Autism, Blindness and Sign Language: A Case Study
A Preschooler with Autism and Blindness: A Case Study
Unlocking the Mystery of Communication
Presented as a poster session at the 2003 FLASHA Convention
This case study profiles one non-speaking client with a dual diagnosis of autism spectrum disorder (ASD) and blindness. I will describe how augmentative-alternative communication (AAC) strategies used with this client. The rational for teaching both AAC strategies is provided along with AAC objectives, directions for implementation, feedback for correct and incorrect responses, list of needed materials, when strategies should be implemented and by whom. The information provided in this case study was used to help train parents and school professionals to implement AAC strategies for a specific client.
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Visual skills are typically an area of strength for children with autism spectrum disorders (ASD). Thus, visual supports are commonly used as teaching strategies for children with ASD. Visual supports may include but are not limited to: 1. picture schedules to help children transition between classroom activities; 2. picture symbols and/or sign language shown when verbal directions are given to improve a students comprehension; 3. pictures symbols and/or sign language to help aide expressive communication in non-verbal children; and 4. visual supports for behavior modification such as a "first do this/then you can have that” board.
Working with a student who has ASD and blindness or severe visual impairment is challenging because traditional teaching strategies and supports used with students who have ASD (i.e., visual supports) can not be used to teach visually impaired students. However, with help of a vision specialist and lots of creativity the preschool educational team was able to adapt many traditional visual support strategies used with children who have ASD and normal vision into tactile support systems for our student who was blind.
Paul is a friendly, 4 year-old, non-speaking, male with a dual diagnose of ASD and congenital blindness. Paul began preschool at 2 years, 5 months of age. Since that time he has been enrolled in a full day preschool program which uses an educational curriculum designed for children ages 2.5 to 5 years of age who have been diagnosed with ASD. The preschool curriculum is loosely based on a combination of Dr. Stanley Greenspan’s DIR/Floor Time Model and TEACCH.
Paul’s level of autism was assessed to be in the severely autistic range based on the Childhood Autism Rating Scale (CARS). He exhibited delays across all developmental milestones and atypical behaviors such as self-stimulatory behaviors (i.e., flopping his wrists or flipping objects for hours if uninterrupted), hypersensitivity to certain textures, and lack of initiation of communication. Paul screeched in protest and actively resisted when transitioning to non-preferred activities. Paul demonstrated immediate and delayed echolalia of environmental sounds and speech; he appeared to make no distinction between speech sounds verse non-speech sounds. Paul walked with stiff legs and small guarded steps at a slow pace due to his blindness. He demonstrated a strong preference for music, musical instruments and listening activities such as books on tape. Paul had strong verbal and rhythmical imitation skills and emerging ability to play simple musical instruments such as the piano and drums. Residing with both his parents and older sister; Paul's mother initially had difficulty accepting and understanding what kinds of challenges her son faced.
Paul's communication skills were assessed prior to entering preschool using the Developmental Assessment of Young Children (DAYC) at age 2 years 3 months. The age equivalency score for his total communication skills was 12 months. Paul's receptive language skills were described on his FSP as: 1. able to follow routine commands given tactile and physical cues, 2. able to identify several body parts and common objects through touch, 3. frequently repeated musical tunes or rhythms through vocalizations, 4. sensory issues noted in response to auditory stimuli - fluctuating between hypersensitivity and hyposensitivity.
Paul's expressive language skills were described on his FSP as: 1. some words said in imitation (delayed echolalia) but little functional use of language, 2. immediate and delayed echolalia of environmental sounds and speech - no distinction between speech sounds verse non-speech sounds.
My goal was to teach Paul to independently use speech to make requests. At this time, he was not yet attaching meaning to the words he echoed. Just as I would teach a non-visually impaired child with autism who uses echolalia exclusively, I taught Paul to use an alternative form of communication. By teaching Paul sign language, he learned that words have meaning. Only then was he able to attach meaning to words and use single words to make simple requests.
Treatment Method #1 Use of Object Symbols was Unsuccessful
Object Symbols glued to 2X2 cardboard squares to be used as a symbol exchange communication system similar to Picture Exchange Communication System (PECS). The objects were glued to cardboard squares so Paul could distinguish these objects as tactile communication symbols. It became apparent very quickly that this system would not be successful due to Paul's self-stimulating behavior of flipping objects with his hand. Paul was not able to learn to use the communication symbols because his self-stimulating behavior of flipping objects interfered with his ability to recognize the object symbols.
At this time I consulted with the Helen Keller Center for the Blind. I told The Helen Keller Center about Paul's difficulty using object symbols and that I was interested in implementing sign language to teach Paul to communicate. They explained that individuals with blindness from birth do not understand gestures such as waving or sign language because they have no concept of sight or that other people have sight to receive the gesture or sign. They told me it is difficult to teach sign language for this reason and the best way to approach it would be to teach Paul to use two handed signs so he would have tactile feedback while producing the signs. Based on input provided from the Helen Keller Center a new treatment method was developed.
Treatment Method #2 Two Handed Sign Language Paired with Speech was Successful
The second treatment method I designed was to teach Paul to use two-handed sign language. By using two-handed sign language (signs that are produced using two hands touching each other), he would receive tactile feed back when he produced a sign. Single handed signs provide little tactile feedback and may require more sophisticated fine motor skills than two-handed signs.
Teaching began with hand-over-hand assistance to produce a modified sign to request a "goldfish cracker" during snack time. Goldfish cracker was chosen as the first item to request because it was highly motivating for Paul. The sign for "goldfish cracker" was actually an approximation of the ALS sign for "fish." The sign was modified so Paul would hold the palms of both hands together and move them forward like a swimming fish. Paul was reinforced immediately after each production of the sign with a goldfish cracker.
Once he learned how to produce the sign independently to request goldfish crackers it was time to teach him to discriminate between two different signs. He now had a way to communicate when he wanted more goldfish crackers. Next, I introduced the ALS sign for "cookie." This is another two-handed sign to provide tactile feedback. This sign was also highly motivating for Paul and taught during snack time. Paul was immediately reinforced after each production of the sign with a piece of a cookie; he soon learned to produce the sign for "cookie."
Two more adapted/modified, two-handed signs were taught to request highly motivating actions: 1. a push on the swing and 2. listening to music. Paul quickly learned these signs and was able to independently produce the signs to make requests.
To promote generalization of these skills to the home environment, family members, vision specialist, and baby sitter were trained on the use of the two-handed signs. Everyone who worked with Paul at school and home were given pictures of how to produce the adapted signs to wear on a key ring, so everyone who worked with Paul would facilitate the correct production of each sign.
As Paul began to independently produce signs to request these four highly desired items/actions, I began to teach Paul to say the word associated with the sign. Paul had excellent verbal imitation skills so I began by giving him a phonemic cue (i.e., saying the first sound of the word) in a soft voice and as he began to imitate me, I finished the word. As soon as he finished saying the word, in imitation, I reinforced his behavior with the desired item or action.
Within two months time, Paul began to independently and consistently use single words to communicate for these four desired items and actions and no longer used his signs. This brief use of sign language unlocked the mystery of communication for Paul and he rapidly learned to generalize this skill to other words. He was now using single words to communicate his basic wants; he understood that words had meaning and power.
1. D. S. Hunter (1983). Nicola: The use of sign language with a blind, autistic child. Child and Youth Care Forum, 12(4) 321-336.
2. S. K. Lund, J. M. Troha (2008). Teaching Young People who are Blind and have Autism to Make Requests Using a Variation on the Picture Exchange Communication System with Tactile Symbols: A Preliminary Investigation Journal of Autism and Developmental Disorders, 38(4) 719-730.
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