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Dear Ladies and Gentlemen,
Twenty years ago, when we
first started carrying out mobile early interventions in the
family home for children
with both multiple handicaps and visual impairments, our search for
suitable methods and materials
led us, above all, to approaches based on the idea of visual
stimulation. We should like
to summarize these under the heading "input approaches."
Theoretically, this "visual
stimulation" was based, above all, on findings on the
plasticity of the brain
and physiological characteristics of the visual system, in particular,
about
the structure and function
of the visual cortex. The findings of Hubel and Wiesel led to the
assumption that an impaired,
poorly functioning visual system could be activated, stabilized, or
even, to a certain extent,
repaired through frequent and regular exposure to selected stimuli
under controlled conditions.
Children were first placed in darkened rooms and then presented
with all kinds of light
stimuli. These were high-contrast patterned charts, slides, or video
sequences designed in line
with the "preferences" of the visual cortex.
Generally, the number, frequency,
and duration of visual presentations was set by the
therapist. Parents--when
included at all--were only required to repeat them exactly every day
at home. The exclusive goal
of these mechanistic exercises was to train the "neural tools" for
vision, and this was carried
out in artificially designed situations removed from real life.
Criticism of this one-sided,
reductionist implementation of the, in itself, correct idea that one
could in any way intervene
to promote a damaged visual system was raised by those affected
most directly: the children
themselves, who dropped out increasingly from these strict
stimulation sessions, withdrew
from the constant stream of stimuli by simply refusing to
cooperate, or defended themselves
through active refusal. Detailed analyses of these training
situations as well as insights
into childhood behavior patterns and needs gradually also
strengthened the experts'
doubts about these rigid procedures: When stimuli are presented
mechanistically and automatically,
they are unlikely to become meaningful for the children. In
contrast, there is a strong
risk that such an isolated procedure will evoke disinterest and lead
to overstimulation with
chaotic results. Andreas Fröhlich has formulated his doubts about
such
function-training programs
as follows: "If nobody is with the child apart from the machine,
then this is no acceptable
intervention in development" (translated).
As long ago as 1979, Natalie
Barraga emphasized that:
Learning to see calls for
more demanding framing conditions than any given in
an inanimate environment;
in other words, human beings can only acquire
vision within a social context.
This is because visual development follows its
own inherent logic. It is
embedded within the child's total development and
dependent on his or her
general development. As a result, developmental
potentials in the visual
domain depend essentially on the child's possibilities of
using his or her vision
in everyday activities.
When the child exhibits
no interaction with the objects of vision, a
further development of visual
ability cannot occur.
We believe that it is a serious
mistake to understand the term "visual stimulation" as
meaning the exposure of
a passive child to some kind of light stimulus in artificial situations.
From the very outset, seeing
is an activity; it means active looking, searching, and
selecting. What is searched
for, fixated, analyzed, and recognized depends on the subjective
significance of a stimulus.
Children will seek, fixate, analyze, and recognize only those stimuli
that are significant to
them and to which they can assign some importance within their
personal life context. When
doing this, they have to perform a continuous selection from the
enormous flow of information.
This means that children are always asking themselves "Is what
I am seeing useful for me?"
"Can I grab hold of it?" "Can I eat it?" "Will it give me pleasure?"
Put succinctly: "Is vision
worth my while?" Beyond the sensory process of reception and
further processing, every
perception involves a meaning-making act in which some
significance is assigned
to stimuli. We do not perceive spots and colored blobs, but search
actively for forms, structures,
and objects with a certain meaning.
Perception is never passive
reception or reflection, but always an active blueprint of
reality. Recent years have
seen a strong revival and extension of this idea by supporters of
"biological humanism," in
particular, Maturana and Varela. What we have to do is to assist
handicapped children with
visual impairments in developing precisely this blueprint of their
own reality. This is why
visual stimulation can never be, and must never be, an isolated
function training, but a
sensory schooling directed toward the total personality of the child--
and this should not only
include psychological elements such as motivation, emotion, volition,
and decision-making but
also integrate and be continuously oriented toward sensorimotor
activity.
Therapy should also be determined
by respect for the child's own activity and the
awareness that only the
child can develop him or herself, and he or she has to do this alone.
Milani Comparetti has pointed
out expressly that children can only develop further when they
also want to themselves.
If such a will is missing, there is no way to promote the child's
development. No single exercise
can achieve this. In contrast, isolated exercises are the most
certain way of destroying
the child's desire to grow. The child's experience is more important
than such exercises; in
other words, interventions have to comply with the needs and
emotional relationships
of the child and thus become meaningful for that child. Milani
Comparetti's guideline for
treatment is thus "don't just carry out exercises, gather experience!"
Regardless of the type of
impairment, treatment or intervention measures need to be
designed to help strengthen
the children's own activity (i.e., their autonomy) and stabilize their
relationship to the environment
(the so-called dialogue). A holistic understanding leads to the
rejection of any isolated
promotion of a single function or treatment of a circumscribed
disorder that is not embedded
within the total context of the child's psychosocial situation.
This applies particularly
to the promotion of vision.
Vision, namely, the reception
of the world and its integration into the personal life
concept, calls for additional
elements such as the desire to see, the motivation to do something
with what is seen, being
cognitively willing to grasp what is seen, to store it, and to remember
it. In other words, it is
not the eye that sees, and also not the visual cortex, but the individual;
in this case, children with
multiple handicaps and a visual impairment in their completely
special life situations
and under their completely individual learning conditions.
Our clients are generally
children with severe brain damage whose impairments are not
simply cumulative but interdependent.
Those who cannot see will have little interest in lifting
up their head, will not
want to crawl, and so forth. Their brain damage is severe; in other
words, it is not just the
function of the visual cortex that is impaired but other brain structures
as well. This means that
we have to assume an impairment of the entire functioning of the
brain, and that there are
reciprocal effects on the complex interplay of all vital functions.
It is not just stimulus
input, but also stimulus processing, stimulus storage, and the
motor response that are
occurring under special conditions. We have to anticipate an
incomplete image input,
incomplete synthesis, unstable recall, and reactions that frequently
seem to be inadequate from
our perspective. What does this mean in concrete terms for our
work?
Intervening to promote vision
has to mean designing the direct environment of children
such as the child's cot,
the play pen, as well as the broader living environment such as the
dinner table, the room,
apartment, hallway, and so forth in a way that enables their impaired
visual system to grasp it.
This involves close contacts with their parents or other important
persons in their lives and
an emphasis on daily activities. We consider that promoting vision
can only mean to promote
functional vision, in other words, to help children to apply their
residual vision in daily
life.
Before beginning any intervention,
it is meaningful to review the spectrum of activities
that could actually involve
functional vision: We use the following list of questions to describe
the entire spectrum of possible
visual activities. Naturally, the given sequence does not imply
any ranking in terms of
importance.
Does the child use vision:
1. (a) to recognize persons?
(b) to guide communication?
2. (a) to search for and
recognize objects (find and recognize something)?
(b) for fine-scale visual
exploration and analysis, for recognizing details, for exploring
the surfaces of objects?
3. (a) for eye-hand coordination
(in the sense of reaching and grasping)?
(b) for optically controlled
activity (visually guided work and play)?
4. (a) for spatial orientation?
(b) to guide locomotion?
We also ask: Does the child
apply residual vision at all? If not, would he or she be able
to do so given certain assistance
or under certain conditions? In which daily living situations?
Is the child's daily life
or immediate living conditions designed in a way that permits him or her
to gain any visual experience
at all? Or does the child spend most of the day "looking" at white
walls or beige-colored cupboards?
What exactly does the child do when he or she engages in
visual exploration? And
so forth.
The challenge facing us
is to develop appropriate materials to help children to gain
visual experiences that
relate to their personal lives, because this is the only way in which what
they see can acquire meaning
and significance for them.
For example, are showcases
with black and white stripes a worthwhile visual
experience? It is certainly
conceivable that black and white stripes have no intrinsic visual
value--they acquire meaning
only when children have learned to see them and, for example,
rediscover them in the pattern
of their mother's blouse, or notice that the cross-bars of a
window are made up of a
certain sequence of "stripes" that are familiar from previous
exercises with a series
of slides. One way to encourage this would be to make the cross-bars
"visible" by sticking florescent
strips to them.
We consider that our main
task in early intervention for children with multiple
handicaps and visual impairments
is to search continuously together with parents and
guardians for opportunities
to present meaningful visual stimulations; in other words, to make
it possible for children
to detect visual objects or situations in their daily lives that relate
to
their current action interests.
What we have to do is to provide structure where the impaired
visual system can no longer
do this by itself, and to add stimuli in situations that provide
insufficient stimulation
to function as the "staple diet" for vision.
Some basic principles have
to be taken into account here:
1. It is necessary to ensure
sufficient light to nourish vision.
2. Stimuli have to have
a simple and meaningful structure in comparison with the
complex patterns in the
child's environment.
3. The presentation of stimuli
has to be slowed down in comparison with the speed at
which images change in daily
life.
4. Interventions have to
involve frequent repetitions and, in particular, variations. The
need is therefore for variation
combined simultaneously with the systematic integration of
redundancy in order to make
recognition possible.
5. Particular attention
and motivation have to be elicited through closeness to
individual needs and through
ensuring that interventions are meaningful for the specific child.
However, it is not possible
to promote and stabilize basic visual skills in daily life
alone, and we are regularly
forced to construct special situations. These special situations are
legitimate and necessary
when the stimuli available in daily life do not suffice to provoke visual
activity. This is when we
darken the room; this is when it is correct to use slides, light boxes,
black light, and visual
education rooms as necessary aids and catalyzers. However, all the
motivational rules mentioned
above continue to be just as valid and essential in these special
situations. In principle,
what we want to do is design visual intervention so that the reference
to the child's daily life,
to being embedded in daily family routines, and, in particular, in
childhood play is taken
into account from the very outset.
However, what does this
mean? What do we mean by relating vision to daily life?
Fröhlich considers
this to mean that children might gradually learn that the world does not
just
consist of rough differences
between light and dark, but that the persons and things with which
they come into contact also
possess a visual form. In general terms, children could learn that
vision is useful for coping
with daily life; in specific terms, that they will see more and see
more completely when they
look around and try to take possession of their world for
themselves.
Vision can only become a
real part of their behavioral repertoire when the children
themselves can regularly
rediscover those stimuli that they have learned to recognize during
the special therapeutic
situations and the structures they have experienced during the visual
stimulation as part of their
daily lives. We have to ensure that their daily lives provide this
autonomous, repeated confrontation
with these structures: This is why the feeding bottle is
marked; this may well also
be why the mother is wearing make-up on her face. This is why the
home environment has visual
landmarks and is not simply painted white or pink.
The regularly experienced
persons, objects, or locations should possess a visual form
that the child is able to
register optically. This is a core aspect of promoting vision in a way
that is close to daily life.
It naturally involves constraints for children with multiple handicaps
and visual impairments because
the stimuli presented need to be significant to each individual
child on his or her personal
level of cognitive development. Possibilities of encountering and
interacting with these stimulus
materials have to be provided--and these also have to
correspond to the needs
of the child during the current developmental phase. In other words,
what is offered visually
has to be exciting and have something to do with the child's interests
and activities. Our task
is to make arrangements and to provide assistance that will permit
these children to detect
stimuli and recognize and discriminate various, initially easily
discernable stimuli as they
take their first steps in visual activity.
Discriminating further stimulus
qualities such as form, color, or size could then follow.
The next step could be promoting
hand-eye coordination. One major component of such an
intervention to promote
vision in daily life is to design a setting, a home environment that
facilitates spatial orientation
and object perception through landmarks, appropriate contrasts,
meaningful selection of
colors, and, if necessary, special lighting. One goal is to make it easier
to recognize the special
characteristics of everyday situations. Examples are:
1. I can recognize the--marked--bottle.
2. I can remember the colored
mobile over my bed.
When selecting visual materials,
it is best to choose ones that occur regularly in play
and activity and are able
to acquire an action relevance for the child. Such a subjective
meaning will, in turn, be
easier to establish at locations in which play materials and everyday
objects can be designed
more clearly and unequivocally through simplification, structuring,
and intensification.
Particularly when promoting
vision in children with both multiple handicaps and visual
impairments, it seems to
be absolutely essential to ask oneself regularly what is the "benefit"
for the child. The answer
is that is should make the environment a bit more predictable, so that
the child can say, "I know
my way round here."
So, what do children learn
through their vision?
In summary, we can state
that they learn that the world is not just made up of rough
differences between light
and dark, but that all objects, all persons with whom they come into
contact, also possess a
visual form. They learn that it can be exciting to look at something,
that it is worthwhile to
look around, because then they will see more, and that it is meaningful
to get up close to things,
because this enables them to discover new details. They will gain the
experience that social contacts
can also be experienced visually, that handling things is easier
when it is guided visually,
and, last not least, that vision can also be used to orient oneself and
move through the environment.
When in this initial situation, the promotion of perception
should address the child
in a holistic and playful manner, it is essential that (a) the presented
stimuli are appropriate
to the child's level of cognitive development; (b) there are possibilities
of playing with and varying
this stimulus material; and (c) the materials and activities
correspond to the child's
needs and active interests. This is the only way to awaken the child's
interest in wanting to see
what there is to look at. However, vision only becomes experience, a
real enrichment for children,
when they are personally able to rediscover the structures
provided in the visual stimulation
in their daily lives.
It is continuously necessary
to creatively apply the criterion of closeness to need in
order to select materials
in a way that attracts the particular attention of the children and their
desire to try them out for
themselves through vision and action.
We cannot deny that this
is often a very arduous path with our clients that is frequently
subject to narrow constraints,
and we are familiar with the temptation of apparently highly
controllable schematic visual
stimuli. However, our many years of experience in working with
these children has particularly
shown that long-term successes only come about when visual
stimulation does not just
remain a method but becomes a principle that finds its way into the
life-world of our children.
They then begin to apply their vision more frequently, and gradually
also more precisely. In
the following, we would like to briefly show you how this promotion
of vision in daily life,
this promotion of vision in relation to personal life, may actually be
implemented in practice,
and then discuss this with you.
Author Notes
We wish to thank Jonathan
Harrow at Bielefeld, Germany, for translating this text
from German into English.
Biographical Notes
Marina Strothmann and Matthias
Zeschitz are both qualified graduate psychologists who have
been working for more than
20 years in the early intervention department at the
Blindeninstitutsstiftung
Würzburg, Germany. One of the tasks of the Blindeninstitutsstiftung
is
to carry out early intervention
with all children in the German federal state of Bavaria who are
multiply handicapped and
blind or partially sighted. This early intervention takes the form of
weekly visits to the children's
homes. Marina Strothmann, who is particularly interested in the
special problems that these
children have with perception, is responsible for early intervention
at Munich. Matthias Zeschitz,
whose interests include the potentials and limitations of mobile
early intervention in the
home, is responsible for early intervention at Würzburg.