selection of Frequently Asked Questions is based on the
questions from and discussions with families and service providers
who participated in project activities and workshops. The answers
are drawn from the review of the literature and from the clinical
judgment and experiences of service providers and professionals
who have worked with children who have significant and multiple
How do I determine which types of sensory
input (visual, auditory, tactile) provide the most useful information
to a nonverbal child who has low vision and has other disabilities?
observe the childs response to various sensory input in
different situations to see how the child responds and what
he or she seems to understand. Although a child has some vision
and hearing, he or she may benefit from tactile input at specific
times (e.g., if the environment is dark or noisy). Some childrens
ability to use vision may vary according to the their level
of alertness, health, and the context (e.g., children with cortical
visual impairment). A child may need to use touch to help confirm
or clarify what he or she sees. It is helpful to collect data
on the childs responses to different modes of sensory
input in various situations. Also, functional vision and hearing
assessments should be used to determine how the child is using
Should I use tactile strategies when
the child has some vision?
are many reasons why the use of tactile strategies may benefit
a child with multiple disabilities. All children learn through
a combination of input from their senses. When children have
multiple disabilities and subtle responses to visual stimuli,
it may be difficult to determine whether the child has a clear
understanding of what is being presented or communicated through
visual means. Tactile information will supplement visual input
or clarify other sensory input because it is very concrete.
Will the use of tactile strategies interfere with the child
learning to use his or her vision?
our experience, the use of tactile strategies will not inhibit
or prevent a child from learning to use his or her vision. Appropriate
modifications (e.g., positioning, color, contrast, lighting)
of materials and the environment must also be made to encourage
the childs use of functional vision. In fact, increased
active participation in interaction and activities should motivate
a child to learn to look. Some children with cortical visual
impairments have difficulty looking and reaching or manipulating
an object at the same time. They may look then look away and
reach or tactilely examine the object. It is important for family
members and service providers to agree on the strategies that
they will use with a child. For example, objects may be first
presented visually to a child, then after several seconds, provide
an opportunity for the child to touch and handle the object.
In this way, what the child feels will confirm or clarify what
he or she sees.
Is there a sequence for beginning to use tactile strategies
with a young child?
is no single sequence for using tactile strategies that fits
every child who has multiple disabilities. Each situation is
different, and tactile strategies need to be selected accordingly.
Mutual tactile attention is a place to begin establishing interaction
and supporting the childs communication development. As
discussed in the manual, every child needs both a means to receive
communication and a way to express himself or herself. Begin
by carefully observing the child in familiar activities with
preferred people. What are the features of preferred objects?
What situations seem to be the most motivating for the child?
Note how the child uses the sense of touch to explore and interact
with others and how he or she responds to tactile input from
How do we decide which tactile communication strategies (e.g.,
coactive signs, sign on body, tactile signs, touch cues, object
cues, textured symbols) to use with a child who is deaf-blind?
identify the childs receptive and expressive communication
behaviors. Next, consider the childs motor and cognitive
abilities. Use techniques that the child will easily understand
so that he or she will experience immediate reinforcement and
pleasure for effort during interactions. If there is little
or no response from the child, try a strategy that provides
more concrete information (e.g., whole objects that are familiar
to the child). Be sure that any strategy that is used with the
child is integrated in natural, respectful, and enjoyable conversations
that involve turn taking and shared attention. Over time, a
child may progress to more abstract and complex communication
How do we determine whether to use a textured symbol or an object
Object cues are easily understood because of their obvious relationship
to their referents (e.g., a cup to represent drink). When it
is difficult or inconvenient to use an object cue (e.g., to
represent lets go outside and play on the lawn),
then a more abstract communication mode, such as a textured
symbol, may be needed. See previous discussions on object cues
and textured symbols. What an object cue or textured symbol
represents must be made immediately apparent to a child (i.e.,
by giving the child the item, beginning an activity, or going
to the place) so that he or she will understand its meaning.
What should I do to help the child understand what textured
symbol or object cue means?
key to helping a child understand the meaning of any communication
cue or symbol is to link it closely to its referent (mutual
tactile attention within conversations will support this) and
to use it consistently within meaningful activities in a variety
of settings. The child needs to learn that a particular textured
card or object stands for a particular activity or object. When
the child touches the textured card or object, he or she must
receive or experience the referent immediately.
8. How can a child who is blind differentiate
between a touch cue and a sign made on his or her body?
the child may perceive the sign made on his or her body as a
touch cue having a very fixed meaning within a specific context.
Through consistent exposure to the sign (i.e., by encouraging
the child to feel the signers hands and by using coactive
and tactile signs) and its referents (objects, people, or activities),
he or she may gradually recognize a sign that is produced on
his or her body (e.g., if the signer places his or her hand
on the childs mouth to sign EAT, the child will feel the
placement of the touch on his or her mouth and not perceive
the flat O hand shape that is a feature of EAT)
has the same meaning when it produced coactively or signed tactilely
in different situations.
I get confused between coactive signing and tactile signing.
How are they different?
signing is a means of receptive communication. The child tactilely
perceives or reads the signs by keeping his or her hand over
the signers hand. Coactive signing is used for instructional
purposes, to teach a child how to produce a new sign in the
appropriate situation, or to help a child to produce signs to
convey a message that he or she wants to express. Use tactile
signing when you want to send the child a message and coactive
signing when the child wants to communicate something. Just
as listening precedes speaking in children who can see and hear,
understanding tactile signs (receptive language) precedes the
production of signs (expressive language) by children who have
a hearing loss and no vision.
How can I develop some concrete way to let the child know that
he has completed a particular activity rather than my just signing
children who are blind and nonverbal may not know how long an
activity will last or understand our expectations for a particular
task. They may be quite startled by a sign for FINISH that seems
to come out of nowhere. It is important to make the message
and expectation very concrete and easy to understand. One simple
way is to tell the child how many times he or she is expected
to do a task and make that expectation apparent from the materials
that are available. For example, in a block and container play
activity, put out 5 blocks for the child and say use key tactile
signs PUT BLOCKS IN BUCKET, 1,2,3,4,5, FINISH.
at clean up time, you can specify how many things
and the names of the things that the child needs to locate and
put away. This is helpful if the child cannot see whether or
not the whole area is cleaned up. For example, Jimmy,
find the car and the hat and put them away. You can let
children know when there is Five more minutes of playtime.
Introduction to number and time concepts within everyday activities
will build on the childs early literacy skills. At music
or circle time, provide a tray or container with objects or
other tactile representations of songs and activities, so children
can make a choice and also learn that when the tray is empty
the activity will end. Again, telling the child One more
song and then we are finished is also important. A modified
timer may also be useful if the child can hear the buzzer or
What can I do if a child is tactilely defensive and hates to
of all, do not force the child to touch and handle the things
that he or she rejects. Very often, the termtactilely
defensive is misused by service providers to label a child
who does not want to touch or handle certain materials. It is
most important to consult with an occupational therapist that
has expertise in sensory integration. He or she will have specific
procedures for identifying whether a childs responses
are indicative of tactile defensiveness, some other sensory
defensiveness or hyper-responsiveness to certain sensory stimuli.
If the occupational therapist determines that the child has
a sensory modulation dysfunction, then he or she will recommend
certain activities to address this neurologically-based problem.
If the childs reluctance to touch and handle certain materials
is based on unpleasant experiences, take time to develop a trusting
relationship, make your hands quietly available to the child,
use mutual tactile attention, tactile modeling, and hand-under-hand
guidance to gradually offer opportunities to touch, explore,
and handle preferred objects without forcing the child to do
so. Provide anticipatory cues and expand the childs communication
and understanding of activities.
How can I encourage service providers to be more consistent
in the use of selected tactile strategies for a particular child?
who have multiple disabilities are likely to interact with many
different service providers during their school programs. It
will be very confusing for the child if each person uses a different
method of communication and has conflicting expectations. The
childs communication options should be noted in the IFSP/IEP.
It is very important to have a team meeting with family members
and service providers who interact most frequently with the
child to identify and agree on tactile strategies that will
be used consistently. Practicing selected strategies and viewing
videos of the childs interactions are very helpful procedures.
Once strategies are selected and agreed upon, methods for sharing
information, documenting practice, and planning for follow up
are needed. Written guides on the use of cues and signs should
be available in easily accessible places. Data collection sheets,
communication notes, or e-mail are ways to document practice
and share information. Short, regularly scheduled meetings facilitate
opportunities for data analysis, evaluation of current strategies,
and agreements on any changes that need to be made.
When interacting with my child I have realized that I pay more
attention to his facial expression and body movements but not
to his hands. How can I become more aware of my childs
hands to engage in tactile conversations?
become more aware on how you use your hands when interacting
with your child. Use the Self Awareness Questions in the SALUTE
manual to think about your own body language. Next, carefully
observe your childs hands while he or she is interacting
with objects and people. Become familiar with his or her hand
movements. Practice focusing on the childs hands as well
as facial expressions and body movements during interactions.
Try closing your eyes during touch conversations between your
hands and the childs hands. This will help you become
aware of how your hands receive tactile information from the
What should I do if a child persists in putting objects in his
mouth rather than touch them with his hands?
is a priority, so children must not be allowed to put small
objects or other health hazards in their mouths. Young children
without disabilities vary in the age at which they no longer
put things in their mouths (Juberg, Alfano, Coughlin & Thompson,
2001), but this mouthing behavior does not inhibit their hand
use. Children who are blind may use mouthing as a way to maintain
contact with and obtain information about an object. If so,
objects should be washed for hygienic purposes. Children usually
decrease their mouthing of objects as they increase their hand
use. Play activities that involve throwing in appropriate situations
(e.g., throwing beanbags onto a big drum) may promote outward
hand movements that will help separate the childs hand
from his or her mouth. If mouthing is a concern, then professionals
of relevant disciplines (e.g., occupational therapy, visual
impairment, nursing) should develop a working hypothesis about
the function of the mouthing behavior. What sorts of objects
are mouthed? Does the child seem to discriminate between certain
sizes, shapes, or textures through mouthing? How does the child
use his or her hands? When and how does he touch and handle
objects? Will the child touch and handle objects if something
is in his or her mouth (e.g., a pacifier for a toddler)? Through
a comprehensive interdisciplinary analysis, an appropriate approach
can be developed to encourage the childs manual exploration.
What can I do if a child rejects my efforts to interact with
him and seems more interested in engaging in self-stimulatory
behaviors (e.g., patting self or objects)?
that a child needs to see an activity before he
or she will want to participate. Concentrate on providing opportunities
for the child to touch your hands and objects without the expectation
that he or she participates in a certain way. Spend time just
making your hands available to the child and see what he or
she does. Have fun making conversations with hands
by imitating the childs hand movements in a gentle and
playful way. It takes time to establish a relationship and to
develop an understanding of the childs experience and
perspective. Carefully observe the childs actions and
identify when you might join in his actions. For example, if
a child persists in patting an object, you could gently place
your hand beside his hand and imitate his patting action, thus
communicating I see what you are doing, lets pat
together(mutual tactile attention). Once the child accepts
your imitative tactile interaction, try to introduce other activity
involving a different hand movement (e.g., varying the tapping
rhythm) or object (e.g., a drum). This will provide a basis
for developing other kinds of social games and interactions.
16. My child dislikes having his hands
touched or manipulated. How can we interact with him in a more
not manipulate the childs hands or force him or her to
touch something that he resists. Consult with an occupational
therapist regarding the childs hand use and responses
to tactile input, and to obtain suggestions. Use tactile strategies
that allow the child to maintain control over his or her own
hands (see the previous discussions on mutual tactile attention,
hand-under-hand and hierarchy of prompts). Create playful interactions
involving hand games or finger plays that you both enjoy (e.g.,
pat-a-cake for a young child and High Fives for
an older one) and follow the childs lead by imitating
his manual actions (e.g., clapping hands, tapping a tambourine,
or playing a keyboard).
My child is totally blind and has some hearing and poor muscle
strength (very low tone). He doesnt like to manipulate
or explore objects. I have to manipulate his hands to help him
with everything. How can I help my child participate without
continuously moving his hands?
your concern with your childs teacher and physical or
occupational therapist to determine the best way to help your
child. Depending on your childs motor ability, they may
suggest some simple adaptations to materials (e.g., Velcro or
built-up handles on objects to help your child grasp them),
ways to increase the childs attention (e.g., by tactile
kinesthetic play) as well as ways to gradually decrease his
dependence on your total physical assistance. Begin with activities
that your child enjoys so that he is motivated to participate.
Instead of using hand-over-hand guidance, try supporting him
at the wrist or elbow to see how he responds to those physical
prompts. See how he responds to hand-under-hand guidance when
you introduce your hand under his. Will he keep his hand on
top of yours if you touch his hand with your finger?
My child is blind and has severe cerebral palsy. He has very
limited hand and arm movement and tends to keep his hands in
fists. What kind of tactile strategies can I use?
to meet with your childs educational team to discuss your
questions. The physical or occupational therapist can explain
your childs motor abilities and optimal positioning needs;
and may suggest ways to help decrease your childs tone
to help him open his hands. The speech and language therapist
and teacher will have suggestions about adaptive switches or
other communication devices to support your childs communication.
Together you can determine what tactile strategies to try first
and how your child uses and responds to tactile information
How do you know what a child is learning (e.g., understands
language/communication input)? How do you determine the next
whether an instructional strategy is effective for a particular
child must be a priority in teaching all children who have disabilities.
Otherwise we would not be providing the most appropriate educational
opportunities. Its a challenge to determine what a child
is learning if the child has significant and multiple disabilities
that influence his or her behaviors. The childs responses
may be extremely subtle or atypical. Careful observation, systematic
interaction, data collection, and analysis of the childs
behaviors are essential in determining what a child is learning.
How does the child respond to a delay or interruption
of a very predictable sequence in an activity? How does the
child react when he is given the object cue for a certain activity?
Videotape an interaction or routine when the child is first
learning about it, and then do so again later on when he or
she has become more familiar with the activity. Comparing the
childs behaviors on these tapes may be helpful in identifying
subtle changes in his or her quality of responses.
How can I encourage other children to use tactile strategies
with the child who is deaf-blind?
is very important to encourage these interactions because most
children like and learn from peers. Moreover, many children
with significant disabilities have limited opportunities to
interact with other children unless adults provide sufficient
support. Similarly, children without disabilities need to learn
how to interact effectively with a child who is deaf-blind.
You can use your own interactions as a model. Help children
follow the interest and lead of the child who is deaf-blind
rather than manipulating his or her hands. Teach them how to
adapt signs appropriately for the individual child who is deaf-blind.
Show them simple strategies such as offering an object under
or to the side of the childs hand rather than physically
moving his or her hand to the object. Discuss the importance
of waiting for the child to respond by allowing enough time.
Help children practice tactile strategies with each other or
an adult. Encourage them to interpret the behavioral responses
of the child who is deaf-blind and respond appropriately.