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DOCUMENT RESUME

ED 359 698 EC 302 258

AUTHOR Downing, June E.TITLE Communication Intervention for Individuals with Dual

Sensory and Intellectual Impairments.PUB DATE May 93NOTE 29p.; In: Kupper, Lisa, Ed. The National Symposium on

Effective Communication for Children and Youth withSevere Disabilities (2nd, McLean, Virginia, July10-12, 1992): Topic Papers, Reader's Guide &Videotape. p109-134. See EC 302 252.

PUB TYPE Guides Non-Classroom Use (055) Viewpoints(Opinion /Position Papers, Essays, etc.) (120)

Speeches/Conference Papers (150)

EDRS PRICE MF01/PCO2 Plus Postage.DESCRIPTORS Agency Cooperation; *Communication Skills; *Deaf

Blind; Early Intervention; *Educational Practices;Elementary Secondary Education; Evaluation Methods;Higher Education; Interdisciplinary Approach;*Intervention; *Multiple Disabilities; ProfessionalEducation; *Severe Mental Retardation; TeacherEducation; Teamwork; Technology

ABSTRACT

This paper presents a summary of best practices forcommunication assessment and intervention with individuals who aredeaf/blind and have a severe intellectual impairment. Focus is onindividuals who have difficulty both receiving and understandingauditory, visual, and tactual information. The impact of sensorylosses on communicative development is considered, followed by adiscussion of general practices for communication intervention whichstress a functional approach linking assessment and intervention anda multimodal delivery form. Means of facilitating communicativedevelopment include creating an optimal communication environment,using the team approach effectively, developing augmentativecommunication modes, and using compensatory teaching approaches andprompting techniques that bypass the sensory impairment.Recommendations address collaboration between organizations,increasing the number of potential communicative partners, earlyintervention, utilization of technological advances, and personnelpreparation and inservice training. The paper concludes with a listof 52 references and related resources including 20 related articles,5 assessment tools, 15 monographs and books, 9 video training tapes,6 organizations, and 8 technological aids. (DB)

Reproductions supplied by EDRS are the best that can be madefrom the original document.

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Communication Intervention for Individualswith Dual Sensory and Intellectual Impairments

byJune E Downing Ph.D.

University of Arizona

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Communication intervention for individuals with dual sensory impairments (deaf-blindness)continues to receive considerable attention as a critical need in the field. While significant advancescertainly have been made, many individuals with both a dual sensory impairment and a severeintellectual impairment continue to experience extreme difficulty making their needs known. Althoughvarious means of communication have been tried with this population, truly effective interactions remainelusive. The extreme diversity of this population makes it difficult to address their equally variedcommunication needs.

To keep the focus on individuals having a dual sensory and intellectual impairment, thoseindividuals who are labelled deaf-blind but who are not intellectually impaired and who do uselanguage (spoken, signed, or written) will not be addressed in this paper. Instead, this paperi presentsa summary of current best practices for communication assessment and intervention with thoseindividuals who have difficulty both receiving and understanding auditory, visual, and tactualinformation. Recommendations for future intervention research and strategies address the areas inwhich greater development is needed to ensure effective communication skills for all individuals withthis challenging disability.

Effective communicative exchangesoften prove difficult for individuals withsevere disabilities. This difficulty isexacerbated when the severe disability isboth a dual sensory and intellectualimpairment (Jensema, 1979; Rowland,1990; Siegel-Causey & Guess, 1989).Helping these individuals develop andenhance communication skills poses amajor challenge for direct serviceproviders, many of whom have had limitedexperience and/or training in this area.

Perhaps one of the greatesthindrances to effective intervention isdetermining the makeup of this popula-tion. Many equate the label dual sensoryimpaired (or, more commonly, deaf-blind)with the familiar figure of Helen Kellerand anticipate needs of the populationaccordingly. Despite the popular associa-tion with this very talented woman, themajority of individuals labelled deaf-blinddo not fit this classic picture. In fact, 60%of the population with this label also have

This paper was prepared for and presented at the Second National Symposium on EffectiveL,, Communication for Children and Youth with Severe Disabilities, held July 10-12, 1992 in McLean,

' Virginia. The Symposium was supported through Grant No. H086B10002, a Cooperative Agreement\C) between Interstate Research Associates, Inc., and the Office of Special Education Programs (OSEP)cy- of the U.S. Department of Education. The opinions expressed herein do not necessarily reflect the

\ position or policy of the U.S. Department of Education, and no official endorsement should beinferred.

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intellectual, physical, and behavioraldisorders that seriously impact their abilityto interact with others in a desired andconventional manner (Jensema, 1979;Stein, Palmer, & Weinberg, 1982). UnlikeHelen Keller, most individuals with dualsensory, intellectual, and otherimpairments do not have a language perse (whether spoken English or AmericanSign Language), but attempt to makebasic needs known by whatever meansavailable to them. Since their uniquesituation poses such a profound challengeto interventionists, the target of this paperwill be this group of individuals havingsevere sensory and intellectual (plusadditional) disabilities.

Even within the subpopulation ofpeople labelled dual sensory impaired whohave intellectual and other impairments,an extreme diversity exists with regard toability and needs. A few individuals haveno functional hearing or vision. Othersmay be primarily visual learners withlimited auditory ability; still others haveno functional vision but have some abilityto hear. Some individuals (labelledfunctionally deaf-blind) have no apparentphysiological impairments of eithersensory mode, yet do not make use ofvisual or auditory information. Thepurpose of this paper is to present the

This paper appears in L. Kiipper (Ed.),The Second National Symposium on Effec-tive Communication for Children and Youthwith Severe Disabilities: Topic papers,reader's guide & videotape. McLean, VA:Interstate Research Associates.

communicative interventions most oftenemployed with these individuals and tosuggest areas in which future efforts canbe directed.

Impact of Sensory Losses onCommunicative Development

The development of effectivecommunication skills relies heavily onappropriate sensory input and the abilityto interpret that input during the earlydevelopmental years. Individuals withcongenital sensory impairments, especiallythose with additional impairments, are atextreme risk for exhibiting delays incommunicative skills (Rogow, 1988;Siegel-Causey, Ernst, & Guess, 1988).Visual and auditory information providesmotivation for the young child to explorethe environment, interact with people andobjects, and understand the interrela-tionships between actions and events.Furthermore, these two sensory modes,especially vision, allow for considerableincidental learning. Approximately 90%of what a person perceives is obtained viathe visual mode (Barraga, 1986). Sincelanguage learning depends heavily onaccurate sensory input, the impact of anysevere visual and hearing loss on thedeveloping child will be significant.Compounding a vision and hearing losswith an intellectual (and possibly physical)impairment makes it clear why individualswith these multiple disabilities oftenexperience difficulty in understanding orinfluencing their physical and Socialenvironments.

For example, at two years oki,Carrie exhibits behaviors that reflect a

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severe intellectual delay. Without visionor hearing, Carrie has not associated abasic vocabulary with meaningful people,objects, and events. She fears explorationof her world because it often results inpainful accidents, and her physicalimpairments limit her ability to explofeinteresting items tactually. When shescreams or thrashes, she gets picked up;besides this, she prefers to explore herown body, which is safe, readily available,and stimulating. She has learned to archher back, shake her head, and scratch,pinch, or slap body parts for the stimula-tion these behaviors provide. Thisbehavior is all absorbing and is notreinforcing for careproviders and otherchildren. Carrie is left alone for longperiods of time.

When a formal language is notlearned, individuals with this complexdisability rely heavily on partial communi-cation systems. Some individuals mayhave a few formal signs (but are not fluentin American Sign Language). Thesepeople may also make use of facialexpressions, vocalizations, gestures, andbody movements, as well as manipulationsof objects, pictures, and/or textures.Communication with familiar others maybe somewhat effective but is usuallylimited to a few concrete referentsrepmsenting needs, wants, and rejections,all very much bound to the present (e.g.,pushing a bowl of food away to mean"finished"). Expressing abstractions (suchas feelings, dreams, thoughts, or ideasabout past or future events) often is notpossible. This lack of meaningfulexpression and reception of ideas andfeelings results in considerable frustration,

which is sometimes manifested inbehaviors often labelled sociallyinappropriate or unacceptable (Durand &Kishi, 1987; van Dijk, 1985). As theindividual ages into adulthood, thecontinued inability to communicateeffectively results in social isolation,frustration, and, presumably, depression.

General Practices for CommunicationIntervention

A review of the literature ineffective communication strategies for thetarget population indicates that someareas overlap with interventions used forstudents labelled severely intellectuallyimpaired (but no sensory loss). Whilemuch of the content area of the literaturehas significant implications for studentswith a dual sensory impairment, certainmodifications may be needed.

A Functional Approach to Intervention

The functional approach tocommunication intervention recognizesthat the acquisition of meaningful skills ishighly individualized and depends to agreat extent on individual needs andenvironmental demands (Rowland &Stremel-Campbell, 1987; Siegel-Causey,Ernst, & Guess, 1988). This approachemphasizes the unique situation of eachindividual and anticipates that, to a largeextent, acquisition of skills depends onmotivation (as determined by need anddesire) and expectations of social roles innatural environments. Using thisapproach, an individual with dual sensoryand intellectual impairments may learn

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some symbolic communicative behaviors(e.g., using a smooth texture to request adrink), even though developmental scalesmight indicate that this individual does notexhibit the necessary "prerequisite" skills(e.g., sustained eye contact, reaching foran object).

Intervention is initiated based on anindividual's need to communicate in atypical circumstance. The focus is not onhelping the individual acquire develop-mental milestones but, rather, onenhancing specific skills for that individualwithin meaningful socio-communicativesituations. All students are consideredable to communicate and are not requiredto demonstrate skills that typically precedemore formalized linguistic expression(Downing & Siegel-Causey, 1988; Siegel-Causey & Downing, 1987).

Assessing Communication Skills and Needs

The recognition that studentscommunicate not at certain times of theday and in special environments withspecially certified professionals but as theneed and motivation arise throughout atypical day requires a unique type ofassessment approach. Isolated testprocedures that determine performancelevels on some standardized form orchecklist may severely underestimateactual communicative skills. Furthermore,such tests typically fail to evaluate thesocial environment and the real needand/or opportunities to communicate.

In order to be beneficial, assess-ment of communication skills must lead topractical intervention techniques. As such,a functional-ecological approach that

identifies communication demands of thesocial environment and unique individualskills and discrepancies is recommended-(Downing, 1989, in preparation). Assess-ment is individualized and contextual, andis shared as an ongoing responsibility byall direct service providers. Communi-cation needs of each individual areidentified within the context of meaningfulactivities, and observed discrepancies inperformance are targeted for intervention(see Figures 1 and 2). The assessmentprocess looks at the means and functionsof communication required for a variety ofinteractions (see Stremel-Campbell, Clark-Guida, & Johnson-Dorn, 1984; Tedder &Sikka, 1992), with an emphasis on thecommunication strengths and limitationsof all interactants. A team decision isthen used to determine the most efficientintervention strategies for all communica-tors. As the student gains skills and/or aslife needs change, additional activities andenvironments that are meaningful for theindividual are assessed. The assessmentprocess is ongoing, cumulative, anddynamic, not static.

From Assessment to Intervention

A functional-ecological assessmentguides the team decision regarding themost effective teaching strategies toenhance communication skills. Specifictechniques focus on what communicativepartners can do to enhance the socialatmosphere. These techniques involvereinforcing initial communicative attemptsby being responsive to the intent of thestudent (Siegel-Causey, Ernst, & Guess,1988); creating opportunities throughout

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Communication Intervention - Dual Sensory and Intellectual Impairments

each activity for communication (Downing& Siegel-Causey, 1988); and creatingsocial environments (cooperative learning,peer buddies, shared materials, physicalproximity) (Downing & Eichinger, 1990).Other techniques focus on the specificinteraction with the individual, with theintent of shaping limited behavioralrepertoires into more established andconventional behaviors. Toward this goal,interventionists have demonstrated theeffectiveness of modeling the desiredbehavior (Rowland & Stremel-Campbell,1987; van Dijk, 1985); .sing prompt delayto encourage the student's initiativebehavior (Goetz, Gee, & Sailor, 1985;Halle, Baer, & Spradlin, 1981); and fadinginstruction (Halle, 1987; van Dijk, 1966,1985).

Multimodal Approach to Intervention

Since communication needs andabilities are extremely diverse, determi-nation of the one most appropriate modeof communication for these individualsmay not be possible. Current thinkingrecognizes the value of exploring a varietyof possible communicative modes both forreception and expression (Allaire,Gressard, Blackman, & Hostler, 1991;Downing & Siegel-Causey, 1988; Hamre-Nietupski, Nietupski, & Rathe, 1986;Mirenda & Iacono, 1990; Reichle &Karlan, 1985). This approach isparticularly appropriate for individualswith dual sensory impairments whoselimited sensory input demands a widerange of communicative options.

Individuals with dual sensory andintellectual impairments often receive

instruction in manual signs as one of thefirst options. While American SignLanguage (ASL) is the fourth mostcommonly used language in the UnitedStates, and certainly the language mostfrequently used by those who are deaf, itsbenefits for children labelled dual sensoryand intellectually impaired remain inquestion (Bryen, Goldman, & Quinlisk-Gill, 1988; Rotholz, Berkowitz, &Burberry, 1989; van Dijk, 1985). Ameri-can Sign Language is a true abstractlanguage with its own semantic andsyntactic structure (Klima & Bellugi,1979). It also is a visual-spatial languagerequiring motors dexterity, visual ortactile perception, and extensive cognitiveabilities. The requirements of such alanguage make it questionable as the mosteffective means of communication for thispopulation of individuals having visual,intellectual, and possibly physicalimpairments. As a result, many indivi-duals may use a few manual signs (notASL) for both reception and expression,but must rely on other modes of commu-nication when the appropriate sign is notknown or cannot be physically proacced,or when the communicative partner has nuknowledge of a manual system.

Considerable effort has gone intodeveloping and teaching alternative modesof communication. Interventionists havereported on the use of:

nonsymbolic communicative modes(gestures, facial expressions, bodymovements) (Siegel-Causey &Downing, 1987; Siegel-Causey &Guess, 1989);

June E. Downing

tangible symbols (objects or parts ofobjects) (Rowland & Schweigert,1989);pictorial symbols (photographs, linedrawings) (Hunt, Atwell, & Goetz,1991; van Dijk, 1985); andtextured symbols (Murray-Branch,Udvari-Solner, & Bailey, 1991).

Determination of the most effectivemodes of communication vary dependingon the ability level of student, the abilityof the audience with whom that personinteracts, and the motivational level of theindividual. One student with dual sensoryand intellectual impairments may well useseveral modes of communication through-out each day as abilities, needs, and socialexpectations change. For example, Siduses eye contact and facial expressions togreet peers, express feelings, and clarifyintent. He also uses five signs to expressbasic generic needs (want, help, eat, more,and drink), and he extends or points toobjects to clarify intent and to commenton things of interest.

Facilitating CommunicativeDevelopment

While basic principles of effectivecommunication intervention for individualswith severe disabilities hold considerablevalue for the target population, certainadaptations are needed to compensate forthe sensory loss. These adaptations takethe form of developing unique augmenta-tive communication devices, teachingcompensatory strategies to help theindividual make use of residual sensoryinput, and using specialized promptingtechniques. These adapted strategies are

felt to be most effective when learningenvironments are normalized for theindividual and when an effective teamapproach is used.

Creating an Optimal CommunicationEnvironment

Proponents of the inclusion model(Downing & Eichinger, 1990; Giangreco,Dennis, Cloninger, Edelman, &Schattman, 1993; Hamre-Nietupski,McDonald, & Nietupski, 1992; Stainback& Stainback, 1992; Thousand & Villa,1990) recognize the importance ofeducating all individuals in their homeschools and communities. Factors such asthe importance of family and friends, thedifficulty with transferring learned skills tothe natural environment, and the need tobuild natural community support systemsare the guiding principles behind therationale for educating individuals withdual sensory impairments in their homeschools and communities.

Obviously, placement issues play amajor role in communication intervention.It is difficult to maintain the critical roleof the family as team members when theindividual lives far from home. Identifyingactivities, environments, and people withwhom the individual must learn to com-municate becomes particularly challengingwhen that individual is being taught in anentirely different community.

Enhancing communicative optionsfor individuals with the deaf-blind labelrequires broadening the number of naturalcommunicative partners. It is imperativeto specifically teach parents, siblings,nondisabled students, and coworkers how

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to interact with this individual. Thesecritical communication partners will needto be taught how to respond to anextremely limited behavioral repertoire,what to do in the case of nonconventionaland inappropriate behaviors, and how toencourage daily interactions. In addition,these people serve as the role models forappropriate communicative behavior.When individuals with this disability arehomogeneously grouped residentially, forleisure, work, or instruction, the limitedcommunication skills of all present makeit extremely difficult to enhance skills.Ongoing daily interactions with highlyresponsive and competent communicationpartners are recommended. Nondisabledpeers of all ages and family members arelikely candidates to provide the necessarycommunicative support.

Using the Team Approach Effectively

When individuals have dual sensoryand intellectual impairments, the numberof potential team members can be quitelarge. Given the target population'scomplex learning and communicativeneeds, no one professional can be expect-ed to address all problem areas. Theknowledge, skills, and experience of manyindividuals working collaboratively areessential. Information is needed onoptions for alternative and augmentativecommunication modes. Vision assess-ments must be interpreted to assist in thedevelopment of appropriate augmentativecommunicative modes that best meet thevisual skills and abilities of the individual.Information from audiological exams,audiograms, and functional hearing assess-

ments can address the need for reducedenvironmental noise, amplification, recom-mended distance from the speaker, andpotential use of manual sign systems.Team members need to determine themost appropriate position(s), range ofmotion options, methods of messageselection (direct, scanning, encoding), andthe need for any physical adaptations tomake the communication exchange mostefficient.

The primary direct service providerincorporates the expertise of all teammembers into a unified program thataddresses the individual's communicationneeds throughout each day. This provideris in an excellent position to identifycommunication skills and limitations asthey naturally occur during meaningfuland age-appropriate activities.

Family members are essential toany effective intervention strategy; theycan provide critical informationconcerning communicative skills displayedat home, as well as communicative needs.Their input must be obtained to determinepresent and future plans for their child,such as friendship development andparticipation in typical social events(Giangreco et al., 1993). Such inputprovides the necessary direction forcommunication skills intervention. Inaddition, nondisabled peers will need tobe encouraged to provide valuableinformation on content, age-appropriatemeans of expression, and the need forcommunication in typical environments.These peers, as equal communicationpartners f )r the individual with dualsensory and intellectual impairments, needto problem-solve with other team mem-

June E. Downing

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bers to ensure that the intervention is age-appropriate and acceptable to the peergroup.

Integrating available services worksbest when team members are providedwith the time to collaborate and areallowed to contribute what they can to theprocess of intervention versus what theyare expected to contribute based on certi-fication or training (York, Giangreco,Vandercook, & Macdonald, 1992). Inter-vention in this manner requires consider-able role release, respect for otherdiscipline expertise, and a person-centeredfocus that takes precedence over profes-sionals' schedules and areas of speciali-zation.

Developing Augmentative CommunicationModes

When vision and hearing losses plusintellectual impairments interfere withconventional receptive and expressivecommunication, alternative modes must bedeveloped. Determining the most effec-tive modes of communication for a givenindividual depends on that person's needsand preferences, as well as his or herlearning mode.

For students who are able to seemanual signs clearly, reproduce these signsclearly, and recall these signs as needed,and who have access to others who under-stand the signs, a manual system may beeffective. Some may respond well to thesigns presented to them (both visually ortactually), but may not use these signs forexpressive purposes. The problems ofrelying solely on manual signs for allcommunicative purposes are the limited

audience knowledgeable in sign systems(especially modified ones) and the physicaland cognitive demands placed on theperson.

For many individuals with thisdisability, augmentative communicationdevices provide the necessary additionaladaptation for more effective interactions.However, given a substantial visual impair-ment, the customary use of pictorial and/or graphic symbols for such devices maynot be sufficient. Pictures may need to beenlarged, contrasted with color, and/orcolor highlighted. Some individuals withcolor vision may learn to associate givensymbols with the color, even if unable tosee the actual design (Bailey & Downing,in preparation).

Individuals with insufficient visionto receive visual information for communi-cation will need to be taught how to makeuse of auditory information. To assistsuch an individual, information of thisnature can be amplified, provided withlimited background noise, and presentedat a reduced rate of speech. With insuf-ficient hearing to detect speech clearly,exaggerated tone of voice can provideadded information (e.g., the rise inintonation at the end of a sentencetypically signifies a question is beingasked).

A relatively small number ofindividuals will require a tactile mode ofcommunication when both visual andauditory modes provide insufficientinformation for effective communication.Tactile communication modes have beendeveloped which make use of real-lifeobjects to represent events (Writer, 1987;van Dijk, 1984), parts of objects or

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miniatures (Rowland & Schweigert, 1989),and abstract textured symbols (Mathy-Laikko et al., 1989; Murray-Branch et al.,1991). The systematic pairing of thesetactile objects or textures with theircorresponding referent provides theindividual with a means of expressingneeds and of understanding upcomingevents. Since none of the adaptedaugmentative devices represents acomplete communication system for agiven individual, such devices must bepaired with instruction in the use ofnonsymbolic modes (e.g., facial expres-sions, gestures, vocalizations), especiallywhen such communicative behavior clearlyconveys the message. Determining themost effective augmentative communica-tion modes to use per social situationrequires a careful team analysis, thecreativity of various team members, andsystematic experimentation with theselected devices.

Compensatory Teaching for Effective Visionand Hearing Use

Some individuals may have suftlciem sensory input to make some use ofpictorial/written augmentative communi-cation devices or oral language. However,without the proper training in interpretingvisual and/or auditory input, the individ-ual may not be able to rely on this type ofsensory input. The individual must betaught how to use vision and hearingbefore effective interactions with theenvironment are possible.

Associatively pairing the visual orauditory stimuli with the response thatfollows helps the individual make sense of

incoming visual and auditory stimuli(Bailey & Downing, in preparation).Repetition for practice, consistency ofpresentation, and exaggeration of visual/auditory information represent strategiesused to teach the individual to make senseof incoming, albeit limited, sensory input.Once the individual learns the relationshipbetween auditory and/or visual stimuliand the resulting event, more readilyavailable communication modes (speech,pictorial communication devices) can beemployed. As with the instruction ofcommunication skills, teaching an indivi-dual to make use of sensory informationoccurs during typical and meaningfulactivities, not in isolation.

Prompting Techniques that Bypass theSensory Impairment

Since the visual mode provides thegreatest access to information, it is notsurprising that most teachers focus on thissensory mode. Teachers typically modelthe desired response and rely on visualimitation for student acquisition of skills.Verbal instruction is provided to clarifythe demonstration. The individual withdual sensory and intellectual impairmentsmay not receive or understand enough ofthis type of information to meet teacherexpectations.

Enuring that information isreceived by the individual requires theaddition of tactual information. The useof common objects to signal upcomingevents is one such form of tactual input.For example, the individual is cued to godress for swimming by placing the swim-suit in his or her hands. Touch cues

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(often in conjunction with objects) alsoclarify teacher direction (e.g., a touch onthe hand signifies that it is time to beginwork following a break). Considerableinformation can be shared with an individ-ual via the use of specific touch cues(Rowland & Stremel-Campbell, 1987).

Pressure against someone's shoulder toprevent forward movement signals theneed to stop or wait. A pat on theshoulder can indicate satisfaction withone's work. A brush along the forearmcan be a sign of greeting. These touchcues, provided contextually and pairedconsistently with events, can convey atleast some of the information availablethrough more conventional visual andauditory behaviors.

Physical manipulation of anindividual's hands and body to performtasks occurs frequently with this popu-lation, due to the absence of sensoryinformation and, therefore, reduced abilityto respond to natural cues in the environ-ment. Though physical manipulationprovides the necessary information, it maypromote a form of learned helplessness byteaching the individual that the interactionrequires this type of hand-over-handmanipulation. Spontaneity of expressionmay be reduced as the individual learns torespond to communicative requests butdoes not learn to initiate interactions. Toavoid this situation, a systematic procedurefor fading physical assistance as soon aspossible is recommended (Halle, 1987; vanDijk, 1985).

Based on van Dijk's (1966) theoriesof communicative intervention for childrenlabelled deaf-blind, a movement-basedapproach that requires the teacher to

move co-actively with the child holdsconsiderable merit for the student withlimited sensory input (Writer, 1987).Initially, the teacher moves with theindividual as a form of tactual modeling orshadowing in order to establish desiredcommunicative behaviors. The distancebetween student and teacher is increasedas the desired behavior is acquired. Theability to increase distance from theindividual and fade assistance is mostlikely when activities are structured insuch a way that they become easilyrecognized routines. One step of theactivity cues the individual to perform thenext step. The individual internalizes theroutine to avoid relying on externalsensory information (e.g., natural cues inthe environment) that are not readilyavailable due to the sensory losses.Careful adherence to the steps of theactivity in the sequence preferred by theindividual and effective manipulation oftactual items in the environment canreduce the need for excessive and highlydirective physical prompting.

Future Recommendations

A number of recommendations canbe made to address the critical problemsassociated with serving individuals withdual sensory impairments and intellectualimpairments.

Collaboration Between Organizations

Organizations serving people withdual sensory impairments will need tocollaborate on efforts to find the mostefficient and effective means of communi-

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cation skill intervention. The Associationfor Persons with Severe Handicaps(TASH), the American Speech-Language-Hearing Association (ASHA), the Associa-tion for Education and Rehabilitation ofthe Blind and Visually Impaired (AER),the American Association of the Deaf-Blind, and the American Foundation forthe Blind, Deaf-Blind Project, haveconsiderable knowledge related to servingstudents with dual sensory and intellectualimpairments. Although the knowledgebase comes from different perspectives,the ability of these organizations to impactservice providers on a national level canbe considerable. The different areas ofexpertise which each of these organi-zations possesses need to be integratedinto a body of knowledge that is readilyavailable to the practitioner and in aneasy-to-implement form. Collaborativeefforts could occur in research activities toidentify more effective means of facili-tating communicative development, per-sonnel preparation to increase the numberof skilled professionals for this population,and technical assistance efforts to provideneeded knowledge and skills to serviceproviders and families currently supportingindividuals with this disability.

Increasing the Number of PotentialCommunicative Partners

Limited attention has been paid tothe critical area of social interactions withnondisabled peers (of any age). Despitethe extreme loneliness and isolationassociated with this disability (Smithdas,1981; van Dijk, 1966), efforts to developnatural supports (friendships) have yet to

receive the attention they deserve. Thefocus has remained on communicationtraining by teachers, emphasizing theacquisition of basic communicativefunctions (e.g., requesting, rejecting)(Halle, 1987; Romer & Schoenberg, 1994._

Since communication is a dynamic.--interaction between individuals, futureefforts must address the need to teachpotential communicative partners theunique ways of communicating with some-one who is dual sensory and intellectuallyimpaired. Building on the work done byHunt, Atwell, and Goetz (1991), nondis-abled peers and individuals with dualsensory and intellectual impairments canlearn to become conversational partnerswho use other functions of communicationbesides requesting and rejecting. Forexample, a student with this disability canuse a specially adapted scrapbook ofcollected objects acquired on variousoutings to show peers. Turning pages,pointing to objects, and receiving tactilecues back from peers (e.g., pats on thehand) takes the place of the typical verbalexchange. The interac Live nature of truecommunication requires that both conver-sational partners understand and make useof multimodes of communication. Inter-vention will need to target both partners,not just the individual with the disability.

Early Intervention

Little disagreement exists over theneed to provide support services to chil-dren with this low incidence disability.Limited sensory input severely impacts thedeveloping child, making it extremelydifficult for the child to understand causal

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relationships in the environment that areso critical to basic language skills (Michael& Paul, 1991; Walker & Kershman, 1981).The longer the child has difficultyreceiving and interpreting sensory infor-mation, the greater the likelihood of thechild turning inward and becoming lessresponsive to the social environment. Thenegative impact of sensory deficits .on thedevelopment of language and learning isclear. Children with dual sensory impair-ments cannot be expected to respond tostimuli they cannot detect.

The relatively new focus on thefamily for early intervention efforts hasparticular relevance for the young childwith this complex disability. Since such achild may not respond as expected tovisual and/or auditory stimuli (mother'sface, sound of father's voice, etc.),careproviders must receive specific supporton how to most effectively communicatewith their child (Siegel-Causey, Ernst, &Guess, 1988). Both caregivers and thechild require ongoing support from birthto develop alternative and satisfactoryways to interact.

Technology

Technological advances in the fieldof special education and augmentativecommunication have greatly impacted pro-fessionals' abilities to meet the needs ofthose they sem-. Technology exists toimprove visual functioning, auditory func-tioning, motoric functioning, and commu-nicative reception and expression. Tech-nology also exists to bypass limitationsimposed by sensory and physical disabil-ities (e.g., vibrotactile communication aids,

computers with synthesized speech out-put).

Traditionally, technological advan-ces have been employed with students whohave disabilities but who are able todemonstrate understanding of the tech-nological tool. Individuals with a dualsensory impairment that is compounded byan intellectual impairment have not bene-fited substantially from the onslaught ofadvances in the technological field. Theseindividuals may be excluded from techno-logical assistance due to their perceivedinability to make use of these tools(Fredericks & Baldwin, 1987; Jones,Spellman, & Ozier, 1988; Locke &Mirenda, 1988; Schweigert, 1987). On theother hand, a study by Parker et al. (1990)suggests that it is in fact the professionalswho may feel reluctant to use technolog-ical aids, due to their lack of familiarity,knowledge, and skills.

Hindered by the inability to accesssensory information (as well as interpretthis information), individuals with thisdisability need every opportunity to bypassbarriers to their learning potential andexperience effective technological alterna-tives. While some researchers haveexplored the potential of teaching contin-gency awareness to individuals withcomplex needs (Schweigert, 1987, 1989), abroader use of technology to address morecomprehensive communicative needs hasyet to be fully investigated.

Personnel Preparation and Inset-viceTraining

Since the incidence of individualswith deaf-blindness is quite low

(Fredericks & Baldwin, 1987), it is notsurprising that an equally low number ofskilled personnel exists to support theseindividuals. Information concerning theimpact of sensory losses on the developingchild and adult, especially with regard tocommunication, must become part ofcourse content required for teacher andrelated staff certification for thispopulation. In addition, a multi-disciplinary approach at institutions ofhigher learning is recommended to modeland teach the collaborative skills neededwhen diverse groups of professionalsconverge to support a given individual.

Given the complexity of communi-cation needs and the fact that availableadaptations and strategies change soquickly, it is difficult even for experts inthe field to stay on top of the most currentinformation. Due to the paucity of trainedprofessionals in this field, efforts must betaken to provide preservice and inservicetraining where needed. The increasedinterest in and development of long dis-tance learning and interactive satelliteteleconferencing (Parsons, 1990; Sanspree,Allison, & Gargiulo, 1991) may providethe means of getting the necessary infor-mation to those faced with the challengeof supporting an individual labelled deaf-blind. Educating the professionals whoserve these individuals in their homecommunities would build stronger familialand community supports.

Summary

For individuals with dual sensoryand intellectual impairments, the lack ofeffective communication skills placessevere limitations on their learning poten-tial and sense of belonging. Educationalintervention for this population has recog-nized the critical need to develop commu-nication skills, yet the complexity of theindividual's needs continues to plagueprogress. The unique needs and situationsof individuals in this category, coupledwith the extremely limited numbers oftrained and experienced professionals,challenge the field to develop creativemeans of addressing this vital issue.

Documented case studies providethe field with examples of potentialoptions to employ when addressing thecommunicative needs of individuals withdual sensory and intellectual impairments.However, these case studies provide par-tial communication systems that addresspartial communicative needs. Providingindividuals having severe sensory, intel-lectual, and other disabilities with a truelanguage that can meet all communicationneeds, both receptive and expressive, isstill beyond our grasp. Future efforts withthis focus will need to combine earlyintervention, creative technology, andprinciples of normalization in order to besuccessful.

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Bibliography and Related Resources

Ankles

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Cipani, E. (1989). Providing languageconsultation in the natural context: Amodel for delivery of services. MentalRetardation, 27, 317-324.

Downing, J., & Bailey, B. (1990). Sharing theresponsibility: Using a transdisciplinaryteam approach to enhance the learning ofstudents with severe disabilities. Journalof Educational and PsychologicalConsultation, 1, 259-278.

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Mascia, J. (1991). Audiological services:Meeting the needs of people who are deafand blind. Asha, 33, 36-37.

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Assessment Tools

Otos, M. (1983). Nonverbal prelinguisticcommunication: A guide to communicationlevels in prelinguistic handicappedchildren. Salem: Oregon Department ofEducation.

Rowland, C., & Schweigert, P. (1991). ACE:Analyzing the communication environment:An inventory of ways to encouragecommunication in functional activities.Portland, OR: Oregon Research Institute.

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Tedder, N., & Sikka, A. (1992). Communica-tion Observation Schedule. MississippiState, MS: Mississippi State UniversityRehabilitation Research & TrainingCenter on Blindness and Low Vision.

Monographs, Books, and Chapters in Books

Blackstone, S. (1986). Augmentativecommunication: An introduction.Rockville, MD: American Speech -Language-Hearing Association.

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Bullis, M. (1986). Communication developmentin young children with deaf-blindness:Literature review II. Monmouth, OR:Communication Skills Center for YoungChildren with Deaf - Blindness.

Bulls, M. (1987). Communication developmentin young children with deaf-blindness:Literature review III. Monmouth, OR:Communication Skills Center for YoungChildren with Deaf - Blindness.

Bullis, M., & Fielding, G. (1988).Communication development in youngchildren with deaf-blindness: Literaturereview. Monmouth, OR: CommunicationSkills Center for Young Children withDeaf -Blindness.

Campbell, P. (1987). Integrated programmingfor students with multiple handicaps. InL. Goetz, D. Guess, & K. Stremel-Campbell (Eds.), Innovative programdesign for individuals with dual sensoryimpairments (pp. 159-190). Baltimore:Paul H. Brookes.

Covert, A.M., & Carr, T.S. (1988). Value-based services for young adults with deaf-blindness. Sands Point, NY: Helen KellerNational Center.

Downing, J. (1990). Communication skillsdevelopment: Service provider trainingmodule. In E. Bailey (Ed.), Inservicetraining monograph: Children whoexperience dual sensory impairment andother severe handicapping conditions.Seattle, WA: The Association for Personswith Severe Handicaps.

Downing, J., & O'Dea, A. (1990). Facilitatingfunctional communication: A trainingmodule for parents. In E. Bailey (Ed.),Inservice training monograph: Childrenwho experience dual sensory impairmentand other severe handicapping conditions.Seattle, WA: The Association for Personswith Severe Handicaps.

Gaylord-Ross, R., Stremel- Campbell, K., &Storey, K. (1986). Social skills training innatural contexts. In R. Horner, L. Meyer,& H. Fredericks (Eds.), Education oflearners with severe handicaps:Exemplary service strategies (pp. 161 -

188). Baltimore: Paul H. Brookes.

Goetz, L., Guess, D., & Stremel- Campbell, K.(1987). Innovative program design forindividuals with dual sensoryimpairments. Baltimore: Paul H. Brookes.

Orelove, F., & Sobsey, D. (Eds.). (1991).Educating children with multipledisabilities: A transdisciplinary approach(2nd ed.). Baltimore: Paul H. Brookes.

Reichle, J., York, J., & Sigafoos, J. (1991).Implementing augmentative andalternative communication: Strategies forlearners with severe disabilities.Baltimore: Paul H. Brookes.

Stillman, R., & Battle, C. (1986). Develop-mental assessment of communicativeabilities in the deaf - blind. In D. Ellis(Ed.), Sensory impairments in mentallyhandicapped people (pp. 319-335).London: Croom -Helm.

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van Dijk, J. (1967). The nonverbal deaf -blind child and his world:His outgrowth towards the world of symbols. Proceedings of theJaaverslag Institue voor Doyen, 1964-1967 (pp. 73-110). Saint-Michielsgestel, Holland.

Video Training Tapes

Bailey, B.R. (1991). Finding independencethrough technology for people with deafblindness. Indianapolis, IN: IndianaDepartment of Human Services, Office ofVocational Rehab: Project ATTAIN.

Distributor: Jennifer Meadows, ITRAIDProject, Blumberg Center, School ofEducation, Indiana State University,Terre Haute, IN 47809. Voice telephone:(812) 237-2830. TT: (812) 237-3022.Cost: $27 (includes shipping).

California Deaf -Blind Services (1990).Communication: Forms & function.Sacramento: CA Department of Education.

Publisher: CA Deaf -Blind Services, 650Howe Ave., Ste 300, Sacramento, CA95825. Telephone: (916) 641-5855. Cost:$20.

California Deaf -Blind Services (1991). Trans-disciplinary team strategies: Focusing oncommunication skills development andDeveloping communication skills throughtrans disciplinary team intervention.Sacramento: CA Department of Education.

Distributor: CA Deaf -Blind Services, 650Howe Ave., Ste 300, Sacramento, CA95825. Telephone: (916) 641-5855. Cost:$20 for 1 videotape; $35 for both.

Cooley, E., Singer, G., & Willard, D. (1989).Bringing out the best: Encouragingexpressive communication in children withmultiple handicaps (videotape & manual).Champaign, IL: Research Press.

Distributor: Research Press, Box 3177,Dept. E, Champaign, IL 61826-3177.Telephone: (217) 352-3273. Cost: $150($55 to Rent).

Cooley, E., Singer, G., & Willard, D. (1989).Getting in touch: Communicating with achild who is deaf-blind. Champaign, IL:Research Press.

Distributor: Research Press, Box 3177,Dept. E, Champaign, IL 61826-3177.Telephone: (217) 352-3273. Cost: $150($55 to Rent).

Rowland, C., & Schweigert, P. (1990).Tangible symbol systems: Symboliccommunication for individuals withmultisensory impairments. Tucson, AZ:Communication Skill Builders.

Publisher: Communication Skill Builders,3830 E. Bellevue Rd., P.O. Box 42050 -P90, Tucson, AZ. Telephone: (602) 323 -7500. Cost: $69.00.

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South Dakota Department of Education andCultural Affairs. (1990-91). Helping yourchild learn series (Multiple videotapetopics on families and children with dualsensory impairments). Pierre, SD: Author.

Producer: Baker Street Productions, 88Coach Lamp Drive, Rochester, MI 48306.Cost: $10 per 10 minute topic.

TASH TA Project & Oregon Department ofEducation. (Producers). (1987). Withinreach: Getting to know people who aredeaf-blind. Monmouth, OR: TeachingResearch.

Publisher: Teaching Research Publi-cations, 345 N. Monmouth Ave.,Monmouth, OR 97361. Telephone: (503)838-8779. Cost: $10.

Teaching Research Publications. (Producers).(1985). New concepts in communication.Monmouth, OR: Author.

Publisher: Teaching Research Publi-cations, 345 N. Monmouth Ave.,Monmouth, OR 97361. Telephone: (503)838-8779. Cost: Cost of blank tape, plusshipping and handling.

Organizations

Association for Education & Rehabilitation ofthe Blind and Visually Impaired (AER),Division of Multihandicapped & Deaf - Blind,206 N. Washington St., Alexandria, VA 22314.

American Foundation for the Blind, Deaf-Blind Project, 15 W. 16th St., New York, NY10011. Telephone: (212) 620-2000.

American Speech-Language- HearingAssociation (ASHA), 10801 Rockville Pike,Rockville, MD. Telephone: (301) 897-5700.

Helen Keller National Center - TechnicalAssistance Center (HKNC-TAC), 111 MiddleNeck Rd., Sands Point, NY 11050-1299.Telephone: (516) 944-8900 (Voice/TDD).

ISAAC (International Society forAugmentative & Alternative Communication),P.O. Box 1762, Station R, Toronto, OntarioCanada Ivi4G 4A3. Telephone: (416) T37 -9308.

Teaching Research Assistance to Children &Youth Experiencing Sensory Impairments(TRACES), Teaching Research Division(WOSC), 345 N. Monmouth Ave, Monmouth,OR 97361. Telephone: (503) 838-8150.

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Technological Aids:A Sample of Software Used With Children With Dual Sensory Impairments

Title: Charlie Brown's ABC'sDescription: Alphabet software with large print, large animated graphicsUse With: Standard Keyboard, Unicorn Keyboard, AFCPublisher: American School Publishers, Princeton Road, P.O. Box 408,

Hightstown, NJ 08520Telephone: (800) 843-8855AvailableFrom: Local Computer Store

Title: Creature Antics, Creature Capers, Creature FeaturesDescription: Animated Cause and Effect SoftwareUse With: Standard Keyboard, Touch Window, AFC, SwitchesPublisher: Laureate Learning Systems, Inc., 110 East Spring Street,

Winooski, VT 05404Telephone: (802) 655-4755AvailableFrom: Laureate, Don Johnston, Computability, Access-Unlimited

Title: Explore-A-Story, Explore-A-Science, Explore-A-ClassicDescription: Software with Moveable GraphicsUse With: Standard Keyboard, Joystick, Mouse, AFCPublisher: D.C. Heath & Company, 125 Spring Street, Lexington, MA 02173Telephone: (617) 860-1847AvailableFrom: D.C. Heath

Title: McGee, McGee Visits Katie's Farm, McGee at the Fun FairDescription: No words Preschool SoftwareUse With: Apple llgsPublisher: Lawrence Productions, Inc., 1800 South 35th St,

Galesburg, MI 49053-9687Telephone: (800) 421-4157AvailableFrom: Local Computer Store

Title: Muppet Slate, Seasons and Special Days, More Special DaysDescription: Large Print Word Processor With PicturesUse With: Muppet Learning Keys, Standard Keyboard, Unicorn KeyboardPublisher: Sunburst Communications, 39 Washington Ave,

Pleasantville, NY 10570Telephone: (800)431-1934AvailableFrom: Sunburst Communications

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Title: Stickybear ABC, Stickybear Numbers, Stickybear OppesitesDescription: Preschool Software With Large Colorful GraphicsUse With: Standard Keyboard, Unicorn Keyboard, AFCPublisher: Weekly Reader Software, 245 Long Hill Road, Middletown, CT 06457AvailableFrom: Local Computer Store

Title: Touch'N Match, Touch'N SeeDescription: Picture and Word Matching SoftwareUse With: Touch WindowPublisher: Edmark Corporation, P.O. Box 3903, Bellevue, WA 98009Telephone: (206)746-3900AvailableFrom: Edmark Corporation

Title: Touch'N WriteDescription: Software for Handwriting Skills, Visual Motor SkillsUse With: Touch WindowPublisher: Sunburst Communications, 39 Washington Ave,

Pleasantville, NY 10570Telephone: (800)431-1934AvailableFrom: Sunburst Communications