12th International Mobility Conference, Plenary Session VI
November 29, 2006, Hong Kong, China
  • visual and cognitive disabilities (by Eileen Siffermann, COMS);
  • visual and hearing impairments (by Dona Sauerburger, COMS);
  • visual and physical or health impairments (by Dr. Sandra Rosen, COMS)

    NOTE: Click here for an article based on this paper, "Principles for providing Orientation and Mobility to People with Visual Impairment and Multiple Disabilities," published in the International Journal of Orientation and Mobility, Volume 1, Number 1, 2008

    Orientation and Mobility for Visually Impaired Persons with Multiple Disabilities Including Deaf-Blindness

      Dona Sauerburger, Orientation and Mobility Specialist
    Gambrills, Maryland USA
      Eileen Siffermann, Orientation and Mobility Specialist
    Tucson, Arizona, USA
      Sandra Rosen, Coordinator Orientation & Mobility Program
    San Francisco State University, California, USA

    Providing orientation and mobility (O&M) services to visually impaired people with multiple disabilities presents an exciting challenge. It is especially rewarding when it enables students to achieve a meaningful life (personal, family, community and vocational) -- a life which they and their families might not have thought possible.
    The following principles may help when providing O&M to people with multiple disabilities.
  • Understand that multiple disabilities have more impact than the simple addition of each disability.
  • Have high expectations for success.
  • Be functional in the assessment and instruction.
  • Be creative and flexible, and design the program for the individual.
  • Encourage participation in the community, even if it cannot be done independently.
  • Find resources and information related to each of the disabilities.
  • Work with a team or in consultation with others who have expertise in the additional disabilities.
    Multiple disabilities have more impact than the simple addition of each disability:
    Each combination of disabilities presents a unique situation, with challenges that add up to more than the challenges of each disability put together. People who do not have visual impairments, but who are deaf or have mobility or cognitive disabilities use adapted techniques that rely on their vision to function. Many of the strategies that people without vision use to orient themselves, move safely around obstacles and on stairs, cross streets, and communicate require normal cognitive functioning, normal hearing, and/or good mobility. Many of these strategies are not feasible for blind people who can not hear well, or can not understand the strategy nor process the information, or can not move safely and maintain their balance.
    So when vision loss and other disabilities are added together, the impact on people’s options and their ability to function are not added together -- they are multiplied.
    Have high expectations for success:
    In spite of the seemingly insurmountable challenges that multiple disabilities present, people who are blind and have multiple disabilities can achieve high levels of independent travel, often beyond the level at which people thought they were capable. People who are completely blind and have moderate cognitive disabilities are using buses and traveling to and from their homes and their work places or centers every day by themselves. People who are completely blind and have severe cognitive disabilities are independently moving around inside buildings where they live or work. People who are completely blind and profoundly deaf or using wheelchairs or mobility aids travel around the world by themselves.
    When expectations are high, students can be inspired and motivated to achieve their best. Therefore keep an open mind and let the student teach you about how much he or she can achieve, and encourage each student to reach his or her potential for independent travel.
    Be functional in the assessment and instruction:
    Students with multiple disabilities should be assessed within the activity and environment in which they naturally travel. Instruction should be done at the times and places that the student would normally travel.
    Be creative and flexible, and design the program for the individual:
    Standard "recipe" strategies and solutions that are successful for most blind people may not work for the person with additional disabilities, but there are ways to get around most challenges. Be creative and willing to try new strategies and ideas developed for the individual student with multiple disabilities.
    Encourage participation in the community, even if it cannot be done independently:
    All people have the right to acquire skills which allow them to function, at least in part, in a wide variety of environments and activities in their community. Experience in the community should not be denied to any people because they are unable to perform certain activities without assistance.
    Find resources and information related to each of the disabilities:
    None of us can be experts in all things, nor can it be expected that we know all that is necessary to work with all students. Thus we need to know where to get help and resources. We should know about professionals and agencies which serve people with other disabilities; sources of devices and equipment used by people with other disabilities; and sources of information.
    Work with a team or in consultation with others who have expertise in the additional disabilities:
    All students have the greatest opportunity for success when the O&M instructor works together with program administrators. When those who are responsible for funding and managing the program understand the students’ needs for O&M, they are better able to support and facilitate the O&M program, and when O&M instructors work with and understand the program administrators, they are better able to utilize or promote resources to enhance the O&M instruction.
    In addition to working with administrators, when providing O&M to students with multiple disabilities it is considered best practice for the O&M specialist to consult, or work together as a team, with others. This is because students with multiple disabilities have needs that are beyond the job description or body of knowledge that is normally expected of O&M specialists. It is unethical and often ineffective or even detrimental to provide services outside of our area of expertise. In addition, working or consulting with others makes the best use of resources, and provides support when consultants or team members suggest strategies and help brainstorm for solutions to problems.
    Sometimes all that is needed is consultation, where the O&M specialist asks others for information or ideas to meet the complex O&M needs of the student, after which the O&M specialist provides the instruction, consulting again only if needed. At other times, the O&M specialist works with others as a team during the entire O&M program. The team members assess needs and develop goals together, share expertise and ideas throughout the instructional program, and take equal responsibility for monitoring the progress of the student and reinforcing skills. Usually, however, the best model for providing O&M to any particular student with multiple disabilities is somewhere in between the two extremes of consulting and team work -- some of the program development and instruction is done as a team, and some of it done by the O&M specialist alone, with consultation as needed.
    Which professionals are chosen to serve as consultants or team members to provide O&M service to students with multiple disabilities will depend on the characteristics of the student; what support or knowledge the O&M specialist needs in order to be able to serve that student appropriately; and what resources and personnel are available in that culture to students with those disabilities. These consultants and team members typically include physiotherapists; occupational therapists; professionals who serve people with cognitive or hearing disabilities such as special education teachers or communication specialists; travel instructors for people with cognitive, physical, or other disabilities; city planners and engineers; etc. Often, people who should be consulted or part of the team because they know about the student’s special needs are the family or staff who live and work with the student and who provide the student with emotional support. And of course, the most important person to consult and be a member of the team is the student.
    Usually, the professionals and personnel who are consulted or part of the team know little or nothing about blindness and what people can achieve without vision. The task of the O&M specialist is to:
  • share with the others expertise about O&M strategies and adaptations for people who are blind;
  • learn from the others information and ideas about strategies in their area of expertise; and
  • work together with the others to develop solutions and strategies for the student to get around safely and efficiently.
    Working With People Who Have Visual and Cognitive Impairments
    Eileen Siffermann, COMS

      Most frequently the referral for O&M instruction for school aged visually impaired students is initiated by the classroom teacher or as a joint request from the classroom teacher and the parents. Once support for the referral is obtained from the administration, the O&M specialist is scheduled to complete an assessment. Within this system the team of parent, teacher and administrator is required. Frequently other support personnel become part of this team, such as the teacher of the visually impaired, low vision therapist, occupational therapist and physiotherapist. Within adult services, rehabilitation or agencies serving developmentally disabled individuals with visual and cognitive impairments will refer to an O&M specialist for service. A team is then identified which includes the individuals case manager, care takers or residential staff, parents or guardians and support personnel such as low vision therapist, occupational therapist, and physiotherapist.
    An assessment is then completed by the O&M specialist by interviewing parents or residential staff, teachers and other team members; and observing the student several times. An assessment should start with the identification of the student’s daily/weekly schedule. It should be noted when mobility tasks are critical to the schedule, such as when the student arrives at school/work using private transportation and then walks from the bus drop off to the classroom/work area, or when the student leaves the classroom/work area and walks to the lunch room. As part of this assessment it is also very important to obtain information on the student’s visual function, hearing function, psychological function and medical status. The O&M specialist might request additional assessments from the audiologist, the occupational therapist and the physiotherapist. During this process the O&M specialist should make several direct observations of the student within the normal environments of school/work, residence, and the community, such as when the students ride from their residence to school/work, or at their regular scheduled lunch time. The assessment is then shared with the student and the person(s) who made the referral. The O&M specialist sets forth areas and circumstances in which O&M skills could be taught including any mobility devices which might be used. The team prioritizes the areas of instruction and identifies specific skills to be worked on by the O&M specialist. For example, it might be that it is very important to the classroom teacher that the student learns to leave the classroom and, with only distance supervision, travel independently to the school cafeteria.
    The O&M specialist then develops an instructional plan to address the identified O&M skill. The instruction on that skill will be scheduled at the time the activity occurs during the day. With cognitively impaired persons extensive repetitive practice is required. Instruction should be presented sequentially from lesson to lesson. Once the skill has been mastered to a satisfactory level, staff members who work with the student will be instructed in how to reinforce the skill throughout the week. Then the O&M specialist can move on to the next skill which has been identified by the team.
    When introducing a mobility device, success has been accomplished with the use of the two-shafted canes. If students do not require an orthopedic device but are limited in their standing balance and have difficulty walking distance, the two-shafted cane might be beneficial. When grasping the two-shafted cane with both hands, the body is positioned in such a way to provide some support. For others whose nervous system requires greater sensory input, the two-shafted cane provides stimulation through both hands. Greater sensory input is provided by the heavier weight of the two-shafted cane. Attaching ankle weights to the low base of each shaft provides greater proprioceptive input. The two-shafted cane provides the opportunity for simple repetitive behaviors which enhances learning.
    When teaching O&M skills to persons who are visually and cognitively impaired, instruction should address:
  • critical skills: skills determined essential to participation which must be completed by another individual should the student not accomplish it.
  • functional skills: skills which have high probability of future use and essential to student performance in an environment.
  • infused basic skills: academic, communication, motor/mobility, auditory, and visual skills integrated into functional activities within the normal scheduled day and reinforced by everyone who comes in contact with the student.
    Students who have the cognitive ability to learn to travel independently in the community may need adapted strategies. The more severe the cognitive impairment, the less is the ability to understand concepts that are complex or abstract. Independent travel normally requires concepts for such tasks as problem-solving or figuring out what to do in unexpected circumstances; knowing how to handle strangers; measuring and using time; and handling money. Students with cognitive impairments need rules, concepts, and strategies that are effective, yet simple and concrete enough for them to understand.
    Simple, yet effective concepts and strategies for traveling in the community are challenging to develop. For example the rule “don’t talk with strangers” is simple and concrete enough for many students to learn, but it is not an effective rule when students need to get information from strangers, such as which bus has arrived. A rule to “never give any information to strangers” will not work when the students have to give strangers their telephone numbers to call for help. Strategies such as getting assistance to cross a street may not be an option for students who can not distinguish that they should not talk with or try to become friends with the strangers who offer to help, nor let the strangers guide them somewhere else after the crossing is finished.
    These students must also have a simple but effective strategy to use in emergencies, such as when they become lost or get off at the wrong bus stop. One example of such a strategy is to always carry a card with instructions for making a telephone call to a certain family or staff member, and give that card and some phone money to a salesperson who will call and report where the student is. The chosen strategy must be practiced enough in realistic situations to be sure the student can do it reliably, and the student should be tested after traveling independently, for example by having an unfamiliar staff person pretend to be a stranger and approach and tempt them to do something risky such as accept a ride.
    Working with People Who Have Visual and Hearing Impairments
    Dona Sauerburger, COMS

      Blind people who are deaf or who have a hearing loss have the same needs for O&M instruction as do blind people who have normal hearing. Blind people with normal hearing and those with hearing impairments both need skills with a cane or dog; orientation strategies and skills (such as understanding the layout around them, kinesthetic sense to know how far they are walking and how much they are turning, tactile sense to identify what is near them, use of the sun and slopes and other landmarks, as well as problem-solving skills to figure out where they are if they become lost); and to know how to use buses and public transportation.
    Other than the fact that deaf-blind people will not be able to use sounds for orientation, the instruction for O&M skills and concepts is generally the same for blind students who are deaf as it is for those who have normal hearing, except for the following areas:
  • communication between instructor and student;
  • communication and interaction between the student and the public (strangers);
  • street crossing.
    Communication between instructor and student:
    It is essential that the instructor and student be able to communicate comfortably, clearly, and effectively. When communication is difficult, teaching and learning are difficult, and because teaching O&M involves safety, misunderstandings could be dangerous.
    There is a wide variety of communication techniques and several languages used by people who are deaf-blind. The person who best knows the communication needs of the student is usually the student (or his or her family, if appropriate), so it is important to learn from students how to communicate with them. Often it is necessary for the instructor to also consult or work with people who have expertise or skills with deaf people and their communication needs.
    Students who are born deaf may be fluent and comfortable only in a sign language. Sign languages are not visual representations of spoken languages, so these students will not always understand when the spoken language is expressed with writing, or spelling, or even signing, nor will the instructor always understand the student. It is like trying to convey English using Chinese words without the correct tones – it will not always make sense. Therefore it is essential that these students be taught using an interpreter.
    Some students have minimal language, either because they were never exposed to a language they can understand (such as sign language) or they have cognitive disabilities, or both. To teach these students, it may help to work with a person who is able to convey concepts and skills to the student.
    Some students, such as those who lost their hearing after learning the spoken language, are comfortable and fluent with the spoken language of their culture. The spoken language can be conveyed to these students with spelling (such as printing on their hand, or fingerspelling, or fingerbraille) or with signs that convey the spoken language.
    The instructor must sometimes arrange to teach in conditions where communication can be facilitated. For example, for students who rely on vision, communication is best in well-lit areas. For those who rely on hearing for communication, instruction is best in quiet areas -- assistive listening devices are extremely helpful for communicating in noisy environments.
    Communication and interaction with the public (strangers):
    An important part of O&M instruction for all people is learning to communicate with the public (bus drivers, salespeople, and others). This requires special instruction for people who are blind and also have a hearing loss -- it may be helpful to consult or team with a communication specialist who works with deaf people or deaf-blind people and who is familiar with methods of communication. The following is a procedure that works well for providing this instruction.
    1. Student and instructor consider all possible methods for communication (written cards, gestures, action such as guiding or pointing, writing out messages on the hand or a braille device, recorded messages, signals, etc. Then they choose as many preferred methods to communicate as possible.
    2. Student practices and becomes skilled with these communication methods.
    3. Student considers what equipment or material is needed for communication, and learns how to explain the communication method(s) to others.
    4. Student reviews the following principles and suggestions for deaf-blind people:
  • Always assume that others do not understand the situation and do not know what to do – you must explain it to them (repeatedly, if needed!).
  • Always have back-up plans or alternative ways to communicate or get attention if the first plan fails.
  • Know your needs and how to advocate for them.
  • Before asking for help, figure out what you need, exactly how you want the others to help, and how you can get others' attention and communicate to explain your need.
    5. Student prepares to go out and communicate with the public.
  • Student plans every necessary communication for the entire trip, including back-up plans in case the planned communication does not work.
  • Student prepares notes or cards or equipment needed for each task and organizes them to be used quickly and efficiently.
  • Student plans how to get people's attention and assistance in each expected situation.
    6. Student goes out and communicates with the public (try easy situations first) while the instructor observes unobtrusively.
    7. After the practice, the instructor tells the student what happened.
    8. Instructor and student then discuss what worked well, what did not work, and how to improve next time.
    Street crossing
    O&M instruction teaches students how to align and cross straight, and how to use remaining vision and hearing to determine the shape and width of the streets, what the traffic is doing, and when and where to cross (although there are increasing numbers of streets where even normal hearing is not enough to enable a blind person to know when to cross because of noise or quiet cars, wide streets, careless drivers, etc.). To provide this instruction to students who have hearing impairments, it may be useful to consult or team with the audiologist. The primary concern of audiologists is normally to enhance hearing at frequencies needed for communication, but they may be able to recommend aids and devices and/or strategies or adaptations that can be used for traffic and environmental sounds.
    The level of risk involved in crossing varies greatly – some situations have almost no risk (such as crossing a quiet alley) and some are very risky (such as crossing a wide, busy highway). Students must learn to assess how much risk is involved in crossing each street and how to reduce those risks as much as possible, and then decide whether to accept the risk. Deaf-blind people usually need assistance to assess situations and determine the risk. The assistant can point out and explain such things as the traffic and its speed and the width of the street, and the deaf-blind person can then decide whether to accept the risk of crossing there.
    All students should be able to use alternatives for situations where there is more risk than they are willing to accept. Alternatives can include getting help to cross; crossing somewhere else that is safer; avoiding the crossing by getting a ride or having merchandise delivered to the home; etc.
    Working With People Who Have Visual and Physical or Health Impairments
    Dr. Sandra Rosen, COMS

      As in the general population, the number of people who have additional health concerns is increasing. Medical technology has increased the survival rate of at-risk premature babies and reduced the risk of life-threatening complications often associated with many disabilities. In addition, as people live longer, they may have many of the physical conditions and impairments associated with aging.
    Students who have physical disabilities and/or health impairments may have any of a wide variety of different conditions and needs. Some conditions have visual impairment frequently associated with them (e.g., diabetes, brain injury, multiple sclerosis); others do not, but they are very common in the population and O&M specialists are therefore very likely to work with students who have some of these conditions (e.g., arthritis, heart conditions). Each condition potentially affects mobility in vastly different ways. When people have physical or health concerns in addition to their visual impairment, the O&M specialist may be called upon to modify instruction to accommodate special needs dictated by physical and health conditions.
    Addressing the physical and health concerns during the O&M program does not need to be as much of a challenge as it first may seem. While the number and nature of additional conditions seem endless, there are several universal principles that form the foundation for serving all students.

    1. Understand the nature of the condition and its symptoms. Some students have conditions affecting their neurological systems; some their bones and muscles; others have conditions affecting their lungs, heart, digestive system, and even their skin.
    2. Look at specific motor functions - what activities can the student physically do, and what activities pose challenges. Then modify:
  • the technique or activity (e.g., wrap extra layers of rubber tape around the handle of the cane to enlarge the grip for students with painful arthritis; modify the length of the cane or introduce an electronic travel device).
  • the environment (e.g., shorten the route, arrange the direction of travel so that a student with a heart condition does not need to climb too many stairs or walk into the wind).
  • the teaching approach (e.g., use a soft, modulated voice when working with students who have brain injury and a resulting startle reflex or strong spasticity. Modulating one’s voice can actually help to minimize the impact of abnormal neurological activity during a lesson and enable the student to focus more of his neurological effort on learning rather than on controlling basic movement).
    3. Use universal health precautions when working with students. This is extremely important when working with students who may have contagious conditions or compromised immune systems (e.g., AIDS), those with open sores (e.g., diabetes), and those who may get a cut or scratch during a lesson.
    4. Understand potential health-related problems that can happen during instruction. Know the warning signs of trouble and have an action plan prepared for any problems. Both the student and instructor should carry emergency plan and contact information with them during all lessons.
    5. Work with other professionals who have knowledge of the specific physical or health condition. For example, physiotherapists are great sources of information about gross motor function and use of aids such as wheelchairs, canes, and walkers. Occupational therapists can help with fine motor issues and adapted techniques to perform daily living skills (when the problem is not visual, but physical).
    6. Work with administrators or facilities people in public buildings, city planners, and engineers when possible to advocate for any environmental modifications that might assist your student, such as installing curb ramps to allow access for people who use wheelchairs or scooters, with features that allow blind people to recognize the edge of the street.
    7. When working with students who use aids to walk or move, there are specialized techniques to use a long cane together with the aid, and even techniques in which the aid can replace the long cane when necessary.
    8. Most of all, remember that common sense is worth its weight in gold.
    It can easily be said that no two students with physical disabilities and/or health impairments are the same. For these students, O&M takes on new and fascinating challenges. Knowing the above key points, seeking out informational resources and useful devices, equipment, and products, and working collaboratively with other education and rehabilitation professionals, city officials, and others, can go a long way to making a seemingly impossible task become both fun and successful.

    We hope that these suggestions and principles will be effective in teaching O&M to your visually impaired students with multiple disabilities.
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