Adaptations for Learning to Use Touch Effectively
Asked Questions Page--
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 disabilities. Topics include:
Input, Tactile Strategies, and
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1. 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 these senses.
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.
3. Will the
use of tactile strategies interfere with the child learning to use
his or her vision?
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.
4. Is there
a sequence for beginning to use tactile strategies with a young
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 others.
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 modes.
do we determine whether to use a textured symbol or an 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.
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.
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.
9. I get
confused between coactive signing and tactile signing. How are
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.
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. Similarly, 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 bell.
can I do if a child is tactilely defensive and hates to touch
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.
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.
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 child.
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
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
child dislikes having his hands touched or manipulated. How can
we interact with him in a more acceptable way?
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).
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
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?
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 and
do you know what a child is learning (e.g., understands language/communication
input)? How do you determine the next step?
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.
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.