SPEECH THERAPY AND BLINDNESS

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

Blindness, visual impairment and speech-language impairments

Most people who are visually impaired have some degree of sight. But there are some people who have absolutely no sight whatsoever. Some people’s visual problems are a result of some condition that affects the eyes themselves; others have visual problems because the neural tracts that take the information from the eyes to the brain are damaged – this is what is called CVI (cerebral visual blindness).  Like all children, blind or visually impaired children can have specific language impairments, childhood apraxia of speech, cleft palates, learning disorders, intellectual disorders. They can also have hearing losses. Speech therapists play a role in the lives of visually-impaired people who are risk of, or who have, communication impairments. It is really a whole lot easier for blind people to cope in the world if they can use language to mediate their learning and to negotiate the world. What is absolutely non-negotiable is that blind or visually impaired children need language. It is difficult for low-vision, CVI, or blind children to negotiate their way through the environment because they cannot see it. They need the world to be spoken about.

The child will not associate barking with a dog unless someone tells him it’s a dog. ”Here is a doggie. He is barking.” So we use language to tell the child about what is in the world. We use language to explain the environment to blind children. We use language to tell the child about our minds – they cannot read our facial expressions, and cannot work out context sometimes because they cannot see it. Put your right hand out. Can you feel the door? Okay, Walk a little to the left and you will get to the handle. There you go!

At around 6 to 9 months, the baby may start to reach for the source of the noise – so encourage this. You can help the baby by taking his or her arm to reach. Blind/visually impaired babies generally do not explore the environment because they cannot see what there is to explore, so you need to take them to explore. They cannot see the edge of the room, so you need to take them there – pick them up, hold out their hand, and walk towards the wall, then put the baby’s hand on the wall. Start to use “orientation and mobility” principles from under a year of age. And, all the time, TALK TO THE BABY and use WORDS TO DESCRIBE THE ENVIRONMENT. Don’t underestimate how much babies get to understand less than one year of age.

Blind/visually impaired babies may have delayed physical development such as sitting later than sighted babies. You can encourage this development. Please consult with a physiotherapist if your child’s physical development is delayed. Put your child on his tummy, on the floor, in his cot, in a safe baby chair, and in a high chair safely strapped and always in your sight. Give him or her variety of positions. Encourage movement using tactile, auditory and olfactory sensory input. He or she will learn to reach out for things and will explore things.

The blind/visually impaired baby needs to be attracted to things so make them tactile. A sighted baby looks at a range of things and chooses which one to go for. The blind/visually impaired baby needs the choice too. So give him or her variety of toys, placed close to him or her. The toys must have interesting textures (e.g. a ball covered in tin foil, fabric, cotton wool, or a ball made with a textured covering). The items can also be constructed to make noise (e.g. a match box with a bit of sand in it;  or a cookie box with a toy inside) (NB Never use little things that the child can choke on if the small item comes out of the box!). A rattle, a teething ring, a plastic drinking bottle – anything that the child can hold, explore, listen to, feel.

The child will drop the toy, and will not SEE that it still exists. So he or she will not attempt to find it until object permanence is learned. Teaching object permanence is critical for language development. Babies who are blind/visually impaired need to feel that objects that have ‘disappeared’ still exist. They cannot see them, but you can show them by telling them, or by taking them to where the object is. Object permanence means that the child knows that when something is out of their hands – when they can no longer feel it or hear it – it still exists. Typically developing babies learn this over time – months in fact. By the age of 9 months, they have developed this understanding. Blind/visually impaired babies may take more time.

Blind/visually impaired babies need to learn to explore toys. Adapt toys.  Most modern toys are made of plastic in primary colours. So the orange ball and the purple ball, as well as the black one and the pink one all feel the same. Blind/visually impaired children need to play with different toys and need to learn to identify difference (that is the beginning of ‘comparing and contrasting’, a crucial cognitive skill).   But if the purple one is a bit rough (because we dotted bits of glue all over it) and the pink one is furry (because we stuck little bits of cotton wool on it), and the black one is rough (because we stuck river sand on it with glue), then they are all (1) different and (2) interesting. You really do not need to spend money on ready-made sensory toys. This is especially relevant in South Africa where imported toys cost the earth. Make a sensory board. Go to the hardware shop and buy all kinds of hinges and locks. Stick them on a piece of chipboard and hey presto, you have a board of things to feel. And language to learn: e.g. what’s this? It’s hard, it’s made of metal. Let’s play with this.  It’s a zip. Open and close zzzziiiipppp – can you hear the noise it makes a long zip and a short zip. Open it fast. Close it slowly. Much language can be learned through the tactile world.

Blind/visually-impaired children need to read and be read to! Book reading is a powerful way that children learn language … vocabulary, grammar, narratives and scripts (e.g. beginning, middle and end). They learn about predicting (what is going to happen on the next page or at the end); they learn to infer. They learn about literacy … that there are sounds, words, sentences, punctuation. The list of what we learn through being read to and through reading are endless.  Blind/visually impaired children don’t need pictures – but they need their attention to be kept in other ways. Their very early books can be tactile books … and home-made ones. Audiobooks are wonderful, but cannot replace being read to in an interactive way by an adult who asks questions, points things out, laughs with a child, repeats the pages, changes the scripts, adds his or her own little touches, makes funny voices and accents. Make the world a tactile one and through lots and lots of language, bring the world to the child who does not have the ability to explore the world. Give the child a sense of where s/he is by using touch and language: Take the child around the room by the hand and talk to him or her about where the room begins and ends, where everything is situated in the room (e.g the table is next to the door; the carpet ends here; the chairs are on your left) – even from a very young age!  The child cannot see the environment – you need to show him or her where s/he is, where the boundaries are – even when sitting at a table, let the child feel the edges so the child knows he or she is sitting at a small or big table; that the edge is close or near etc. Use the child’s own body to talk about things like height, depth, distance, size e.g. the plane goes high up in the sky. Put your arm up, the aeroplane is higher than your arm, it’s so high that no one can touch it or the tree is tall, even taller than me. Ok, let’s make a line on the wall (with tape) to show how tall you are. Now let’s do how tall I am. Pick the child up so s/he can feel the tape running from the floor to your marker and compare it to his own marker on the wall by feeling the distance from the floor to his or her own marker.

Adapt toys and make them tactile: Here’s a dice made out of a small box with little balls of tin foil stuck on with glue. There is a stone inside the box so that when the child shakes it, it makes a noise. Here is tactile snakes and ladders made out of cardboard. The dividing lines are made of strips of cardboard stuck on with masking tape. The ladders are strips of cardboard with rungs made of adhesive glue .The snakes have been painted to make them feel smooth and the snakes’ heads are indicated by a blob of adhesive glue. The first and last blocks have been marked with blobs of glue as well.  When we play, the markers are pressed in place with Prestwick (like BluTak) so that they don’t get bumped off by mistake. The markers on this board are a green Lego helmet and an old coin.

Blind/visually impaired babies need to learn about cause effect. This means that they learn that if we do something, there is an effect. Provide them with many opportunities – if they press a button, the toys make a noise. If they open a bottle, the water is there. If they throw a ball, it makes a noise. If they shake the box (with the toy in it), it makes a noise. If they smile, they are spoken to …and so on. Blind/ visually impaired babies need to learn about joint attention. It is necessary to teach joint attention to blind/visually impaired babies in a tactile and auditory way.

Speech production of blind and / or visually impaired children.

Many children who are blind or have visual impairments present with speech sound disorders. For example, they continue to muddle up ‘f ‘and’ th’ for a long time. However, in my experience – I don’t have much literature to guide me – most children who are blind learn all their speech sounds very well and easily if their cognition is intact and if their ears hear perfectly. I am not sure how much vision plays a part in learning speech sounds. I don’t think much – after all, most speech sounds are not visible! That is why it is so very hard to lip read. The problem is that many children with visual impairments have other problems too -and it seems that these other problems interfere with learning speech sounds. So, for me, the main issue in speech sound production is coming up with ways to teach sound production that do not depend on the child looking at how and where sounds are made, but rather by facilitating the learning of speech sounds through feeling and hearing the sounds, and by listening to what to do from very carefully worded instructions.

Language impairments and visual impairments

There are basically two approaches to looking at the development of language in blind or visually impaired children: one is to compare their learning to that of typically developing sighted children. By doing this, we create what we call a ‘deficit’ model – we claim that in the absence of vision, there is a deficit which must impact learning. It’s not a good approach because it locates the problem in the individual and ignores the role of everything else the child encounters in the world which may contribute to the problem. The other way to consider the language development of blind or visually impaired children is a ‘difference’ model which means that that we understand and acknowledge that the children learn in a different way. The route that they take to learning is different; the behaviours that they demonstrate are different; and sometimes their ways of speaking are different. We have to be very sensitive to the behaviours of the child or we will under-estimate their skills. For example, blind children may repeat what we have said (echolalia) a lot – is it a problem? Some people say so and work to STOP the children from using echolalia.  Others disagree and point out that blind children use imitation as a means of communicating and to work with language. Similarly, blind children may use vocalizations and tactile handling where sighted children use gestures – the behaviours achieve the same goals in different ways. But does ‘different’ just mean that they will learn in a different way with the same end-process competencies as sighted children? I am not sure!  I’m not sure whether visually impaired or blind children who have perfect hearing and good cognitive skills are at risk of language impairments, and the literature is not informative enough – we simply do not have enough research to tell us.

The environment plays an exceptionally huge role. A blind or visually impaired child will not comment on or ask about things that are invisible to them so it’s our job to tell him or her about them. We must talk about the broader environment. “We are in a garden. We are standing on the grass, and there are trees and flowers all around us.

 

AAC and blind/visually impaired children

Many children who are blind/visually impaired experience very significant speech and/or language problems that make it very difficult for them to learn language or to communicate with others. Speech therapists use what we call “alternative and augmentative communication” with people with such difficulties. It can be difficult to provide blind or visually impaired people with AAC but it is not impossible!

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