressing a choice; signing
also provides a shared means of communication. These should be
accompanied by speech when used by the adult.
As a sensitive communication partner you will adapt your speech
to meet the needs of the child:
begin with the child's name to alert them
 position yourself at the child's level
 make your voice interesting using rhythm and intonation
 use short clear phrases related to what the child is
experiencing
 support key words (those that the child needs to understand)
with relevant objects, signs etc
 use pauses to give child time to process
 value the child's turn in the interaction
 give feedback to the child to show how you are interpreting
them.
In time the child may use vocalizations in a consistent way that can
be interpreted to represent something. It is essential to give the
child feedback on your interpretations so that these can be further
expanded.
4.6. Communicating with a wider circle
As the child grows so will the opportunities for communication with
a wider circle. The child will meet new communication partners
who will not be tuned in to their idiosyncrasies and particular
communication style.
Using a Communication Passport
One way of passing on what you have found out about the child's
communication strengths is through a Communication Passport.
These present the child in a positive light and reflect the
individuals' personality, their needs and what is important for them.
In describing the child's most effective means of communication
and how others can best communicate with them, the passport can
ensure a consistent approach is taken by all who interact with the
child.
Through encounters with sensitive communication partners the
child will enhance their own communication skills and build their
self-esteem. This will assist the children to take on an active role in
their own communication development.
4.7. References
 Coupe, O, Kane, J. and Goldbart, J. (1998). Communication
Before Speech - Development and Assessment (2nd
edition). London: David Fulton
 Best, A. (1992) Teaching children with visual impairments.
Milton Keynes: OUP
 Visit www.intensiveinteraction.co.uk
 Visit www.lilliworks.com
 Lee, M., MacWilliam, L. (2002) Learning Together. RNIB
 Routes for Learning www.wales.gov.uk
 Ockleford, A. (2002) Objects of Reference. London: RNIB.
Part 5: Using Touch with children with complex
needs
About this part
This part explores how to reduce potential barriers to learning and
participation through touch for children who have multiple
disabilities and vision impairment. This guide is written by
Professor Mike McLinden and Steve McCall, Senior Lecturer in the
Visual Impairment Centre for Teaching and Research (VICTAR) at
the School of Education, University of Birmingham.
Contents:
5.1. How important is touch?
5.2. Case Study: Rosie and Rafie
5.3. Themes arising from the case study
5.4. Direct contact or less directive approaches?
5.5. Types of touch
5.6. Concluding thoughts
5.7. References
5.8. Further reading
5.1. How important is touch?
Vision is a powerful sense for learning and development, as
everyone with useful vision for near as well as distance activities
knows. So children who do not receive consistent visual
information are more reliant on others to structure their learning
experiences and help them make sense of the world.
In this article we examine the role of touch in learning and
development, with a particular focus on children and young people
with vision impairment and complex needs. We will explore how
potential barriers to learning and participation can be reduced
through structuring appropriate teaching and learning experiences.
5.2. Scenario: Rosie and Rafie
We have based the article around a real-life scenario situated in a
special school for children with learning difficulties. We will draw on
the scenario to explore key themes relating to learning through
touch. The location is a day school for children with a range of
learning difficulties. Within the school, there are six children who
are supported by a visiting qualified teacher of children with vision
impairment (QTVI). The focus of the scenario is on two of the
children with a visual impairment, Rosie and Rafie.
The lesson: "Great Explorers"
It is 9.30am and the first lesson is about to begin for nine year old
Rosie and ten year old Rafie. Although the lesson is called "Great
Explorers", the focus is not on traditional explorers who have
discovered new and exciting lands, but on Rosie and Rafie, who
are each provided with carefully crafted opportunities to become a
"great explorer".
The session has been planned through close liaison between the
QTVI, the class teacher and the class teaching assistant (TA),
Dave, who is supporting the two children in the session this
morning.
Dave introduces himself to each child. He shakes the two metal
bangles on his wrist and asks each child if they want to reach out
to feel them. The bangles are used as Dave's personal signifier
and each child in turn is provided with an opportunity to feel around
them.
Treasure chests
Dave tells the children in turn that he will be putting their "exploring
tray" and their "treasure chest" onto their respective wheelchair
trays. The treasure chest contains a number of hand-held objects
that the children have experienced before. These include a digital
talking watch, a metal serving spoon, a sponge ball and a set of
keys on a key ring. Each chest also contains a novel object
introduced as "new treasure": for Rosie, this is a hair slide; for
Rafie, it's a small leather purse with a Velcro opening.
Dave sits alongside the children and carefully supports each child
in feeling the contours of the empty tray and the outside of their
treasure chest. He then invites the children to select some treasure
from their chest, jointly exploring the object's distinctive features
and placing it onto the tray for further manipulation.
Playing with the treasure
Dave tells the children that he will sit quietly alongside them while
they play with their treasure, only talking to show them something
really interesting about the object, or to help them locate another
object from their chest.
He makes sure he is positioned so that his right arm gently
touches Rafie's left side to provide a reassuring presence, and
observes the children carefully, noting down how each child
explores the distinctive features of the selected object.
The session continues for approximately 20 minutes. At the end,
each child is asked to select one piece of treasure that they have
enjoyed playing with and to pass it directly to the other child. Rosie
smiles and passes the hair slide to Rafie to hold. With support from
Dave, Rafie is able to open and close the hair slide and places it
onto Dave's hair. Dave then places the hair slide on to Rafie's hair.
Rafie begins to laugh.
Rafie then feels within the contours of his own tray, seeks out the
talking watch and hands this to Rosie. Rosie takes the watch and
with support from Dave places it onto her wrist. She pushes a
button and, on hearing the clock telling the time, begins to laugh.
Finally, Dave says it's nearly time to end the lesson, and supports
the children in returning the objects from their tray to their treasure
chest. Each child is then encouraged to check that their tray is
empty and to close their treasure chest.
Notes on the scenario
There are three elements of particular interest here:
 the care with which the TA introduced objects to the children
 how he ensured appropriate time was provided for each child to
locate and explore the object
 the careful planning that had been put into the design of the
session to ensure it was appropriate for each child's individual
needs, with particular attention to the learning environment.
5.3. Themes arising from the scenario
We will now consider this scenario in further detail, drawing on a
broad framework which highlights the significance of a child's adult
partners when supporting the child's learning experiences through
touch (McLinden and McCall, 2002).
Within this framework we have identified four broad themes, which
we expand with reference to the scenario.
1) How does each child receive information through the
senses?
The learning experiences of a child who has a vision impairment
and complex needs will incorporate a range of sensory information,
some of which will be distorted in quality and/or quantity. In order
to work effectively with the child, the adult partners need to know
and understand a child's level of sensory function: how the child
receives, interprets and consequently acts upon different types of
sensory information during a given task.
Different sensory experiences are important in learning and
development. The QTVI who supports the school has carried out a
detailed assessment of the functional vision of all the children with
a visual impairment in the school. The findings of the assessment
are used in planning the child's curriculum.
How do Rosie and Rafie use touch?
Rosie: The vision assessment revealed that, although Rosie is
registered blind, she has some useful vision in certain
environments (for example, she can see bright lights in a darkened
room). She also occasionally brings an object she is particularly
interested in close to her eyes for visual inspection. While she has
limited independent mobility, Rosie has good fine motor control in
her hands and fingers, and is usually very keen to explore objects
that are presented to her on her tray.
Rafie: Rafie also has some vision, although it is not clear how
much use he can make of this for everyday tasks. He does not
appear interested in using his vision to view faces or objects, but
he does appear to enjoy watching the changing colours of the fibre
optic lights in the multisensory room. Rafie is hemiplegic and is
unable to manipulate small objects independently with both hands.
It is not clear how much enjoyment he gets from using touch to find
out about his world, and he requires frequent reassurance and
support from an adult partner to assist and encourage him.
Responding to each child's needs
This type of information was very useful to the class teacher in
planning the session. It highlights that, while children may have
common needs created by multiple disabilities that include vision
impairment, the particular approaches need to be structured to
ensure they meet each child's unique blend of needs.
(Examples of common needs in this scenario include the need for
well-defined contours within which the child can independently
manipulate an object; the time required to allow a child to process
the information through touch; alerting the child to what is going to
be happening next prior to the event taking place, etc.)
2) Distant and close senses
In considering how a child processes and acts upon sensory
information, a broad distinction can be made between information
received from a distance (for example through vision and hearing),
and information received close to the body (for example through
touch and taste).
In the absence of consistent information through the distant
senses, the information received through the close senses
increases in significance in a child's learning experiences.
This distinction between distant and close senses is commonly
made in the literature about child development.
Is this a jar of honey?
Vision is often referred to as an "integrating" or "co-ordinating"
sense. Imagine reaching into a dark cupboard to find a jar of
honey. You may have an overall impression of the object in your
hand through touch, as well as information about some of its
features (eg the fact that it is a jar rather than a pot). However,
without additional supporting information (eg smell) you may
struggle to make sense of what the object is.
If you have useful vision and it is light enough, you would be
tempted to bring the object towards your eyes to check if it is
indeed a jar of honey. If you do not have useful vision, or are
unable to see the object, you may draw upon additional close
senses to help you. In this case, your sense of smell, or indeed
taste, would be very useful!
3) Sensory impairment and knowledge acquisition
For a child who is more reliant on information received through the
close senses, their learning experiences can provide imprecise
information about the world if they are not mediated at a level
appropriate to the child's needs.
This can have an important bearing on the child's knowledge and
understanding of the world at critical stages in early development.
The child's adult partners need to appreciate the unique ways in
which each of the senses function.
"It's time to go now"
Imagine how you would respond to somebody suddenly placing a
hand onto your right shoulder while you are sitting down and
saying: "Hello there, its time to go now". You might want to turn
around to see who this hand (or voice) belongs to.
However, if you have a severe vision impairment, you will need to
rely on your other senses. This might include touching the person's
hand (or other part of the person's body), asking the person to
identify themselves, or waiting until he or she speaks further in an
attempt to identify the voice.
What if you also have limited gross and fine motor abilities which
means you are confined to a wheelchair, unable to move your
arms independently and have very limited speech? How much
more of a challenge is it to know where you are being asked to go,
and who with?
4) Good adult support
The child's adult partner will need to have knowledge and
understanding of his or her role in mediating the child's learning
experiences through each of the senses to ensure that these are
appropriate to the child's individual needs.
We have already noted the careful planning that had been put into
the session described in the scenario. This involved close liaison
between the QTVI, class teacher and TA prior to the session to
ensure it had a clear focus. The session allowed the children to
find out about the world in a safe and structured environment that
was both engaging as well as fun.
5.4. Direct contact or less directive approaches?
Is direct contact always needed? It is all too easy to think that
effective learning through touch for a child with a severe vision
impairment can only occur through direct adult contact with the
child, for example introducing an object to a child using 'handsover-hands' guiding strategies (McLinden and McCall, 2002).
Sometimes, a less directive approach can also work: for example,
giving a child the chance to examine an object without always
being physically guided by the adult.
In short, it is important to carefully consider approaches to learning
which include both 'hands-on' as well as 'hands-off' strategies
(Hodges and McLinden, 2004).
5.5. Types of touch
Despite an increased interest in the role of touch, we actually know
very little about how touch is used with the classroom environment
with individual children. However, there is evidence from a small
scale study on a child with a vision impairment and complex needs
in a special school (Hodges and McLinden, 2004).
We can use a number of the key points developed from this study
to describe the use of touch for each of the two children in our
scenario (Rosie and Rafie). These nine key points may also be of
use in helping practitioners who work with children with MDVI to
assess their own practice.
1) Purposeful touch
Within the session, touch always has a clear purpose, relating to
access to the curriculum, communication with the children or
management of tasks (for example, Dave supports Rosie in
placing the watch onto her wrist).
2) Cued touch
The children are not surprised by an unexpected touch, because
touch interactions are signalled through verbal cues. The touch is
also accompanied by additional cues, so that it was part of a
sequence of events which help each child to make sense of the
experiences. For example, Dave draws Rafie's attention to
distinctive features of the watch while he manipulates it in his tray.
3) Social touch
Touch is not only used to find out about objects and sensory
experiences. "Social" touch is also used during the session: for
example, for the TA to introduce himself. Dave also gives the
children structured opportunities to make contact with each other.
4) Independent touch
Although "hand over hand" guiding strategies are used (for
example, to draw Rafie's attention to particular features of an
object) opportunities are also provided for him to feel objects
independently without adult support.
Additional guiding strategies include "hand under hand", where the
adult's hand is underneath the child's hand.
5) Meaningful touch
The interactions involving touch are integrated into a meaningful
session, and careful thought is given to the objects that are
selected.
For example, the talking watch for example allowed for engaging
peer interaction at the end of the session.
6) Consistent touch
There is a high level of consistency in the approaches used by
different adults in the school to support each child's learning
experiences.
The TA uses a carefully crafted "script" that outlines the particular
approach to be adopted with each of the children when interacting
with them through touch.
7) Informative touch
Objects are not placed into the children's hands without a
supporting context.
Touch is used to provide the children with information about a
variety of events, including the layout of the tray in front of them
and the people around them. This information is also presented as
part of whole events, and is included as part of sequences which
each child is learning to understand (ie the beginning and ending
of a particular lesson).
8) Communicative touch
As well as being used to find out information about the world, touch
is used for communicative purposes.
For example, Dave sits alongside Rafie, observing him play, with
his right arm gently placed against Rafie's left side to provide a
reassuring presence.
9) Invited and acceptable touch
Rather than having an object imposed upon them, each child is
invited to join with Dave in exploring interesting materials from their
treasure chest.
When changes are made to their physical position, or when Dave
alerts them to a distinctive feature, appropriate warning is given.
5.6. Concluding thoughts
Within the wide range of educational needs created through
multiple disabilities, the role of touch in a child's learning and
development can easily be neglected. Practitioners and
researchers are only now beginning to appreciate the complexities,
and subtleties, of touch.
Children with a vision impairment and complex needs, need
varying levels of support from adults throughout their education.
Therefore, it may not be appropriate to focus exclusively on a
child's use of touch.
A significant feature of children who have a vision impairment and
complex needs is their increased dependency on other people to
structure their learning experiences. This includes what and who
they interact with, the nature of their interactions, where the
interaction takes place, and the duration of any given interaction
(McLinden and McCall 2002).
Becoming more engaged through touch through close liaison
between the different professionals and with careful planning and
input, Rosie and Rafie were actively engaged throughout the
session.
Both children were alerted to different touch experiences, allowed
to withdraw their hands as appropriate, involved in meaningful
tasks and motivated by them.
This approach means that they should increasingly welcome
tactual experiences and information. That will help them to become
more actively engaged in other classroom experiences - and in
turn, to become increasingly great explorers in their own time.
5.7. References
 McLinden M and McCall S (2002). "Learning Through
Touch". David Fulton: London
 Hodges, L., McLinden, M. (2004). "Hands on - hands off.
Exploring the role of touch in the learning experiences of a
child with severe learning difficulties and visual impairment".
SLD Experience, Spring, 38, 20-24.
5.8. Further reading
Project Salute is a good starting point for information and
resources. The project's subtitle is "Successful Adaptations for
Learning to Use Touch Effectively". Visit: www.projectsalute.net
For more information.
A range of useful resources is listed in the glossary of "Learning
Through Touch" (see References, above).
6: Further guides
The full Complex Needs series of guides includes:






Special Schools and Colleges in the UK
Functional Vision and Hearing Assessments
Communication: Complex needs
Working with complex needs in the classroom
The Staff team
Understanding complex needs
In addition, you may also be interested in the following series of
guides, all of which are relevant to children, young people and
families:




Supporting Early Years Education series
Removing barriers to learning series
Complex needs series
Further and Higher education series
We also produce a Teaching National Curriculum Subjects guide,
and a number of stand-alone guides, on a range of topics. Please
contact us to find out what we have available.
All these guides can be found in electronic form at
rnib.org.uk/educationprofessionals For print, braille, large print or
audio, please contact the RNIB Children, Young people and
Families (CYPF) Team at cypf@rnib.org.uk
For further information about RNIB
Royal National Institute of Blind People (RNIB), and its associate
charity Action for Blind People, provide a range of services to
support children with visual impairment, their families and the
professionals who work with them.
RNIB Helpline can refer you to specialists for further advice and
guidance relating to your situation. RNIB Helpline can also help
you by providing information and advice on a range of topics, such
as eye health, the latest products, leisure opportunities, benefits
advice and emotional support.
Call the Helpline team on 0303 123 9999 or email
helpline@rnib.org.uk
If you would like regular information to help your work with children
who have vision impairment, why not subscribe to "Insight", RNIB's
magazine for all who live or work with children and young people
with VI.
Information Disclaimer
Effective Practice Guides provide general information and ideas for
consideration when working with children who have a visual
impairment (and complex needs). All information provided is from
the personal perspective of the author of each guide and as such,
RNIB will not accept liability for any loss or damage or
inconvenience arising as a consequence of the use of or the
inability to use any information within this guide. Readers who use
this guide and rely on any information do so at their own risk. All
activities should be done with the full knowledge of the medical
condition of the child and with guidance from the QTVI and other
professionals involved with the child. RNIB does not represent or
warrant that the information accessible via the website, including
Effective Practice Guidance is accurate, complete or up to date.
Guide updated May 2014